In today's global society, healthcare providers have an obligation to develop cultural awareness, sensitivity, and competence. Short Term International Health Missions (STIHMs), which allow for immersion in another culture, are a valuable component of professional education (Levi, 2009). The faculty of Molloy College, a private liberal arts college founded by the Dominican sisters of Amityville, recognized the potential value of such missions for graduate students and partnered with PRN (Physicians, Residents and Nurses as Needed), Relief International's medical mission. The medical mission provides primary care in rural and urban Jamaica, as well as offering communication disorder, psychiatric-mental health, and surgical teams. STIHMs support the college's Dominican tradition of community, service, spirituality, and study. Through immersion, STIHMs increase students' cultural awareness and sensitivity. The goal of these missions is to reduce healthcare disparities and increase students' awareness of social determinants of health in underserved countries.
THE DOMINICAN TRADITION
You are the light of the world Matthew 5:14
The Dominican Sisters of Amityville founded Molloy College in Rockville Centre, New York, in 1955. From this heritage, the Catholic Dominican tradition teaches students to seek truth (veritas), to promote human dignity, and to alleviate social injustice. The four pillars of Dominican life at Molloy College are community, service, spirituality, and study (Figure A). The pillars are palpable on the Jamaican Medical Mission. Openness allows students to question and converse about deeper issues. Through transformative education, Molloy promotes a lifelong search for truth and the development of ethical leadership (Molloy College, 2017).
The goal of Dominican education is for knowledge and truth to be lived forward in the service of others (Eberle, 2016). Disputatio is both a Dominican method and an attitude to engage with the world in a meaningful and responsible way. Veritas is the ultimate goal, reached through disputatio, a process of patient listening and calm argumentation. In today's culture of individualism and indifference, Dominican tradition calls students to be sanctuaries of compassion, authentically grounded in the pursuit of truth, recognizing the uniqueness and freedom of each person, with nonjudgmental commitment, willingness, and courage to care for all, regardless of circumstances, and to collaboratively effect change (Perkins, 2017).
Dominican charism is based on tradition, but also on the spirit of Saint Dominic, which is dynamic according to the changing times. The Order of Preachers, as the Dominicans are known, has theology informed by the lived reality of the poor and oppressed. This theology is embraced on the Jamaican Medical Mission by providing care with compassion, while affirming and protecting human dignity and sacredness. Infusing the Dominican pillars throughout the mission results in student awareness of the need for interdependence and diversity within community; that all persons are unique in their spirituality; that study and reflection are required in the search for Veritas; and service is a privilege, opportunity, and obligation. Ultimately, the mission leads participants to address the distortions of the day, reflect upon the actions they are willing to take to address these distortions, and to be a light for the world in the spirit of Saint Dominic. Working with PRN Relief International makes it possible to carry out the Dominican tradition on the STIHM to Jamaica.
PRN RELIEF INTERNATIONAL PARTNERSHIP
PRN Relief International is an offshoot of a group who ventured to Jamaica in 1999 to work in a community in Kingston's inner city. Under the direction of Sr. Grace Yap, OSF, Franciscan Ministries, the first team of four nurses, a first-year medical resident, and two physicians arrived with seven bags of supplies to set up a clinic in an area known for violence and gang presence. The seven healthcare workers have continued to care for the people of Jamaica annually for 17 years; the interdisciplinary group now numbers 60 professionals, including nursing and medical students, who travel to Jamaica every 6 months.
With a mission dedicated to primary care, the scope of the team now includes:
- medical care for 10 communities throughout the island,
- a surgical team working out of Nuttall Hospital in Kingston,
- a communication disorder team who evaluates/refers speech and hearing problems in primary school children and holds parent/teacher educational programs,
- a psychiatric-mental health program, including art and music therapy and behavioral treatment for abused adolescent women.
The program has reached inner city Kingston, the rural areas of St. Elizabeth, St. Andrew, and St. Mary Parishes. Each year, 50 major operations are performed without cost. The surgical team brings donated equipment and supplies to the hospital at the end of the week. A local U.S.-trained surgeon continues with postoperative care. The primary care team arrives with 60 bags of medications donated by Catholic Medical Mission Board and AmeriCares, whereas nursing students from multiple colleges bring donations of acetaminophen and cough medicine. Patient education regarding staying healthy is part of the treatment plan.
The art and music therapy professionals connect Jamaican students with teens of similar backgrounds in their home state through art projects, whereas the teams of speech and hearing students and faculty supply books for school libraries. PRN Relief International, working with Franciscan Ministries and a private foundation, built a computer center where teenage girls gain computer skills for vocational careers. The public and private partnerships over the years have positively affected the healthcare of these populations and have influenced the volunteers. All hands come together to make the program a success, and Jamaica's Ministry of Health and the Child Advocacy Department welcome the healthcare volunteers.
Jamaica, an island divided into 14 parishes, has a population of 2,951,000; 55% live in urban areas (Central Intelligence Agency, 2018). The World Health Organization (2017) classifies its economy as upper middle-income, with a gross national income of $7,310 USD. Poverty is more prevalent in rural areas, and international migration of healthcare workers and teachers is of significant concern (Lofters, 2012). The history of Jamaica is tumultuous and includes the arrival of early Spanish settlers, the British establishment of a plantation system, incorporating the black slave trade, and finally, full independence from Britain in 1962. English and English Patois are the spoken languages.
In recent years, the Ministry of Health has worked diligently toward increased access and equity to government healthcare. Gaining access has varied, depending on governmental change. Healthcare reform is influenced by many factors in Jamaica, which means working with the public and private healthcare sectors and addressing social, economic, and political issues (Maharaj, 2010).
Public healthcare delivery consists of 24 hospitals and 348 primary care centers. A shortage of healthcare providers has added multiple challenges, including an increased burden from noncommunicable diseases, limited drug production resulting in fluctuating and increased costs that are not sustainable, and a fragmented health information system (World Health Organization, 2013). Community health partnerships with volunteer groups and nongovernmental organizations contribute to meeting the healthcare needs of the population (Bryan, Johnson, Dawes, & Samuel, 2012).
Noncommunicable diseases (NCDs) in Jamaica account for 79% of total number of deaths. The World Health Organization (2014) reports that stroke is the leading cause of death. Ischemic heart disease, diabetes, HIV/AIDS, hypertensive heart disease, interpersonal violence, prostate cancer, kidney disease, lower respiratory infections, and cancers of the trachea, bronchus, and lung account for the top 10 causes of death (Figure B). Life expectancy at birth is 74 for both sexes, although healthy life expectancy is 11 years lower than total life expectancy, due to years lived with morbidity and disability.
UNIQUE MISSION ASPECTS
Many typical mission trips are organized in response to catastrophic events, such as hurricanes, earthquakes, or tsunamis, or focus on a single component of healthcare, such as dental care or surgical problems (Bajkiewicz, 2009). Molloy College's mission trips bring together nurse practitioner (NP) faculty and NP and Doctor of Nursing Practice (DNP) students to collaborate with physicians to deliver primary care. The nursing team consists of NP faculty, an RN assisting in the pharmacy, and the college's associate dean of the graduate program, who coordinates the trip and assists with healthcare delivery. Biannually, NP students are invited to participate in the STIHM. They pay for their airfare, accommodations, and meals. In return, they receive credit for 55 clinical hours toward their clinical practice requirements. The DNP students provide patient care and work on projects addressing population health. The ratio of student to faculty or physician is 2:1.
The team visits a different site each day, ranging from inner city schools and churches to remote rural villages. When they arrive at a site, community members are lined up, having been notified by community leaders that the team was coming. The primary care team visits the same sites each October and March/April, and maintains charts on patients from previous visits. The charts are safeguarded in a local convent, the home of mission liaison, Sr. Grace Yap. The Dominican Pillars of community and service, as well as cultural humility, are embodied at the clinics.
Working with the faculty, NP students provide an assessment and diagnosis, then formulate a treatment plan. Students also educate patients about healthy lifestyles and disease prevention. Because of generous donations from the Catholic Mission Board and AmeriCares, patients receive medications to last up to six months for chronic conditions, mostly diabetes and hypertension. Medications that pose potential harm or that require laboratory monitoring are not provided. Each day, a different student works in the pharmacy, educating patients about their medications. The importance of medication adherence and the dangers of sharing medications are stressed.
In addition to hypertension and diabetes, the team diagnoses and treats patients from newborns through the elderly with common conditions, such as allergic rhinitis, allergies, asthma, degenerative arthritis, back pain, dyspepsia, and vaginitis, as well as problems that occur specifically in tropical areas: fungal infections, pinworms, and post-Chikungunya arthritis. Chikungunya, caused by the bite of Aedes aegypti and Aedes albopictus mosquitoes produces a rash, fever, and joint pain, which may persist for years. The Zika virus, also caused by the bite of the same mosquito species, is a significant health concern, particularly because the virus can be transmitted to an unborn child from an infected mother, as well as being transmitted to partners through sexual contact. There is scientific consensus that Zika virus is a cause of congenital microcephaly, ophthalmological defects, auditory manifestations, and other neurological disorders, including Guillain-Barré syndrome in adults. The Centers for Disease Control and Prevention (2017) considers all of the Americas and the Caribbean at Zika risk. The pillars of study and service, as well as the promotion of self-knowledge, are demonstrated throughout the trip.
Religious Practices. On each mission, the medical team has the opportunity to attend Sunday mass. The church choir, accompanied by keyboard, guitars, and sometimes steel drums, fills the room with music throughout the service, which may last 2 hours. The atmosphere is reverent and unhurried.
After mass, the team sets up clinic space in the church hall, and patients are examined and treated before they go home for Sunday family dinner. The team also holds clinics in churches of other Christian denominations. It is apparent to team members that faith in God is extremely important to the Jamaican people, and faith has carried them through many difficult times. The medical missions embody the pillars of spirituality and service.
Health and Food Preferences. Students learn about cultural differences between the U.S. and Jamaica, especially related to food preferences and health practices. For example, Jamaicans use many fruits and vegetables for their healing properties: papaya for indigestion, guava for diarrhea, and tamarind for rashes and pruritus. Herbal medicines may be administered as teas, poultices, or baths.
Typically, Jamaicans eat a big breakfast of ackee, a cooked fruit that looks like scrambled eggs; green bananas; cassava bread (bammy); cornmeal porridge (cooked with cloves and nutmeg); salted codfish; and callaloo, a spinach-like vegetable. Lunch may be a light snack, whereas supper is substantial. The most popular dish is jerk, meats such as goat, pork, or chicken cooked in a marinade, then barbecued over an outdoor fire. Rice and peas or beans accompany the meat. Dessert may be a festival, which is a fried flour stick that tastes like a doughnut.
Patient-centered, holistic healthcare includes an interprofessional approach. On recent missions to Jamaica, faculty and students from speech, language pathology (SLP), part of the college's Communication Disorders Department, joined the team and screened hundreds of children and adults. This STIHM utilized the abilities and education of NP and SLP students and their faculty, who collaborated to provide comprehensive patient care. The students utilized their primary care skills in a busy, yet nonthreatening, situation, albeit in an environment unfamiliar to them in terms of culture, economics, and lack of resources.
In the primary care clinics, practitioners completed a history that included questions about hearing and speech. If indicated, the head, eyes, ears, nose, and throat were examined. If a patient complained of hearing loss, difficulty swallowing, or speech and language difficulties, they were referred to the SLP students. NPs and physicians provided the SLP students and faculty with a report on the patient and developed a collaborative diagnosis and treatment plan.
Working collaboratively has had positive outcomes for patients, as well as students. After the end of each clinic day, physicians, faculty, and students review cases or disease processes in an interprofessional setting. In one case, SLP students demonstrated how a swallowing study was conducted. The NP students found this helpful, as they may one day need to order this test. Knowing the exact procedure for the swallowing study gave the NP students information to share with future patients, to allay their fears prior to diagnostic testing. Another example of collaboration was a physician's lecture on gastroesophageal reflux disease as a cause of vocal problems and presenting as throat pain. Each group of students described patient scenarios where they had seen patients with these complaints. The interprofessional education sessions gave students from both disciplines an appreciation of the scope of practice of the disciplines and demonstrated how collaboration improves patient outcomes. The pillar of study, which leads to ethical leadership and a lifelong search for truth, is fostered on each medical mission.
Recently, the University Hospital of the West Indies asked Molloy's STIHM faculty to assist in teaching Jamaican nurses in critical care and emergency residency programs. In response, plans are underway to develop recorded online lectures as a first step in collaboration. Molloy College also enjoys a positive relationship with the Jamaican Ministry of Health. The DNP student who is implementing a Zika virus prevention project in five low-resource communities will share her findings with the Ministry of Health, as well as with the World Health Organization.
The faculty noted that students who participated in the STIHM responded positively and enthusiastically, but those responses were anecdotal. Therefore, after their return, recent students now complete a postmission assignment to ascertain their perceptions of the STIHM. The themes of awareness, compassion, vulnerability, confidence, and appreciation were extracted from the student essay responses. Their relation to the four Dominican Pillars, along with student comments, are listed in Table 1. The themes are in alignment with the goals of seeking truth (Veritas), promoting human dignity, and alleviating social injustice; the four Dominican pillars are interwoven throughout.
Every medical mission has numerous moments that touch the affective domain of all involved. Recently, three memorable moments stand out. The first occurred in a rural mountain clinic when two sisters presented for follow-up care for chronic conditions. Each sister, seen on multiple occasions, had years of prior chart records. During this visit, one sister, who had multiple comorbidities, including obesity, type 2 diabetes, hypertension, and arthritis, was found to have poorly controlled blood pressure and blood sugar. The other sister, also hypertensive with type 2 diabetes, had documented improvement in her blood pressure and blood sugar. Both had access to, and regularly saw, additional providers.
After the NP student took a careful history, it was determined that the sister with the poorly controlled blood pressure and blood sugar needed education on diet, exercise, medication compliance, and health promotion and prevention activities. The student documented an appropriate and evidence-based treatment plan. Then the real work began.
The NP student assessed the patient's literacy and addressed her educational needs in the cultural context necessary for behavior change. The patient's sister enthusiastically participated in the educational session. The NP student did not act in a paternalistic manner, but rather, engaged in a patient-centered approach, educating the patient, while also eliciting the patient's goals. In the end, after hugging the NP student and supervising faculty member, the two sisters left, stating that they looked forward to our next visit in 6 months.
In this example, the NP student provided comprehensive care, based on Stewart's Role Development for the Nurse Practitioner (2015), which incorporates both medical and nursing models. The importance of patient education and patient-centered goal setting is paramount. In Jamaica, a high carbohydrate diet, the obesity rate, personal perception of health risk, and healthcare access, all contribute to the need for continued outreach and education for patients with chronic diseases (Bryan et al., 2012). The student learned that, just as in the U.S., patient education can require multiple attempts, a connection with the patient, shared goal setting, and patient readiness.
The second memorable but unfortunate moment involved a 20-year-old primigravida. She presented with vaginal bleeding, and after evaluation was referred to the hospital out of concern for impending miscarriage. This situation was emotionally charged. Fortunately, a new graduate nurse, trained in Jamaica, was with the team that day. She accompanied the patient to the hospital, smoothed her transition into the system, and offered emotional support, providing holistic care. The importance of community involvement and collaboration was evident.
The third memorable moment involved a 94-year-old female who presented for a check-up. She and her grandson had walked for miles to reach the rural clinic. The two stood in line for a long time, with smiles on their faces. When finally examined, the woman was remarkably healthy, with excellent blood pressure, blood sugar, and weight. She did not smoke or drink and took no medications. Her only complaint was poor vision, saying she could no longer see to read. The NP student performed an eye exam with an ophthalmoscope, expecting to find cataracts or other pathology. When she did not, she performed a vision exam. The outcome: a simple pair of reading glasses, donated by team members. The woman started to cry. She was heard telling her grandson, “Now I can read my Bible again!” This intervention, initially deemed small by the student, had a tremendous impact on the patient's quality of life.
With the support of Molloy College, the faculty plan to continue providing primary care in Jamaica every six months, while offering an interprofessional education experience for students. Patients, students, and faculty have reacted favorably to the mission trips, but more evidence is needed to support the mission's effectiveness. Currently, a research study is assessing the impact of the medical mission on patients' lives, as well as data analysis on a research project assessing cultural humility in students participating in the mission.
As guests in Jamaica, it is important for students to become familiar with the guidelines of the Jamaican Ministry of Health, as well as with the formulary of available medications. Students who have previously been on the trip become excellent recruiters, advising prospective participants. They are heard saying, “This is a no judgment zone”; “keep an open mind”; “do not take hydration and indoor plumbing for granted”; “bring plenty of insect repellent”; and “always make time for patient teaching.”
Faculty are motivated by the belief that STIHMs benefit students, the healthcare professional team, and patients served. Seasoned professionals are reminded of the need for cultural humility–to accept without judgment and learn from people of a culture different from their own. The competence that the students exhibit and the cultural awareness they develop are overshadowed by the compassion they express for the Jamaican people. Many students have indicated that the experience sensitized them to social determinants of health and to the plight of the less fortunate, creating awareness of the part faith plays in maintaining emotional wellness for those with few material resources. The mission held a mirror up so students could fully visualize the distortions of the day.
Lessons from the medical mission may best be illustrated with an excerpt from a student's poem:
We went and we saw
And were changed to our core.
The human spirit is so strong,
It persevered with all that went wrong.
We went to help and to learn
And acquired life's lessons in return.
Our intention was to heal and show,
Yet their grace and courage helped us grow!