A Needs Assessment of Family Planning Within a Ngöbe–Buglé Patient Population in Bocas Del Toro, Panama The Harvard community has made this article openly available. Please share how this access benefits you. Your story matters Citation Longacre, Mckenna Mary. 2017. A Needs Assessment of Family Planning Within a Ngöbe–Buglé Patient Population in Bocas Del Toro, Panama. Doctoral dissertation, Harvard Medical School. Citable link http://nrs.harvard.edu/urn-3:HUL.InstRepos:32676115 Terms of Use This article was downloaded from Harvard University’s DASH repository, and is made available under the terms and conditions applicable to Other Posted Material, as set forth at http:// nrs.harvard.edu/urn-3:HUL.InstRepos:dash.current.terms-of- use#LAA Collaborators and Roles Mckenna Longacre, MM: Thesis author. Project design, in partnership with Floating Doctors. Grant proposals and IRB. Questionnaire design and translation. Survey sampling methodology. All fieldwork, including focus groups, key informant interviews and patient surveys. Final data analysis. Composition of final manuscript (with contribution from coauthors). Project follow-up. Austin T. Jones, BA: Fieldwork, including focus groups, key informant interviews and patient surveys. Edit of results and discussion in final manuscript. Jeffrey N. Katz, MD, MS: Project mentor, including design, analysis and scientific writing. Edits of manuscript for content and style. Kim Wilson, MD, MPH: Project mentor. Advisement of study design and data analysis. Edits of content and style in manuscript. Competing Interests The authors declare that they have no competing interests. 2 Acknowledgements I would like to extend my gratitude to Dr. Bobby Gottlieb Dr. Rebecca Luckett for their guidance and enthusiasm throughout this endeavor. I am also deeply grateful to Dr. Kerim Munir who provided additional mentorship with respect to preparation of this thesis. I thank Harvard Medical School, the Harvard Center for Primary Care, and HMS Scholars in Medicine Office for their financial support of this project. I extend my deepest gratitude to Floating Doctors and their staff, including Dr. Ben LaBrot, Karine Tchakerian, Sky LaBrot, and Jolie LaBrot, for identifying this research need, providing a critical platform by which to access this vulnerable population, sharing the important task of reporting on the health status of this community, and taking additional steps to support community health and empowerment following this study. Other Floating Doctors volunteers and partners that have been instrumental in the study follow up include: Dr. Juliana Opatich, Carolina Vicens-Cardona (MD candidate 2019), and Avery Novak (MD candidate 2019). In addition to Floating Doctors, I extend my thanks to the other local health care organizations such as the local Peace Corps and the Red Cross, as well as representatives from the Ministero de Salud de la Republica de Panama (MINSA), for their continued commitment and humanitarian aid in the care of the this population. Most of all, I convey my deepest gratitude to the indigenous Ngöbe–Buglé of the comarca and Bocas del Toro region for entrusting us with their personal stories and health information. 3 Table of Contents Title Page……………………………………………………………………………………………...1 Collaborators & Competing Interests………………………………………………………………....2 Acknowledgements…………………………………………………………………………….….….3 Table of Contents………………………………………………………………………………..…....4 Glossary……………………………………………………………….…...........................................5 Abstract………………………………………………………………………….…………………....6 Introduction…………………………………………………………………………………….……..7-8 Background…………………………………………………………………….……………………..8-24 The Health and Welfare of Indigenous Groups in Latin America and the Caribbean………..9-12 Indigenous Populations in Latin America and the Caribbean & Family Planning…………..12-14 The Indigenous Decade……………………………………………………………………....14-15 Economics and Health in Panama……………………………………………………………15-16 Family Planning in Panama………………………………………………………………..…16-18 Family Planning Disparities in Panama…………………………………………………..….18-19 Panama and its Indigenous Peoples……………………………………………………….…19-20 Indigenous Disparities in Panama…………………………………………………………....20-23 The International Response to Indigenous Disparities in Panama…………………………...23-24 The Ngöbe–Buglé …………………………………………………………………………....24-26 Floating Doctors……………………………………………………………...........................26-27 Significance…………………………………………………………………………………..27-28 Methods………………………………………………………………………….…...........................28-29 Patient Surveys (Quantitative Data) ………………………………….……...........................29-32 Key Informant Interviews (Qualitative Data)………………………………..........................32-34 Results………………………………………………………………………………. ………………34-40 Quantitative Patient Surveys………………………………………………………………....34-35 Qualitative Key Informant Interviews…………………………………….............................35-40 Discussion……………………………………………………………………………………………40-43 Conclusions, and Suggestions for Future Work …………………..................…………………..….43-45 Study Impact and Follow Up………………………………………………………………………...45-50 References………………………………………………………………………………………........50-53 Table 1. Quantitative Patient Survey Data……………………………………..................................53-56 Table 2. Key Informant Interviews: Demographics……………………………………………….....56 Table 3. Qualitative Patient Survey Data: Key Themes……………………………………………..56-58 Figure 1. Satellite Position Map of 9 Clinics Visited in this Study…………………………………..59 Figure 2. Quantitative and Qualitative Samples and Overlap………………………………..……...59 Figure 3. Patient Surveys: Unmet Need for Family Planning……………………………………….60 Appendix 1. Quantitative Patient Survey Instrument………………………………………..……....61-63 4 Glossary! APLA-FA- Asociación Panameña para el Planeamiento de la Familia (an International Planned Parenthood Federation member association) CELADE- The Latin American and Caribbean Demographic Centre CSS- Caja de Seguros Social (Social Security System) DHS- Department of Health Statistics MINSA- Ministerio de Salud de la Republica de Panama OCP- oral contraceptive pill PAHO- Pan-American Health Organization UNPF- United Nations Peoples Fund USAID- US Agency for International Development WHO- World Health Organization 5 Abstract BACKGROUND: The World Bank has characterized poverty among Panama’s largest indigenous population, the Ngöbe–Buglé, as “abysmal.” In addition, family size is significantly above and age of first conception significantly below the average for Panama. We conducted a Needs Assessment of Family Planning to better understand the preferences, barriers to access, and interplay with local culture and socioeconomic status within this population. METHODS: We conducted a mixed methods study among the indigenous patient population of a local NGO, Floating Doctors. 70 patients were interviewed using a quantitative survey based upon the DHS Individual Questionnaire. Data was analyzed for two primary outcomes: preferences for family planning and unmet need. In addition, 41 key informant interviews were conducted, with data organized around barriers to access, cultural preferences, and issues of human rights. RESULTS: Fifty three percent (33/62) of subjects met the DHS criteria for unmet need. Lack of money and access were identified as the most significant barriers to obtaining family planning. Key informant interviews suggested that young motherhood and large family size were significantly impacting issues of local health, education and socioeconomic status. CONCLUSION: This study reveals a profound unmet need for family planning resources. It also highlights the impact of this need on local education, socioeconomics, and public health. Finally, the data suggests that these disparities may be increasing due in part to complex economic shifts. Family planning may mark a clear starting point by which to empower Ngöbe–Buglé families to reclaim health, cultural, and economic stability. 6 Introduction “Sexual and reproductive health and rights are central to people’s lives and essential for their well- being. In practice, this means that women and couples must have the means to have a healthy sexual life, have the number of children they want when they want them, deliver their babies safely and ensure their newborns survive…Improving sexual and reproductive health and rights contributes to reducing poverty and achieving other development goals. Of the eight UN Millennium Development Goals (MDGs), three goals—to reduce child mortality, to improve maternal health and to combat AIDS—rely directly on sexual and reproductive health care.” In UNFPA 2014 report, Adding it Up (1) The Ngöbe–Buglé constitute over half of the indigenous population in Panama, representing over 6% of the overall population.(2) In 1999, it came to the attention of the international community that, in spite of Panama’s overall economic prosperity, the Ngöbe–Buglé suffer from profound disparities of wealth, education and health. In 1992, the contrast between Panama’s national gains, and the persistent suffering of its indigenous led to its ranking as the third most unequal country in the world (alongside Brazil and South Africa).(3) Though the national GINI index and other indicators suggest a redistribution of wealth since 1992 (2015 GINI coefficient of 0.527), certain vulnerable minority populations continue to bare a disproportionate burden of morbidity and mortality, including the indigenous Ngöbe–Buglé.(4, 5) In the 1990s, Panama saw numerous humanitarian initiatives to address these disparities,