From Cultural Competency to Cultural Immersion: Lessons from A Community Advocate in Guatemala


Yolande M. Pengetnze, MD1 and Zoila Gonzalez, RN, NP2

Perm J 2020;24:20-017 [Full Citation]
E-pub: 07/24/2020


The article introduces the novel concept of  “Cultural Immersion”, going beyond cultural competency to immerse oneself into the local culture for sustainable community impact.

It’s 7:30 pm on this spring evening in Sarstún. University of Texas Southwestern Medical Students and their preceptors have just completed a long day of clinical, surgical, and dental care at Clinica Regional de Sarstún (“The Clinic”) in Sarstún, Guatemala. The Clinic is supported by a United-States-based non-profit organization, Refuge International. Sitting on inflatable mattresses and wooden benches, we listen to Zoila Gonzalez, The Clinic’s Nurse Practitioner and Midwife, talk about the challenge of underage pregnancies in Sarstún.

Sarstún is a small fishing community on the shores of the Sarstún River, a waterway that separates Guatemala and Belize. The region encompasses multiple Mayan villages embedded in the mountains and remote from the coast. Ladinos and Mayans are the two predominant ethnic groups in Guatemala. Ladinos have a Spaniard background and speak primarily Spanish. Mayans are the indigenous population and speak primarily one of twenty-one Mayan languages. Q’eqchi’ (pronounced “Kek Chee”) is the predominant Mayan language in Sarstún.

Zoila is a Ladina from the neighboring multi-cultural town of Livingston. She is a Licensed Professional Midwife. Ten years ago, when she joined The Clinic, Zoila elected to also register as a Traditional Midwife, the other professional group performing midwifery in Guatemala. As a Traditional Midwife, Zoila was most likely to gain the trust of the Mayan people she serves, although the move was controversial among other Licensed Professional Midwives.

As she began to work in Sarstún, Zoila noticed a high prevalence of underage pregnancies among Mayan girls age 13 to 15 years. Zoila immersed herself in the local Mayan culture to better understand the problem. She traveled on foot to remote Mayan villages to meet community members, participate in community activities, and build relationships.  She learned that in Sarstún’s Mayan culture, girls 12 years and older are deemed ready for marriage. Young girls are typically married off to a boy/man 16 years or older, and the couple is off to start a family. Moreover, a Guatemalan law promulgated in the 1990’s provides financial assistance from the government to families with multiple children. Impoverished families, therefore, are pervasively incentivized to marry off young girls to collect government financial subsidies for children born of these unions.

This cultural and political context contributed to high rates of underage pregnancies in deprived communities, towing along poor outcomes for both the child and the mother, still a child herself. In 2008, the government’s response to the problem was to promulgate another law criminalizing underage pregnancies fathered by any male 16 years or older. Birth attendants were to report underage pregnancies to the local prosecutor who would initiate a criminal investigation to bring the responsible male to justice. Convictions could lead to 5-12 years in prison.  

Mayan communities in Sarstún are opposed to the latter law, which they perceive as a threat to their matrimonial and childbearing customs. Consequently, many underage pregnant girls are not brought in for prenatal care for fear of being reported to authorities, and many end up with unassisted home births in remote villages. Moreover, children born to underage mothers are often not recorded in vital statistics registries to avoid contact with authorities, leading to a crucial lack of important documents such as birth certificates when children are ready for school. In this context, the true prevalence and burden of underage pregnancies in Sarstún remains vastly unknown.

As Zoila immersed herself into the community and gained understanding of the cultural, legal, and political context, she conceived the idea of a community-driven approach to address the issue of underage pregnancies among Mayan girls in Sarstún. She developed a trusting relationship with the community. She led and facilitated community conversations about the clinical and legal risks of underage pregnancies, the benefits and availability of affordable and reversible birth control methods, the benefits of delayed pregnancies, and the importance of young girls’ education. Together with the community, they co-designed a community-wide birth control program for married girls under 17 years old, to delay the onset of pregnancy until after their 17th birthday. With Zoila’s guidance, the community took charge and set program parameters. For instance, they indicated preference for medium-term depo-progesterone injections as the birth control method of choice. Eligible girls either would come to The Clinic once every three months for depo-progesterone shots or would receive their shots during community outreach events organized conjointly by The Clinic and the government-owned Center of Health in Livingston. This approach addressed the problem of underage pregnancies in a culturally sensitive manner that preserved local Mayan matrimonial customs. 

Community participation was timid at first, with only a few parents showing interest. Four years into the program, however, more and more parents, especially mothers, proactively reach out to Zoila at the first indication of an upcoming betrothal to discuss birth control. Zoila screens and enrolls at-risk girls in the program and keeps a registry of eligible and enrolled patients for community outreach planning, inventory management, and medication adherence monitoring. As part of a comprehensive approach to community care, Zoila also has established a community-wide prenatal care program with onsite visits at The Clinic and community outreach into the villages, to give all pregnant women access to quality prenatal care. To maintain the hard-earned community trust, the program has elected not to proactively report underage pregnancies cared for at The Clinic to authorities, except per family request. Community members have also designed workaround solutions such as reporting inaccurate ages for underage mothers when establishing a birth certificate for a newborn, to avoid brushing with authorities.

As Zoila speaks passionately of the community birth control program in the beautiful Sarstún sunset, she proudly points to a 17-year-old pregnant woman who was seen for prenatal care in The Clinic that morning. The patient’s story is an example of program success. She got married at age 13 to a 16-year-old male right about the time the program began. Zoila and community stakeholders convinced the patient’s family and husband to enroll her in the community birth control program. They agreed, and the patient assiduously received depo-progesterone injections every three months for four years. A few months ago, as she turned 17, the patient discontinued birth control. She is currently seven months pregnant. She comes down the mountain every month for prenatal care with Zoila at The Clinic, and she is due to deliver her first child in two months.

Zoila has catalyzed a meaningful community transformation. She has identified an important problem and immersed herself into the community to uncover its roots. She has engaged the community to codesign and implement a culturally sensitive birth control program, which has led to community-level health behavior change and empowerment to reduce underage pregnancies among young Mayan girls in Sarstún. She has secured strong community engagement and ownership, and developed a collaboration with the local government-owned health system, to ensure program sustainability. She has extended prenatal care services offerings to all pregnant women in a comprehensive approach to community health, and she continues to work on expanding the reach and breadth of the program in Sarstún.

Remarkable progress has been made, but much remains to be accomplished. In Sarstún, underage Mayan girls are still being married and subjected to precocious sex and underage pregnancies. The prevalence and scope of underage pregnancies remain elusive in Sarstún and in other communities, partly exacerbated by the unpredictable political context in Guatemala. Laws are implemented by administrations with varied political interests and scarcely ever evaluated for their full impact on communities within their cultural ecosystem, thus potentially creating the breeding ground for undesired behaviors detrimental to community health and wellbeing.

As the evening conversation winds down, the team is deeply reflective, as we realize the lift required to make a lasting impact in a community. The key to success is a mixture of ingredients, including compassion, respect, humility, courage, inventiveness, dedication, sacrifice, collaboration, persistence, planning, education and, most certainly, “Cultural Immersion.” Zoila showed courage and inventiveness by striking the right balance between providing care and obeying the law. She only achieved success because she immersed herself into Sarstún’s Mayan culture and was compassionate enough to “walk a mile” with these young Mayan girls in their pregnancy journey.

Disclosure Statement

The author(s) have no conflicts of interest to disclose.


Patti Pagels1, PA, Alana Carrasco1, Jamala Christopher1, Natalie Bonner1, Luke Dosselman1, Isabel Garcia1, Christopher Gluckman1, Joel Rodriguez1, Virginia Wang1, William Young1, Lucio Zapata1, Sarah Y Djomo3, Kimberly Johnson2.

Author Affiliations

1 University of Texas Southwestern Medical School, Dallas, Texas

2 Refuge International, Longview, Texas

3 Oak Crest Private School, Carrollton, Texas

Corresponding Author

Yolande Pengetnze, MD (


Keywords: global health, At-Risk Communities, pregnancy, cultural, competency


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