Calnali International Service Learning Experience

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Calnali International Service Learning Experience
Summary Report 2006
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• Elizabeth J. Emery
• Indiana University School of Medicine
• Department of Public Health
• Master of Public Health Program
• Spring 2006

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Table of Contents
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Background

• The Calnali International Service Learning
  Project established five clinics in rural
  communities in central Mexico (State of Hidalgo)
  during the week of March 11-19, 2006.
• Faculty students from several disciplines
  participated in the brigade
• Medicine
• Sarah Stelzner, MD
• Diane Lorant, MD
• Benjamin Henkle, MD, MBA
• Jason Woodward, MD
• Brian Bales
• Laura Sech
• Chirag Patel
• Brad Recht
• Nursing
• Francie Rogers
• Deb Bedwell
• Barb De Rose
• Social Work

• Dentistry
• Armando Soto, DDS, MPH
• Joe Guido, DDS
• Kevin Beadle
• Brett Grube
• Jeff Jones
• Lauren Weddell
• Nicole Weddell
• Nathan Williams
• Public Health
• Phillip Adams
• Liz Emery

• Friends of Hidalgo representatives ( our hosts
  for the week) included
• Juana Watson
• Carla Chickedance

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Methods

• Data Collection Analysis
• Clinics were held in the following communities
  Papatlatla, San Andres, Pezmatlan, Coyula,
  Calnali.
• Intake forms were completed for each patient.
  The data in this report has been extracted from
  the general information medical portions of the
  form. A copy of the intake form is included in
  Appendix III, Clinic Program Documents.
• Gender data was inferred from patient names.
• Up to four diagnoses per patient were recorded.
• Spanish translation was completed with the
  assistance of Dr. Roberto Gamez Goytia, MD.
• The medical diagnoses were coded using the
  International Classification of Diseases, 10th
  Revision (ICD-10) from the World Health
  Organization.1 Three levels of ICD-10 codes were
  assigned to each specific diagnosis, with
  frequency data computed for all three levels of
  classification. A complete list of the ICD-10
  codes and titles can be found in the appendix.
• ICD-10 coding was completed with assistance from
  Dr. Linda G. Emery, MD.
• Completeness of Data
• Of a total 1143 patients, diagnosis data is
  missing for 200 patients (17.5), and 943
  patients have at least one valid diagnosis.

Patient data collected during the brigade is
analyzed in this report in an effort to identify
the health needs of these underserved
communities. With this information, future
service learning projects will be able to better
serve the residents of Calnali and the
surrounding communities. Since pediatric
patients are the focus of IUs medical dental
efforts, data on the patient population is
primarily described with respect to age group.
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Demographics

• There were 1143 total patients
• 260 patients from San Andres
• 249 patients from Calnali
• 245 patients from Papatlatla
• 197 patients from Coyula
• 192 patients from Pezmatlán
• The San Andres Calnali clinics, as the highest
  attended, together accounted for almost half
  (44.5) of all patients seen during the week.

• The majority (62.0) of patients were female.
  Approximately 33.0 were male and gender was
  unknown for 5.0 of the population.
• Patients ranged in age from 2 months to 93 years,
  with a mean age of 34.5 years.
• Overall, adults age 18-59 years made up the
  largest percentage of patients (40.9). Infants
  and young children (birth to 5 years of age)
  accounted for the smallest percentage (10.8).
  Children ages 6-17 years followed with 25.5,
  while the elderly (60 years or older) made up
  20.9.

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Demographics

• Patient gender distribution was roughly equal in
  each community. However, gender varied among age
  groups for all communities combined. Adult men
  were likely working during the daytime clinics
  and may therefore be underrepresented in the
  patient population.

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Diagnoses

• A total of 1326 diagnoses were recorded
  throughout the week. The leading four categories
  of Level 1 ICD-10 codes combined for just under
  half of all diagnoses made during the brigade,
  with musculoskeletal diseases connective tissue
  conditions at 14.6 general medical dental
  exams at 12.0 respiratory system diseases at
  11.5 and infectious parasitic diseases at
  10.3.
• Further, 20.5 of cases were diagnosed with a
  musculoskeletal/connective tissue disease 16.9
  of cases were seen for a general medical checkup
  or dental exam 16.1 of cases had a respiratory
  system disease and 14.5 of cases were reported
  to have an infectious or parasitic disease.
  Digestive system conditions afflicted 13.8 of
  patients, while general signs symptoms were
  problematic for 11.5 of cases. All other
  categorized conditions each affected less than
  10 of cases.
• Musculoskeletal connective tissue diseases
  included arthropathies (6.1 of total diagnoses),
  dorsapathies (4.5), soft tissue disorders
  (3.4), and osteopathies chondropathies
  (0.53). Papatlatla had the highest rate of
  these conditions (18.7), representing 29.0 of
  diagnoses within this category.
• Low back pain was the most common level 3
  diagnosis within the musculoskeletal connective
  tissue diseases category, contributing 20.2 of
  disease and affecting 4.1 of the patient
  population.
• Respiratory system diseases included acute upper
  respiratory infections (64.5), chronic lower
  respiratory diseases (11.2), other diseases of
  the upper respiratory tract (10.5), other acute
  lower respiratory infections (9.9), and
  influenza pneumonia (3.9).
• San Andres had the highest rate of respiratory
  conditions (17.2), representing 37.5 of
  diagnoses within this category.
• Within the respiratory system disease category,
  unspecified acute upper respiratory infections
  had the highest rate (of level 3 diagnoses) at
  36.2. The prevalence rate of unspecified acute
  upper respiratory infections among the entire
  patient population was estimated at 5.8.
• The prevalence rate of infectious parasitic
  disease diagnoses was highest in Coyula, at
  14.3. The most common conditions in this
  category were intestinal infectious diseases
  (50.4) and mycoses (34.3).

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Diagnoses Level 1
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Diagnoses Level 1
Level 1 Classification of Diagnoses by Clinic,
All Patients
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Diagnoses Level 2
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Diagnoses Level 2
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Diagnoses Level 3
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Diagnoses Level 3
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Pediatric Patient Population
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Pediatric Demographics

• There were 415 total pediatric patients, with 292
  (70.4) between the ages of 6 and 17.
• 79 patients in Papatlatla
• 100 patients in San Andres
• 71 patients in Pezmatlan
• 83 patients in Coyula
• 82 patients in Calnali
• Pediatric patients in Coyula accounted for the
  largest percentage of total patients (43.5) in
  that community Papatlatla had the smallest
  percentage (32.8).
• The mean age of all pediatric patients was 7.7
  years, with the average age of infants young
  children at 2.8 years, and children at 9.7 years.

• By clinic, Pezmatlan had the greatest percentage
  of infants young children ages 5 and under
  (42.3), while San Andres had the largest
  percentage of children (ages 6-17) with 80.0.
• With respect to age, six-year-olds were the
  pediatric patients most frequently seen in
  clinic. In terms of gender, females made up just
  over half (53.0) of pediatric patients.

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Pediatric Diagnoses

• Diagnoses were reported for 349 pediatric
  patients, or 84.1 of children seen in clinic.
• With a total of 419 pediatric diagnoses, 31.6 of
  all diagnoses (N 1326) are attributable to
  children under 18 years of age.
• Pediatric patients were most commonly seen in the
  clinical setting for routine examinations, with
  28.9 of cases (under age 18) receiving only a
  dental exam, being seen for a well child visit or
  a general medical exam.
• Routine pediatric care (including dental
  examinations, well child visits, general
  medical exams) accounted for 10.7 of all cases
  (all ages), 7.6 of all diagnoses, and 24.1 of
  all pediatric diagnoses.
• Approximately 15 of pediatric patients were
  diagnosed with an acute upper respiratory
  infection, which included acute laryngitis, acute
  nasopharyngitis, acute sinusitis, acute
  tonsillitis, streptococcal pharyngitis, and other
  unspecified upper respiratory infections.
  Combined, these infections accounted for 12.2 of
  all pediatric diagnoses.
• Unspecified upper respiratory infections alone
  accounted for 6.0 of pediatric diagnoses and
  afflicted 7.2 of pediatric cases.
• Intestinal infectious diseases were responsible
  for almost 11 of diagnoses in this age group.
  Just over 13 of pediatric cases were afflicted
  with amoebiasis, bacterial foodborne
  intoxication, or unspecified protozoal intestinal
  disease.
• Unspecified protozoal intestinal disease was the
  leading Level 3 diagnosis among these intestinal
  infectious diseases, accounting for 93.5 of
  diagnoses in this category.
• General signs symptoms combined for roughly 7
  of pediatric diagnoses and affected 5.7 of
  pediatric patients. Headache, pain not
  classified elsewhere, lack of expected normal
  development, and lack of appetite were among the
  most prevalent conditions in this category.
• Otitis media alone accounted for 4.1 of
  pediatric diagnoses, affecting 4.9 of pediatric
  cases.

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Pediatric Diagnoses Level 1
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Pediatric Diagnoses Level 1
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Pediatric Diagnoses Level 2
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Pediatric Diagnoses Level 2
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Pediatric Diagnoses Level 3
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Pediatric Diagnoses Level 3
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Adult Patient Population
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Adult Demographics

• There were 707 adult patients, with the majority
  (66.2) between the ages of 18 and 59.
• 162 patients in Papatlatla
• 159 patients in San Andres
• 118 patients in Pezmatlan
• 108 patients in Coyula
• 160 patients in Calnali
• Adult (vs. pediatric) patients in Papatlatla
  accounted for the largest percentage (67.2) of
  total patients in that communityCoyula had the
  smallest percentage (56.5).
• The mean age of adults (age 18-59 years) was 40.9
  years and elderly patients, 68.4 years. The
  overall average age for all adult patients was
  50.2 years.

• By clinic, Pezmatlan had the smallest percentage
  of elderly (24.6), while Papatlatla Calnali
  had the largest percentage of elderly patients
  with approximately 40, each.
• With respect to age, sixty-year-olds were the
  adult patients most frequently seen in clinic.
  In terms of gender, the percentage of female
  patients was roughly three times that of males.

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Adult Diagnoses

• Diagnoses were reported for 576 adult patients,
  or 81.5 of adults seen in clinic.
• With a total of 884 adult diagnoses, 66.7 of all
  diagnoses (N 1326) are attributable to adults
  over 18 years of age, and 1.7 are attributable
  to patients of unknown age.
• The data reported in this section reflect the
  prevalence of age-related conditions. The three
  most prevalent conditions among adult patients
  were musculoskeletal connective tissue
  diseases, 29.5 digestive system diseases,
  19.1 and circulatory system diseases, 15.1.
  These conditions accounted for 19.2, 12.4, and
  9.8 of adult diagnoses, respectively.
• Among musculoskeletal connective tissue
  conditions, arthropathies, dorsopathies, and soft
  tissue disorders were the most common, making up
  40, 32.9, and 24.1 of diagnoses in this
  category, respectively. Osteopathies
  chondropathies made up the remaining 2.9.
• Affecting 6.6 of cases, low back pain was the
  most prevalent Level 3 diagnosis (among adults)
  in the musculoskeletal connective tissue
  disease category. Unspecified arthrosis,
  unspecified arthritis, and myalgia followed, with
  rates of 3.8, 3.6, and 3.3, respectively.
• Among digestive system diseases, conditions
  affecting the esophagus, stomach, and duodenum
  were the most common, accounting for 73.6 of
  disease in this category. Other diseases of the
  intestines, hernias, and noninfective enteritis
  collitis followed at 10.9, 4.5, and 4.5,
  respectively.
• Unspecified gastritis and gastroesophageal reflux
  disease predominated among Level 3 diagnoses in
  this category, with prevalence rates of 8.2 and
  4.9, respectively. All other Level 3 diagnoses
  had rates less than 2.0, each.
• Among circulatory system diseases, essential
  (primary) hypertension was the most common,
  accounting for 69.0 of disease in this category
  and affecting 10.4 of all adult cases. All
  other circulatory system conditions had
  prevalence rates less than or equal to 3.0 among
  adults.
• Diseases of the veins, lymphatic vessels, lymph
  nodes combined for 1.9 of adult diagnoses
  affected 3.0 of adults and accounted for 19.5
  of circulatory system conditions. Chronic,
  peripheral venous insufficiency was the most
  common Level 3 diagnosis reported in this
  subcategory, with a rate of 2.1 among adult
  patients.

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Adult Diagnoses Level 1
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Adult Diagnoses Level 1
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Adult Diagnoses Level 2
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Adult Diagnoses Level 2
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Adult Diagnoses Level 3
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Adult Diagnoses Level 3
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Brigade Images
Left Dr. Guido, with two special patients,
UAEH dental student who worked as his
assistant. Right Adult patients waiting to be
seen pediatric clinic, in background.
Left UAEH physicians with Dr. Woodward,
medical students Chirag Patel Brad
Recht. Right Dental students Brett Grube
Kevin Beadle with a special patient.
Left Drs. Henkle Woodward working with
medical student Chirag Patel nurse practitioner
student Barb De Rose, in Papatlatla. Right
Epidemiologist Dr. Martinez Campos with public
health student Liz Emery.
Left UAEH dental student instructing young
patient on proper brushing techniques. Right
Nurse practitioner student Francie Rogers
medical student Laura Sech examining a pediatric
patient.
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Brigade Images
Left UAEH students delivering health
education. Right Patient intake at clinic in
Calnali on last day of brigade.
Left Dental student Nicole Weddell performing
a procedure. Right Dr. Lorant examining a
pediatric patient.
Left Medical student Laura Sech examining a
patient. Right View of Calnali clinic layout,
last day of the brigade.
Left Hidalgo Nuestra Casa mobile dental units
served adult patients. Right UAEH pharmacy
students dispense free medication.
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Brigade Images
Left Medical student Brian Bales examines a
patient. Right Nurse practitioner student Deb
Bedwel Friends of Hidalgos Carla Chickedance
are thanked by a patient.
Left Dr. Stelzner working with a patient at the
San Andres clinic. Right Dental students
Lauren Weddell Kevin Beadle work together
during the Papatlatla clinic.
Left Dr. Soto talking with mother of
pediatric dental patients. Middle Dental
student Jeff Jones assisting Dr.
Guido Right Medical student Brad Recht
helping administer treatment to patient. Below
Layout of Papatlatla clinic, with patient
intake, medical services, health education,
dental exam stations shown.
Left Dr. Soto working with patients. Right
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Public Health Images
We awoke to a fire on the our first day in
Calnali, two houses down from where we were
staying. Students jumped out of bed to help in
the bucket brigade. Public health messages
throughout town relay the importance of clean
water.
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Public Health Images Atlapexco Hospital

• Epidemiologist Dr. Francisco Martinez Campos
  from UAEH spent the morning of Day 5 teaching us
  public health students about the Mexican health
  care system. We drove to the nearest hospital
  (one hour away from Calnali, in Atlapexco),
  toured the facilities, and met with physicians
  staff on site.
• This hospital is equipped with a laboratory with
  basic testing capabilities, 5 inpatient beds, a
  delivery room and incubator, a room devoted to
  womens health issues, and a pharmacy/medical
  storage space. An administrative office equipped
  with several computers is used for medical
  records storage statistical tracking.
  Reporting of diseases conditions to health
  officials in Pachuca occurs on a regular basis
  statistical programs are used to analyze patient
  data.
• Pictured (clockwise from top) entrance to the
  hospital laboratory facility public health
  students with hospital staff neonatal facility
  inpatient room pharmacy waiting area nurses
  station.

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Public Health Images Calnali Centro de Salud
After visiting the Atlapexco hospital, we
returned to Calnali and toured the local health
center. This facility offers basic health care
services. There is a delivery room, small triage
room, an exam room, a limited pharmacy, and
surprisingly, a seemingly brand new dental chair
(donated by Colgate-Palmolive in April 2005).
Services are provided for a nominal fee however,
this is often a barrier to Calnali residents and
routine preventive care is not commonplace. Pict
ured (clockwise from top left) entrance to the
clinic sterilization equipment waiting area
front desk pricing for services delivery room
triage room dental chair baby scale.
Calnali International Service Learning Experience

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Summary Remarks

• For eight years, the Calnali International
  Service Learning Project has established health
  care clinics in underserved communities in the
  Calnali region. These clinics, with a
  multidisciplinary approach, seek to improve the
  health of the population in this area. Barriers
  to care in these remote communities include
  distance from health care facilities, access to
  and cost of transportation, and local
  availability and cost of services. By
  establishing mobile clinics in these communities,
  the brigade acts to overcome several of these
  obstacles.
• The brigade focus is on providing acute care,
  including both medical and dental treatment.
  Data collected during the March 2006 brigade has
  been analyzed in this report in an effort to
  identify the leading medical conditions in our
  clinic population. Dental health status will be
  correlated with the dental survey findings in a
  study conducted by pediatric resident, Joe Guido,
  DDS. Together, these data sets will provide a
  more comprehensive picture of the medical and
  dental needs in the Calnali area.
• In looking at the medical diagnoses, data
  indicate that the leading causes of illness in
  this population include musculoskeletal and
  connective tissues diseases, respiratory system
  diseases, infectious and parasitic diseases, and
  digestive system diseases. While the leading
  diagnoses vary somewhat by age group and by
  community, the overall trend is that many of the
  prevalent conditions are potentially preventable.
  Further investigation may implicate poor living
  conditions as a factor in this trend. A
  comprehensive community assessment is recommended
  to better evaluate the underlying public health
  issues that give rise to these conditions.
• For program sustainability, it is also critical
  to assess these needs and design an intervention.
  By shifting the focus of the brigade to health
  assessment and preventive services, our resources
  may be better utilized. The goal of our efforts
  should be to better equip the community with the
  education and skills needed to develop
  self-sustainability at this level. Training,
  exchanging ideas with, and working alongside
  local health care providers (i.e. providing case
  management expertise) will not only benefit the
  local community but will also stress to our
  students the importance of working within the
  local system to enhance existing services. With
  this in mind, we should work with local officials
  to establish a continuity of care system for
  patients seen during any future brigade clinics
  (i.e. duplication of patient records) better
  understand specialty care services in the region
  and further identify existing public health
  infrastructure.
• The data presented in this report underscore the
  need for further public health involvement in the
  Calnali project, as well as the transition of the
  program to a preventive health focus. Future
  public health projects could include a water
  quality and environmental assessment a baseline
  pulmonary assessment to quantify respiratory
  health a survey on diet and nutritional needs
  or further research on oral health indicators.
  While womens health issues are not among the
  leading diagnoses in our data, the prevention of
  cervical cancer seemed to be stressed in our
  visit to the Atlapexco hospital and was the topic
  of the UAEH health education mini-sessions in our
  clinics. A study on the prevalence of this
  condition in the patient population may be of
  interest. Educational programs on this issue,
  nutrition, water purification techniques, or
  preventive dental practices could be among those
  developed and implemented.
• The Calnali program has reached a critical, yet
  exciting, turning point. With specific changes
  to the program structure and format, our
  multidisciplinary team has the potential to
  effectively limit disease incidence and
  prevalence in this region. Public health
  assessment, surveillance, and intervention will
  help strengthen the program as it begins to focus
  on the long-term objectives of improved health
  care status and self-sustainability at the
  community level.

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Appendix ISummary Tables
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Comprehensive List of Diagnoses by ICD-10 Codes
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Appendix IIReference Tables
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Appendix IIIClinic Program Documents
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List of medications provided by UAEH There
should be 3 more pages to this document however
only 2 were provided to physicians during clinic,
which made prescribing medications somewhat more
difficult
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Page 1 of 3
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Page 2 of 3
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Clinic Organization

• Organizational diagrams for four of five clinics
  held during the brigade are included for future
  reference. These can be used to anticipate
  supply needs (number of tables chairs) and to
  prepare for mobile clinic set-up. Having an
  organized plan for clinic construction could save
  valuable time in the morning and minimize on-site
  confusion.
• KEY

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SAN ANDRES CLINIC DAY 2 (Adult Pharmacy
Services Separate from Pediatrics)
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PEZMATLÁN CLINIC DAY 3 (Adults Separate from
Pediatrics)
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COYULA CLINIC DAY 4
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CALNALI CLINIC DAY 5
BRUSH
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Suggestions

• Patient Intake Forms
• Both IU and UAEH supplied their own forms to
  track medical diagnoses in the clinics, which may
  have affected data completeness. Since the IU
  form was only in English, the Mexican physicians
  often did not complete this form for their
  patients. Therefore, the UAEH data may more
  accurately represent the disease prevalence among
  adults in the region. If there are future
  clinical brigades, it would be best to develop
  one double-sided form that meets the needs of
  both parties, with English on one side and the
  Spanish translation on the other.
• Creating a form with a standardized diagnosis
  section would also be ideal for future clinics.
  Perhaps the most frequent diagnoses could be
  formatted into a checklistthis would minimize
  the need for Spanish medical translation and
  would also limit difficulty reading physician
  handwriting. The patient form should also
  include check boxes for patient gender and a line
  for physician signature. Specifying the units
  for height weight is also important.
• If it is possible to make copies of the patient
  intake forms prior to leaving, it would be best.
  While packing and transporting these forms can be
  a burden, it would save time money during the
  trip. Almost every day we had to make copies of
  the form before leaving for clinic and this took
  time. Even then, we ran out at least once during
  clinic and we had to frantically create
  make-shift forms while still trying to direct
  clinic operations.
• Travel Issues
• If there are future clinics in which medications
  will be transported to Calnali, it may be best to
  sort medicines prior to leaving for the trip.
  Large plastic bags could be used to organize
  medications by type and each bin could be filled
  with bags of each medication, with enough for
  one clinic. In preparation for this trip, we
  poured individual packets of medicines (of
  different types) into the bins and then spent the
  first afternoon in Calnali sorting out the
  various types. We then poured enough of each
  medicine for one clinic back into each binand
  then UAEH pharmacy students had to re-sort the
  medications once we reached the clinic location.
  In an effort to save time energy, simple
  sorting procedures could be performed ahead of
  time. Using plastic bags in this way may also
  help avoid a relative disaster should the bins
  inadvertently open in the course of transport to
  Calnali (when checked on the airplane) or enroute
  to the clinics.
• Participants should be provided with a packing
  list that is specific to the trip. A preliminary
  version is included in this report. Better
  emergency contact information should also be
  provided for students to leave with family
  members at home. A preliminary form is included
  in this report once filled out, students can
  retain a copy for themselves and a faculty member
  on the trip can have a copy for each student.

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Appendix IVHidalgo Public Health Forms
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Front
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Back
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Front
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Back
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Front
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Front
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• Liz Emery
• Indiana University School of Medicine
• Department of Public Health
• Master of Public Health Program
• Spring 2006