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Mainstreaming Acupuncture through Health Care Structures
in the District of Quiche, Guatemala
Analysis of Opportunities for Community Change: Introducing Traditional Chinese
Medicine
Diane E. Dreyfus, M.S. Arch.
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Contents
Summary ................................................................................................................................................... 2
Introduction .............................................................................................................................................. 3
Background: .............................................................................................................................................. 5
Health Delivery Systems ........................................................................................................................... 7
District: Santa Cruz del Quiche ................................................................................................................. 8
Interviews and Analysis ............................................................................................................................. 9
EXHIBITS .................................................................................................................................................. 12
Annotated Bibliography: ......................................................................................................................... 20
UNITS of PRACTICE .................................................................................................................................. 22
Ecological Model – 5 levels of change .................................................................................................... 23
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Summary
“Big breakthroughs happen when what is suddenly possible meets what is desperately
necessary.” Thomas Friedman 15MAY12 New York Times
Probably less than 25,000 people in Guatemala have experienced acupuncture. This is not
because there is cultural resistance to Traditional Chinese medicine (TCM ) but more because
demand for this cost effective treatment has not been cultivated on a large scale. For at least a
decade, underserved patients have accepted the occasional visiting workshop (Jornada,) but
addressing chronic health problems at the Community level using TCM will require some
sensitive promotion and time. (The Maoist government affected a positive change for 300
million Chinese in 30 years.) The offering needs to be framed as a complement to extant (and
scarce) services and resources.
Training and supporting informal and local care providers is a wanted and necessary part of any
long term outreach. Presenting a 75 to 100 hour training (in 4‐6 week modules) is complicated
by the Mayan’s preferred use of their 24 languages and their very high illiteracy rate – (in places
upwards of 80% among women.)
This paper briefly examines a way for acupuncture to gain a firm hold in Guatemala, starting
with the District of Quiche (and fielding the trainings beyond that to five other heavily Mayan
Districts.) This paper proposes creating a formal structure for volunteer TCM practitioners to
work in conjunction with Guatemala’s Public Health Department ‐at the Community or Puesto
level. A second and less attractive model is privately opening storefront(s)/Tienda(s) near the
markets and hoping that word of mouth suffices to bring in patients The third, and least
desirable, is to continue “as is” with uncoordinated groups arriving from time to time in Petan
or Quiche Districts.
From the individual’s perspective, one of the largest hurdles for TCM delivery, in areas of
poverty, is the patient’s onerous time commitment: waiting for and receiving TCM treatment
puts a hole in the work day. Mayans much prefer “injections” because they are culturally
appropriate and fast.
At the Policy level, the largest risk in pursuing this larger goal is triggering scrutiny for TCM
(which is currently not monitored) under the new president.
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Introduction
There are plenty of opportunities for medical volunteers of all stripes in Guatemala.
Medical NGO’s routinely “sponsor” Western Medicine Jornadas at the District or CAP level and
at the Community or Puesto level. For Western Medicine practitioners, their host organization
clears paperwork – checking both licenses and medicine donations for acceptability and dates.
Meanwhile the regulatory climate is changing. Western Medicine has come under the stricter
controls since the inauguration of Perez‐Molino.
Cooperation with Private Hospitals currently offer TCM a limited option. For example, Christian
Nix has developed a partnership with Hospitalito Atitlan and demonstrated that obtaining
“privileges” in one of the many private faith based hospitals can be done. Pursuing a public
approach, such as officially registering a treat and train program with government of
Guatemala, would immediately engage the system – for better or worse.
Regarding introducing cultural change, part of the legacy of the civil war is that many survivors
were and remain displaced. The effects of diaspora are relevant because, even large cities like
Santa Cruz del Quiche, the indigenous tend to remain clannish and parochial. Their long‐
standing private rebellion has them by‐pass colonial Spanish. In the three targeted heavily
Mayan Districts, people share strong ethnic identities and conduct most of their business in one
of the five indigenous languages: Quiche, Katchiquel, Tzuil, Xixil or Mam. They enjoy
extraordinarily strong community ties but their linkage to common resources such as
government services, education and health care is limited by linguistic barriers. This lack
persists despite a primary education mandate to teach indigenous languages.
In the contiguous Mayan Highlands Districts of Totnicapan, Solola and Quiche, people treasure
their remaining family and community ties over distance and time. For example, the tiny aldea
of Patanatic in Solola was settled by several families who fled Totnicipan in the late 1960’s. The
pueblo’s ladies still wear the mottled traje (suit) from their former home; eschewing the local
garments. They have created a “New Toto” where even the local church is dedicated to the
same patron saint as the old one was.
The “independent” community of Quiche speaking Maya can effectively ignore or screens out
what does not conform to their norms and their informal selection process can make or break
any outreach. Consider that despite of the local acceptance and preference for syringes and
injections, such non‐traditional services as acupuncture might still require careful introduction
and, perhaps, the long term support of a known entity such as a trusted NGO or a favored
church.
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Based on informal interviews, it appears that empowering a respectable group of local
midwives and curanderos and connecting them to the community at the Puesto level might
mainstream bits of TCM in the short term. And, looking longer term, building both confidence
and demand might incentivize private practices and require more formal training. This is
another point where “regulators” might step in.
The good news is that there is a cultural bias that favors needles dating from pre‐colonial times
and the local healers already use herbs and massage in a similar ways to TCM. “Natural
medicine” shops bogus or not are as plentiful as pharmacies. The bad news is that TCM
requires regular and sustained application and there are insufficient practitioners of the art and
as mentioned above, this shortage can cost a patient wages.
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Background:
Guatemala
Like most of her neighbors in the Caribbean and Central America, Guatemala suffers high
morbidity from infectious diseases, acute socioeconomic imbalances and rampant population
growth. At the Policy level, this classic “banana republic” exports food in the face of severe
malnutrition and improperly grants lucrative infrastructure and mining permits to foreigners. In
short, governmental and legacy social structures actively deplete the commonwealth. The
pernicious capital drain coupled with the consistency of national emergencies caused by
earthquakes, mudslides and flooding leaves a dearth for public healthcare.
Guatemala is roughly the size of Tennessee and among the youngest countries in the world. It
has an unsustainable fertility rate of 2‐3 children per family and almost 45% of the population
lives in cities.
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Health expenditures:
5.7% of GDP (2009)
0.9 physicians/1,000 population (1999)* 0.6 hospital beds/1,000 population (2009)
Population:
14,099,032 (July 2012 est.)
Age structure:
0‐14 years: 37.4% (2,684,966 male/ female 2,587,063)
15‐64 years: 58.6% (4,006,895 male/ female 4,253,546)
65 years and over: 4% (262,968 male/ female 303,594) (2012 est.)
Median age:
total: 20.4 years
male: 19.7 years
female: 21.1 years (2012 est.)
Source: CIA World Fact Book
* World Average for Physicians/1,000 is 1.4
A large population of adolescents entering the labor force and electorate strains at the seams of the
economy and polity, which were designed for smaller populations. This creates unemployment and
alienation unless new opportunities are created quickly enough ‐ in which case a 'demographic dividend'
accrues because productive workers outweigh young and elderly dependants. Yet the 16‐30 age range is
associated with risk‐taking, especially among males. In general, “youth bulges” in developing countries are
associated with higher unemployment and, as a result, a heightened risk of violence and political
instability. Huntington, Samuel P. 1996. The Clash of Civilizations and the Remaking of World Order. New York, NY:
Simon and Schuster;
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Health Delivery Systems
National
There are three levels of health delivery in Guatemala the largest entity is the District level.
There are (22) National Districts each has at least one Permanent Center of Attention or CAP
A CAP runs 24/7 is normally staffed by a Doctor, an RN and (3) LPNs, a health inspector and a
rural Health Technician. A CAP refers cases to one of the 4 District Hospitals
Below the CAP level are the 9‐5 M‐F Puestos (rural Outposts) usually staffed by an auxiliary
nurse (LPN) and an inspector of sanitation and a Puesto refers cases to the CAP.
Regional: Department of Quiche´
The Quiché (QUI) is the fourth largest Department in Guatemala 8,378 km2. It has 23 health
districts, offering 115 services, There are 24 CAP level health centers and under them, 90
Puestos. All municipalities have at least one Puesto except for very rural areas like Nebaj (which
has 17), Chajul (15), Ixcán (15) and San Miguel Uspantán (12.). Additionally, there are 4
hospitals; one is located in Santa Cruz. That gives the district capital 2 CAP level entities. The
other hospitals are located in Joyabaj, Nebaj and San Miguel Uspantán..
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District: Santa Cruz del Quiche
Santa Cruz del Quiche has one Hospital, one CAP and five Puestos
The municipio of Santa Cruz del Quiche´, located 2021 m above sea includes the city of Santa
Cruz and the surrounding villages and rural area. More than 82% of the municipio’s residents
identify themselves as Mayan (Guatemala Instituto Nacional de Estadı´stica 2003a), most speak
Quiche.
Santa Cruz del Quiche faces serious economic and ecological challenges as a result of rapid
population growth that is projected to continue well into the future. Peasant farmers divide their
land among their children, the consequence of which is an increasingly large number of small
farms. Data and anecdotal evidence suggest that small‐scale farmers tend to practice more
intensive agriculture, and devote less land to pasture, forest, and fallow periods. Population
Growth and Fertilizer Use: Ecological and Economic Consequences in Santa Cruz del Quiche´,
Guatemala. 2008
0
200,000
400,000
600,000
800,000
1,000,000
1,200,000
MAR‐81 MAR‐94 NOV‐02 JUN‐12
Growth Curve for District of Santa Cruz del Quiche1981‐2012
Population
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Interviews and Analysis
We were able to visit one CAP and one Puesto.
The CAP is located in nearby Zacualpa (which is much less populous (15,000 people) but is more
urban based on densely.) Additionally, we interviewed the staff at one of Santa Cruz’s Outposts
in Lemoa (10,000 people) spread over 9 cantons.
Zaculpa Clinic area ‐ approximately 5,000 SqFt / centered on a 30,000 SqFt campus with
an open shed (suitable for meetings) and one ambulance ‐ has internet
The clinic has reception and administrative areas as well as closed consulting rooms.
The clinic supplied me with the 2011summary and some year to date reports from
SIGSAWeb.that revealed some anomalous trends and 2 cases of Dengue. The Number One
complaint year over year was diagnostic group J.00.X “Common Cold” for the whole year of
2011 there were 449 visits for this. For the current year, the number cases reported as of mid‐
November was 1,389. The number of total patients seen at the CAP for 2011 was 1,888 and for
the partial year (to mid‐November of 2012) the number was 3,877.
It is not clear if the population has increased or just gotten sicker. The data for this CAP show
incidences of parasites, urinary infections, and amagdiliyis almost tripling; Non‐specific Gastritis
rose from 151 to 624 in the partial YoY. Most alarming was the incidence of non‐specific
dermatitis that went from not in the top ten in 2011 to 321 cases in 2012.
Lemoa Clinic area ‐ approximately 1,200 SqFt on a 10,000 Sq.Ft. campus with no out‐
buildings. The clinic has an office for each position and one office is dedicated as the records
and storage area. This Puesto has no internet; weekly status reports are hand carried into Santa
Cruz del Quiche.
The Puesto serves 6860 persons in 9 cantons; the furthest is 19km away – according to their
map and may be less according to Google.
There are 1,144 single story dwellings (typically adobe with corrugated roof) with an average
occupancy of 6 persons.
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Interviewees:
Dr. Ana Maria Chinchilla, a recent Medical School graduate, who will cycle out after six months
in January.
Aura Tzunun (5336‐9637) is the LPN; she expressed in interest in NADA/moxa
Pedro Lemon (4538‐3440) is the Public Health Inspector he test water for chlorine levels,
conducts health seminars like on brushing teeth and advises of government resources and
guidelines when people are diggings wells or laying out septic fields.
Dr Ana Maria Chinchilla says that this Puesta has injectable and oral vitamins – children are
given folic acid and iron on a six month schedule. Patients are supplied with four month’s
supply of bad tasting vitamins. If they are found with severe malnutrition children are referred
to special hospital for weight gain in Joyabaj. The Puesta has no medicines but stocks sulfa
drugs antibiotics for adults: Amoxicillin, Eritromicina, Dociciclina; and for children:
Trimetoprimy and Sulfametoxasoc. This is an agricultural community that has amoebas and
giardia.
NOTES:
Children’s antibiotics leach folic acid and give them diarrhea and stomach pain.
Feed the Children recently reduced Lemoa’s 3 meal supplements down to two so that
children in the “Xixl triangle” – further north in Quiche will get two meals.
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ESTIMATED MONTHLY EXPENSES for an Office in Santa Crus del Quiche ‐ Preliminary
SAMPLE (3) Extant Health Promoter NADA Worker Expenses ‐ Marooka, Rosa, and Magdelena
RT Taxi from Sacapulus to the Bus Stop 40
RT Bus to Santa Cruz del Quiche 20
Per Diem for 2‐ Meals 50
0vernight accommodation if not at BFCP 75
RT transport if sleeping at BFPC 10Q
Salary TBD ‐ estimate per day 100 285
Cost for Estimated person Days (6) per week x 4 weeks 7980
Estimated monthly rent for 10'x 20' store front with electric 3500
TOTAL w/o Acupuncturist(s) and supplies GTQ
11,480.00
$ conversion rate 7.5
Rent and Personnel estimate in US$ $1,531
It costs 6Q RT to shuttle from Santa Cruz del Quiche to Lemoa.
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EXHIBITS
Map of Guatemala Showing District of Santa Cruz del Quiche
Map of District Capital, Santa Cruz del Quiche, showing Distribution of Health Services
Croqui Map of the nine Cantons of Lemoa
List of all Districts in Guatemala
List of Health Services in the Quiche District
List of Health Services in the Municipality of Santa Cruz del Quiche
List of all thirteen Acupuncturists in Guatemala City (the Capital)
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District of Sta. Cruz d Q
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Zacualpa
Sta.Cruz d Q
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Name
Abbr
.
Capital A (km ²)
Cf
03/26/19
81
Cf
17/04/1994
C
24/11/2002
P
30.06.2012
i
Alta Verapaz AVE Coban 8.686 322.008 543.777 776.246 1147600
i
Baja Verapaz BVE Salamá 3.124 115.602 155.480 215.915 277.400
i
Chimaltenango CMT Chimaltenango 1.979 230.059 314.813 446.133 630.600
i
Chiquimula CQ
M Chiquimula 2.376 168.863 230.767 302.485 379.400
i
The Progress EPR Guastatoya 1.922 81.188 108.400 139.490 160.800
i
Escuintla ESC Escuintla 4.384 334.666 386.534 538.746 716.200
i
Guatemala GUA Guatemala
City
2.126 1311192 1813825 2541581 3207600
i
Huehuetenang
o HUE
Huehuetenang
o
7.400 431.343 634.374 846.544 1174000
i
Izabal IZA Puerto Barrios 9.038 194.618 253.153 314.306 423.800
i
Jalapa JAL Jalapa 2.063 136.091 196.940 242.926 327.300
i
Jutiapa JUT Jutiapa 3.219 251.068 307.491 389.085 444.400
i
Petén PET Flowers 35.854 131.927 224.884 366.735 662.800
i
Quetzaltenang
o
THA
T
Quetzaltenang
o
1.951 366.949 503.857 624.716 807.600
i
Quiche QUI Santa Cruz del
Quiche
8.378 328.175 437.669 655.510 985.700
i
Retalhuleu RET Retalhuleu 1.856 150.923 188.764 241.411 311.200
i
Sacatepéquez SAC Antigua
Guatemata
465 121.127 180.647 248.019 323.300
i
San Marcos SMA San Marcos 3.791 472.326 645.418 794.951 1044700
i
Santa Rosa SRO Cuilapa 2.955 194.168 246.698 301.370 353.300
i
Sololá SOL Sololá 1.061 154.249 222.094 307.661 450.500
i
Suchitepéquez SUC Mazatenango 2.510 237.554 307.187 403.945 529.100
i
Totonicapán TOT Totonicapán 1.061 204.419 272.094 339.254 491.300
i
Zacapa ZAC Zacapa 2.690 115.712 157.008 200.167 225.100
Guatemala GTM Guatemala
City
108.889 6054227 8331874 11237196 15073400
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UADRO No. 14
SERVICIOS DE SALUD EN QUICHÉ‐ 2000 No.
Municipios
Distritos de Salud
Serviciosde Salud No. de
HabitantesNo. De
Viviendas
Habitantes por S / SC / S P / S
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
Santa Cruz del Quiché Chiché Chinique Zacualpa Chajul Chichicastenango Patzité San Antonio Ilotenango San Pedro Jocopilas Cunén San Juan Cotzal Joyabaj Nebaj San Andrés Sajcabajá* San Miguel Uspantán Sacapulas San Bartolomé Jocotenango Canillá * Chicamán Ixcán Pachalum
2 1 1 1 1 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
1 1 1 1 1 2 1 1 1 1 1
1** 1** 1
1** 1 1 1 1 3 1
5 1 0 1 14 7 0 1 3 3 5 3 16 2 11 4 0 0 1 12 1
46609211737174
1427126445
1001405091
17471207942352920550472855386417070405953443460378120
22455622797474
7773 3533 1197 2380 4408
16697 849
2913 3466 3926 3427 7887 8986 2849 6438 5739 1007 1355 3748
13569 1247
6658.43
10586.507174.007135.501763.00
11126.675091.008735.505198.505882.253425.009457.002992.445690.003122.696886.806037.008120.00
11227.504151.933737.00
Fuente: Sistema de Información Gerencial de Salud (SIGSA), 2000 * Para los municipios de San Andrés Sajcabajá y Canillá se utilizaron proyecciones de población del INE para el año 2000 ** Joyabaj, Nebaj y San Miguel Uspantán no cuentan con centro de salud sino con Hospitales distritales
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SERV IC IOS DE SALUD EN QU ICHE
1. Munic ip io de Santa Cruz del Quiché
L o c a l i d a d No . de No . de Dis t . al S/S
Hab i t a n t e s V i v i e nda s e n Km s .
L o c a l i d a d No . d e No . de Dist . a l S/S
Hab i t a n t e s V i v i e nda s e n Km s .
1 . Santa Cruz del Quiché 1 . 0 C / S " B " S a n t a C r u z
S a n t a C r u z 1 1 5 0 4 1917 0
Xa t i n ap I 1646 2 7 4 8
Sa t i na I I 1 9 8 3 3 8
Xat inap I I I 2 6 0 4 3 1 5
Xa t i nap I V 5 4 9 9 2 1 0
Xa t i nap V 1331 2 2 2 5
Xes i c I 1139 1 9 0 8
Xes i c I I 5 1 0 8 5 8
Xes i c I I I 6 9 3 1 1 6 1 5
Xes i c IV 4 9 3 8 2 1 2
Chu i s i g u a n 4 1 5 6 9 5
Pa s e s eba l I 5 2 6 8 8 8
Pa se s eb a l I I 8 1 5 1 3 6 1 2
Pa se seba l I I I 2 6 1 4 4 1 6
Pa se seba l I V 2 7 7 4 6 1 2
C ru z che I 2 9 3 4 9 1 6
C ru z che I I 4 5 2 7 5 2 0
C ruz che I I I 1 3 5 2 3 1 8
C ruz che I V 4 1 2 6 9 2 0
Ch i t a t u l 7 8 0 1 3 0 3
E l C h a j b a l 7 7 1 1 2 9 8
Ch i c o r r a l 3 0 2 5 0 4
L a s Ru i na s 4 9 1 8 2 4
1 . 1 P / S L emo a
L em o a 1213 2 0 2 0
P a c h o S a n J o s é 4 0 8 6 8 7
Pacho Ch i c a l t e 3 8 4 6 4 1 0
Paca j á I 1058 1 7 6 1 3
Paca já I I 1084 1 8 1 1 3
Cucuba j I 6 7 6 1 1 3 1 4
Cucuba j I I 7 8 5 1 3 1 1 5
Ch i c ab r a c an I I 5 1 5 8 6 1 8
1 . 2 P / S S a n t a Ro s a Chu j u y u p
S a n t a Ro s a Chu j u y u p 3 5 3 5 9 0
Ch i u l 2 9 8 5 0 N/D Grad i t a s
4 2 0 7 0 N/D E l Naran jo 4 9 7
8 3 N/D Mama j 3 6 0 6 0
N/D Qu i v a l á 3 9 3 6 6 N/D
P a c h o j 8 5 6 1 4 3 N/D Chu j u y ub
1327 2 2 1 N/D Paj i j 2 9 5
4 9 N/D L o s R e y e s 2 1 5 3 6
N/D T z u c a c 1 3 2 2 2 N/D
P a q u i n a c 5 1 7 8 6 N/D S i v a ca
9 1 4 1 5 2 N/D L a s Min a s 1 1 3
1 9 N/D T ie r ra Ca l i en te 2 4 2 4 0
N/D Agu i l i x 4 4 6 7 4 N/D
Xa t i n imi t 4 4 2 7 4 N/D
Ch i gonón 1 4 8 2 5 N/D I x coma l
1 5 5 2 6 N/D
1 .3 P/S Pana j x i t
Pana jx i t I 1540 2 5 7 0
Pana jx i t I I 8 6 4 1 4 4 2
Panajx i t I I I 1157 1 9 3 3
1 . 4 P / S C h o a c amá n
Cho a c amán I 2 8 1 4 7 0
Choa c amán I I 1 5 2 2 5 1
Choa c amán I I I 2 9 4 4 9 3
Choa c amán I V 1539 2 5 7 4
Cho a c amán V 1 7 4 2 9 5
1 . 5 P/ S L a E s t an c i a
L a E s t an c i a I 3 7 0 6 2 0
L a E s t an c i a I I 1002 1 6 7 2
4 6 6 0 9 7773
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ACUPUNCTURE and other TRADITIONAL CHINESE MEDICINE in Guatemala
There are no formal Acupuncture Schools in Guatemala and the closest place to purchase
supplies seems to be in Mexico City. A brief survey of listings for Acupuncturists in the on‐line
Yellow pages produced 13 practitioners who offer acupuncture in the Capital City. There are
also a few listing in Antigua and at Lake Atitlan but these would be viewed as a type of Spa and
New Age offering. With few exceptions, the practitioners are not associated with licensed
Medical Doctors or Chiropractors.
Besides Integral Health’s Quiche based outreach there are at least (3) other intermittent
volunteer Jornadas providing services and NADA training in the Peten area and, H2H also visits
in Santa Cruz del Quiche. They are AcuwithoutBoarders Christian Nix Foundation Healer to
Healer (H2H) and Guamap,
LIST OF ACUPUNCTURISTS IN GUATEMALA CITY
DACCARETT OMAR JUAN DR. 5 C 1‐30 Z‐1
CENTRO QUIROPRÁCTICO Y DE REHABILITACIÓN ORTOPÉDICA S.A. 10 C 2‐45 Z‐14 Clínicas Hospital de las América Of 1004
INDEMACUP 13 C B 27‐93 Z‐7 Col Kaminal Juyú II
LEE MARISA MACK DE DRA. 6 Av 3‐22 Z‐10 Edif Centro Médico II Niv 6 Of 601
LOU DONIS GUILLERMO 5 C 20‐69 Z‐11 COL MIRADOR
ESCUELA INTERNACIONAL TAI CHI Y WU SHU 12 AV 8‐17 Z‐2 CIUDAD NUEVA
ESMENTA 2 Av 10‐27 Z‐1
PISCIS, S.A. 6 AV A 13‐24 Z‐9 TORRE CANNET OF 102
EXCELENCIA ACUPUNTURA 30 Av 6‐30 Z‐11 Res 5
MUNOZ GONZALEZ CARLOS AV ELENA 9‐76 Z‐3
CARLO CARUSSO PSÍQUICO ASTRÓLOGO 27 C 15‐37 Z‐5
CENTRO DE ACUPUNTURA ORIENTAL 18 calle 15‐40 z‐13
OSORIO REYES PATRICIA DRA. 5 Av 15‐45 Z‐10 Edif Centro Empresarial Torre I Of.406
Key: Medical Doctors and Chiropractors (4) Acupuncture Centers (2) Other (2) Unknown Affiliation (5)
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Annotated Bibliography:
Health in Latin America and the Caribbean ‐ Challenges and Opportunities 2009 Lists some of the important inter‐government and NGO players in the area – has a very good analysis of area demographics. Some date is more dire than other sources…i.e, Guatemala is ahead of Haiti in reproduction – 4.1 replacement rate is cited rather than the more conservative 2‐3 cited in CIA report above. WHO report on Traditional Medicine 2008 Very informative Fact sheet.. includes Africa and Asia does not mention Western Hemisphere Acupuncture: Review and Analysis of Reports on Controlled Clinical Trials 2002 This publication is a brief review of the current literature on acupuncture practice, which may provide information about the effectiveness of different aspects of acupuncture therapy based on existing clinical data. Since the methodology of clinical research on acupuncture is still under debate, it is very difficult to evaluate acupuncture practice by any generally accepted measure. In this publication, only the results of controlled clinical trials that were formally published through the year 1998 (and early 1999 for some journals) are collected and reviewed. World Health Report 2002 ‐ Reducing Risks, Promoting Healthy Life ‐ Methods Summaries for Risk Factors assessed in Chapter 4 Provides an overview of the methodology employed to estimate burdens due to selected risk factors in the Full Report – The sections on Malnutrition and STD are very pertinent to Guatemala. Canadian Site on Acupuncture very informative but cosmetically challenged.
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link to the Ecological Model article I use http://heb.sagepub.com/content/15/4/351.abstract An Ecological Perspective on Health Promotion Programs
Kenneth R. McLeroy, PhD Department of Public Health Education, University of North Carolina, Greensboro
Daniel Bibeau, PhD Department of Public Health Education, University of North Carolina, Greensboro
Allan Steckler, DrPH Department of Health Behavior and Health Education, University of North Carolina, Chapel Hill
Karen Glanz, PhD, MPH Department of Health Education, Temple University, Philadelphia
Abstract During the past 20 years there has been a dramatic increase in societal interest in preventing disability and death in the United States by changing individual behaviors linked to the risk of contracting chronic diseases. This renewed interest in health pro motion and disease prevention has not been without its critics. Some critics have accused proponents of life-style interventions of promoting a victim-blaming ideology by neglecting the importance of social influences on health and disease. This article proposes an ecological model for health promotion which focuses attention on both individual and social environmental factors as targets for health promotion interventions. It addresses the importance of interventions directed at changing interpersonal, organizational, community, and public policy, factors which support and maintain unhealthy behaviors. The model assumes that appropriate changes in the social environment will produce changes in individuals, and that the support of individuals in the population is essential for implementing environmental changes.
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11/4/2012 11:13:42 AM
UNITS of PRACTICE
Units of practice are built on units of identity ‐ such units are families, associations/organizations, hometowns ‐ human units to which we feel a sense of belonging. When the change agent decides to work with one of these units, it becomes her/his unit of practice. Sometimes the resources/solution to a particular problem lie within the unit of identity (e.g. a community) and sometimes with other groups and organizations/units ‐ wherever the resources lie are the units of solution. This issue is covered in more detail in the first module of the JHSPH course "Social and Behavioral Foundations of Primary Health Care" the slides for which can be found on www.jhsph.edu Open Course Ware.
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11/4/2012 11:13:42 AM
Ecological Model – 5 levels of change
1) Intrapersonal Factors: Characteristics of the Individual How do a person’s beliefs, perceptions, etc impact change? How will an individual perceive the benefits and constraints of the proposed intervention? What will help or prevent them from participating? 2) Interpersonal Process and Primary Groups: Formal and Informal Social Networks and Support How does household power and influence of community groups impact change? What is the family structure? Do the most vulnerable members (often pregnant women, children, elderly) have access to the intervention? 3) Community Factors: Relationships Among Organizations and Networks How easy is it to organize the community? Can they take ownership/leadership of the project? Are there disenfranchised segments of the population? What is their history, involvement in the community? Is there marketing? Are there local manufacturing and distribution efforts? Is the proposed intervention a priority for the community? Will the community invest in follow‐up? 4) Institutional Factors: Organizational Characteristics and Rules How do public resources and the private sector impact change? What is the existing infrastructure? How will other sectors (education, commerce, finance, etc) play a role? 5) Public Policy and Laws: At Local, Regional and National Level How will taxes, tariffs, customs (lack of) guidelines, etc impact change? What are the relevant policies and priorities already in place? Is the private sector included (probably important for long‐term sustainability)? Who makes policies? Is there communication between different government agencies to coordinate the project?