Global Health & Health Disparities Program (GH2DP): Public Health Projects

 
 

A key component of our global health work involves public health interventions. Via partnerships with numerous non-profit organizations and Departments across Virginia Commonwealth University, in close collaboration with the local Ministry of Health and community leaders, our program has been active in quality improvement as well as public health projects at our Yoro, Honduras site since 2008. The following paragraphs briefly outline some of this work and highlight some of the key lessons we have learned.
















January 2012: Drs. Mason, Stevens & Bearman meeting with local health and community leaders.


In 2006 we evaluated clinical encounter forms from a brigade to the Siguatepeque area of Honduras to categorize the presenting complaints of patients seen. A total of 2,124 patient encounter sheets were investigated; there were 1,660 female patients (78%) and 464 male patients (22%). A total of 3,378 complaints were examined with the majority of complaints being related to pain (56%), dermatologic complaints (7.5%), gastrointestinal complaints (6.7%), constitutional symptoms (5.8%) and respiratory complaints (5.2%). This analysis taught us a great deal about the principle health concerns we were likely to encounter on subsequent medical relief brigades to Honduras, and helped us streamline and improve our medical care on these subsequent trips.


In 2008 we conducted a needs assessment survey in Yoro that consisted of a 29 question survey that collected information on demographics, environmental health pressures, presence of chronic illness, access to healthcare and perceived critical health issues. The majority of respondents indicated living in sub-standard, crowded housing. 39% noted having dirt floors (increasing the risk for infections such as hookworm), with 20% having mud/stone walls (which increases the risk for chagas disease). 8% indicated their primary source of drinking water was a river or stream, and 21% indicated no method of water treatment prior to drinking (both of which are risk factors for water-borne illnesses). 13% of respondents noted having access to sub-standard latrines, and 57% indicated that animals (such as chickens and pigs) had direct access to homes. 52% noted disposing of waste via burning in their yards (which can be associated with acute and chronic respiratory illness). 47% noted having chronic medical conditions such as arthritis, diabetes or hypertension. Although the majority of patients (97%) noted brushing their teeth daily, less than 50% used a toothbrush to do so. 41% noted having issues with their vision. In terms of principle health concerns, water sanitation, nutrition, access to medicines and medical care and infections were noted as the primary concerns.


A slightly modified version of the same needs assessment survey was administered in 2009 with similar findings.


In 2009-2010 a workgroup was formed to evaluate our work to date in Yoro with the goal of improving our care delivery and process. Out of this workgroup we changed our clinical encounter mechanism from a traditional one patient to one provider clinical encounter to a “team-based” process designed to improve care delivery, standardize the care delivered (across providers with various levels of experience practicing in this resource-limited setting) and to improve patient satisfaction. When we compared the traditional method to the team-based method we found the latter was associated with improved compliance with various health screens. 314 patients were seen under the team-based model with 153 patients being seen using the traditional model. In terms of screening for diabetes 311 patients (99%) were screened with the team-based model whereas 61 (39%) were screened with the traditional model (p < 0.001). 304 patients in the team-based group (96.8%) were screened for candidacy for anti-helminithic therapy, versus 139 (90.8%) in the traditional model group (p =0.006). Given the success of this model it has been deployed on our subsequent brigades to the Yoro area.


In 2011 Kate Pearson, currently a second year medical student at VCU, conducted a survey project on barriers and access to healthcare. Her work focused on the suburban community of Coyoles and the rural, mountainous areas of La Hicaca and Lomitas. She collected 220 surveys and found that 70% of respondents in Lomitas had no contact with a healthcare provider in the preceding 12 months, versus 43% of people in La Hicaca and 28% in Coyoles. All 3 communities reported cost, distance, transportation, facility crowding, work obligations and availability of childcare as being barriers to accessing care. Lomitas had the greatest barriers to accessing care, with over 80% of respondents noting significant barriers. These data clearly indicated that barriers to accessing care were greater in the rural communities of La Hicaca and Lomitas as opposed to the suburban area of Coyoles. These data were discussed with local community leaders and the Ministry of Health, and helped our group decide to focus our efforts more exclusively on the rural areas of La Hicaca, Lomitas and the surrounding villages. During our January 2012 trip we confirmed that we are currently the only group traveling to these remote areas and that people in this region have little to no alternative access to medical care.


In 2011 Gaby Halder, MPH, currently a second year medical student at VCU, administered a 20-item survey on water sanitation to people in Coyoles, La Hicaca and Lomitas. 263 surveys were obtained. 12.5% of respondents noted obtaining their drinking water from a river. Notably, the percentage of respondents obtaining their water from a river was significantly higher in the most rural of these areas, Lomitas, when compared to the other sites (62%, p < 0.0001). The most common water sanitation methods included using filters (31.9%), purchasing bottled water (19%) and using chlorine (14.8%). Lomitas had the largest percentage of respondents not utilizing any method of water sanitation (60%). This community also had the highest self-reported incidence of diarrheal illness, with over a quarter of participants reporting diarrhea in the preceding 30 days.


We have also been actively involved in a water filter program designed to deliver clean drinking water to people in La Hicaca and the 17 surrounding villages since 2008. Via an in-country group employing local artisans (Potters for Peace) we obtain water filters from Tegucigalpa; these filters are ultimately deployed in and around the La Hicaca area. Each water filter provides clean drinking water to an entire family for 2 years. To date, approximately 150 families in these 17 villages have a working water filter, with the incidence of diarrheal illness decreasing from 2.62 per 100,000 person days prior to this program to 1.23 per 100,000 person days following the initiation of the program. Anecdotally, local health officials have noted a decrease in infant mortality secondary to diarrheal illness in this area.


In 2012 Jackie Arquette, a second year medical student at VCU, conducted a formal survey investigating the utility of our water filter project with concurrent testing of water from the filters. She found that our water filters do not completely sterilize water, however, they do significantly reduce the presence of diarrhea-genic bacteria, and decrease the self-reported incidence of diarrheal illness, as well. Audrey Le, also a second year medical student at VCU, conducted a survey investigating issues around indoor air quality, a project that was requested by the local Ministry of Health and our community partners. She found that people living in this area have a poor understanding of the relationship between smoke inhalation and respiratory problems. This research was shared with the local Ministry of Health and our community partners in January 2013 and led to the development of an educational campaign that was rolled out in May-June 2013; Audrey Bowes, a rising VCU 2nd year medical student, was the lead on this project.


In addition to the indoor air pollution educational campaign, in May-June 2013 we also administered a ‘satisfaction with brigade care’ survey designed to improve the care and services we provide. This project is being led by Dr. Jeff Wang and Kate Pearson, a rising 4th year VCU medical student. We also administered a Chagas disease knowledge and attitudes survey, a project led by Dr. Summer Donovan.










 

Global Health & Health Disparities Program (GH2DP)

Public Health Work in the La Hicaca Region; What We Have Learned & Progress to Date:


*Most people live in sub-standard housing in crowded conditions with significant environmental health pressures


*Most people are impoverished with poor access to medical care and medicines


*Access to clean drinking water is a major issue and associated with significant morbidity


*Water filters are a practical means to provide clean drinking water; since the inception of our water filter program the incidence of diarrheal illness has decreased by approximately 50% in this region


*Long-term, sustainable access to clean water and sanitation are major goals of the local communities and our group; one of the biggest challenges to providing sustainable access to clean water is poor infrastructure (e.g., roads that would permit heavy drilling equipment for well creation don’t exist)


*Our water filters do not completely sterilize water, however, they do decrease the burden of diarrhea-genic bacteria dramatically, and decrease the self-reported incidence of diarrheal illness, as well


*Community leaders in this area note indoor air quality as being a principle health concern; this may in part be related to issues with stove construction


Key Resources:

*Global Health Research

For more information contact:


Michael P. Stevens, M.D., M.P.H.

P.O. Box 980019

Richmond, Virginia 23298-0019

Phone: (804) 828-2121

mstevens@mcvh-vcu.edu

June 2008, Dr. Lillian Flores Stevens administers a needs assessment survey in La Hicaca.

June 2010: Residents and students seeing patients via the team-based encounter method.

June 2011: Gaby Halder & Kate Pearson interviewing people in La Hicaca

June 2010: Working on the water filter project.

May 2013: Indoor air pollution awareness project