Belize Health Needs Assessment Results

March 19-27, 2005

University of Wisconsin Medical School with the Hillside Clinic

Punta Gorda, Belize

Introduction:

Seven pre-clinical medical students from the University of Wisconsin Medical School spent a week volunteering with the Hillside Healthcare Center.  We gave nutrition presentations to schoolchildren and conducted health needs assessments in communities served by Hillside. During our stay, we visited four small villages.  Daytrips to Mopan and Ke’kchi Mayan villages in the western mountains were bookended by visits to seaside Garifuna and Creole villages.  In each village, we split into two teams.  One team was responsible for giving an hour-long, interactive presentation on basic nutrition to school-aged children from the village, while the other team interviewed community leaders and other villagers about their health concerns. 

We are trying to reach individuals who can provide a fresh perspective on their community’s health needs to enhance what health workers from Hillside learn by caring for patients who come to the monthly mobile clinics in their villages or are willing to trek to the clinic.  Villagers were asked to describe what they felt were the most common health problems facing their community and then encouraged to suggest ways that government and non-government health providers could do a better job of addressing those problems.  The questionnaires were also intended to help gauge villagers’ willingness to use western medicines, abide by western health standards, and seek medical assistance from outsiders.  The results from the assessments were compiled into this report and will be used by the Hillside Healthcare Center as a basis for future research.  In addition, a copy of the results will be given to leaders in each community for their own information. 

Our guide throughout the week, Arnoldo Melendez, designed the health needs assessment forms, helped us understand local diets and food sources, and went to great effort to arrange the interviews and nutrition presentations in each community. Our spring break this year coincides with Holy Week, a national holiday for Belize and a time when many business, government services, and all schools are on vacation.  In each town, Arnoldo helped us locate village council members, Community Nurse Assistants (individuals trained by the government to provide limited medical services for a community, such as dispensing some pharmaceuticals and suturing small wounds), community health promoters, and other village leaders. We had time for recreation each afternoon, and greatly enjoyed playing with village children and seeing natural attractions such as waterfalls, caves, and Mayan ruins.  It was a fantastic trip, and hopefully our work will play a small role in helping improve the delivery of healthcare to the wide area of Belize served by Hillside Healthcare Center. 

Survey Results:

The survey results are shown in figures.  The raw numbers are used. The numbers in this survey do not reflect prevalence, rather, they are the number of respondents who gave each answer.  Some respondents gave multiple answers.  Appendix 1 is a copy of the original survey. 

The main health concerns of each village are outlined in Figure 1.

Figure 1.  Number of survey respondents that listed each disease as a health concern in the village. 

The source of health care in each village is shown in Figure 2.  Again, the numbers do not reflect prevalence, rather, the number of respondents who said they use each source of health care. 

Figure 2.  Source of health care. 

The common problems with the CNA are shown in Figure 3.  These are obstacles to optimal health care that people reported that related the CNA in particular.  Comments from the CNA directly are included the respective village summaries.   

Figure 3.  Common problems individuals have with their CNA

Along with the CNA problems, we asked people if the CNA needed more training and if so, what type of training was needed.  The results are shown in Figure 4. 

Figure 4.  Types of CNA training needed, by village. 

For the next survey question we asked respondents whether they seek health care when they are healthy, a little bit sick, or very sick.  The question was asked as a multiple-choice question.  The results are shown in figure 5. 

Figure 5.  How sick people are when they decide to seek medical care. 

The water source of the respondents is shown in figure 6. 

Figure 6.  Water source. 

The next survey question was what is done to prevent scabies.  The results are shown in figure 7.

Figure 7.  Scabies prevention.

The last question on the survey dealt with where people get medicine.  The results are shown in figure 8.

Figure 8.  Where medicine is obtained. 

Village Summaries

What follows is a narrative summary of each village based on the data as well as the answers to several qualitative questions specific to the CNA or the Village Alcade. 

Barranco

            Barranco is a small Garifuna community, with around 150 people, located on the Atlantic coast south of Punta Gorda (PG), Belize.  By far the major health concerns of those surveyed were the long-term conditions diabetes and hypertension. Fever was the next most common complaint, followed by cough, cold, and diarrhea. The other common diseases named included: high cholesterol, obesity, conjunctivitis, and arthritis.  Chicken pox was going around the village at the time of the survey. Some conditions that were mentioned as being rare included malaria, dengue fever, worms, enlarged heart, and worms. Though scabies has not been a problem for at least 2 years, there is a plan for treatment if any new cases present.  This involves changing clothing and bedding while providing medicine to kill the scabies parasite

            The mobile clinic conducted once a month by the Hillside Jericho Road Clinic was the most popular source of treatment for illness among those surveyed.  The community nursing aid (CNA), Darcy Sandoval, and the PG hospital were the next most common sources of treatment.  A few people stated that they went to the Hillside Jericho Road Clinic and one person said they went to a Bush doctor for treatment. A majority of the respondents only seek medical assistance when they are very sick.  A few seek help when they are a little sick.  None of those surveyed sought medical care while healthy.

            The local CNA was unavailable for interview.  A few of those surveyed avoided the CNA, because they felt she lacked education.  Some of the areas where those surveyed thought the CNA could use more training included: HIV/AIDS, exercise, women’s health (including Pap smears), and nutrition.  Training in HIV/AIDS was mentioned the most, though it should be noted that the CNA does provide condoms for anyone who wants them.  A lack of necessary medicine was another obstacle that the CNA faced. Most of those interviewed get their medicine from the mobile clinic, followed by the Punta Gorda Hospital, with only a few people getting their medicine chiefly from the CNA or the Hillside clinic. A number of people interviewed also make and use their own herbal remedies first when treating minor illnesses.

            There is water treated with chlorine that is piped into the community, however, there is a split between those who use the treated water and those who use water from the untreated well. Those who use the untreated well water do so because they say it tastes better than the water from the pipe, though many of them use the treated water for cooking and cleaning. One person claimed to only drink rainwater.

            The community council and the community at large seemed willing to work with the Hillside clinic to discuss ways to improve health care in Barranco. The residents of Barranco would also like to see more nutrition presentations, HIV/AIDS presentations, and testing for diabetes and hypertension. They also wish the mobile clinic would come more often than once a month.

Aguacate

Aguacate is a Ke’kchi Mayan village of roughly 330 residents (down from over 500 residents) located about an hour inland from Punta Gorda by car.  Seventeen surveys were completed.  The main health concern in the village at the time of the survey was cough and fever, with 16 of 17 respondents expressing concern.  Other common health concerns include malaria, loose stool/vomiting, and pink eye.  Less common heath concerns include diabetes/hypertension, rashes/allergies, sores, pertussis, asthma, heartburn, arthritis, and lice.  Most people said that scabies was not a problem.  The CNA’s main method of scabies prevention was to change the bedding and isolating infected people.

12 of the 17 villagers surveyed reported seeking health care when they were a “little bit sick”.  Residents mainly sought health care either from the Jericho Road Hillside Mobile Clinic or the Punta Gorda Hospital.  For medicine, they would first try the CNA, but would often receive nothing and be forced to visit the CNA in St. Teresa or travel to the PG Hospital.

Teresa Kukul is the CNA in Aguacate.  Teresa is not well liked in town for inadequate competence in basic procedures and lack of medication.  Villagers’ main complaints are that she had no medication, doesn’t know how to suture, and is not around enough.  She herself wishes that she could have more training in suturing but also wishes that the villagers would not expect a cure-all solution to come from a pill.  Teresa would like to see more preventive medicine education taught to the villagers, especially nutrition, hygiene, and disease prevention classes for the children, whereas the villagers want a new CNA; one who will be around more, is more friendly, knows how to suture, and is a man like the CNA in St. Teresa.

Most of the village obtains it water from an untreated water pump.  These residents boil their water before drinking, and none claim to have any problems from drinking water that was not boiled.  The Aguacate school principal informed us that 30 families have running water in their homes from a community water line but that this water is untreated.  The hope is that they will be able upgrade their water system and provide clean, chlorinated water to the entire population.

San Jose

San Jose is a Mopan Mayan community located in the hills about an hour outside of Punta Gorda (PG), Belize.  The major health concerns of the villagers are conjunctivitis, cough, fever, diarrhea (especially in babies who often get very sick with diarrhea), and stomach aches.  There is a small subset of people that have diabetes and hypertension (including pre-eclampsia in pregnant women), arthritis, and asthma.  Scabies and head lice were reported but didn’t seem to be a large problem and it doesn’t seem that anything is done to prevent it.  Malaria and yellow fever occur but are not common.  Routine skin problems included rashes, insect bites, warts, sores, and foot infections.   Most people go to see the CNA first when they are sick and then to the hospital in PG if he cannot take care of them.  Some people said that they go to the Hillside clinic on occasion but that it is difficult to find transportation (they generally have to pay someone to take them to town).  A few people said they received care from a local bush doctor.  Most people go to see a health worker only if they are very sick but some went when they were only a little sick and few went when they were healthy to make sure everything was ok.

The community nurses aide (CNA), Isidoro Peck Sr., is well respected in the community but there was an overriding concern in the village that he did not have enough medications and that he wasn’t always available (he is only part-time).  There was also concern over lack of available transportation to larger health centers (especially for pregnant women with complicated pregnancies).  The villagers suggested that he could use training in suturing, IV rehydration, tooth extraction, and educating villagers about proper hygiene around babies.  The CNA (who spent some time training in the U.S.) thinks that the community could use a full time nurse and that he didn’t have enough access to medications.  He also stated that he would like more training in suturing and caring for machete wounds (slash and burn agriculture is a common practice in this village in the spring time).  His major concern at the moment is that his radio is broken so he cannot communicate with the hospital.  He is willing to work with the Hillside clinic to discuss ways to improve health care in San Jose.

Most people get their water from a chlorinated water pump but a few drink river water (often boil it before drinking) and rain water (do not boil).  Most people get their medication from the CNA but some get it from the Hillside Mobile clinic when it is in town or from PG.

The teacher asked that students or other volunteers from Hillside provide many more presentations on nutrition, hygiene, and disease transmission.

Monkey River

Monkey River is a Creole village with 204 residents located along the coast of Belize, about a 45 minute boat ride north of Punta Gorda.  Twenty-three surveys were completed in Monkey River.  The main health concern in the village at the time of the survey was tuberculosis (with 17 of 23 respondents expressing concern).  Currently, there are 6-7 cases of tuberculosis in the village affecting 3 families, which has other residents worried about disease transmission.  The other most common health concerns for villagers are malaria, diabetes, hypertension and cold (all with more than half of respondents implicating).   The CNA notes that malaria is rare, though still a risk in the area.  Less frequently reported health issues were diarrhea, flu, fever, headache, conjunctivitis, hepatitis, cuts, HIV, Dengue Fever and mumps.   All but one resident indicated that scabies was not a problem in the village and nothing was done for prevention. 

The majority of villagers reported seeking health care when they were a “little bit sick,” and they predominantly sought care at the Independence Hospital. The trip to Independence cost villagers about BZ$60.  Other care was obtained from the CNA, the Hillside Mobile Clinic, a private physician in Independence (Dr. Hilu), and the Bush Doctor.  One person reported getting care from the Belize City Hospital and Home Remedies.  Medications were most frequently obtained from Independence with other medications coming from the CNA and the Hillside Mobile Clinic.  One reported getting medication from the village chairman while a couple reported making homemade medications and buying them from the drugstore.      

Inelda Garbutt is the CNA in Monkey River and villagers generally sought care from her for minor problems; however, there was a general reluctance to seek care from her.  Several people were concerned that the CNA did not have enough medications and that she was unavailable.  One resident reported problems receiving midwife services from her.  While many people agreed that the CNA needed further training, few had specific suggestions.  A couple said that she needed more suturing skills—currently, she was able to make a couple stitches to stabilize a wound until someone could get to Independence.  One also noted that she needed more diagnostic, “hands-on” skills and that her communication skills were lacking.   Ms. Garbutt indicated that she was willing to work with Hillside to improve care in Monkey River; however, she did not feel like she wanted to take on extra work.

The village obtains water from a chlorinated reservoir located across the river, which 17 respondents reported using for drinking.  Four people surveyed relied on rainwater for drinking since the treated water “tasted bad”.  Two also reported bathing in the river. 

At the time of the survey, residents had concerns about waste removal, since the village currently didn’t have garbage removal services.  Additionally, there was a lot of paranoia about tuberculosis.  Several villagers interviewed felt uncomfortable mentioning the presence of tuberculosis in the village, and one woman was chastised by her husband for reporting it to us.  In general, villagers want to have TB skin tests more readily available and several had questions about transmission, indicating that more education is necessary.          

Recommendations

          There are several recommendations we can make for future trips similar to ours.  First of all, we know from feedback from the teachers, principals, and village alcades that they would like more presentations at the schools.  Requested topics include nutrition, disease transmission, hygiene, and HIV/AIDS.  The presentations should be planned and prepared well ahead of time and checked over for cultural appropriateness by a member of the Hillside staff. 

            As far as the surveys, we found respondents to be very welcoming and gracious.  Groups like ours could definitely continue to do similar surveys in the future, perhaps more focused on a specific area in which the Hillside Clinic would like more information.  Again, the surveys need to be done well ahead of time and be written in collaboration with a contact at the Hillside clinic. 

If you have any questions about this report, feel free to contact Sharon Anderson at sjander3@wisc.edu or Lori Diprete Brown at dipretebrown@wisc.edu

Appendix 1.  Original survey. 

HILLSIDE HEALTHCARE CENTER

COMMUNITY NEED ASSESSMENT

1.         Name of Community: ______________________________________________.

2.         Population: ______________              Ethnicity: _________________________.

3.         Name of Community Nurses Aide: ___________________________________.

4.         Name the different kind of disease treated in your Community?

·                    __________________________________________

·                    __________________________________________

·                    __________________________________________

·                    __________________________________________

·                    __________________________________________

·                    __________________________________________

·                    __________________________________________

·                    __________________________________________

·                    __________________________________________

·                    __________________________________________

5.         Name the most common disease treated in order of priority?

·                    _________________________________________

·                    _________________________________________

·                    _________________________________________

·                    _________________________________________

·                    _________________________________________

·                    _________________________________________

·                    _________________________________________

·                    _________________________________________

·                    _________________________________________

·                    _________________________________________

6.   Who provide medical assistance to the community? _______CNA ________Hospital

Mobile Clinic ______________Hillside Jericho Road ______Bush Doctor ______ others.

7.  What are the most common problems that you face as Community Nurses Aide?                                                       ____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________.

8.         Base on the result of this survey are you interested to work along with a medical volunteer from Hillside to research on the root causes of the most common health problems from your  community. _________ yes ____________ no.

9.         Is the Village Council, Alcalde and the community in general willing to collaborate in order to do this research? ________ yes _______ no, why?

            ______________________________________________________________________________________

10.       Do you feel that the C.N.A’s need additional training to deal with the health problems of your community: ________ yes ______ no.

11.       If yes, what kind of training do the C.N.A’s need?

a.                 ______________________________________

b.                ______________________________________

c.                 ______________________________________

d.                ______________________________________

e.                 ______________________________________

f.                  ______________________________________

g.                 ______________________________________

12        Do you have  any other information to add? ___________________________

Additional Questions for UW students:

13.       Do you/your patients seek medical assistance when you/they are

a)      healthy

b)      a little bit sick

c)      very sick

What is your/your patient’s source of water?

What do you/your patients do to prevent scabies?

Where do you/your patients go to get medicine?

Note that a copy of the result will be given to the TDHS (MoH) and to the community for their information.