Medical students' experiences of compulsory rural service in Guatemala: a qualitative study.

INTRODUCTION: Compulsory rural service is one method of addressing limitations in health care access in marginalized areas of low- and middle-income countries, including Guatemala. This study aimed to explore Guatemalan medical students' experiences of compulsory rural service and the impact of rural service on their professional development. METHODS: Qualitative semi-structured interviews were conducted with 40 medical school graduates who completed compulsory rural service between 2012 and 2017. Interview transcripts were coded for dominant themes using an inductive approach. RESULTS: The majority of interviewees felt that rural service contributed to their professional development by increasing their clinical autonomy, awareness of social determinants of health, and humanistic practice. Interviewees identified limited supervision as a key challenge during the rotation. The majority found rural service rewarding. CONCLUSION: Guatemalan medical students felt that rural service contributed to their professional and personal development. Rural rotations build primary care skills and may increase awareness of health inequity among clinical trainees. Given ongoing healthcare worker shortages in Guatemala, innovative approaches to improving professional supervision and rural health mentoring are needed.

Expanding access to primary healthcare for women through a microfinance institution: A case study from rural Guatemala.

The utilization of existing social networks is increasingly being recognized as a powerful strategy for delivering healthcare services to underserved populations in low- and middle-income countries. In Guatemala, multiple barriers prevent access to healthcare services for rural and indigenous populations, and strategies for delivering healthcare in more efficient ways are needed. The case study we describe here is a unique collaboration between a microfinance institution (Friendship Bridge) and a primary care organization (Wuqu' Kawoq | Maya Health Alliance) to scale up healthcare through an existing lending-borrowing social network. The program provides primary care services to female clients of Friendship Bridge in rural areas of Guatemala, with nurses working as frontline primary care providers, providing door-to-door healthcare services. Over the first 22 months of the project, we have reached over 3500 of Friendship Bridge's clients, with overall high acceptance of services. All clinical documentation and program monitoring and evaluation are done through audit trails within an electronical medical record system, which improves efficiency and lowers the associated time and resources costs. We utilize quality improvement methodologies to aid in decision making and programmatic adjustments scale up. These strategies have allowed us to expand services rapidly under challenging geographic and logistical constraints, while concurrently iteratively improving staff training and supervision, clinical care, and client engagement processes.

Cultural considerations for informed consent in paediatric research in low/middle-income countries: a scoping review.

INTRODUCTION: Conducting research with children in low/middle-income countries (LMIC) requires consideration of socioeconomic inequalities and cultural and linguistic differences. Our objective was to survey the literature on informed consent in paediatric LMIC research, assessing for practical guidance for culturally and linguistically appropriate procedures. METHODS: We conducted a scoping review on informed consent in paediatric LMIC research searching the PubMed, Web of Science and PsycINFO databases. Eligible articles were published in English, from any date range, of any study design or format. RESULTS: The search identified 2027 references, of which 50 were included in the analysis following full-text review. Reviewed guidelines emphasised individual, informed and voluntary consent from parents and caregivers. Reviewed articles provided detailed practical guidance on adapting these guiding principles to LMIC settings, including considerations for community engagement, verbal or other alternative consent procedures for low-literacy settings or less commonly spoken languages and guarding against therapeutic misconception by caregivers. There was uncertainty, however, on how to best protect individual autonomy, especially when influenced by gender dynamics, leadership hierarchies or the social status of researchers themselves. There was, furthermore, limited research discussing the special case of research involving adolescents or of procedures for documenting assent by participating children. CONCLUSIONS: A scoping review of paediatric research in LMICs revealed substantial guidance on several features of culturally appropriate informed consent. However, additional research and guidance is needed, especially in the areas of gender imbalances, research with adolescents and children's own assent to participate in research.