Barriers and opportunities in implementing adolescent sexual and reproductive health interventions in rural Guatemala: an exploratory descriptive study

ABSTRACT

Objective.

To explore barriers and opportunities in implementing adolescent sexual and reproductive health interventions in four rural Indigenous communities in Alta Verapaz, Guatemala.

Methods.

An exploratory descriptive qualitative study was conducted using stakeholder mapping and a reflexive thematic approach. Data were collected through 20 semistructured interviews with key stakeholders involved in adolescent sexual and reproductive health programming.

Results.

Persistent barriers included limited institutional capacity, inadequate access to and coverage of comprehensive sexuality education and health care services (including youth-friendly spaces), and resistance rooted in family, religious, and community values. Structural issues, such as underfunding, political turnover, and limited multisectoral coordination, further hinder program sustainability. Opportunities for enhancing interventions were identified through community participation, youth leadership, demographic changes, technological advancements, and the integration of mental health.

Conclusions.

Strengthening governance, promoting inclusive multisectoral coordination, and leveraging adolescent and community engagement are crucial for implementing sustainable, culturally grounded sexual and reproductive health interventions in Indigenous communities in Guatemala and similar contexts.

Although the global adolescent fertility rate (AFR) decreased from 47.2 to 42.5 live births per 1 000 girls between 2015 and 2021 (1), the Latin America and the Caribbean rate remains high at 61 in ages 15–19 (2). Several Latin American countries have implemented interventions to reduce adolescent pregnancies (3), emphasizing universal sexual and reproductive health (SRH) access, comprehensive sexuality education (CSE), gender equality, SRH rights, and intercultural/intersectoral approaches. For example, Ecuador’s Intersectoral Policy for Preventing Adolescent Pregnancy (2018–2025) reduced the AFR from 69.5 to 47.3 live births per 1 000 (4). However, challenges remain. Uruguay’s Intersectoral and National Strategy for the Prevention of Unintended Adolescent Pregnancy (2016–2020) faced barriers, including persistent norms prioritizing early motherhood, abortion stigma, inadequate SRH services, and resistance to recognizing pregnancies under 15 as gender-based violence (GBV) (5). Similarly, Mexico’s National Strategy for the Prevention of Adolescent Pregnancy (2021–2024) highlights the need for adjusting initiatives for rural, Indigenous, and Afro-Mexican adolescents (6).

Guatemala’s National Plan for the Prevention of Adolescent Pregnancy (known by its Spanish acronym, PLANEA) was launched in 2013 and updated in 2018 (7). It targets three strategic focus areas (7): 1) ensuring adolescent access to and retention in education; 2) providing comprehensive, differentiated health care, including youth-friendly spaces (YFS) and CSE; and 3) fostering youth leadership and participation. PLANEA also emphasizes multisectoral and interinstitutional partnerships and coordination. The Ministry of Education led the first strategic focus area, collaborating with the Ministry of Health on the second area and the National Youth Council on the third area. PLANEA was supported by the National Reproductive Health program, the World Health Organization, the United Nations Population Fund, the United Nations Children’s Fund, and civil society. An updated version is forthcoming, with pending clarifications.

The authors conducted an exploratory descriptive study and stakeholder mapping to understand barriers and opportunities in implementing adolescent SRH initiatives in four rural communities in Alta Verapaz, Guatemala. As part of a larger research project in rural Guatemala (8), this study focuses on institutional experiences; additional papers will address community-level findings.

METHODS

Study Setting

Alta Verapaz, north of Guatemala City, has 1.2 million inhabitants, comprising 612 160 women, 602 878 men, and 290 962 adolescents aged 10–19 (9). Some 68% of residents live in rural areas, and 89.7% self-identify as Indigenous, mainly Q’eqchi (86.3%) (9, 10). In total, 78% live in poverty, while 37.7% live in extreme poverty (10). Between 2017 and 2022, 70 535 adolescent pregnancies among girls aged 10–19 were reported, of which 2 906 involved girls under 14 (11).

Methodological Rigor and Partnership Approach

Methodological rigor was ensured by applying trustworthiness principles, including credibility, dependability, confirmability, and transferability, while leveraging a research partnership with an international cooperation organization experienced in SRH strategies, violence prevention, and women’s economic empowerment in the region. This partnership strengthened the study’s cultural and contextual grounding by providing knowledge of local communities and institutions and supporting research planning and implementation. They facilitated hiring a local Indigenous research assistant, supported community engagement and participant enrollment, helped refine data collection tools, and participated in preliminary analysis and dissemination. These contributions enhanced cultural relevance, bolstered credibility through member checking and triangulation, ensured dependability through systematic memoing and an audit trail, confirmed validity through transparent documentation that linked findings to data, and supported transferability by situating the study’s results within the broader literature.

Selection of Rural Communities

Building on this partnership, the international cooperation organization also helped identify four rural communities, including Chamil, Xucup, Chiquixji, and Sa’mococh. Selection was guided by rural location, proximity to a health post or YFS, variability in reported pregnancies, predominance of the Q’eqchi population, and previous implementation of adolescent SRH interventions, including PLANEA. All had health posts or YFS; education was available up to the basic secondary level.

Study Design and Criteria for Participation

An exploratory descriptive methodology, employing semistructured interviews, was used. The following were the inclusion criteria: 1) stakeholders involved in designing and implementing adolescent SRH initiatives, including PLANEA; 2) representatives from public or private organizations; and 3) stakeholders from international cooperation agencies. Those who did not meet these criteria, declined participation, or lacked informed consent were excluded.

Sampling and Participant Recruitment

Purposive and snowball sampling were employed. A stakeholder mapping process guided the identification of institutions and stakeholders. They were initially contacted via email with a standard letter of introduction. Interested stakeholders were scheduled for meetings to further explain the study. Additional institutions and participants were identified during these conversations. Those who agreed to participate received the informed consent electronically and were interviewed based on availability.

Sample Size

Twenty stakeholders participated: five from the central government, two from the departmental level, one from the municipal level, four from international cooperation institutions, three from local nongovernmental organizations (NGOs), three from youth organizations, and one each from an academic institution and a religious organization. Data saturation was determined based on the number of participants and by documenting evidence in field notes and memos (12). When new data emerged, subsequent interviews were conducted to cross-check, validate, and complement the existing information. This iterative process continued until no new data were identified.

Data Collection

Data were collected between October 2022 and April 2023. The interview guide was pretested with stakeholders similar to the target population, and feedback informed the needed adjustments. Subsequently, a representative from the partner organization reviewed and validated the guide for cultural and contextual appropriateness. The guide included core questions for all institutions, with tailored items reflecting each institution’s specific roles and responsibilities. For example, health or education-specific questions were prioritized for institutions directly involved in those services. Interviews were conducted in Spanish via Zoom, mostly with participants joining from their workplaces. Security measures included password-protected sessions, locked meetings, and recording alerts requiring consent. Interviews were audio-recorded and lasted approximately 75 minutes.

Data Management and Analysis

Recordings were transcribed verbatim using Trint. After revision, cleaned transcripts were imported into NVivo V.12 for analysis. Interviews were analyzed in Spanish, with quotes translated into English and reported by the participant code number. A reflexive thematic analysis was employed (13), using an inductive in vivo coding (14). Open codes were created based on participants’ words, and analytic decisions were documented through memos and an audit trail. Preliminary findings were shared with the partner organization for reflection, review, and validation, which informed subsequent analytic steps. As the analysis progressed, the data were classified into existing codes, with new codes created as needed. Similar codes were merged when similarities and patterns were found and subsequently consolidated into themes and subthemes. This process resulted in two main themes (barriers and opportunities) with 12 subthemes that addressed the research objective (Table 1).

TABLE 1. Themes and subthemes that inductively emerged from stakeholders’ interviews.

Themes and description	Subthemes	Description
Barriers: Factors that hinder the implementation of adolescent SRH interventions in rural Guatemala	Limited educational access and integration of CSE into the national curricu-lum	Factors that compromised the delivery of CSE included insufficient teacher training and limited integration of CSE into the curriculum, resulting in superficial and inconsistent implementation.
	Limited health care access, including youth-friendly spaces	Describes in-stitutional barriers that constrained the delivery of SRH services and were further compounded by the COVID-19 pandemic, limiting the health system’s capacity to provide differentiated and responsive care.
	Limited community acceptance and outreach capacity	Describes community-level factors that limit adolescents’ uptake of SRH information and services.
	Budget constraints	Highlights the limited and inconsistent funding and investments allocated to adolescent SRH strategies.
	Political turnover	Reflects how frequent changes in political leadership disrupt the continuity and long-term implementation of SRH initia-tives.
	Limited multisectoral integration	Refers to a limited multisectoral integration, resulting in fragmented, inconsistent, and uneven implementation of SRH strategies.
	Limited monitoring and evaluation capacity	Refers to the challenges in generating timely and high-quality SRH monitoring and evaluation data needed to track adoles-cent health outcomes and programmatic progress, challenges that were further compounded by the COVID-19 pandemic.
Opportunities: Factors that facilitated the implementation of adolescent SRH in-terventions in rural Guatemala	Strategic alliances	Describes the growing experience and capacity to build partnerships that strengthen long-term institutional cooperation in support of adolescent SRH initiatives.
	Community support networks	Describes the emergence of community members’ support networks to facilitate the acceptance of SRH information and ser-vices.
	Demographic changes	Refers to ado-lescent population trends that underscore the need for targeted policy attention and investment in adolescent SRH and well-being.
	Technology and social media	Highlights the increasing use of technology and digital platforms to provide adolescents with accessible SRH information and services.
	Integration of mental health services	Refers to how the growing recognition of mental health as a fundamental aspect of adolescents’ well-being has created oppor-tunities to integrate SRH with mental health support.

Source: Original table for this article based on data collected during fieldwork.

RESULTS

Study Participants

Seventeen females (85%) and three male stakeholders (15%) participated; 16 (80%) were aged 25–55 and four (20%) were aged 56–70. Ten (50%) self-identified as Mestizo, eight (40%) as Maya, and two (10%) identified as Ladino (Table 2).

TABLE 2. Stakeholders’ sociodemographic char-acteristics (n = 20).

Variables	n (%)
Sex
Female	17 (85)
Male	3 (15)
Age (years)
25–40	6 (30)
41–55	10 (50)
56–70	4 (20)
Ethnicity
Maya	8 (40)
Mestizo	10 (50)
Ladinoa	2 (10)
Language
Spanish	12 (60)
Both lan-guages (Q’eqchi and Spanish)	7 (35)
Spanish and Tz’utujilb	1 (5)
Marital status
Single	5 (25)
Married	13 (65)
Cohabitation	2 (10)
Religion
Catholic	13 (65)
Evangelical	1 (5)
Christian	3 (15)
Maya	2 (10)
None	1 (5)
Education level
Diversified secondary school	2 (10)
Undergraduate	7 (35)
Postgraduate	11 (55)

Source: Original table for this article based on data collected during fieldwork.

^aLadino is a mixed Indian-European descent and acculturated Indigenous people.

^bTz’utujil is another Mayan language predominantly spoken in the Sololá and Suchitepéquez depart-ments.

Barriers

Limited educational access and integration of CSE into the national curriculum. The analysis revealed significant barriers to educational access and the integration of CSE into the national curriculum. A departmental government stakeholder mentioned that high poverty rates force many young people to prioritize work over education. This situation leads to lower enrollment and retention rates, leading to disparities in access to education between female and male adolescents:

I have observed more adolescent boys than girls in schools. Although women constitute 51% of the population, this is not reflected in educational opportunities for girls and women. —A departmental government stakeholder, EIG-18.

This participant added that the Ministry of Education faces a scarcity of human resources, limited capacity for training schoolteachers, and monitoring CSE implementation. Although training schoolteachers is important, ensuring effective knowledge transfer remains challenging:

The [Ministry of Education] has failed to evaluate teachers’ CSE implementation with students because teacher training is one thing. Ensuring its implementation is another. The Ministry has designed monitoring tools but lacks financial resources, so verification has not been conducted. —A departmental government stakeholder, EIG-18.

Stakeholders from a central and a departmental government institution, two from international cooperation institutions, one each from a local NGO and a youth organization, shared that despite the national curriculum being legally mandated, teachers face various challenges in integrating and implementing CSE into classrooms. Few educators recognize its importance, and some resist due to their values, beliefs, and pressure from family and religious leaders. Consequently, teaching often focuses on biological and physiological aspects, while topics related to SRH rights, gender, and diversity are frequently overlooked.

Limited health care access, including youth-friendly spaces. The analysis identified several factors limiting health care coverage and access in rural areas. A departmental government stakeholder attributed this situation to budget constraints hindering the hiring and retention of community health care workers, further compounded by workloads that exceed their capacity:

The problem for the Ministry of Health is the workload. The Ministry manages over 22 health care programs. So, it is complicated to do everything well. —A departmental government stakeholder, EIG-11.

A municipal stakeholder echoed these observations, highlighting additional barriers such as inadequate infrastructure, limited supplies, and geographic distance to health posts. Another barrier was adolescents’ lack of recognition of health care services as a source for SRH information and services. A central government and two local NGO stakeholders reported that female adolescents seek care only when ill or for pregnancy-related follow-ups. One local NGO stakeholder emphasized the challenges pregnant adolescents face in accessing age-appropriate, differentiated care:

It does not matter if you are 11 or 12 years old; your role has changed because you are no longer a girl, you have become a pregnant woman. They will not treat you with the same rights as girls, but rather treat you as a pregnant woman, irrespective of your age. —A local NGO stakeholder, EIG-3.

The COVID-19 pandemic worsened these challenges, hindering the progress in expanding YFS coverage. The pandemic led to the temporary closure of these spaces, mobility restrictions, and fewer adolescents receiving care:

The Ministry of Health should be serving more than 300 000 adolescents. However, last year [2021], they could only serve 5 000 adolescents because the coverage decreased due to COVID-19. In 2019, the Ministry had approximately 250 friendly spaces, which dropped to 100. —A departmental government stakeholder, EIG-11.

Limited community acceptance and outreach capacity. The analysis revealed limited community acceptance and outreach capacity as barriers to community-based SRH programs. Three stakeholders from youth organizations reported resistance from community members, parents, and religious leaders toward adolescent participation.

One youth organization stakeholder added that geographic barriers further restrict outreach, with activities often concentrated near municipal centers. High transportation and food costs compounded this challenge. In response, some youth organizations train community youth leaders to disseminate SRH information, but ensuring effective knowledge transfer remains challenging.

Additionally, a central government and a youth organization stakeholder shared that community-based organizations mainly depend on volunteers to provide information. However, the need for volunteers to seek stable job opportunities contributes to high turnover, complicating long-term implementation:

We do not control the issue of young people volunteering in community-based organizations. Maintaining coordination with them is complicated, but it is inherent to the dynamics of these organizations. —A central government stakeholder, EIG-6.

Budget constraints. A significant barrier identified in the analysis concerns public health budget constraints. A central government stakeholder, two from departmental governments, three from international cooperation institutions, and one local NGO stakeholder highlighted the Guatemalan government’s limited ability to secure and allocate dedicated funding for SRH strategies. They explained that due to this situation, public institutions rely on international funding. However, one departmental-level stakeholder emphasized that such support is often short-term and lacks sustained commitment. When agencies withdraw, local institutions must continue without adequate resources or capacity:

Most international agencies provide support. The biggest weakness is the short time. They come and support us, but leave, and we stay the same. They expect the Ministry of Health to take over, but how can it if it barely has funding? —A departmental government stakeholder, EIG-11.

Political turnover. A significant barrier to SRH program continuity is political turnover. Stakeholders from two international cooperation institutions, one youth organization, and one faith-based organization explained that each administration introduces strategies aligned with its political agenda. One international cooperation stakeholder emphasized that such turnover hinders continuity of financial resources and long-term implementation, as shifting priorities and resistance to SRH-related topics undermine implementation:

No long-term public policies exist because each new government creates its own, causing discontinuity. Our topics of interest may not be a new government priority, and they are often resistant. Guatemala is a conservative country, and political conservatism is often used to support or oppose public policies. —An international cooperation stakeholder, EIG-16.

Limited multisectoral integration. Limited multisectoral integration is a barrier, leading to fragmentation and uneven implementation of SRH programs. An international cooperation stakeholder highlighted that dividing PLANEA’s strategic focus areas among various institutions has led to disjoint efforts and a lack of integrated interventions:

You have [the Ministry] of Education conducting activities in one municipality and [the Ministry] of Health in another. The logic is the integration of actions; otherwise, it is challenging to achieve results. —An international cooperation stakeholder, EIG-16.

A departmental government stakeholder echoed these observations and added that assigning each focus area to different institutions contributed to fragmentation:

Our mistake was dividing PLANEA’s strategic focus areas and assigning each to a different institution, which is why actions were somewhat fragmented. —A departmental government stakeholder, EIG-18.

Another international cooperation stakeholder shared that this fragmentation hampered the reach to certain communities, creating uneven implementation, with some initiatives advancing more in some areas than others.

I am in Cobán [the capital of Alta Verapaz] and can implement activities here. I don’t work in Carchá, San Cristóbal, or Santa Cruz [other municipalities]. While we form alliances, we cannot extend our reach to all municipalities and communities. —An international cooperation stakeholder, EIG-4.

Limited monitoring and evaluation capacity. The analysis revealed significant barriers hindering the monitoring and evaluation of SRH implementation. Two youth organizations’ stakeholders mentioned logistical constraints, including difficulties with meeting coordination, which limit oversight. Many stakeholders must travel to Cobán, further reducing participation. The COVID-19 pandemic exacerbated these challenges, as public health priorities shifted:

In 2020, the whole world was grappling with the pandemic. We were focused on saving lives and surviving, so evaluating the plan was impossible. —A departmental government stakeholder, EIG-11.

Opportunities

Strategic alliances. The analysis revealed significant opportunities to build stronger partnerships and promote long-term collaboration. A departmental government stakeholder highlighted that years of experience implementing PLANEA have enhanced institutional capacity and fostered alliances with various institutions. Consequently, they emphasized the importance of nurturing these partnerships to advance multisectoral, interinstitutional, and long-term cooperation:

We have matured; we now understand what we must do; we have established strategic allies. I have discussed long-term projects with NGOs, UNICEF, and PAHO. —A departmental government stakeholder, EIG-11.

Community support networks. The analysis revealed that despite community resistance to adolescent SRH programs, progress has been made in increasing participation and building community support networks. A local NGO stakeholder highlighted the increased involvement of youth leaders, parents, traditional midwives, and community leaders. While engaging church leaders remains challenging, some faith-based organizations are willing to promote informative spaces, offering opportunities for collaboration:

The Catholic and Evangelical churches often avoid SRH topics. However, we have identified leaders who are highly aware of the implications of these issues. Therefore, they can serve as strategic allies. —A local NGO stakeholder, EIG-1.

Demographic changes. This study identified significant opportunities resulting from demographic change, particularly Guatemala’s growing adolescent population. An international cooperation stakeholder explained that this shift offers an opportunity to address adolescents’ SRH needs, mobilize resources, and increase investments in programs and policies, promoting development and social transformation:

Sixty percent of the population is under 30. This demographic shift represents what is known as a demographic bonus. Guatemala has a significant population of adolescents and young people, and we must begin developing policies to address the needs of this demographic group. —An international cooperation stakeholder, EIG-16.

Technology and social media. Significant opportunities were identified that are associated with access to technology and social media for disseminating SRH information, particularly following the COVID-19 pandemic. Stakeholders from a central government institution, an international cooperation institution, and a local NGO highlighted the shift to digital platforms as an opportunity to enhance professional training and expand outreach in remote areas.

Stakeholders from a departmental government institution, an international agency, and two local NGOs noted that the Internet and social media are valuable channels for engaging adolescents and community members, thereby increasing access to SRH activities and preventative care:

The post-COVID era represents an opportunity to leverage virtual platforms. Providing adolescents with their space is essential, as they remain connected. Rather than delivering traditional workshops, we can use technology to send them information to their phones. —A local NGO stakeholder, EIG-3.

Integration of mental health services. Stakeholders reported increased demand for and acceptance of mental health services, attributed mainly to COVID-19. Stakeholders from a central government institution, an international cooperation institution, and a youth organization mentioned that the pandemic heightened mental health awareness, fostering greater openness to seeking support.

This shift created opportunities to integrate mental health into SRH interventions, addressing GBV and suicide prevention related to adolescent pregnancy. A youth organization stakeholder also mentioned a decline in mental health stigma, contributing to more open and normalized discussions:

COVID-19 has adversely affected mental well-being. In Alta Verapaz, we have observed more patients requiring psychiatric and psychological services. This trend indicates that there is now more open dialogue about mental health issues. —A youth organization stakeholder, EIG-10.

DISCUSSION

Developing and implementing adolescent SRH initiatives and policies is complicated and multifaceted. Guatemala exemplifies the government efforts of lower- and middle-income countries (LMICs) to reduce adolescent pregnancies through multisectoral and interinstitutional strategies, such as PLANEA. The study identified barriers and opportunities in implementing adolescent SRH strategies in rural Guatemala.

Persistent barriers hinder SRH program implementation. The Ministry of Education struggles to integrate CSE into the national curriculum. Although Guatemalan legislation supports school-based CSE (15), no national program exists (16). Instead, CSE content is integrated cross-sectionally in specific subjects. Ecuador’s Ministry of Education faces similar challenges in incorporating CSE nationally, resulting in youth’s limited access to CSE and reliable SRH information (17). In Mexico, the constitution recognizes CSE as a human right and mandates its implementation (1), yet the provision remains insufficient, especially among Indigenous communities (1).

Challenges in hiring and training teachers are compounded by family, cultural, and religious values that hinder addressing sensitive topics, as documented elsewhere (1, 18). Reaching out-of-school adolescents in poverty and rural communities remains challenging for school-based CSE. Indigenous adolescent girls complete fewer schooling years than boys due to poverty, household duties, early marriage, and motherhood, reinforcing gender disparities (7). Providing CSE through parents, health care providers, youth leaders, and digital platforms may increase access (1). Additionally, incorporating gender perspectives and Indigenous languages could expand outreach while promoting gender equality by empowering girls to challenge restrictive norms (1).

This study found that adolescent girls rarely seek SRH information at health care facilities and access prenatal care sporadically or late in pregnancy. Pregnant adolescents are frequently treated as adult pregnant women. Despite global efforts to implement differentiated care (19), nonpregnant or single adolescents receive pediatric services, while married or pregnant adolescents are treated in adult care settings (20).

The COVID-19 pandemic reduced YFS coverage, compounded by limited awareness of their purpose, scope, and services (21). Addressing these gaps requires mapping existing YFSs, defining services, standardizing indicators, strengthening monitoring and evaluation, securing specific funding, and raising awareness to ensure access for all adolescents regardless of marital or parental status, as documented elsewhere (21). Strengthening differentiated SRH service delivery, particularly preventative, antenatal, and childbirth care that is culturally and age-appropriate, remains essential.

Youth organizations struggle to reach remote communities, underscoring the need to engage youth leaders and community authorities. Youth participation is most effective when adults offer opportunities, assistance, and guidance to develop leadership (22). Many community-based organizations rely on youth volunteers to disseminate SRH information (18). Peer educators serve as role models, facilitating counseling, distributing contraceptives, and referring adolescents to health care (23). Evaluating innovative peer-to-peer strategies is crucial to enhancing engagement, knowledge transfer, and sustainable SRH implementation in isolated communities.

Despite PLANEA’s decade of experience, coordinating multi­sectoral efforts remains challenging. Although multisectoral approaches can improve coverage and reduce inequities (24), limited integration, fragmentation, and uneven implementation undermine outcomes (25). Barriers include differing priorities, funding streams, and timeliness (26). Strengthening multisectoral work requires sustained political commitment, high-level leadership, cross-institutional coordination, and strong partnerships among government, local institutions, international cooperation, and local communities. Coordination must extend to communities to align with local structures, cultural norms, and social dynamics, ensuring responsiveness and sustainability. Further research should examine governance and contextual factors facilitating integration at institutional and community levels in Guatemala and similar LMICs.

Given the growing adolescent population in LMICs (27), improving domestic public funding and governance for SRH initiatives should be a global priority. This study found that budget constraints and political turnover destabilize SRH implementation, as new administrations often shift funding priorities or reshape ongoing strategies. Consequently, SRH relies on short-term external funding, which creates instability when donor projects conclude. Sustained progress requires political commitment, advocacy during government transitions, and dedicated funding that protects SRH investments, as documented elsewhere (18). Governments and partners should prioritize and track long-term funding and investments and explore complementary domestic mechanisms to reduce reliance on external aid. Strategic advocacy, cost-effectiveness analyses, and youth-led initiatives may also support such efforts to demonstrate SRH’s broader societal benefits and justification for prioritization. Donors must uphold principles of equity, equality, diversity, and inclusion to build lasting partnerships and empower communities and local institutions in decision-making and resource governance (28). Accountability mechanisms, mutual agreements, progress assessments, and reflective processes to identify lessons learned and areas for improvement should be considered (29). Together, such approaches can enhance shared goals, transparent resource management, local capacity, leadership, ownership, sustainability, and trust, all essential for advancing adolescent SRH interventions despite financial and political uncertainty.

The authors also highlight the opportunity for integrating mental health services due to the associations between GBV, early pregnancy, forced marriage, emotional distress, and suicide. Protocols for adolescent sexual violence response in Latin America are critical (30), especially for Indigenous girls, who face higher risks of violence, early pregnancy, and suicide (31). While COVID-19 posed challenges, it also increased mental health awareness and service demand. Addressing these needs requires recognizing cultural differences in how Indigenous peoples perceive and express emotional distress (32). Future research should guide the integration of GBV and suicide prevention into SRH services, ensuring culturally responsive care for Indigenous adolescents.

Limitations

Social desirability bias may lead to underreporting or superficial responses (33). Although videoconferencing offers advantages for qualitative research (34), the lack of physical proximity, limited ability to assess surroundings, and privacy concerns may have discouraged disclosure of sensitive information. Purposive and snowball sampling limit representativeness and generalizability (35). Because the study focused on four purposively selected rural, predominantly Q’eqchi communities in Alta Verapaz, the findings are not intended to be generalizable to all Guatemalan settings. However, the study provides a rich, contextually grounded understanding of stakeholders’ perspectives, and themes may hold analytical transferability to similar rural, Indigenous, and resource-constrained contexts. Its value lies in generating nuanced insights to inform adolescent SRH strategies in comparable settings, rather than producing nationally or globally representative conclusions.

Conclusions

This study deepens understanding of barriers and opportunities in implementing adolescent SRH interventions in rural Guatemala. Despite government and local institutions’ efforts to reduce adolescent pregnancies, significant barriers remain, exacerbated by COVID-19. However, the pandemic also catalyzed opportunities to address adolescent SRH needs comprehensively. Future research should explore mechanisms to strengthen government leadership and advocacy, multisectoral coordination, and sustainable funding. Equitable collaboration among the government, donors, local organizations, adolescents, and communities is crucial to integrate efforts, ensure sustainability, and advance adolescent SRH interventions.

Data availability statement.

Following ethical guidelines and informed consent terms, full interview transcripts cannot be shared publicly to protect participants’ and institutions’ confidentiality. De-identified data may be made available upon request to the corresponding author, subject to approval from the Hamilton Integrated Research Ethics Board (HiREB) in Canada (eREBhelpdesk@hhsc.ca) and the National Health Ethics Committee in Guatemala (comitenacionaletica@mspas.gob.gt).

Ethical approval.

This study was approved by the National Health Ethics Committee in Guatemala (Resolution 14-2022) and the Hamilton Integrated Research Ethics Board in Canada (Project number: 14301). All participants provided written informed consent. Participants were informed of their right to withdraw from the research activities at any point in time and could decline to answer questions they did not feel comfortable sharing without the need for explanations. All recordings, informed consents, and transcripts were stored on a secure drive and de-identified with an alphanumeric code to ensure confidentiality and anonymity.

Patient consent for publication.

Participants provided permission to report and publish direct quotations from interviews with all personal information removed and referenced by participant code number. Anonymized excerpts (direct quotes) supporting the study’s findings are included within the manuscript.

Funding Statement

The authors received no financial support for the research, authorship, or publication of this article.

Disclaimer.

Authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the RPSP/PAJPH and/or PAHO.