Innovation summary

Maya indigenous areas of Guatemala experience some of the worst social and maternal and child health (MCH) indicators worldwide1. Women face high rates of gender inequality, characterized by violence, poor opportunity and a concentration of resources and decision-making in the hands of men2. Guatemala ranks among the countries with the highest rate of femicide worldwide3; 42% of women have experienced intimate-partner violence, and 68% of men believe a woman ought to obey her partner even if she doesn’t agree with him4. Additionally, the recent civil war left profound traces on indigenous populations including psychological distress, low self-esteem, substance abuse, and destruction of social support systems in families and communities5. Among women survivors of domestic violence, 51% report anxiety and 78% depression4.  Guatemala’s national health system provides limited access to mental health services and utilization is close to null6.

Buena Semilla was created as a participatory research project7,8 to promote the health and wellbeing of Indigenous communities in Guatemala in settings with little to no access to mental health services. Our mission is to engage vulnerable populations as co-authors of solutions to the health problems that they face, and to support collective processes of social mobilization, self-determination and cultural revitalisation. Our goal is to support marginalized adolescent girls and women in becoming agents of change in their own lives, families and communities, securing health, wellbeing, and a full life free of violence.  The Women’s Circles are the primary component of care underpinning Buena Semilla. The Circles consist of 12 sessions held every 2-4 weeks and led by community health workers.

Impact summary

  • Over 400 women have participated in the Women’s Circles 
  • 66 community health workers have been trained to deliver the intervention
  • Women’s Circles were found to increase women’s emotional wellbeing and self-esteem, improve their communication skills, strengthen their relationships with other women and with their family, and provide them with an important space for problem-solving and information sharing
  • An increased trust of community women in community health workers, increased understanding of local women’s lived reality and improved relationships with their colleagues.   

There are very few spaces for women to participate within their own communities. If women are able to believe in themselves and increase their self-esteem, they are able to identify and have decision-making-power on their health needs. Women have less problems when they know how to solve them. It is a very important step, which can have a strong impact on the life of every woman, every family and every community.

 

- Community health worker, leader of a Women’s Circle in her community

Innovation details

Women’s Circles: a group psychosocial intervention for women

Women’s Circles is the key model that underpins Buena Semilla. It is a community-based, community-led group psychosocial intervention which consists of support groups (Women’s Circles) for vulnerable Indigenous women.  When we say “vulnerable,” we are including for example single mothers, adolescent mothers, victims of violence, women in extreme poverty, mothers experiencing psychosocial distress, and women with unwanted pregnancies.  The Women’s Circles create a space facilitated by trained women peers, including traditional midwives and community health workers.  

The Women’s Circles are a co-designed, community-based collective space where women can build their self-esteem, share difficulties each face and collectively find solutions, strengthen their social support networks, improve their emotional wellbeing and gain confidence in their skills for navigating the specific challenges they face. The goal is to reinforce long-lasting change that has the potential to extend across generations, improving maternal and child health and wellbeing.

The Circles consist of 12 sessions held every two to four weeks and led by trained women peers or community health workers. Within the Circles, individual and group activities draw from a broad range of approaches, including indigenous practices, popular education, arts-based and learning-through-play activities, occupational therapy and cognitive behavioral therapy – all of which engage women through processes of reflection, conscientization, problem-solving, relationship-building and skills-strengthening, supporting them in becoming agents of change in their own lives and families. The goal is to reinforce long-lasting change that has the potential to extend across generations, improving maternal and child health and wellbeing.

The Model was created through ongoing Participatory Research, starting in 2010, with women (including traditional midwives) living in periurban K’iche and rural Mam-Mayan communities in the Western Highlands of Guatemala.  Participating women co-designed the methodology and content of the intervention, focusing on their own everyday challenges and dreams for a better future.

Buena Semilla’s approach draws strongly from decolonizing methodologies and the work of Paulo Freire and Augusto Boal, specifically their focus on popular education, conscientization and social mobilization for change. These are key components to all our project activities.

Deliberative Dialogues: a social mobilization protocol to engage men and women in co-designing strategies to address mental health and wellbeing in their communities

By request, Buena Semilla is now expanding its initiatives to engage men – and to include adolescents, elders and traditional healers through an intergenerational, intercultural approach to health and wellbeing. Community mobilization is critical in spurring and sustaining the complex, locally relevant solutions that are needed for improving the health and wellbeing of marginalized communities of Guatemala and beyond, especially those that have experienced complex histories of systematic oppression. Engaging men in these efforts – including adolescents, elders and traditional healers, all of whom are rarely integrated into maternal psychosocial interventions – is also critical.

Men – and their own state of mental health – play a determining role as partners, fathers and community members. Elders and traditional healers hold ancestral knowledge, are an accessible and culturally safe pillar to women’s health in many indigenous communities, and are important drivers of gender norms, collective identity, social cohesion and the transmission of resilience factors and endogenous resources. Finally, adolescents represent the future of communities and are innately innovative and uniquely placed to integrate strategies into their contemporary, socio-cultural reality

Key drivers

Co-design of the Women’s Circle intervention

Our engagement protocol recognizes that communities are best positioned to understand and generate effective solutions to their own problems. It engages participating populations through a series of steps to (1) identify a specific problem, (2) co-design solutions, (3) agree on prioritized actions, (4) implement collective action plans and (5) co-evaluate. As researchers, with strong backgrounds in mental health and maternal care, we can help generate good local evidence and guide an informed dialogue to produce a rigorous research design that communities can take ownership of. Plural action plans that foster the positive engagement of men and women, reframe gender norms within more equitable and balanced narratives, and allow communities to come together, rebuild their social fabric, draw from endogenous resources and strengthen collective resilience, can have a profound, sustained effect on improved maternal mental health and wellbeing – and ultimately, on maternal and child health.

This approach has ensured cultural safety, local buy-in and ownership, and relevance of the intervention to meet local women’s strategic needs.

Strengthening women’s livelihood-sustaining skills and solidarity economy

Early on in our work, Women Circle participants’ interest in developing livelihood-sustaining skills prompted us to also incorporate productive activities (i.e. doll making, crochet, cooking) as a form of vocational therapy and potential small-scale income generation.  These activities have been adopted in various ways in different communities: some Circle leaders have incorporated them within the Women’s Circle sessions, and others hold “in-between” sessions when women come together to make things together.  In other communities, it is the women participants themselves who organize these “in-between” sessions. This activity has emerged as an especially important space for the women, where they can continue to share with other women and find camaraderie and support from others.

Collaboration with key implementation partners

Our collaboration with several key implementation partners will be critical in achieving progress towards impact. The Inclusive Health Institute has spearheaded the Inclusive Health Model, an award-winning community-based primary health care model inclusive of indigenous Maya perspectives in health9. Their interest in integrating the Women’s Circles into their activities, to strengthen mental health promotion and prevention activities and gender equity has enabled us to pilot test the integration of our model into formal health care services for women, delivered by community health workers.  The interest of several local health districts (namely in the departments of Huehuetenango and Sololá) to pilot this integration within their own health services and with their health personnel, has also been critical.

Taken together, these partnerships will be critical in setting the stage for scaling-up the intervention, and for carrying out the scale-up itself.    

Challenges

  • Difficult geographic terrain and weather conditions
  • Low investment in health at a national level and fragile health infrastructure in marginalized areas
  • Dismantling of community-based primary health care services, making it difficult to build on existing infrastructure. 
  • Mental health not recognized as a public health priority
  • Very poor mental health infrastructure
  • Discrimination against Indigenous populations and traditional midwives

Continuation

We are currently piloting the integration of the Women’s Circles within a community-based primary health care model, the Inclusive Health Model, in collaboration with local health districts and key implementation partners.  This pilot will enable us to further adapt our methods and materials to be relevant to this method of multiplication and delivery, and to prepare for plans for scaling up the integrated intervention toother marginalized areas of Guatemala.

Partners

Partners in Guatemala include:

  • Community health workers and traditional midwives in Quetzaltenango
  • Local health districts of Cuilco, Huehuetenango, and Santiago Atitlán, Sololá
  • The Inclusive Health Institute (Instituto de Salud Incluyente)
  • Institute of Nutrition of Central America and Panama (INCAP)
  • METOCA

International partners:

  • CIET International (USA) - http://www.ciet.org/
  • CIET Canada (Canada) - http://www.ciet.org/
  • CIET International in Guatemala
  • McGill University, Participatory Research at McGill (PRAM) (Canada) - http://pram.mcgill.ca/
  • Douglas Mental Health University Institute, McGill University (Canada) - http://www.douglas.qc.ca/?locale=en
  • King’s College London (UK) - https://www.kcl.ac.uk/ioppn/index.aspx
  • Mental Health Innovation Network (MHIN) (UK) - http://www.mhinnovation.net/
  • SHM Foundation (UK) - https://www.shmfoundation.org/
  • Project Ember (UK) - http://emberincubator.org

Funders:

Evaluation methods

Mixed-methods evaluations have been used, including: (1) Fuzzy Cognitive Maps to assess factors impacting women’s psychosocial health and wellbeing, as understood by local women; (2) Pre- and post-intervention questionnaires applied to Circle leaders and to women in both intervention and control communities, to assess acceptability, feasibility and impact of participation on women’s psychosocial health and wellbeing; (3) Post-intervention focus groups and in-depth interviews to understand acceptability, feasibility and impact; and (4) Collection of narratives of Most Significant Change to evaluate change pathways among Women Circle leaders and participants. 

Ongoing monitoring and evaluation activities include:

 
  1. Attendance in the Women’s Circles
  2. Observation of multiplication of the Women’s Circles at various levels. 

Impact details

  • Over 400 women have participated in our Women’s Circles to date, in the Western Highland departments of Quetzaltenango and Huehuetenango.
  • 66 community health workers have been trained to deliver the intervention, including traditional midwives, social workers, educators, auxiliary nurses and nurses.
  • Participation in the Women’s Circles has been found to increase women’s emotional wellbeing and self-esteem, improve their communication skills, strengthen their relationships with other women and with their family, and provide them with an important space for problem-solving and information sharing. 
  • In our initial pilot in Quetzaltenango, a woman in the intervention groups was more than twice as likely to have a high wellbeing score than one in the control group. 
  • Circle leaders have additionally reported increased trust of community women in community health workers, increased understanding of local women’s lived reality and improved relationships with their colleagues.    

References

  1. UNICEF. Committing to child survival: a promise renewed. Progress Report. New York, NY: UNICEF; 2014. 
  2. USAID. Gender Assessment: Guatemala. United States Agency for International Development; 2009.
  3. United Nation Women, Americas and the Caribbean. Guatemala. http://lac.unwomen.org/en/donde-estamos/guatemala [last accessed 6 Nov 2017].
  4. MSPAS. Encuesta nacional de Salud Materno Infantil 2015 (ENSMI 2014/15).  Ministerio de Salud y Asistencia Social (MSPAS)/Instituto Nacional de Estadistica (INE)/Centros de Control y Prevencion de Enfermedades (CDC). Guatemala (2015).
  5. Anckermann S, et al. Psychosocial support to large numbers of traumatized people in post-conflict societies: an approach to community development in Guatemala. J Community App Soc Psychol 2005;15:136-152.
  6. Mental Health Atlas Country Health Profiles: Guatemala. http://www.who.int/mental_health/evidence/atlas/profiles-2014/gtm.pdf
  7. Canadian Institute of Health Research. CIHR guidelines for health research involving aboriginal people. CIHR: 2007.
  8. Minkler M, Wallerstein N. Community-based participatory research for health : from process to outcomes. 2nd edn. San Francisco, CA: Jossey-Bass; 2008.
  9. Medicus Mundi Navarra. Claves para la transformación de los sistemas de salud en América Latina. Bolivia, Guatemala y Perú: tres experiencias, una sola acción integral e incluyente en atención primaria de salud. Guatemala: MMN; 2013. http://centroderecursos.alboan.org/ebooks/0000/0975/6_MED_CLA.pdf
  10. Chomat AM. Maternal stressors impact maternal wellbeing and cortisol and infant growth in rural Guatemala: Insights from qualitative and quantitative approaches McGill University; 2016.
  11. Clarke K, King M, Prost A. Psychosocial interventions for perinatal common mental disorders delivered by providers who are not mental health specialists in low- and middle-income countries: a systematic review and meta-analysis. PLoS Med. 2013; 10(10):e1001541.
  12. Rosato M, Laverack G, Grabman LH, Tripathy P, Nair N, Mwansambo C, Azad K, Morrison J, Bhutta Z, Perry H et al. Community participation: lessons for maternal, newborn, and child health. Lancet 2008; 372(9642):962-71.
  13. Martín-Baró I. Writings for a liberation psychology. New York: Harvard University Press; 1996.
  14. Napier AD, Ancarno C, Butler B, Calabrese J, Chater A, Chatterjee H, Guesnet F, Horne R, Jacyna S, Jadhav S et al. Culture and health. Lancet. 2014; 384(9954):1607-39.
  15. Bourke L, Humphreys JS, Wakerman J, Taylor J. From 'problem-describing' to 'problem-solving': challenging the 'deficit' view of remote and rural health. Aust J Rural Health 2010; 18(5):205-9.
How useful did you find this content?: 
0
Your rating: None
0
No votes yet
Log in or become a member to contribute to the discussion.

Submit your innovation

Create your own page to tell the MHIN community about your innovation.

Country

Guatemala

Gallery

Similar content