Finding Hope: Guatemalan War Orphans\u27 Responses to the Long-Term Consequences of Genocide

The most brutal period of genocide in Guatemala, known as la violencia and denoting the period of 1978-1983, left tens of thousands of mostly Maya indigenous children orphaned. In this dissertation, I present results from research I conducted with war orphans who are now adults and who were raised at a permanent residential home for orphaned children in Santa Apolonia, a majority Maya Kaqchikel Highlands town. Comparing 20 of these war orphans with 20 of their peers from the town of Santa Apolonia, I found that orphans had suffered greater long-term consequences from the genocide. Relative to their peers, orphans reported more genocide-related childhood trauma and ongoing effects of that trauma, greater economic challenges in adulthood because of economic loss sustained from the death of parents and property destruction brought about by la violencia, and more severed familial and community ties, which dramatically shifted their centers of socialization and enculturation during their most formative years of childhood. Nonetheless, orphans in my research project reported higher levels of emotional resiliency and post-traumatic growth and higher rates of college and advanced education enrollment than their peers, allowing them to outpace their peers economically and professionally. In addition, despite having lost familial and natal community ties, orphans asserted a deeply-rooted sense of identity and belonging in the Guatemalan nation-state today, based on a more fluid conceptualization of identity that allows for a simultaneous internalized sense of continuity and active participation in creative practices. Experiencing neither identity loss\u27 nor an \u27identity crisis,\u27 orphans are actively and creatively adapting to their situations and contexts as orphaned survivors of genocide and maintaining a sense of profound rootedness that cannot be destroyed by external forces. Based on these findings with a particular group of war orphans, I illustrate that even in the long-term aftermath of the most brutal, inhumane violence, genocide survivors, by engaging in creative and constructive practices, can overcome adversity and build a life of hope.\u2

Promotoras as Mental Health Practitioners in Primary Care: A Multi-Method Study of an Intervention to Address Contextual Sources of Depression

We assessed the role of promotoras—briefly trained community health workers—in depression care at community health centers. The intervention focused on four contextual sources of depression in underserved, low-income communities: underemployment, inadequate housing, food insecurity, and violence. A multi-method design included quantitative and ethnographic techniques to study predictors of depression and the intervention’s impact. After a structured training program, primary care practitioners (PCPs) and promotoras collaboratively followed a clinical algorithm in which PCPs prescribed medications and/or arranged consultations by mental health professionals and promotoras addressed the contextual sources of depression. Based on an intake interview with 464 randomly recruited patients, 120 patients with depression were randomized to enhanced care plus the promotora contextual intervention, or to enhanced care alone. All four contextual problems emerged as strong predictors of depression (chi square, p < .05); logistic regression revealed housing and food insecurity as the most important predictors (odds ratios both 2.40, p < .05). Unexpected challenges arose in the intervention’s implementation, involving infrastructure at the health centers, boundaries of the promotoras’ roles, and “turf” issues with medical assistants. In the quantitative assessment, the intervention did not lead to statistically significant improvements in depression (odds ratio 4.33, confidence interval overlapping 1). Ethnographic research demonstrated a predominantly positive response to the intervention among stakeholders, including patients, promotoras, PCPs, non-professional staff workers, administrators, and community advisory board members. Due to continuing unmet mental health needs, we favor further assessment of innovative roles for community health workers