Indigenous Guatemalan Research Articles

On Our Own Terms: Development and Indigeneity in Cold War Guatemala. By Sarah Foss

On Our Own Terms is excellent. In this well-researched book, Sarah Foss assesses the global Cold War through the experiences of Indigenous Guatemalans and the state and military actors who studied, categorized, and conceived of “development” projects to transform them. What was “development” in Guatemala? Readers learn that development was a process, a history, a social construction, a response to the Cold War, a counterinsurgency tool, a nation-building project, and often top-down but always collaborative. Case studies in the departments of El Quiché, Alta Verapaz, and Sacatepéquez show how, to paraphrase, the Guatemalan state “used” development (20). Two arguments are at the book’s core. First, “while for the Guatemalan state, development projects were intended to curb political instability and ensure national progress, this top-down homogenizing project was not neatly implemented, as local-level staff and mid-level bureaucrats reworked it and applied it to different contexts” (1-2). The book’s second argument is that Indigenous people were active in determining the meanings and implementation of development projects. It was not modernization, per se, that “development’s intended recipients” rejected, but “rather parts of the process like top-down impositions and the hierarchies that it imposed” (43-44). By connecting development projects to the ideological anxieties of the Cold War, Foss places Indigenous people who lived far from Guatemala City and Washington, DC, at the global conflict’s heart. These arguments are important. The case studies, particularly the chapters on Magdalena Milpas Altas (Chapter 3) and Ixcán Grande (Chapter 6), stand out.

Reducing inequities in maternal and child health in rural Guatemala through the CBIO+ Approach of Curamericas: 6. Management of pregnancy complications at Community Birthing Centers (Casas Maternas Rurales)

BackgroundIn Guatemala, Indigenous women have a maternal mortality ratio over twice that of non-Indigenous women. Long-standing marginalization of Indigenous groups and three decades of civil war have resulted in persistent linguistic, economic, cultural, and physical barriers to maternity care. Curamericas/Guatemala facilitated the development of three community-built, -owned, and -operated birthing centers, Casas Maternas Rurales (referred to here as Community Birthing Centers), where auxiliary nurses provided physically accessible and culturally acceptable clinical care. The objective of this paper is to assess the management of complications and the decision-making pathways of Birthing Center staff for complication management and referral. This is the sixth paper in the series of 10 articles. Birthing centers are part of the Expanded Census-based, Impact-oriented Approach, referred to as CBIO+.MethodsWe undertook an explanatory, mixed-methods study on the handling of pregnancy complications at the Birthing Centers, including a chart review of pregnancy complications encountered among 1,378 women coming to a Birthing Center between 2009 and 2016 and inductively coded interviews with Birthing Center staff.ResultsDuring the study period, 1378 women presented to a Birthing Center for delivery-related care. Of the 211 peripartum complications encountered, 42.2% were successfully resolved at a Birthing Center and 57.8% were referred to higher-level care. Only one maternal death occurred, yielding a maternal mortality ratio of 72.6 maternal deaths per 100,000 live births. The qualitative study found that staff attribute their successful management of complications to frequent, high-quality trainings, task-shifting, a network of consultative support, and a collaborative atmosphere.ConclusionThe Birthing Centers were able to resolve almost one-half of the peripartum complications and to promptly refer almost all of the others to a higher level of care, resulting in a maternal mortality ratio less than half that for all Indigenous Guatemalan women. This is the first study we are aware of that analyzes the management of obstetrical complications in such a setting. Barriers to providing high-quality maternity care, including obtaining care for complications, need to be addressed to ensure that all pregnant women in such settings have access to a level of care that is their fundamental human right.

Vulnerabilities and Collective Care: Indigenous Guatemalan and Mexican Farmworkers in Diaspora Confronting COVID-19 in the Western United States

This article contributes to scholarly and policy conversations about diasporic Indigenous peoples from Mexico and Guatemala and forms of discrimination, through lack of attention to language and culture, that result in differential health and economic outcomes for Indigenous workers. In tandem, it emphasizes the ways that Indigenous farmworkers attempt to compensate for this discrimination by establishing forms of community care: emotional support, mutual aid of many kinds, and the integration of care work into daily life. I conceptualize Indigenous farmworkers as integral parts of families and communities built on relational connections and circuits of care linked across many borders. This article is based primarily on quantitative and qualitative findings from the Oregon COVID-19 Farmworkers Study (COFS), which included surveys with three hundred farmworkers, qualitative interviews with forty-eight of them, and identified twenty-nine Mesoamerican languages in Oregon.

Adults' Experiences with Type 2 Diabetes in Rural Guatemala: A Qualitative Study.

Given that the diabetes burden is rising rapidly in low- and middle-income countries, it is critical to understand perspectives of people living with diabetes in these settings. This qualitative study examines perceptions of causality and treatment among adults with type 2 diabetes in rural Indigenous communities of Guatemala. We conducted semi-structured interviews with 29 people living with type 2 diabetes from a population survey in two majority Indigenous Guatemalan towns. Data were coded inductively and themes were elucidated by consensus. Participants emphasized strong emotional experiences and stress as perceived causes of diabetes, as well as diet and heritability. All participants took biopharmaceutical treatments, but many also endorsed diet, exercise, herbal remedies, and naturopathic products as important remedies. Perspectives from people living with diabetes in two rural Indigenous towns in Guatemala differ from the biomedical model of disease and have implications for clinical practice and program development.

Defying settler colonial logics: transborder territories and Indigenous Mam Women seeking justice for gendered violence

ABSTRACT Indigenous Guatemalan refugees passing through Mexico to seek asylum in the U.S. move in the space of a larger transborder territory created over the past six decades in response to U.S. foreign policy in Central America, historical patterns of labor movement and retreat from violence in the region. I frame this larger territory within the larger settler colonial politics of dispossession and elimination as carried out by the U.S. Mexican, and the Guatemalan states, albeit in different ways and at different stages, that often result in the fragmentation of human and social bodies. I look specifically at how Mam women navigate this transborder territory to escape gendered violence and seek safety for themselves, their families, and communities, and reconstitute themselves as Maya communities in diaspora. I suggest how the bodies of Mam women who have sought redress for gender violence through the process of seeking asylum in U.S. immigration courts are fragmented into discourses, narratives and forms legible through state loci of biopolitics. Finally, I suggest how Mam women refugees seek reintegration of their human and social bodies through reconstitution in shared transborder communities.

Exploring Barriers to Access Prenatal Care Among Indigenous Mexican and Guatemalan Women in Washington State

Migrant and seasonal agricultural workers including indigenous women who are not of Hispanic descent face many barriers to access prenatal care. We conducted a survey in Spanish and three indigenous languages—Mixteco, Triqui, and Awakateko—to explore knowledge, attitudes, and behaviors regarding prenatal care among 82 female agricultural workers residing in the state of Washington. Our findings highlight the importance of collecting disaggregated data from different indigenous communities and of providing indigenous language support. Our study provides new information for developing messages to promote prenatal care that take into account the knowledge and beliefs that are prevalent in these communities.

“Maybe not 100%”: Co-constructing language proficiency in the Maya diaspora

ABSTRACT Language learning and the development of language proficiency are central concerns in the study of immigrant adaptation. This paper analyzes the social construction of language proficiency among Indigenous Guatemalan Maya youth in the United States– specifically, undocumented young adults who migrated to Los Angeles, California as unaccompanied minors and who grew up as low-wage workers. Our analysis shows that youth used “percentage talk”– i.e., construing current proficiency as apercentage of idealized full proficiency– as a discursive strategy to assess their language ability and level of social adaptación (adaptation) relative to native English and Spanish speakers, other Indigenous language speakers, and their past selves. Through percentage talk, youth wrestled with social stratification and inequality in the U.S. and Guatemala and imagined themselves as future members of Spanish- and English-oriented discourse communities. While outwardly individualistic, percentage talk also allowed youth to gauge their ability to support the language socialization and social incorporation of other L1 Maya speakers in diaspora. Youth’s tricultural adaptation and contestation of an all-or-nothing ideology of proficiency shows their nuanced understanding of the role of language in immigrant socialization.

A retrospective analysis of emergency department usage in rural and semi-urban indigenous Guatemalan populations

Functioning healthcare systems provide emergency medical care. Disparities exist in accessibility and availability of emergency care in low- and middle-income countries. We present a descriptive epidemiologic analysis of Emergency Department (ED) usage in a rural, indigenous Guatemalan population. San Lucas Tolimán is situated in central Guatemala. Hospital Parroquial de San Lucas offers emergency care to San Lucas Tolimán and surrounding villages. All ED visits between January 1st, 2016 and December 31st 2018 were recorded and analyzed. During the study period, 12,229 patient encounters occurred. Almost all patients identified as indigenous. Children comprised 43% of visits. Medical issues represented a majority (83%) of complaints. Respiratory (40%) and gastrointestinal disease (26%) were frequent presenting complaints. Almost all visits (83%) occurred during the day and evening hours. Trauma/surgical complaints were slightly more frequent at night. 93% of patients were discharged, while the rest were admitted or transferred. These data contribute to understanding of disease burden and emergency care needs and capacity in rural areas of low- and middle-income countries. This information may be used to inform local policy decisions, identify research priorities, and create training topics for local health care providers in Guatemala and other countries in this region.

Health Care Access Brokerage by School Employees for Immigrant Mexican and Indigenous Guatemalan Farmworking Families in a Connecticut Elementary School

It is known that Florida school employees known as Migrant Advocates facilitate or broker MSF health care access for migrant and seasonal farmworker (MSF) families, but it is not known how states without a Migrant Education Program might also broker MSF health care access. To address this, present study examines the role of school employees in brokering health care access to immigrant Mexican and Indigenous Guatemalan MSF families in Connecticut. Informed by prior work, interviews (n = 12) with parents and elementary school employees showed that (1) a vast array of non-Migrant Advocate school employees, mostly Latinx women, directly brokered physical and psychosocial MSF health care access, often through developing deep social relationships and (2) barriers to brokerage included language inaccessibility, school employee gaps in knowledge of MSF health care needs, and transportation and related structural issues. Importantly, the school’s location near MSF homes is an important contributor to the success of the school’s brokerage efforts. Findings offer insight into how a school health broker model might be implemented, and advance understandings of MSF health and health care access.

Repensando a San Simón, el sincretismo y la autoridad antropológica

The tradition of San Simón in Guatemala has long garnered considerable interest among foreign and national academics, tourists, and Guatemalans in general from a range of backgrounds. Many, though not all, are drawn to the ambiguity and multiple identities often attributed to this deity, including associations with Pedro de Alvarado and Judas Iscariot as well as autochthonous figures such as the Maya deity Mam or other figures from Indigenous history and culture. In this article, based primarily on ethnographic research conducted since 1994, I trace opinions and assessments concerning San Simón, from a range of interlocutors, and consider how these have developed over time. I argue that academics especially need to rethink the concept of syncretism as we go about identifying and interpreting cases of “religious mixture”, noting that considerable reflexivity is required when applying thisterm. For many indigenous Guatemalans, especially at the community level, little if any contradiction or ambiguity is expressed regarding the identity(s) of this deity, which leads to the question “syncretic for whom”? That said, others, especially those involved (often beyond the local level) in the promotion and institutionalization of Maya Spirituality, may work to establish a more stable Maya pedigree for this tradition. The way these various points of view are expressed and placed in dialog with each other speaks to a dynamism and creativity which is typical of Maya culture at present and through time.

Cervical Visual Inspection with Acetic Acid (VIA) and Oncogenic Human Papillomavirus Screening in Rural Indigenous Guatemalan Women: Time to Rethink VIA.

Single-visit “screen-and-treat” strategies using visual inspection with acetic acid (VIA) and cryotherapy (liquid nitrous oxide ablation) in low-resource settings are commonly used to detect and treat precancerous lesions for cervical cancer prevention. This study compared VIA sensitivity and specificity in rural indigenous Guatemalan communities, to that of oncogenic human papillomavirus (HPV) testing for detection of precancerous changes, using cytology as the reference standard. Between 3–8 September 2017, trained nurses examined 222 women aged 23–58 years with VIA. Specimens for liquid-based cytology and HPV testing were obtained prior to VIA with a cytobrush and transported in PreservCyt to a US clinical laboratory. VIA and HPV test sensitivities were assessed as proportions of women with abnormal cytology that had abnormal VIA or HPV results, respectively, and specificities, as proportions with normal cytology with normal VIA or negative HPV tests. Of 222 women, 18 (8.1%) had abnormal cytology (1 carcinoma in a participant who received VIA-based cryotherapy in 2015, 4 high- and 5 low-grade squamous intraepithelial lesions, and 8 atypical squamous cells of undetermined significance (ASCUS)). Excluding ASCUS, sensitivities of VIA and HPV were 20.0% and 100%, respectively. VIA-based screening may not be acceptable for detecting precancerous lesions, and field cryotherapy for preventing malignancy. The World Health Organization recommended in 2021 “…using HPV DNA detection as the primary screening test rather than VIA or cytology”.

Barriers to dietary modifications for people living with type 2 diabetes in a rural indigenous Guatemalan community

In Guatemala, the prevalence of diabetes continues to increase with a disproportionate burden falling on indigenous rural communities. In this study, we assessed barriers to making dietary modifications for people living with type 2 diabetes in a rural indigenous Guatemalan population. Structed interviews (n=32) were conducted with participants selected from a convenience sample of adults with type 2 diabetes living in villages in and around San Lucas Tolimán, Guatemala. Frequencies were calculated for closed-ended questions and content analysis was used to evaluate open-ended questions. Most participants (81%) were women with low-levels of formal education and average daily food expenditure of just over $1 USD. The majority of participants were able to identify foods important in a diabetic diet, however, with significant barriers to making dietary modifications. Commonly cited perceived barriers included high costs of food due to travel and storage, inadequate local access to fresh fruits and vegetables and incompatibility with traditional diet. Several structural and cultural barriers exist to prevent dietary modifications for people living with type 2 diabetes in this rural indigenous population.

Pedimos Posada: Local Mediators and Guatemalan Refugees in Mexico, 1978-1984

Objective/Context: This article investigates how indigenous Guatemalan campesinos who took refuge in Chiapas, Mexico, relied upon Mexican mediators and community solidarity to secure their safety during the Guatemalan army’s genocidal campaign (1979-1983) against Mayan campesinos. The objective is to identify why different groups of mediators successfully met refugee needs. Methodology: Using the framework of forced migration studies, the article uses archival and oral histories to examine patterns of labor migration and refugee movement. Originality: The study uses previously uncatalogued archival collections, including the Guatemalan Refugees Collection in the Archivo Histórico Diocesano de San Cristóbal de las Casas, local documents from the Instituto Nacional de los Pueblos Indígenas (formerly Instituto Nacional Indígena, ini), and oral histories collected in communities of ex-refugiados. Conclusions: Refugees relied upon local mediators, primarily campesinos and small farmers, for food, shelter, and work. Although formal mediators (governmental and intergovernmental organizations) potentially offered more services to refugee settlements, refugee camps also required formal registration and restricted peoples’ rights to work and move freely. Indigenous Maya villagers on both sides of the border shared long histories of labor migration, along with social, religious, and family ties. These links formed the base of new communities and provided refugees with needed flexibility. More broadly, this research shows how grassroots community formation protected, and at times exploited, the human rights of refugees.

Nothing is easy: educational striving and migration deferral in Guatemala

ABSTRACT This paper ethnographically explores how indigenous Guatemalan youth come to desire non-migration despite local social-geographical contexts of extensive mobility. The 2014 the emergence of a ‘crisis’ of youth migration at the U.S. Southern border drew attention to the deep and longer-term reality of untenable conditions in the countries young people are fleeing. While significant scholarship has been dedicated to exploring the causes and conditions propelling youth migration, the experiences of young people en route, their reception in destination countries, and concerns over youth return and reintegration, little attention has been paid to young people who, in contexts of extensive migration, strive to remain in their communities of origin. This paper disrupts the mobility bias in migration studies and attends to the local and historically situated forces through which migratory contexts are heterogeneously experienced and engaged. In so doing, this research provides ethnographic material to demonstrate how desired immobility emerges in an overwhelmingly mobile context, illustrates the social, historical and structural fields that engage youth (im)mobilities, and argues for the analytic relevance of striving as a means by which desire is enacted (in this case the desire to stay put).

Migranthood: Youth in a New Era of Deportation by Lauren Heidbrink

Reviewed by: Migranthood: Youth in a New Era of Deportation by Lauren Heidbrink Amelia Frank-Vitale Lauren Heidbrink. Migranthood: Youth in a New Era of Deportation. Stanford: Stanford University Press, 2020. 213 pp. Thinking about my own sense of identity, I realise that it has always depended on the fact of being a migrant, on the difference from the rest of you. So one of the fascinating things about this discussion is to find myself centered at last. Now that, in the postmodern age, you all feel so dispersed, I become centered. What I’ve thought of as dispersed and fragmented comes, paradoxically, to be the representative modern experience! This is “coming home” with a vengeance! Most of it I much enjoy—welcome to migranthood. — Stuart Hall (1987:44) It is fitting that most scholars cite Stuart Hall as the coiner of the term, “migranthood.” In this essay, he discusses his own experience, as a migrant himself, of dispersal and fragmentation. His term, his description, come from expertise based on his own experience. This is one of the arguments at the heart of Lauren Heidbrink’s Migranthood: Youth in a New Era of Deportation. We must take seriously, she tells us, the expertise of young people who migrate and are deported to understand the nature of this condition of being a migrant, of migranthood. Migrant children, she holds, are too often discussed as either passive victims made vulnerable by the poor decisions of adults around them or as an inherently criminal, dangerous, invasive force that cannot be trusted and must be expelled. Heidbrink strives to trouble a public discourse that rests on these two polar but connected tropes by grounding an analysis of Indigenous Guatemalan youth migration in the narratives and reflections of, precisely, Indigenous Guatemalan youth migrants. [End Page 345] One of the core arguments of this book is that migranthood, or “how migration is socially constructed, practiced, and experienced” (5), is not an individual experience. Rather, the decision to migrate as well as the attendant risks and potential rewards are all familial, communal, collective. She makes this argument through detailing how the migration and deportation of children has ripple effects on parents, siblings, grandparents, friends and, conversely, how the migration and deportation of parents has ripple effects on children, families, communities. She reinforces this argument through a similar analysis of how the Indigenous communities in Guatemala where she works have come to experience migration; it is grounded in the historical experience of forced labor, internal labor migration, discrimination, state violence, and neoliberal extractivism. As a work of public scholarship, Migranthood does a remarkable job of weaving together statistical data, survey results, ethnographic storytelling, and history to offer a clear and compelling assessment of how the so-called crisis of unaccompanied minor migrants in 2014 (and the series of migration-related crises since then) is, as Heidbrink calls it, a crisis of policymaking. Importantly, Migranthood, points us toward what I think will be a new and necessary approach to deportation. While many of the stories Heidbrink includes involve the deportations of individuals who have lived for years in the United States, she also brings in the voices of youth (and in some cases their parents) who have been deported without ever having had the chance to arrive. While narratives of displacement and dis-orientation for those deported after making a life elsewhere (see Zilberg 2011, Coutin 2016, among others) have done the crucial work of showing how deportation is not a matter of returning out-of-place people back to their “natural” place (Khosravi 2018), the experiences of those deported without ever having “made it” are also rife with trauma and multiple, layered consequences. Migranthood shows us families and communities grappling with the full range of post-deportation experience, and like the story of Sebastián—who at 20, after three deportations from Mexico, falls into depression and dies of alcohol poisoning (163–164)—suggests that those who never arrive may be the least able to survive deportation. As the United States and other countries in the global North further harden their borders, restrict access to asylum and other forms of protection, and externalize migration enforcement, we will...

Ni de aquí ni de alla: A Mythohistoriography of Growing Up In-Between

Abstract Using Aurora Levins Morales’ concept of “medicinal histories,” and Audre Lorde’s “biomythography,” this mythohistoriography weaves together multiple histories of the Guatemalan Civil War, Indigenous stories of resistance in Guatemala, queer and trans presences and erasures, the author’s family stories during this time, and the author’s upbringing as this armed conflict was supposedly ending. Through a Two-Spirit critique this layering project calls for different types of historicizing practices and methodologies for queer and trans studies to focus on in order to do responsible decolonial work. Ultimately, this project is part of a healing praxis meant to deal with generational traumas forged through forcefully forgotten and erased historias and memories of queer and trans Indigenous Guatemalans.

The forgotten parent: a qualitative study of indigenous Guatemalan fathers' perspectives on atypical child development

BackgroundLittle is known about the role Latino fathers have in rearing children with atypical development. Despite the positive effects of father involvement being well studied in other populations, Latino fathers have been historically overlooked in family research. The purpose of this study was to understand the experiences of indigenous Guatemalan fathers of children with atypical development, particularly their understanding of their child's needs and their role in addressing those needs. MethodsUsing Kleinman's semi-structured Explanatory Model (EM) questions, I interviewed self-identified parents of children with atypical development to investigate their perceptions of their child's development and also their role in child rearing. Interviews also included questions about gender roles in child rearing and a brief demographic survey. Participant families were recruited from rural communities in the Department of Sololá, Guatemala. Interviews were analysed using ethnographic methods. FindingsBetween Nov 2 and Nov 10, 2018, 24 mother-father pairs were interviewed in 48 interviews. The results of the interviews indicated that, despite a rigid view of each parent's responsibilities (father as the breadwinner and mother as the caretaker), parents would abandon traditional familial gender roles if it were in the best interest of their child. Further, designated familial gender roles did not predetermine the types of concern parents experienced about their child with atypical development. For example, although a Guatemalan father may believe his main familial responsibility is to meet the financial needs of his family, his main paternal concerns may not only be financial in nature. InterpretationAt a functional level, Guatemalan families will adapt their parenting roles and responsibilities for the benefit their children with atypical development. These findings act as an opposing perspective to other published work on machismo, a concept often used to describe the Hispanic male-female hierarchy. These results suggest that the concept of machismo may be a western concept that is far too generalising for the indigenous couple rearing a child with atypical development. As such, Latino men remain an understudied and potentially underutilised member of the family, especially in high-stress homes where a child with atypical development is being cared for. Ways to increase their involvement in child rearing should be considered by researchers and policy makers. FundingCollege of Latin American Studies pre-dissertation field research grant.

Más allá de la frontera. Movilidad y reconfiguraciones familiares entre los chuj de México y Guatemala

In 1981, thousands of indigenous Guatemalans fled the civil war in their country, taking refuge in the first instance in Chiapas, Mexico, near the border line. In 1996 the Peace Agreements were reached, and part of the refugee population returned to Guatemala, while another fraction remained in Mexico, in localities of the states of Chiapas, Campeche, and Quintana Roo. This triple process –refuge, return, and/or definitive settlement in Mexico– resulted in new dynamics of movement and cross-border mobility, as well as in the reconfiguration of family and parental groups based on differentiated citizenship status. In this article, we provide analytical elements associated with these dynamics, based on the ethnographic observation carried out in the returnee village of Yalambojoch, in the department of Huehuetenango, municipality of Nentón, Guatemala, and in Santa Rosa el Oriente, a town in Chiapas that received refugees.

Building Capacity to Provide Maternal Health Care in an Indigenous Guatemalan Community Through Ultrasound and Skills Training

Sustainable Healthcare in Underdeveloped Regions, SHURinc, is dedicated to improving health care delivery in low-resource regions through use of technology and educational training, with the goal that the improvements will be managed and sustained by the local group (www.shurinc.org). This article outlines SHUR's involvement in a project to bring ultrasound technology and skills training to ACAM clinic located in Concepcion, Guatemala and describes strategies used to meet the learning needs of a diverse audience caring for pregnant indigenous women in a rural low-resource area. This article offers experience in working collaboratively with the midwives and other groups to achieve the overarching goal of improving the health of the indigenous pregnant women in the region and their newborn babies.

Access to Reproductive Health Services and Maternal Perceptions on Family Planning in an Indigenous Guatemalan Valley.

Objective. To identify reproductive health barriers and perceptions regarding family planning among mothers in ten rural communities of Guatemala. Methods. Data were collected from 85 women in a Nutrition Recuperation Project (NRP) conducted by a freestanding nonprofit clinic in Palajunoj Valley, Guatemala. All nonpregnant women participating in the NRP were eligible for enrollment in this study, and NRP staff members aided in their enrollment. Participants were interviewed and data were entered into a structured questionnaire. Data analysis was conducted using R version 1.1.456. Results. After asking participants if they believed fertility is higher on certain days, only 5 women (5.9%) correctly identified these days as occurring in the middle of the menstrual cycle. 35 women (41.2%) practiced some form of family planning, and 27 (31.8%) reported that they do not know of a place where they could obtain a contraceptive method. Conclusion. There is a lack of education regarding family planning methods in this valley, and the levels of contraception use are below average for rural Guatemala. These findings may implicate substantial health risks for women and children in the valley, and they support the pertinence of education-based interventions in the area of reproductive health behaviors.