Introduction

The Maya population in the Guatemalan Highlands has a critical need for improved health care. The western health care system in the region is hampered by low quality equipment, lack of staff, cost barriers and an organizational structure that fails to cater effectively to the population it was created to serve [1]. This article will examine the health care-seeking behavior of the Maya in the Guatemalan Highlands, summarize the current state of the government health care system and present recommendations for improvement of the system. The Maya Indians in the Highlands have traditionally been neglected and mistreated by the dominant Ladino (mestizo, non-indigenous) population. Indians were directly targeted in the Guatemalan civil war and hundreds of government-sanctioned massacres were executed in the highlands. Eighty-three percent of fully identified victims were Maya [2]. Poverty is also widespread among the indigenous population, averaging 76%, with extreme poverty at 28% [3]. Guatemala has some of the highest maternal and infant mortality rates in Latin America with a maternal mortality rate of 190 deaths per 100, 000 live births and an infant mortality rate of 43 deaths per 1000 live births [4]. These high mortality rates are partly due to the frequent use of traditional midwives in the highlands [4]. These high death rates illustrate the urgent need for improving the health care system and increasing utilization levels. It appears that when seeking treatment, Maya Indians in the Guatemalan Highlands act in the manner they believe is most likely to improve their health in a setting of significant resource constraints by considering severity of the illness, cost of treatment, quality of services, and their trust in the provider. This article will examine relevant treatment options, health-seeking behavior, and barriers to care to make suggestions for improving the Guatemalan health care system so that it can better provide for the Indian population.

Treatment Options in Rural Guatemala

The Maya have access to three sectors of care; the popular sector, the folk sector, and the professional sector [5]. In the popular sector, individuals may self-treat by using herbal preparations that they obtain from nature or by purchasing medicines from a store or a “pharmacy” run by a drug vendor. Drug vendors in the Guatemalan Highlands prescribe and dispense treatments including injections, but they typically lack formal training [6]. They frequently sell western medicines such as antibiotics, which normally require a prescription by a licensed physician [7]. If individuals decide it is necessary to visit a practitioner, they can utilize either the folk sector or the public sector. Practitioners in the folk sector include traditional and popular providers, such as curers (curanderos), midwives (comadronas), massage specialists (sobadores), and spiritual healers (espiritistas, brujos, and others) [8]. As biomedicine becomes increasingly available, traditional healers typically use a combination of biomedicine and herbal treatments as well as spiritual techniques in curing the sick [9]. If Indians decide to use the professional sector they may attend one of the four levels of facilities overseen by the Guatemalan Ministerio de Salud Pública y Asistencia Social (Ministry of Health and Social Welfare): specialized national hospitals, regional department hospitals, municipal health centers, and hamlet-based health posts or individual community health workers [1]. In practice, Maya typically have access only to health posts that offer limited services in primary care, and are run by an auxiliary nurse or a medical student. Hospitals are typically farther away [8]. Private physicians are sometimes available in or near communities but their services are prohibitively expensive for the majority of the Maya population [8]. Thus, when Maya become ill the economically feasible options are self-treatment, care from traditional healers, or receiving treatment from the public health care posts in the region.

Overview of Health Care-Seeking Behavior

Given the varied options in the biomedical and traditional realms, Maya have many options to consider when seeking treatment. Those who are ill typically use self-treatment strategies. In a treatment-seeking study, 64% of the illness episodes were treated with home remedies or over-the-counter medicines without seeking outside advice throughout all stages of the illness [10]. The preferred drugs against diarrhea are antibiotics, particularly tetracyclines, which are available in granulate form in most grocery stores. When a combination of modern drugs and herbs are used, the antibiotic is dissolved in an herbal concoction. Antipyretics such as ASA and acetaminophen, which can be obtained in most grocery stores, are generally selected to treat fever. The most common treatment for cough is a syrup containing an expectorant or an antitussive [6].In the past, traditional herbal treatments were normally used in curing [11], but western medicine has now become easily accessible and has largely replaced traditional treatments in curing [10]. The fact that even traditional practitioners now integrate western medicine into their recommendations illustrates how widespread its use has become. One reason is that western medicines such as antibiotics, antipyretics and cough syrups are efficacious and produce relatively rapid recovery. The treatment seeking study also demonstrated that when seeking treatment, some (18%) chose to seek advice from others in the community. Half of the individuals surveyed sought care from friends and neighbors and the other half sought the counsel of the owner of a store or “pharmacy” [10]. Advice-seeking behavior helps spread knowledge of effective treatments, which fostered the integration of western medicine into common practice.

The remaining 18% of individuals surveyed used mixed strategies: 9% consulted a government health post or village malaria worker, 7% went to a doctor or hospital, and 2% went to a folk healer. Visiting a pharmacy, physician, and hospital were typically last in a series of steps [10]. By treating themselves independently prior to seeking the help of a practitioner the Maya reduce the expense and effort required to alleviate their symptoms. Health posts tend to be most accessible and cheapest, which may be one reason why they were more frequently consulted than doctors or hospitals. The median distance to a physician was 12.5 kilometers while the median distance to a health post was only 4 kilometers [13]. Despite the high prevalence of non-biomedical beliefs among the Maya Indians [8] only 2% of individuals sought treatment from a folk healer. The Maya consult western medicine providers more frequently than folk healers despite the fact that western medicine providers are more costly and less accessible. A possible explanation for this behavior is that the Maya believe they are more likely to receive effective treatment at a western medical facility than from the folk healer; making the expense and travel worthwhile. The Maya are making calculated, logical decisions regarding care by weighing the amount of expense required with the tangible improvement in health they are likely to receive.

Summary of Traditional Maya Beliefs

Mayan traditional beliefs generally attribute illness to a lack of balance in the body. A sick person was thought to be in a state of disequilibrium. Many factors could bring about this disequilibrium such as working too hard, being overtired, or committing a sin such as a sexual transgression [11]. One fairly common belief in Highland Guatemala is that the imbalance of hot and cold causes illness. Hot and cold qualities apply to foods as well as activities, such as touching cold ground, emotions such as anger, and physical states such as pregnancy [8]. Remedies typically involve restoring balance through the consumption of proper foods, herbal treatments, or by using sweat baths. Illness can also be attributed to mountain spirits. Shamans were traditionally sought to communicate with these spirits to intervene on behalf of the sick [13].Although, seeking healers was common in the past, as Western medicine becomes more accessible and word of its effectiveness diffuses into Maya society, use of healers has declined.

Barriers to Use of the Western Health Care System

Despite the reduction in the use of healers, utilization rates of the western health care system are still consistently low [6]. Furthermore, indigenous families are less likely than Ladinos to report use of formal-sector maternal and child health services on average [14]. There are many possible reasons for this, one being accessibility. Access to health services is commonly cited as an issue in rural areas. Surprisingly, it appears to play a limited role in highland Guatemala, with the majority of the population living less than 5 km (about a 1 hour walk) from a health post. The low utilization rates are likely due to the extremely limited drawing power of the health posts. While about 16% of the population of Sololá, Totonicapán and San Marcos lives less than 1 kilometer from a health post, over 50% of patient visits are accounted for by people living less than a kilometer from the post [13]. Similarly, while half the population lives more than 3.5 kilometers from the health post, people who live more than 3.5 kilometers from the health post account for only 15% of the health post visitors [13]. Clearly, distance does have an impact on acquisition of health care as those living farther away distance are much less likely to seek care. At the same time, most of the population does appear to have reasonable access to health posts but the majority of the population is unwilling or unable to travel over 1 kilometer (about a 12 minute walk) to receive care at these facilities. Therefore, it appears that other factors play a much more significant role in care-seeking behavior than physical access. Improving the health posts in other ways to encourage the Maya to travel the required distance would be more cost effective than building, staffing and supplying additional health posts in the region.

Family income is one of the major barriers to the acquisition of care because poor Indian families are less likely to be able to pay provider fees and to afford recommended medicines. Consultation at government health centers and posts is free, yet there is often a small per visit fee of 25 centavos(US $0.05). Even though the fee may appear to be modest, it is high relative to family income in these communities [8]. Probably a larger deterrent is that the health posts typically do not provide medicines free of charge, requiring that impoverished patients pay significant amounts in order to receive treatment. The cost of medicine coupled with the power dynamics between the provider and the patient makes such a system extremely unappealing to impoverished Mayans. Doctors frequently ask the family to buy drugs that cost the equivalent of several days’ wages, and the family cannot challenge the doctor’s prescription due to their limited knowledge of biomedicine [15]. Therefore, by traveling to a health facility they are opening themselves to requests to buy prohibitively expensive drugs. These individuals will have little choice but to mobilize, borrow, and beg to buy those drugs [15]. Consequently, by charging fees and requiring relatively high payments for medicines, the system is failing to address the severe resource constraints of those who most require its services.

The quality of care received is also commonly cited as an issue. The health posts and centers often lack medical equipment, have limited staff, and frequently have stock outs of the few medicines they supply [1]. The quality of care provided is often cited as a major barrier to seeking biomedical help for obstetric emergencies [15]. It is important to recognize, however, that “quality” in this context is defined by the patient rather than solely by Western ideas of quality. Furthermore, the Maya are typically untrusting of the Ladino health workers due to a long history of violence against them and disenfranchisement by the Ladino population. Therefore, the above factors (such as lack of medical equipment) are serious issues that should be addressed but other structural issues must be considered. For example, in one case study a patient traveled to a hospital after being told by a midwife that her baby was in an unsafe position for delivery. As a result, her husband concluded that an X-ray would be required to determine the orientation of the baby. The physician determined through palpitation that the baby had shifted to a safe orientation and therefore determined that an X-ray (which would expose the fetus to potentially harmful radiation) would be unnecessary.

[The husband] knew what he wanted…For him, the quality of care offered to his wife at the hospital was directly related to whether he would be able to get her an X-ray. In this case, his criteria pertaining to the ‘‘quality of care’’ are in direct conflict with the biomedical protocols concerning the quality of care, as explained by the doctor, that dictate [his wife] not receive an X-ray while pregnant unless diagnostically necessary. [15]

Consequently, the husband left the hospital angry. Furthermore, his lack of trust of the physician compounded the problem as he believed his wife was being denied an important diagnostic test. He is now much less likely to return to the hospital in the future and to encourage others not to seek care there either. Additionally, the structure of the hospital care system often fails to conform to Maya expectations for care. In one hospital, general care was performed in the morning while specialist care was performed in the afternoon. Maya patients were often unaware of this distinction and became frustrated when they observed primary care physicians chatting casually during the afternoon and seemingly ignoring waiting patients [15]. Another structural problem involves frequent questioning of the patient. In western-based systems patients are frequently asked for their name by each health care provider to ensure that the correct individual is being given treatment. The Maya perceived the repeated questioning as cluelessness on the part of the staff and thus became concerned [15]. Finally, families were prevented from staying overnight with loved ones in the maternity wards. In traditional Maya culture, individuals are typically accompanied by extended family before and while giving birth. Thus the patients felt isolated and family members were concerned that the patient would not receive the care he or she needed. These structural factors which fail to cater to the Maya population combined with a lack of trust in the providers makes hospitals very unappealing. Therefore, the lack of quality as defined by the patient is a serious consideration that must be made if utilization rates are to be improved.

When choosing where to seek care, Maya consider the severity of illness and the quality of treatment and relief they are likely to receive given a particular amount of expense. The best predictors of treatment action are total number of sick days, the number of days missed from work, and respondent’s judgment of severity of the illness episode. These predictors indicate that the seriousness of the illness is a major factor in determining whether the patient seeks care [10]. One interesting and informative study was carried out by designing scenarios in which a patient had differing illness severities and financial resources and interviewing Maya regarding their recommendations for the patient. Given a non-serious illness, the vast majority recommended that the sick individual use home remedies or visit a store for medicine rather than seeing a practitioner. Given sufficient financial resources and a serious illness, most people recommended the patient visit a doctor or hospital. This illustrates that the Maya recognize the superior ability of western medicine to deal with difficult cases. However, it also indicates that they are unlikely to use the system for non-serious conditions and will wait until a problem becomes serious rather than seeking care to prevent a problem. By only seeking care at hospitals for serious illnesses they increase the likelihood that the system will fail to cure them. This will discourage others from seeking care at a hospital as well. Given a lack of financial resources and a serious illness, results were much more mixed, however, the majority recommended using home remedies or a store for treatment. The distribution of responses seemed to correspond roughly with the actual care-seeking behavior presented above. Therefore, limited financial resources are recognized as a significant barrier to hospital care, which would be sought if resources were present for serious illnesses. In addition, those surveyed, almost never recommended that the patient visit a health post, probably because of the poor quality of facilities. Because the quality of health posts is extremely low, the high accessibility ceases to be relevant because an individual would not want to seek care there anyway. Therefore, severity of illness, cost and quality seem to be the main drivers of care-seeking behavior.

Recommendations for Improvement

Although western medicine has many advantages, it is by no means perfect and certain disadvantages that should be acknowledged. For example, it tends to be expensive, rely upon many diagnostic tests (in some situations) and require a great deal of training of providers. Therefore, it is important to consider the role western health care should play in highland Guatemala. An emphasis on prevention would be the most efficient approach because more lives could be saved and better health fostered by making cheap, basic care available to everyone rather than providing more expensive, advanced care to only a few individuals who can afford it. [16]. At the same time, effective treatment of conditions is critical to increasing use of the system.

One way to improve the system and increase utilization rates is to make it more culturally sensitive. As mentioned above, many Maya lack trust of the system and the providers and feel that it fails to cater to their needs and preferences. At Casa Materna, (a free, high quality, private program for high-risk pregnancies) for example, family members are encouraged to accompany the patient at all times and to bring foods that are appealing to the patient’s tastes. Caregivers also provide emotional support and personal touch to women staying at the center allowing the women to feel more comfortable [17]. This model of care has been shown to be at least somewhat effective, as Casa Materna has noted a consistent increase in enrolment for prenatal and postpartum services as well as a three-fold increase in acceptance of Pap smear services [17]. Additionally, the quality of care was cited to be higher than in most other medical service providers in the region [17]. Further research into the effect of added culturally sensitive care on preventive and care-seeking behavior is necessary in the setting of a health post as many factors (such as the increased quality and low cost) may have resulted in the increasing utilization rates for the program.

As discussed previously, cost appears to be one of the most significant factors in determining health-seeking behavior. Therefore, a reduction in cost, while maintaining quality, may lead to greater health care utilization and preventative care-seeking behavior. In certain settings, removal of user fees has shown to increase health care utilization rates [18]. However, further research is needed to demonstrate the effectiveness of this approach and its applicability to highland Guatemala, as current studies were often cited to be of low quality and have produced mixed results [18]. The cost of treatment and medicines is also a deterrent for seeking care for serious conditions. Thus, health care providers should be sensitive to the severe resource constraints of the patients and make the most cost-effective, realistic recommendations possible. This awareness is especially important if the patient has traveled from a distance to reach a hospital that typically serves comparatively wealthy individuals. By providing a treatment that the patient can afford, even with slightly reduced efficacy, the patient is more likely to return in the future and may engage in more preventative care-seeking behavior. Finally, improving quality of equipment, staff, and physical plants of the easily accessible health posts should be a long-term goal of the government as this should lead to greater use and result in a healthier population.

The main obstacles to using the Western health care system were cost barriers, low quality due to a lack of resources, a lack of trust of providers and its inability to provide the type of care they feel they need. Consequently, a system that eliminates cost barriers to as large a degree as possible, while trying to provide culturally sensitive, higher quality care may lead to greater access and increased preventative behavior among the Maya. Additional research into general and local Maya care preferences should be undertaken so that each health care facility can be tailored most effectively to the patient population, build trust between providers and patients and increase utilization rates.