Abstract
Service learning experiences abroad provide an excellent opportunity for seasoned health educators to share their skills with underresourced communities in other parts of the world while enriching their own professional development. Health educators have not traditionally participated in short-term medical service trips, which have become a popular humanitarian effort, yet their contributions can expand the scope of these efforts. With our responsibilities often focused on assessing needs, planning, implementing, and evaluation, seasoned health educators can provide guidance for new initiatives and share health promotion materials and other resources with communities in other parts of the world. In this commentary, I detail my experience as the first health educator to volunteer with a medical brigade that has served a rural community in Honduras for nearly two decades, and describe my added contribution of a brief intervention to address teen pregnancy during the brigade’s annual, medically oriented visit. I also reflect on the benefits to my professional growth from this opportunity to immerse myself in four very familiar areas of responsibility for health education in a new and unknown setting.
Keywords
There are more opportunities than ever for service learning experiences abroad, providing a chance for seasoned health educators to share their unique skills and expertise in a very different venue from that to which they may be accustomed. With our responsibilities often focused on assessing needs, planning, implementing, and evaluation, health educators have much to offer underresourced communities in other parts of the world. In this commentary, I will detail my experience as a volunteer on a short-term medical assistance trip to Honduras describing my contributions to the community and how this work has enhanced my professional development. Although this commentary is primarily focused on this type of volunteer experience abroad that I sought to further my professional development later in my career, service learning abroad experiences can also provide practicum settings for graduate students to apply concepts and skills learned in the classroom.
In recent years, there has been significant growth of short-term medical service trips, also known as “medical brigades,” comprising mostly health clinicians volunteering medical services often in response to disasters like hurricanes and earthquakes but also for nonemergent conditions and humanitarian causes (Asgary & Junck, 2013). They may be organized by medical, religious or other organizations and offer health services that include family medicine, surgical, dental, ophthalmologic, or other specialist services (McLennan, 2014). These services, often provided in temporary clinics, are usually targeted at poor or rural populations and generally are welcomed by communities in need but have been criticized for both their failure to address the primary sources of the health care problems in the community and also for not providing sustainable programs or services (McLennan 2014, Sykes, 2014). Health educators surprisingly have not had a large presence on volunteer medical brigades (Sookhoo, 2014).
Community Abroad Context
In Honduras, more than 66% of the population are living in poverty; in rural areas, approximately one out of five Hondurans lives in extreme poverty (World Bank, 2016). For the past 18 years, ever since a hurricane devastated the area, the Organization for Community Health Outreach (OCHO) has sent a medical team to Atima, Honduras, a remote, medically underserved, mountain community of approximately 16,000 located within the province of Santa Barbara. While the majority of the homes in town now have electricity, many of the dwellings in the outskirts still have dirt floors and are without electricity or plumbing. Most of the older adults in the community have not attended school beyond sixth grade. Those who have found work are often employed by coffee farms in the area. The younger members of the community are staying in school longer and have broader career goals despite the many obstacles that remain. In addition to providing direct medical care in pediatrics and family medicine, obstetrics, and ophthalmology during its annual 5-day summer visit, OCHO has assisted this very motivated community with sustainable projects that include building clean-burning cooking stoves, supporting the construction of a water purification plant, and setting up pediatric occupational therapy treatment for the disproportionate number of youth suffering from birth defects (http://ocho.org/en/our-projects/).
In June 2015, a physician friend told me about the OCHO 40-person medical brigade based in Baltimore, Maryland. Eager to have an international health experience to enrich my teaching of an undergraduate multicultural health class, I became the first health educator to join the brigade. Originally, I was unsure as the brigade’s health educator of how I could best contribute to OCHO’s many efforts, but it was on Day 1 of my first visit to Atima that I learned of the alarming teen pregnancy rate of 67% (of the approximately 4,000 young women age 12-19 residing in the area; Centro de Juventud de Atima, 2016), and quickly recognized where I could be of most assistance. Town leaders informed me that reducing teen pregnancy is a priority area for Honduras, which has the third highest adolescent fertility rate in Central America at 77.8 births per 1,000 women ages 15 to 19 (United Nations, 2017), and that the First Lady of Honduras has encouraged local governments to intensify their efforts. The very next day, without much in the way of materials, I delivered a half-day workshop, with a translator, for teen leaders and concerned parents that covered adolescent health issues. The teens and parents warmly invited me to participate in additional gatherings that week, which served as a helpful preview to a more intensive effort I would plan to address teen pregnancy during the brigade’s visit the following summer.
Preparing For Service Learning Trip Abroad
I quickly began planning “off-season” for the following summer. Since my Spanish was limited, my first step was to apply for a grant from the university for funding to hire a Spanish-speaking, public health undergraduate student to help me develop training materials and serve as my translator when I returned to Atima. The student also helped me practice and improve my command of Spanish to that I would be able to present some of the material myself. I also submitted an application to my university’s institutional review board so that I could conduct pre-and posttest surveys with participants to evaluate my work in Atima.
Next, to get a better idea of the community’s needs, practices, and culture, I developed a written questionnaire (and had it translated into Spanish) for the town’s medical and teen directors. The questions inquired about the teens’ attitudes and norms related to sexual health and pregnancy, their general knowledge about contraception and the current threat of Zika, the acceptance of teen pregnancy within the community, the effects of early pregnancy on educational attainment, the living arrangements for young parents, and career opportunities for teens in the region. I also asked the medical director about the involvement of promotores de salud, trusted community members trained to provide health information who have a long history of providing health promotion to Latinos (Fisher et al., 2014).
The responses from the town’s medical and teen directors informed the charlas I created for Atima’s teens, parents, and promotores. Charlas are structured discussions with activities and materials (workshops) that have been found to be culturally appealing and successful in reaching populations in rural Honduras with low literacy levels (Sookhoo, 2014). I developed a basic 90-minute workshop that could be adapted to fit the needs of the different stakeholder groups: the younger teens from the high school, teen leaders participating in a separate teen empowerment program, parents/grandparents, and promotores. The goals for teen workshop participants were to (1) consider the risks involved with having a baby early, including the potential interruption of educational/career goals and financial stability (as well as the threat of Zika to a baby’s development); 2) increase familiarity and comfort with condoms and Depo Provera and accessing them from the clinic; and (3) practice expressing their wish to delay sexual activity and suggest alternative activities with a romantic partner. The adult workshops with the parents and promotores focused on helping teens in the family and in the community reduce early pregnancies, and included a contemporary Spanish video demonstrating how to talk to teens about delaying sexual relationships (Planned Parenthood, n.d.).
I created a 12-item evaluation instrument that was translated into Spanish to be administered pre- and postworkshop. As part of the planning process, I also collected health education materials, created Spanish materials and met with a health educator from Planned Parenthood to learn more about their resources for Spanish speakers as well as culturally relevant materials from other sources.
Highlights Of Experience Abroad
During the brigade’s 5 days in Atima, I conducted 5 workshops with 13 teen leaders, 20 teens from the high school, 8 promotores, and 45 parents and grandparents. Despite the sensitive nature of the material, the trainings were extremely well received. Both groups of adolescents were enthusiastic about engaging in the workshop activities and surprisingly not shy about the topic. The promotores, mostly young adult men, many of whom were fathers themselves, were eager to serve as a resource helping teens in their assigned areas delay pregnancy. Having so many grandparents attend the charlas was a pleasant surprise. It was an unexpected privilege to educate these receptive older adults, many of whom are the primary caretakers of the adolescents and were unfamiliar with contraceptive methods and how to engage their grandchildren in these difficult conversations.
In an effort to help the new town clinic be more welcoming to adolescents, I convinced the medical director to hold a teen party at the clinic. What was planned as a small gathering turned out to be a huge fiesta with over 100 people attending. The youthful subset of the brigade and I walked into a lively party where we received a standing ovation from a spirited crowd, the mayor, and a five-piece band! The teen leaders presented a comical skit about a young father who was unable to raise his son properly and then an edgy video they had produced that very afternoon immediately following the workshop. The video featured the more sophisticated teen leaders sharing the many reasons and strategies they would employ for delaying parenthood. Seeing this unplanned video produced as a result of my workshop with this enterprising group of young people was one of my proudest moments as a health educator.
An unexpected opportunity for health education occurred when I was invited for an interview on the town’s evening news television show watched by most residents each night. My undergraduate student translator and the clinic nurse, who helped me deliver the workshops, joined me on the set to explain how the contraceptives worked and could be obtained from the clinic. We also used this opportunity to share information about Zika, and had the camera zoom in on Spanish print materials about the virus. To my delight, the television producers then showed me that they were running the Planned Parenthood video on a continuous loop in between station programming, to educate the parents and grandparents who were unable to attend the workshop.
Program Evaluation
Only the teens and promotores completed the pre- and posttest surveys around the workshops since many of the parents and grandparents did not read and write. A statistician at my university assisted me in analyzing the mean differences in the pre–post scores for the survey. We used a two-sample t test that provided information about the significance of changes in pre-and posttest knowledge and skills related to using and obtaining contraceptives, and changes in attitudes about early pregnancy and the importance placed on graduating from high school. These data, along with the rich responses to open-ended questions included in the survey, helped form the recommendations I provided to the community.
For all three groups completing the surveys, responses revealed that there is widespread concern about early pregnancy and awareness of the obstacle it poses to achieving future goals, as well as interest in the use of contraceptives to help reduce early pregnancy. There was a significant change in knowledge and skills related to use of condoms and Depo Provera especially among the group of the younger, less informed teens. Survey results with the town’s eight promotores confirmed that they are eager to serve as a resource for family planning for young people in the community.
In addition to the positive evaluation data from the pre-and posttest surveys given around the workshops, I felt that my success in Atima working to reduce teen pregnancy was measured by the robust participation in the teen party held at the clinic and the overall warm and receptive sentiment expressed by the community in response to my efforts. They welcomed me into their homes and their television studio. On our last night in Atima, during the brigade’s farewell party, the medical director expressed the most heartfelt “gracias” for my work. From the analysis of the data I collected from the workshop surveys and my personal observations, I provided recommendations to the town leaders for reducing teen pregnancy (see Table 1).
Recommendation for Atima’s Town Leaders for the Reduction of Teen Pregnancy
Lessons Learned
Health educators can greatly expand the impact of volunteer medical brigades by providing receptive communities with workshops and much-needed health education materials. In my opinion, it works best for health educators to support goals already identified by the community, and programs that communities can implement on their own during the 51 weeks of the year that the brigade is absent. In a debriefing session following the brigade’s return to Baltimore, a veteran physician member shared that she thought the addition of health education initiatives to OCHO’s efforts would be of more lasting benefit than the quicker medical fixes typically provided (D. Silver, September 24, 2016, personal conversation with brigade pediatrician).
This unexpected comment affirmed the notion that health educators have the potential to expand the efforts of short-term medical brigades in meaningful ways. I enjoyed this special opportunity to work more closely with clinicians than is usual for me. My time in Atima has enriched my professional development in other ways as well. This experience allowed me to immerse myself in four very familiar areas of responsibility for health education: (1) assessing needs, resources, and capacity; (2) planning; (3) implementing; and (4) conducting evaluation and research (National Commission for Health Education Credentialing, 2015) in a new and unfamiliar setting with different cultural norms. And, for the first time, I used resources at my university for funding and research support, creating a manageable research project that has provided opportunities for professional presentation and publication. In the classroom, I enjoy sharing my brigade work with my students as an example of how a health educator approaches a community health challenge while also showing passion for my career choice. As a result of sharing my work in Atima with students in my classes, I received an invitation to serve as the faculty leader of an alternative spring break trip to another region of Honduras. I also look forward to returning to Atima this summer and hope that other health educators, no matter where they are in their careers, will consider the many benefits of engaging in service learning experiences abroad.
Footnotes
Acknowledgements
Sincere appreciation is extended to Melissa Hawkins, Moon Oulatta, and Gabe Gan for assistance with data analysis; to Chloe Abarbanel, Luis Landau, Anna Lapera, Sarah Lever, and Cristina Saens de Tejada for programmatic and translation assistance; and to the teen participants and the many supportive adults in Atima, Honduras, including Dr. Patrocinio Sarmiento, Dani Vega, Karen Vega, Marvin Sarmiento, the concerned parents and grandparents, and the promotores.
