Medicine and Health Sciences Commons^™

Empowering Community Health Workers In Guatemala, Oswald M. Attin, Gineska Castillo, Grace Sibert, Andrea Harper

Virginia Journal of Public Health

Introduction:

Community health workers (CHW) have been integral in helping middle- and low-income countries. This research paper discusses the benefits of the involvement of CHWs in health screenings.

Methods:

Health screenings were performed for three rural communities in Guatemala, in 2021, alongside a church in Zacapa, to identify community wide health risks. The screenings included a detailed questionnaire that collected demographic data, height and weight, a blood glucose check, a hemoglobin check, and a blood pressure reading. Additional nutritional data was collected to understand diet patterns and habits. In-depth educational sessions were done with the CHWs, emphasizing preventative care, and …

Exploring The Post-Surgical Needs Of Guatemalan Children And Their Families From Low Socioeconomic Status (Ses) Communities Using An Occupational Therapy Perspective, Diana Del Carmen Tojin Romero, Karen Aranha, Angela Labrie Blackwell

Summer 2023 Virtual OTD Capstone Symposium

Background: Despite a decline in infant mortality rates in the Global South (GS), there has been a rise in congenital and developmental disabilities. International short-term medical (ISTM) missions in Guatemala seek to address the surgical needs of children from low SES communities, but the understanding of the impacts of such assistance and the post-surgical needs of these communities remains limited. Embracing the Human Rights-Based Approach (HRBA) to healthcare as a foundation for this study recognizes health as a fundamental human right. The main tenets of this approach will guide this investigation to understand the post-surgical needs of children and their …

The Effects Of Multiple Micronutrient Fortified Beverage And Responsive Caregiving Interventions On Early Childhood Development, Hemoglobin, And Ferritin Among Infants In Rural Guatemala, Alysse J. Kowalski, Victor Alfonso Mayen, Silvia De Ponce, Kaley B. Lambden, Nick Tilton, Lisa M. Villanueva, Ana M. Palacios, Greg A. Reinhart, Kristen M. Hurley, Maureen M. Black

Department of Health Policy and Community Health Faculty Publications

Undernutrition and a lack of learning opportunities can jeopardize long-term growth and development among infants in low- and middle-income countries. We conducted a 6-month 2 × 2 cluster-randomized trial to assess the effects of multiple micronutrient-fortified beverages and responsive caregiving interventions among infants 6–18 months in 72 community sectors in southwest Guatemala. We administered baseline and endline assessments of childhood development (Bayley Scales of Infant and Toddler Development) and socioemotional development (Brief Infant Toddler Socio-Emotional Assessment) and measured ferritin and hemoglobin on a subsample. The trial was analyzed using linear mixed models. At the baseline, the mean age (SD) was …

Environmental And Social Factors Associated With High Chronic Kidney Disease Mortality Rates In Municipalities Of Guatemala: An Ecological Study Of Municipal-Level Mortality Data, Alejandro Cerón

Anthropology: Faculty Scholarship

The purpose of this study was to determine the association between social and environmental indicators and high mortality rates from chronic kidney disease (CKD) in municipalities of Guatemala. An ecological study of municipal-level factors associated with CKD mortality in Guatemala was conducted. Crude mortality rates were calculated for the 2009–2019 period for each of the country’s 340 municipalities, by gender and age groups. Municipal-level social and environmental indicators were used as independent variables. Linear regression was used for bivariate and multivariate analysis. A total of 28,723 deaths from CKD were documented for the 2009–2019 period. Average crude mortality rate for …

Reducing Inequities In Maternal And Child Health In Rural Guatemala Through The Cbio+ Approach Of Curamericas: 2. Study Site, Design, And Methods, Henry B. Perry, Mario Valdez, Stanley Blanco, Ramiro Llanque, Shayanne Martin, Jason Lambden, Corey Gregg, Kaitlin Leach, Elijah Olivas, Barbara Muffoletto, Jacqueline Wallace, Nina Modanlo, Erin Pfeiffer, Carey C. Westgate, Breanne Lesnar, Ira Stollak

School of Medicine Faculty Publications

Background The Curamericas/Guatemala Maternal and Child Health Project, 2011–2015, included implementation research designed to assess the effectiveness of an approach referred to as CBIO+ , composed of: (1) the Census- Based, Impact-Oriented (CBIO) Approach, (2) the Care Group Approach, and (3) the Community Birthing Center Approach. This is the second paper in a supplement of 10 articles describing the implementation research and its findings. Paper 1 describes CBIO+ , the Project Area, and how the Project was implemented. Objective This paper describes the implementation research design and details of how it was carried out. Methods We reviewed the original implementation …

The Mission System: An Electronic Health Record For Medical Treatment In Guatemala, Tawniece M. Curry

Dissertations

Abstract

Problem: The introduction of an electronic health record (EHR) system has become an essential component in monitoring and tracking patient information in most developed countries but are difficult to implement in underdeveloped countries. Guatemala is a country with poor health care and limited resources for patient tracking and monitoring. An organization in Guatemala, Nursing Heart Inc. (NHI), provides care to over 40 underserved rural communities but lacks the ability to monitor and track patient information. In order for NHI to properly monitor and evaluate their programs and track patients’ continuity of care, the introduction of an EHR system is …

Children Receiving A Nutrition And High-Quality Early Childhood Education Intervention Are Associated With Greater Math And Fluid Intelligence Scores: The Guatemala City Municipal Nurseries, Ana M. Palacios, Lisa A. Villanueva, Matthew B. Flynn, Erik Parker, Stephanie Dickinson, Helen W. Bland, Greg A. Reinhart

Department of Health Policy and Community Health Faculty Publications

Background: About 47% of children < 5 years of age are stunted in Guatemala. In this study, the investigators aimed to compare growth and cognitive outcomes between children in second grade that attended five Guatemala City Municipal Nurseries (GCMN) vs. same sex, grade, and age-matched children. Methods: A cross-sectional design nested in a retrospective cohort was implemented between 2015 and 2019. Children that attended the GCMN and matched controls completed a math test and validated receptive language and fluid intelligence tests. The primary caregivers completed a sociodemographic survey. General and generalized linear mixed effect models were used to compare children that attended the GCMN vs. controls. The models were adjusted by maternal education, sex, asset score, and other relevant covariates. Results: Children that attended the GCMN exhibited greater math and fluid intelligence scores relative to the controls in the adjusted models (ß = 6.48; 95% CI (2.35–10.61)) and (ß = 1.20; 95% CI (0.12–2.29)), respectively. Lower odds of stunting were significant for children who went to any early childcare institution (AOR = 0.28; 95% CI (0.09–0.89)). Conclusions: The importance of integrating nutrition and high-quality early childhood education interventions in cognitive and growth outcomes is highlighted in this study. The GCMN model may be a scalable model in similar low-resource settings.

Indicadores De Desigualdad Y Mortalidad Por Enfermedades Cardiometabólicas En Guatemala / Inequality Indicators And Cardiometabolic Diseases Mortality In Guatemala, Alejandro Cerón, Gila Y. Goldstein

Anthropology: Faculty Scholarship

La medición de las desigualdades en salud al interior de los países de ingresos bajos y medios es necesaria para la planificación, monitoreo y evaluación de intervenciones de salud pública, especialmente para problemas que contribuyen altamente a la carga de enfermedad, como las enfermedades cardiometabólicas. El objetivo de este estudio fue caracterizar los patrones de desigualdad de las tasas de mortalidad para las principales causas cardiometabólicas en Guatemala. Se usó datos del Censo Nacional de Población, y estadísticas oficiales de defunción de 2018 para calcular tasas crudas de mortalidad para diabetes (DM), infarto agudo de miocardio (IAM), y accidente cerebrovascular …

Factors Associated With Viremia In People Living With Hiv On Antiretroviral Therapy In Guatemala, Dean W Ortíz, Olivia Roberts-Sano, Hugo E Marroquin, Lindsey Larson, Katherine B Franco, Andrej Spec, Johanna R Melendez, Rodolfo Pinzón, Ana J Samayoa, Carlos Mejia-Chew, Jane A O Halloran

2020-Current year OA Pubs

INTRODUCTION: Viral suppression prevents HIV transmission and disease progression, but socio-economic and clinical factors can hinder the goal of suppression. We evaluated factors associated with viral non suppression (VNS) and persistent viremia (PV) in people living with HIV (PLHIV) receiving antiretroviral therapy (ART) in Guatemala.

METHODS: We conducted a cross sectional analysis using data from an ongoing cohort of PLHIV attending the largest HIV clinic in Guatemala. Univariable and multivariable analyses were conducted between PLHIV with viral suppression and detectable viremia. VNS was defined as most recent HIV RNA ≥ 200 copies/ml and PV as two consecutive HIV RNA ≥ …

Perceptions And Practices Of Indigenous Populations About Diabetes In Guatemala, Liesl Cohn De Leon

English Language Institute

Diabetes is becoming a common disease among indigenous populations in Guatemala. They perceive diabetes not only as a medical disease, but also a condition linked to emotions. They say they have total confidence in the official health system, but in practice they rely on the ancestral Mayan knowledge of the healers and spiritual guides to complement biomedical treatments.

Factors Associated With Chronic Kidney Disease Of Non-Traditional Causes Among Children In Guatemala, Alejandro Cerón, Brooke M. Ramay, Luis Pablo Méndez-Alburez, Randall Lou-Meda

Anthropology: Faculty Scholarship

Objective. To identify factors associated with chronic kidney disease of non-traditional causes among children in Guatemala. Methods. A cross-sectional survey was conducted. The study population was all pediatric patients with stage 5 chronic kidney disease active in FUNDANIER’s pediatric nephrology unit (N = 156). Simple random sampling led to a total of 100 participants. Data collection consisted of a questionnaire addressing individual and household characteristics, access and utilization of health care, and place of residence when the disease began. Chronic kidney disease etiology was obtained from medical records. Municipality-level secondary data were collected. Descriptive statistics were estimated. Logistic regression was …

Rates And Risk Factors For Preterm Birth And Low Birthweight In The Global Network Sites In Six Low- And Low Middle-Income Countries, Yamini V. Pusdekar, Archana B. Patel, Kunal G. Kurhe, Savita R. Bhargav, Vanessa Thorsten, Ana Garces, Robert L. Goldenberg, Shivaprasad S. Goudar, Sarah Saleem, Fabian Esamai

Community Health Sciences

Background: Preterm birth continues to be a major public health problem contributing to 75% of the neonatal mortality worldwide. Low birth weight (LBW) is an important but imperfect surrogate for prematurity when accurate assessment of gestational age is not possible. While there is overlap between preterm birth and LBW newborns, those that are both premature and LBW are at the highest risk of adverse neonatal outcomes. Understanding the epidemiology of preterm birth and LBW is important for prevention and improved care for at risk newborns, but in many countries, data are sparse and incomplete.
Methods: We conducted data analyses using …

Accuracy Of The Tuberculosis Point-Of-Care Alere Determine Lipoarabinomannan Antigen Diagnostic Test Using Α-Mannosidase Treated And Untreated Urine In A Cohort Of People Living With Hiv In Guatemala, Juan Ignacio García, Carlos Mejía-Chew, Et Al.

2020-Current year OA Pubs

BACKGROUND: Improved point-of-care diagnostic tests for tuberculosis (TB) in severe immune suppressed people living with HIV (PLWH) are needed to decrease morbidity and mortality outcomes. The aim of the study is to evaluate the performance of the lipoarabinomannan antigen test (LAM-test) with and without α-mannosidase pre-treated urine in a cohort of PLWH in primary care clinics in Guatemala. We further determined TB incidence, and mortality rates and its risk factors in PLWH with TB symptoms.

METHODS: Prospective longitudinal study of PLWH with TB symptoms. Urine samples were collected at 2 HIV sites to test the sensitivity of the LAM-test in …

Availability Of Over-The-Counter Antibiotics In Guatemalan Corner Stores, Purificación Moreno, Alejandro Cerón, Karen Sosa, Marinees Morales, Laura M. Grajeda, Maria Renee Lopez, John P. Mccraken, Celia Cordón-Rosales, Guy H. Palmer, Douglas R. Call, Brooke M. Ramay

Anthropology: Faculty Scholarship

Widespread availability of antibiotics without prescription potentially facilitates overuse and contributes to selection pressure for antimicrobial resistant bacteria. Prior to this study, anecdotal observations in Guatemala identified corner stores as primary antibiotic dispensaries, where people purchase antibiotics without prescriptions. We carried out a cross sectional study to document the number and types of antibiotics available in corner stores, in four study areas in Guatemala. A total of 443 corner stores were surveyed, of which 295 (67%) sold antibiotics. The most commonly available antibiotics were amoxicillin, found in 246/295 (83%) stores, and tetracycline, found in 195/295 (66%) stores. Over the counter …

Municipios Indígenas De Guatemala: Conocimientos, Actitudes Y Prácticas Frente A La Covid-19 Resultados De La Segunda Ronda De Recopilación De Datos, Population Council

Poverty, Gender, and Youth

No abstract provided.

Guatemala: Conocimientos, Actitudes Y Prácticas Frente A La Covid-19—Perspectivas De 144 Informantes Clave En 10 Municipios Con Mayoría De Población Indígena. Resultados De La Segunda Ronda De Recolección De Datos, 21–26 Julio De 2020, Population Council

Poverty, Gender, and Youth

El Population Council tiene una asociación de larga data con las comunidades indígenas y rurales de Guatemala a través del programa Abriendo Oportunidades. Para mediados de agosto de 2020, las restricciones gubernamentales permitían la movilidad entre departamentos a nivel nacional, las clases siguen suspendidas y se permite a las empresas operar en conformidad con los protocolos de prevención de COVID-19. Para entender mejor los conocimientos perspectivas y la evolución de las necesidades relacionadas con la pandemia por la COVID-19 en Guatemala, realizamos una segunda ronda de encuestas telefónicas con 144 informantes clave en 10 municipios con mayoría de población indígena. …

Guatemala: Covid-19 Knowledge, Attitudes And Practices—Perspectives From 144 Key Informants In 10 Indigenous Municipalities. Results From The Second Round Of Data Collection, July 21–26, 2020, Population Council

Poverty, Gender, and Youth

The Population Council has a longstanding partnership with indigenous communities in rural Guatemala through the Abriendo Oportunidades program. In compliance with COVID-19 prevention protocols, as of mid-August 2020 government restrictions allowed for inter-district mobility at the national level, classes remain suspended, and businesses were allowed to operate. To better understand indigenous knowledge, perspectives, and evolution of needs related to the COVID-19 pandemic in Guatemala, we conducted a second round of phone interviews with 144 key informants in ten municipalities. The second round represents 75% (n = 108) of the cohort interviewed April 14–18, 2020. Thirty-six new informants were recruited to …

Nurse Practitioner Student Confidence And Competence In Common Women's Health Diagnostic Procedures, Jessica Cowan

Dissertations

Problem: In areas with limited health resources, such as Guatemala, cost-effective and reliable methods for sexually transmitted infection and cervical cancer screenings are needed. The purpose of this Quality Improvement (QI) project was to develop standardized training in Vaginal Wet Mount (VWM) preparation and cervical cancer screening using Visual Inspection with Acetic Acid (VIA) for Nurse Practitioner students who traveled to Guatemala for a week-long global immersion experience.

Methods: This was a QI project with a prospective descriptive design utilizing a purposive sample of 10 University of Missouri-St. Louis Nurse Practitioner students who traveled to Guatemala on medical mission trip …

Encuesta De Conocimientos, Actitudes Y Prácticas Del Covid-19: Informantes Clave En 10 Municipios Con Población Indígena De Guatemala, Population Council

Poverty, Gender, and Youth

No abstract provided.

Guatemala Indigenous Municipalities: Covid-19 Knowledge, Attitudes, And Practices, Population Council

Poverty, Gender, and Youth

This presentation recounts findings on COVID-19 knowledge, attitudes, and practices in Guatemala’s indigenous municipalities. A total of 144 phone-based key informant interviews were conducted from April 14–18, 2020, in ten municipalities. Key informants included indigenous women, heads of households, teachers, community leaders, municipal officers, and frontline health workers. Recommendations include: 1) intensifying government efforts to deliver accurate information on the prevention of COVID-19 to indigenous communities with a focus on developing a COVID-19 roadmap for community action after the first case is identified in a given municipality, and considering alternatives for self-isolation for the poorest households; 2) conveying tailored, actionable …

Guatemala: Covid-19 Knowledge, Attitudes And Practices—Perspectives From 144 Key Informants In 10 Indigenous Municipalities, Population Council

Poverty, Gender, and Youth

NOTE: This brief represents research in progress. Content has not been peer reviewed, and this version may be updated with additional analyses in subsequent publications.

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The Population Council has a longstanding partnership with indigenous communities through the Abriendo Oportunidades program. Our experience working in indigenous settings has allowed us to witness a lack of indigenous inclusion in government activities. To better understand indigenous knowledge, perspectives, and needs related to the COVID-19 pandemic in Guatemala, we conducted 144 key informant interviews using mobile phones in ten municipalities from April 14–18, 2020. This brief describes highlights of the key informant interviews; …

Availability Of & Access To Prenatal Care & The Effects On Maternal & Infant Mortality Rates: A Comparison Of Central American Countries, Costa Rica & Guatemala, Joanne Danae Youngblood

Theses and Dissertations

Costa Rica and Guatemala share similarities in history, culture, and a relatively congruous geopolitical philosophy. Yet despite these superficial parallels, access to prenatal care between the two countries is shockingly disparate. Costa Rican women have better access to prenatal care and both the maternal and infant mortality rates are comparable to more developed countries with significantly higher rates of economic development and higher spending on healthcare per capita. In juxtaposition, the lack of prenatal care within Guatemala’s health care system is a prime example of a country’s failure to implement protections and policies that promote and elevate the level of …

Birth Across Borders: Migueleña Maternal Experience In Palm Beach County, Florida, Inbal Mazar

Maya America: Journal of Essays, Commentary, and Analysis

Dangers for pregnant Maya women in San Miguel Acatán, a highland hamlet in Huehuetenango, Guatemala are exceptionally high. Those who migrate to Palm Beach County, Florida also face significant risks during pregnancy. However, conceptualizing migrants as vulnerable and non-agentive dismisses the opportunity to explore other dimensions of migrant women experiences. Interviews with Migueleña mothers and midwives and health professionals and advocates in both regions revealed resilience strategies Migueleña migrants create and employ as they navigate linguistically and culturally foreign medical systems. The support they provide each other results in more positive maternal experiences under arduous circumstances. Over time, Migueleñas are …

Covid-19-Related Knowledge, Attitudes, And Practices Among Decisionmakers Of Indigenous Municipalities In Guatemala: Study Description, Angel Del Valle, Hannah Briggs, Benjamin Chang, Aiken Chew, Brian Medina, Gabriela Muñoz, Thoai Ngo, Elizabeth Vásquez, Corinne White, Ramón Zamora

Poverty, Gender, and Youth

Indigenous communities are often socially and economically marginalized which makes them particularly vulnerable to the impact of COVID-19. The Population Council has a longstanding partnership with indigenous communities in Guatemala through the "Abriendo Oportunidades" program. To understand the knowledge, perspectives, and needs related to the COVID-19 pandemic, we will conduct key informant interviews with indigenous community leaders and frontline workers. Phone-based surveys will be carried out with approximately 130 key informants in the municipalities of Chisec, Patzún, San Andrés Semetabaj, San Juan Ostuncalco, San Juan Sacatepéquez, San Pedro Carchá, Santa María Chiquimula, Totonicapán, Uspantán and Sololá in April 2020. These …

Low-Dose Aspirin For The Prevention Of Preterm Delivery In Nulliparous Women With A Singleton Pregnancy (Aspirin): A Randomised, Double-Blind, Placebo-Controlled Trial., Matthew K. Hoffman, Shivaprasad S. Goudar, Bhalachandra S. Kodkany, Mrityunjay Metgud, Manjunath Somannavar, Jean Okitawutshu, Adrien Lokangaka, Antoinette Tshefu, Carl L. Bose, Abigail Mwapule, Musaku Mwenechanya, Elwyn Chomba, Waldemar A. Carlo, Javier Chicuy, Lester Figueroa, Ana Garces, Nancy F. Krebs, Saleem Jessani, Farnaz Zehra, Sarah Saleem, Robert L. Goldenberg, Kunal Kurhe, Prabir Das, Archana Patel, Patricia L. Hibberd, Emmah Achieng, Paul Nyongesa, Fabian Esamai, Edward A. Liechty, Norman Goco, Jennifer Hemingway-Foday, Janet Moore, Tracy L. Nolen, Elizabeth M. Mcclure, Marion Koso-Thomas, Menachem Miodovnik, R. Silver, Richard J. Derman, Aspirin Study Group

Global Health Articles

BACKGROUND: Preterm birth remains a common cause of neonatal mortality, with a disproportionately high burden in low-income and middle-income countries. Meta-analyses of low-dose aspirin to prevent pre-eclampsia suggest that the incidence of preterm birth might also be decreased, particularly if initiated before 16 weeks of gestation.

METHODS: ASPIRIN was a randomised, multicountry, double-masked, placebo-controlled trial of low-dose aspirin (81 mg daily) initiated between 6 weeks and 0 days of pregnancy, and 13 weeks and 6 days of pregnancy, in nulliparous women with an ultrasound confirming gestational age and a singleton viable pregnancy. Participants were enrolled at seven community sites in …

Demographics And Treatment Strategies Utilized During A Service-Learning Trip To A Medically Underserved Region: Guatemala 2019, Anna Chang, Alex Knapp, Holly Roberts

Physical Therapy Research Symposium

Demographics and Treatment Strategies Utilized During a Service-Learning Trip to a Medically Underserved Region: Guatemala 2019

By Anna Chang, SPT, Alex Knapp, SPT, and Holly Roberts, PT, DPT, GCS, NCS

BACKGROUND: Students in the Global Health Perspectives in Physical Therapy elective at the University of Puget Sound participated in a five-day service-learning trip. They partnered with a host organization to provide physical therapy services in Zacapa, Guatemala.

PURPOSE: Synthesize demographic information and intervention plans to educate physical therapists and students to effectively evaluate and treat medically underserved populations abroad.

METHODS: Age, gender, physical therapy diagnosis, and type of intervention were …

The Cost Of Improving Nutritional Outcomes Through Food‐Assisted Maternal And Child Health And Nutrition Programmes In Burundi And Guatemala, Jessica Heckert, Jef L. Leroy, Deanna K. Olney, Susan Richter, Elyse Iruhiriye, Marie T. Ruel

Faculty Publications

Evidence on the cost‐effectiveness of multisectoral maternal and child health and nutrition programmes is scarce. We conducted a prospective costing study of two food‐assisted maternal and child health and nutrition programmes targeted to pregnant women and children during the first 1,000 days (pregnancy to 2 years). Each was paired with a cluster‐randomized controlled trial to evaluate impact and compare the optimal quantity and composition of food rations (Guatemala, five treatment arms) and their optimal timing and duration (Burundi, three treatment arms). We calculated the total and per beneficiary cost, conducted cost consequence analyses, and estimated the cost savings from extending …

An Overview Of Diabetes And Community Health Concerns In Guatemala, Jennifer A. Davidson, Halie M. Higgins, Alex Krona, Danny R. Luna

All Electronic Theses and Dissertations

Type 2 diabetes mellitus (T2DM) has emerged as a worldwide epidemic in recent years. Rates of this disease continue to rise annually. While many countries have adequate access to prevent and treat T2DM, developing countries often lack education and resources to combat the diabetes epidemic. This shortcoming results in alarming rates of uncontrolled T2DM cases among individuals in developing countries, namely, Guatemala. Additionally, the lack of resources in Guatemala results in a myriad of other health disparities beyond T2DM including deficiencies in sanitation and adequate nutrition. This community service project specifically aims to address the disproportionate burden of T2DM, sanitation, …

Application Of Theory To Guide Development Of A Rehabilitation Service-Learning Project In Guatemala, Mary Zadnik, Suzanne Trotter, Cindy Mathena

Journal of Occupational Therapy Education

International community-based rehabilitation service-learning projects in physical and occupational therapy education programs may impact underserved communities internationally. The intentional inclusion of learning in service activities has been identified as service-learning. Extending the impact and education beyond the service project is necessary in order to provide a sustainable outcome for the community. Faculty at the University of St. Augustine for Health Sciences partnered with Potter’s House Association International to develop an interprofessional program to address the rehabilitation needs and continuity of care following a one-week project serving the community members of the Guatemalan City Garbage Dump. The purpose of this article …

Implications Of Direct Access To Physical Therapy In A Global Health Context, Coty Hogue, Mercedes Friend, Holly Roberts

Physical Therapy Research Symposium

The purpose of this study was to examine the implications of direct access in a global health setting through the process of medical screening during physical therapy (PT) examinations in rural Guatemala. Six patients (5%) presented with signs and symptoms requiring follow-up medical care or when medical follow-up was unavailable, modification of physical therapy intervention. The role of physical therapists (PTs) in the delivery of health care is expanding. PTs practicing abroad must be prepared for the unique health needs of medically underserved populations. Additionally, as direct access to physical therapy services becomes increasingly common in the United States, clinicians …