Two years ago, Dr. Saskia Bunge-Montes was completing her medical degree at the University Francisco Marroquin in Guatemala City. Medical school in Guatemala is a six or seven year commitment that includes both pre-med and medical school curricula, but in her final years of school, Saskia became more interested in public health.
Population health was not the focus of her academic training, but she describes how she began to recognize the importance of this approach. “I got more interested in understanding how systems attempted to meet the needs of the population, and how culture, education, geography, and language were such strong determinants of health in my country,” she explains. “In my fifth year, I had a rural rotation in San Juan Sacatepequez. Those four months were so valuable, and so interesting to me that I asked for an additional four months of rotation there. Instead of going back to the hospitals in Guatemala City, I was providing primary care and community health approaches.”
With her clinically heavy medical school years behind her, Dr. Bunge-Montes shifted her attention.
These experiences had piqued her interest, but knowing Guatemala’s schools did not offer the kind of formalized public health education she wanted, Saskia began looking for educational opportunities outside of Guatemala.
Through colleagues, she learned about the Celgene Global Health Fellowship offered by the Center for Global Health in the Colorado School of Public Health at the University of Colorado Anschutz Medical Campus.
Dr. Bunge-Montes was one of the first recipients of the fellowship, which is funded by Celgene, a global biopharmaceutical company based in New Jersey.
Celgene approached the Center for Global Health in 2013 with the goal of establishing a fellowship to enable medical investigators from low- and middle-income countries to come to the United States for training in public health.
The program allows fellows to complete the Global Health Certificate at the Colorado School of Public Health, and work on projects being carried out by faculty at the Center for Global Health. The ultimate purpose is for trainees to return home, bringing new ideas, experiences and skills.
Saskia became closely involved with the project, and received a second year of fellowship funding to continue her work, and to complete a Masters of Public Health degree.
Saskia’s responsibilities increased in the second year, and in September 2015, she led a census and mapping study in the Trifinio area under the mentorship of Edwin Asturias, MD, associate professor of Pediatrics and Epidemiology at the University of Colorado School of Medicine and Colorado School of Public Health, and Maureen Cunningham, MD, MPH, assistant professor of Pediatrics at the University of Colorado School of Medicine.
“The last census in Guatemala was in 2002,” Saskia explains. “Although mapping programs have been widely used in public health, there are only three published articles in the literature that use geographic analysis for improving access to healthcare in Guatemala. ... Our own maternal and child health outreach programs needed baseline data and maps of this rural area. Using GIS, we created distribution maps that provided visual representation of how the clinic [Clinicas Desarollo Humano/Center for Human Development] was situated in relation to the density of the population.”
In the literature review Saskia conducted in preparation for the census, she noted that community-based participatory research methods improved overall participation rates, led to high quality asset mapping (identifying and mapping things in the communities like libraries, clinics, pharmacies, etc.), increased trust and cultural acceptability, and led to better design and implementation of studies.
Applying these methods to her own study design, she carefully selected the survey team from the communities of the surrounding areas. With the input of a local authority, Saskia identified a few young, literate people that were willing and able to walk for most of the day.
The team was led by a minister, and composed of a single mom, a part-time law student, and two recently graduated high school students. Also instrumental were the community leaders called COCODES (an acronym for Consejos Comunitarios de Desarrollo Urbano y Rural or Community Councils for Urban and Rural Development).
The COCODES assisted by first determining the acceptability of the census project, and by helping to develop the survey questions, and then later by appointing community guides to accompany the surveyors, or acting as guides themselves in many instances.
In the community, surveyors followed a two-part process; they used GPS devices to mark the geographic coordinates of homes and other assets, and they conducted a 10-question survey in the homes of consenting participants.
Dr. Bunge-Montes created a training manual for the surveyors, “The manual detailed the research practices we wanted to employ, like getting informed consent, reacting appropriately and non-judgmentally to different survey responses, maintaining confidentiality, collecting data accurately, using the GPS and Palm Pilots, and paper records. We spent a week training how to use the GPS, and we did two trials asking the survey questions.” All four surveyors were operating in one community at a time. They each took turns capturing community assets/landmarks.
“This helped us understand the resources available to each community. The church plays a huge role in these places, so mapping those was important, as well as pharmacies, stores, and other features in the towns,” she explained.
The community guides that accompanied the surveyors helped ensure that all assets and landmarks of the local community were mapped. Dr. Bunge-Montes felt that the surveyor/community guide dyad was also extremely helpful for garnering high rates of participation, stating, “I think our participation rate of over 95 percent is evidence that this strategy was effective.”
Saskia and her collaborators at the Center for Global Health are still in the process of analyzing the data, but some results have been calculated.
Thirteen out of 15 communities accepted the invitation to participate in the survey; within those communities, 15,202 people and 4,086 homes were counted.
The average age of the population is 24 years. Sixty-three percent of women are literate, and 3 percent of women are pregnant. Only 31 percent of homes had improved sanitation services, and 47 percent had ready access to clean water.
Dr. Bunge-Montes says, “Participation rate was the result that I was most surprised by, and most proud of. I didn’t expect so many people to be willing to participate in the census.”
Dr. Bunge-Montes believes the results of the census will impact how other investigators at the Trifinio project site conduct their work.
“For instance, there have been a lot of studies showing that maternal literacy has a great influence on child outcomes such as vaccination rates, developmental milestones, and other child health outcomes. It’s a strong indicator of other family outcomes, too, like food security. This is an important baseline data for our child development program (Ninos Sanos), since the way you deliver information to literate moms is very different than illiterate moms,” explains Bunge-Montes.
Ten out of 13 communities are beneficiaries of the Ninos Sanos and Madres Sanas (maternal health and pregnancy registry) programs.
Soon, the maps and census results will be shared with the community leaders, schools, and health posts in the area. For schools, this data will provide an idea of how many children are in the area, the distribution of where kids are physically, and their demographic information.
For the health posts, the physical and demographic distribution will help them and understand some of the determinants of health that reside outside of the healthcare system. It will also help them make better preparations with resources (e.g. how many vaccines the post will need during certain time frames).
Saskia elaborates, “Our projects will use this information in the same way. It will help us understand the distribution of risk, like pregnancy, or poor access to water. Maybe there are places that need our help more than others. Distance plays a really important role in health access, especially in a place like this where there aren’t paved roads. We hope to learn more about these things from the data.
“From a programmatic level, we have many more pregnant women in the area than are participating in our projects. This will help motivate us to find new ways of reaching these women. The data will serve as a point of reference, a denominator for planning and measuring the effectiveness of future interventions,” she finishes.
Saskia is in Guatemala at the time of this writing to share the maps and preliminary data with the communities. Empowering local leaders with this information is an important step towards greater participation in planning their health agendas.
Dr. Bunge-Montes public health training has been a boon to the project and the projects’ beneficiaries.
After completing her fellowship in July, she will continue working part-time as a Community Nurse Coordinator on the community outreach programs in the Trifinio. The Center for Global Health is delighted to retain Saskia as a collaborator moving forward.
Story by Molly Terhune of ColoradoSPH's Center for Global Health.