by Dahlia Chacon
This paper analyzes the Duke University Student Research Training: Honduras Program, entitled “Saving Sight in Roatán”. The primary purpose of this program was to screen children of Roatán, a Bay Island of Honduras, for myopia and assess risk factors of poor vision through one-on-one oral surveys. The team partnered with Clínica Esperanza, a comprehensive medical facility, to address community needs related to eye care, such as administering Snellen chart eye exams to school children, providing glasses to children who tested for a visual acuity of worse than 20/40, surveying randomly selected students to evaluate risk factors associated with nearsightedness, and collecting BMI data to understand how child growth varies across the island. Although the research benefited from over 600 data points, the sustainability of the project was not prioritized. Several ethical and social concerns prevented successful project outcomes including an ineffective intervention, team members’ inability to communicate in the population’s language about vision health, and a lack of effort to cultivate community relationships. Insights are based on the experiences of a member of the 2018 Summer team.
Student Research Training (SRT): Honduras is a two-month-long immersive educational opportunity on the island of Roatán, Honduras supported by the Duke Global Health Institute. During the 2018 program, students travelled to different schools along the West to East ends of the island to administer basic Snellen vision tests. Children who scored a 20/40 or worse on a vision test were provided with corrective lenses due to the implications poor vision can have on learning ability within the classroom setting. The team also offered tests for glaucoma, a disease that threatens blindness in older adults, at the request of the host organization.
The team worked closely with Clínica Esperanza, a medical facility based in Sandy Bay, who helped to acclimatize students to the island and provided the team with resources when necessary. Clínica Esperanza provides low-cost/no-cost medical care to the people of Roatán, Honduras. People can receive services from the walk-in medical clinic, women’s health center, pediatrics, birthing center, dental clinic, laboratory, or pharmacy. The clinic also provides community health education programs and school health screenings for oral and vision health, the same services as the Duke SRT Team. It operates five days per week from 7:30AM until 6:00PM, treating approximately 100+ patients per day, usually about 65% adults and 35% children. More than 3,500 patients consider the clinic to be their primary medical care provider. Thus far, more than 50,000 patients have been treated in the clinic (Clínica Esperanza—Honduras | INMED). Due to the limited number of medical facilities available, patients have travelled from several different areas on the island and the mainland to seek treatment or medications. The clinic provides a needed service to people who would otherwise likely not seek treatment due to costs and crowded conditions of the local public hospital.
There is limited eye care in this community and the damage caused by certain vision issues (blindness in many cases) can be debilitating to the lifestyle of Roatán. The clinic asked the SRT team to administer Snellen chart vision screenings to students in local schools and glaucoma tests to adults who visited the clinic to address a demonstrated need. Our tools which were tailored for Spanish-speaking population were acquired from the clinic to avoid inappropriate screening techniques and approved by the Duke Campus Institutional Review Board.
Our team also administered oral surveys to the children being tested to understand possible risk factors of poor eyesight in Roatán. Data collected could help the clinic inform initiatives to improve community vision outcomes. Surveys were written in collaboration with the clinic to ensure that the data would be significant to their progress as well as to our research. One of our major questions explored if children had previously received an eye exam. Previous data has stated that 61.2% of Honduran children had never received an eye exam (Ramai et al., 2015). Our other questions were used to help clarify reasons for utilization of eye-care resources. For example, lower-income communities may be less likely to seek out optical care because the costs of such care have been estimated to be close to 30 days’ worth of salary (Brown et al., 2003). Although Clínica Esperanza offers these services at low to no cost, accessibility is often an issue in distant communities. Our fieldwork brought these resources, such as corrective lenses, to individuals so that their basic health screenings could be up-to-date, their learning could be less impacted by preventative concerns, and they could be referred to their local ophthalmologist if needed.
Clínica Esperanza arranged our transportation each day to and from our school site. For the first two weeks, clinic supervisors helped us schedule screenings at schools. The last six weeks, our team self-scheduled visits at schools using a government-organized sheet of the schools on the island and contact information for school directors provided by our partner clinic. This was essential to our success throughout our time there. In addition, we were able to connect with nurses in the clinic and assess which communities were most in need and determine their locations.
Although this experience was supported by Duke Global Health Institute and there was daily communication with the host organization, several ethical concerns arose throughout the two months. The first concern arose because our research focused on school-aged children. It was difficult to enter each school as a brigade from the United States. Our work required us to disrupt class time to administer basic vision tests. Administrators often emptied a teaching classroom for our team to set-up which displaced students. Depending on the size of the schools, this could be ongoing for hours at a time.
The second concern was the sustainability of our team’s intervention. It was difficult to see the true results of our work after the child left with a new pair of glasses. Several questions would rush through my head such as “Will the child ever wear these glasses? Will they break them the next day? Will they stop wearing them because their classmates are ridiculing them?”. It was challenging to gauge which students were truly the ones who needed the resources and more than that, which students would utilize them.
Ultimately, I believe the impact of our fieldwork was low. We visited some of the same schools as previous SRT teams, and the children who were given glasses in the past did not seem to have them anymore. Upon questioning, the team learned that these children no longer had their glasses a month after they were distributed to them. Their disclosure was disheartening to hear during oral interviews as the glasses initiative was one of the main components of our time there. This project lacks continuity and focuses more on short-term successes. Our impact was greatest when we were physically stationed at the clinic, although accessible to only certain populations on the island.
Culturally, vision problems go undiagnosed and untreated, and glasses are rare in Roatán. I recall a mother of a child to whom we had given glasses approaching my teammates. They had difficulty communicating and so she was ushered over to me because of my Spanish fluency. She was confused as to why her child received glasses because her child had already received a vision test in the past. I explained to her that her child’s vision had worsened, and I explained how the Snellen vision test worked. I answered her questions and assured her it was not a bad prognosis and the glasses would only help her child. She seemed content with this response and I provided her with the clinic’s information if she had further questions.
After this interaction, the team was more mindful of explaining to each child why they needed regular vision tests and if they did have poor vision, why they needed corrective lenses. In our attempts to accelerate our process and each vision test, we failed to pause and explain our purpose to the community we were serving. This realization eased communication with the children, parents, and teachers throughout the remainder of our time.
Personally, this experience required me to rigorously exercise my leadership skills in a capacity unfamiliar to me. I quickly realized that my language proficiency, cultural competency, and my Latina appearance were helpful to effectively execute our project. For example, I primarily scheduled our visits by contacting school directors from an outdated directory. When I finally received responses, I struggled to decipher the often-vague directions to these schools or sometimes, understand different dialects. Similarly, at the schools, I was the point of contact for administrators if they had questions or concerns.
Most substantially, I collected a majority of the survey data because of my ability to find different ways to express concepts to Spanish-speaking students and their increased level of comfort with me. However, it was ineffective to have only one person who could reliably communicate with the community. This not only decreased project efficiency but also possibly caused mistrust amongst those we interacted with due to our unfamiliarity with their language and culture.
Output vs. Outcome
The team’s final outputs included performing Snellen vision screenings on 4,200 children aged 5-21 enrolled in 32 public and private schools across Roatán, providing corrective lenses when needed; we conducted 650 oral surveys to randomly selected students addressing potential demographic, biological, behavioral, and social risk factors to assess characteristics associated with low vision outcomes. Our data set was substantial; ultimately, the Body Mass Index (BMI) data was the most significant as it helped tell a story about the resources available on different parts of the island.
My team reported these results during the Duke Global Health Re-Entry Retreat, a one-day debrief of student’s experiences facilitated by department advisors. After a small group discussion, the biggest challenge of the Student Research Training: Honduras program emerged: the experience was too focused on outputs rather than outcomes.
An output is simply a result or a process measure, and does not measure the value or impact of our work. As discussed in previous sections, this project lacked a strong sustainable component. The project cannot accurately evaluate the effectiveness of providing corrective lenses since the team is on the ground for a limited time. Although outputs should be acknowledged,the development of thoughtful outcome measures and mechanisms for tracking is essential to ethical engagement with a community during global health fieldwork.
I have witnessed the worth of outcome-focused projects firsthand during other global health experiences. The goal is creating relationships with our community partners and research participants. There are three reasons as to why relationships are essential to an ethical experience: 1) forming close personal relationships with community leaders creates a level of trust for them and others; 2) relationships with natives can reveal how the dynamics of their community functions which is necessary when working with vulnerable populations such as children; and 3) if a team is a constant and known presence in the community, the likelihood of more fruitful and candid data increases (applicable to both qualitative and quantitative answers).
It is necessary that global health researchers familiarize themselves with the community and partner organization before beginning an experience. It is important to address expectations from a project mentor and host organization so that time is not needlessly allocated to establishing roles in the field. Each team member will struggle adjusting to the community and the team, but mutual support and pursuit of a common goal can help mediate related setbacks. Asking relevant questions and requesting help when needed also facilitates research goals,strengthens communication, and creates a more profound experience.
I would recommend SRT Honduras and similar experiential learning activities if students are comfortable interacting with people, especially in a foreign language. It is a test of organization, personable abilities, and Spanish fluency. The team dynamic is necessary to the success of the project and needs to be fostered in tandem with the research. It is a great opportunity to learn about how a clinic functions, engage with a Spanish-speaking community, and educate oneself on optic diseases and healthy eye care.
From my experiences, I value sustainability within global health. The SRT Honduras project needs to modify how it impacts the community in the long-term. I recognize and support the long-standing relationship the program has with Clínica Esperanza; however, the community should feel the same benefits. For example, educational workshops where we teach children and parents about eye care and how to care for one’s vision could be extremely valuable. It is a simple improvement that could potentially encourage regular health screenings or a more Vitamin A-filled diet for attendees. Ultimately, future teams must be more mindful of the distinct difference between their outputs and outcomes.
Cover photo by Hemal Patel.
Brown, M. M., Brown, G. C., Sharma, S., & Landy, J. (2003). Health care economic analyses and value-based medicine. Survey of Ophthalmology, 48(2), 204–223. https://doi.org/10.1016/s0039-6257(02)00457-5
CDC (2017). Central American Refugee Health Profiles | Immigrant and Refugee Health. https://www.cdc.gov/immigrantrefugeehealth/profiles/central-american/index.html
Clinica Esperanza—Honduras | INMED. (n.d.). Retrieved March 15, 2020, from https://www.inmed.us/training-sites/clinica-esperanza-honduras/
Ramai, D., Elliott, R., Goldin, S., & Pulisetty, T. (2015). A cross-sectional study of pediatric eye care perceptions in Ghana, Honduras, and India. Journal of Epidemiology and Global Health, 5(2), 133–142. https://doi.org/10.1016/j.jegh.2014.06.004