Needs assessment of the Loreto region
The beginnings of Comunidades Unidas Peru trace back to the summer of 2008, when three first year students from University of Colorado School of Medicine (CUSOM), Annie Slaughter, Todd Carlson and Chris Warner, traveled to the Loreto region of Peru. They planned a project mapping the region’s health resources (providers, facilities, etc.) using Geographic Information Systems (GIS) technology in order to help Colorado-based Centura Health Global Health Initiatives and other international NGOs collaborate and best serve the area’s health needs. They also participated in two week-long mission trips with Centura and Lima-based DB Peru, working in clinics, familiarizing themselves with the region and making helpful contacts in the area. They identified several barriers to health care access faced by villagers, including poorly supplied health facilities, lack of medicines in villages or health facilities, long distances to government health care facilities with poor transportation. Villages were situated up to 8 hours by boat from the nearest doctor, and as many as 2 hours from the nearest health post with a tecnico. The only easily accessible health care was provided by lay village health workers or promotores, who were farmers and fishermen elected from within the communities, and who rarely had formal health care training.
Planting the seeds of a student global health project
Enticed by opportunities for global health projects and adventure in the Amazon, four new first year medical students traveled back to the region in the summer of 2009. The group again participated in Centura’s week-long medical mission, performing surgeries at the regional hospital in Iquitos and village clinics on the Napo and Amazon Rivers. This week with Centura opened their eyes to the importance of understanding of the local health care system and epidemiology of local illnesses and of focusing on enhancing local capacity. The group wrote a manual of important things to know and best practices for future Centura volunteers. The group also focused on developing a long-term student project in the region that was sustainable, culturally appropriate and based on proven interventions. To this end, they collaborated with Diana Bowie of DB Peru, who helped them brainstorm project ideas and connected them with invaluable contacts and logistical information. Armed with this information, three first year medical students as well as a first year pharmacy student were added to help develop a curriculum. Holding to the belief that any curriculum would have to be compatible with the roles and skills expected of promoters by the Peruvian national and local Ministry of health.
The first trainings
In June of 2010, first year students traveled to Loreto, again collaborating with Centura on their village clinic trips. Working with Diana Bowie and meeting with regional Ministry of Health officials, the students began to organize the logistics and plan the curriculum of our first set of health promoter trainings. When rising fourth year medical students Chris Warner, Annie Slaughter and Todd Carlson returned to the region, the entire group hammered out a lesson plan for two day trainings. The curriculum was based on Ministry of Health materials, including a “rotafolio” or a flipchart of drawings and bullet points for health promoters to take into homes in their village and teach community members about health behaviors. Over four weeks the combined group taught four two-day classes of approximately 30 promoters. The group also split into three smaller groups to visit randomly selected villages and observe the promoters’ interaction within their communities and to practice home visits using the rotafolios.
CU Peru is born
Encouraged by our early success, four new first year medical students were recruited as well as three Physician Assistant students. In order to ensure long-term viability, enhance our leadership, and provide a vehicle for fundraising, we registered as a not-for- profit 501(c)3 in January 2011. We also brought in a new faculty adviser, Dr. Richard Anstett, to replace Dr. Cal Wilson who moved to Rwanda at the end of 2010. We later added Dr. Jennifer Bellows and her husband, Dr. Jason Bellows, to our advisory group. With a growing number of volunteers and tasks to complete, we structured our organization in four committees: curriculum development, research, fundraising and logistics.
On further literature review, we discovered the Integrated Management of Childhood Illnesses (IMCI) program, developed by the WHO and validated in multiple settings. Based on IMCI principles of danger sign recognition, we designed lesson objectives for vital signs skills, diarrheal illness triage and management, and community health and disease prevention. We also expanded the training duration to three days each, and redesigned our lessons around brief lectures to introduce concepts followed by small group didactics led by a CU Peru volunteer.
The second trainings and village visits: successes and lessons learned
In July of 2011, the team of fourth year medical students, a pharmacy student and first year medical and PA students held simultaneous trainings in Mazan (the capitol of Mazan district) and Llachapa, drawing 61 promoters (out of about 80 communities in the district). Our small group approach to teaching vital signs, diarrhea management, and health promotion worked well to engage the learners, who were extremely eager. Pre- and post-tests, which were orally delivered and asked promoters to state their answers to standardized cases and demonstrate vital sign skills, showed a vast range of knowledge between promoters, but a dramatic improvement from pre- to post-test results overall. We heard that the promoters overwhelmingly enjoyed the topics and the format, but asked for greater emphasis on various topics, including first aid and other hands-on skills. They also were excited about the idea of “expert promoters” selected to teach the groups, an idea that we intend to incorporate into our training. The funding we raised allowed us to pay for the promoters’ travel, food and lodging for the duration of the trainings and provide them with digital watches, thermometers, stethoscopes and blood pressure cuffs, all of which were major hits with the crowd.
The subsequent weeks were spent in communities we randomly selected to reinforce skills and knowledge taught at trainings, practice home visits to discuss healthy behaviors, and administer our survey. These village visits are invaluable in the information we gain about the appropriateness of our curriculum, the role of promoters, and the factors contributing to or blocking the success of promoters.
3rd annual training, a multidisciplinary approach
During the summer of 2012, 12 students representing 5 different health professional schools conducted our third annual village health worker training with a total of 80 promoteres in attendance (54 in Mazan and 26 in Llachapa). Didactic topics included vital sign review, first-aid, respiratory illnesses, and community health. It was exciting to see students in the PharmD, RN, NP, PA, MD, and MPH programs working together to better health outcomes in resource poor settings. As health care continues to emphasize the team based approach, the importance of different professions interacting outside of clinical practice will become that much more crucial. In the future, we hope to recruit dentistry and physical therapy students so that their input can benefit a region that desperately lacks such services.