title: Abuse and discrimination towards indigenous people in public health care facilities: experiences from rural Guatemala.
abstract: BACKGROUND
  Health inequalities disproportionally affect indigenous people in Guatemala. Previous studies have noted that the disadvantageous situation of indigenous people is the result of complex and structural elements such as social exclusion, racism and discrimination. These elements need to be addressed in order to tackle the social determinants of health. This research was part of a larger participatory collaboration between Centro de Estudios para la Equidad y Gobernanza en los Servicios de Salud (CEGSS) and community based organizations aiming to implement social accountability in rural indigenous municipalities of Guatemala. Discrimination while seeking health care services in public facilities was ranked among the top three problems by communities and that should be addressed in the social accountability intervention. This study aimed to understand and categorize the episodes of discrimination as reported by indigenous communities.
  
  
  METHODS
  A participatory approach was used, involving CEGSS's researchers and field staff and community leaders. One focus group in one rural village of 13 different municipalities was implemented. Focus groups were aimed at identifying instances of mistreatment in health care services and documenting the account of those who were affected or who witnessed them. All of the 132 obtained episodes were transcribed and scrutinized using a thematic analysis.
  
  
  RESULTS
  Episodes described by participants ranged from indifference to violence (psychological, symbolic, and physical), including coercion, mockery, deception and racism. Different expressions of discrimination and mistreatment associated to poverty, language barriers, gender, ethnicity and social class were narrated by participants.
  
  
  CONCLUSIONS
  Addressing mistreatment in public health settings will involve tackling the prevalent forms of discrimination, including racism. This will likely require profound, complex and sustained interventions at the programmatic and policy levels beyond the strict realm of public health services. Future studies should assess the magnitude of the occurrence of episodes of maltreatment and racism within indigenous areas and also explore the providers' perceptions about the problem.
authors.affiliation: Center for the Study of Equity and Governance in Health Systems (CEGSS), Guatemala, Guatemala. alejandro.ceronvaldes@du.edu.|University of Denver, Denver, CO, 80208, USA. alejandro.ceronvaldes@du.edu.
authors.forename: Alejandro
authors.initials: A
authors.lastname: Cerón
authors.affiliation: Center for the Study of Equity and Governance in Health Systems (CEGSS), Guatemala, Guatemala.
authors.forename: Ana Lorena
authors.initials: AL
authors.lastname: Ruano
authors.affiliation: Center for the Study of Equity and Governance in Health Systems (CEGSS), Guatemala, Guatemala.
authors.forename: Silvia
authors.initials: S
authors.lastname: Sánchez
authors.affiliation: Center for the Study of Equity and Governance in Health Systems (CEGSS), Guatemala, Guatemala.
authors.forename: Aiken S
authors.initials: AS
authors.lastname: Chew
authors.affiliation: Center for the Study of Equity and Governance in Health Systems (CEGSS), Guatemala, Guatemala.
authors.forename: Diego
authors.initials: D
authors.lastname: Díaz
authors.affiliation: Center for the Study of Equity and Governance in Health Systems (CEGSS), Guatemala, Guatemala.
authors.forename: Alison
authors.initials: A
authors.lastname: Hernández
authors.affiliation: Center for the Study of Equity and Governance in Health Systems (CEGSS), Guatemala, Guatemala.
authors.forename: Walter
authors.initials: W
authors.lastname: Flores
mesh_terms: D005260:Female; D017144:Focus Groups; D006166:Guatemala / Q000208:ethnology; D006801:Humans; D008297:Male; D044382:Population Groups / Q000208:ethnology* / Q000523:psychology; D036301:Qualitative Research; D011787:Quality of Health Care / Q000592:standards*; D063505:Racism / Q000639:trends*; D012424:Rural Population