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FEATURED ARTICLE

Building a Lasting Trust: Students Contribute to
Community Development Through Service-Learning


By KIRK SMITH, PhD, MD, ELIZABETH REIFSNIDER, PhD, RN,
Sr. PHYLIS PETERS, DC, and TINA CHAO, MS, PA

service-learningHealth care students from three schools (health professions, medical, and nursing) from the University of Texas Medical Branch (UTMB) at Galveston and the residents of Cameron Park (a vulnerable community on the Texas/Mexico border that experiences many health problems related to poverty, geographic isolation and social marginalization) worked together through community development and service learning to mutually benefit each other. Service learning is a teaching strategy that engages students in service as they learn, helping them to understand what they are learning as a function of their service experience.

Cameron Park is a community of 7,000 at the southernmost tip of Texas, only a few miles from the US/Mexico border. It is unincorporated, but lies just outside the Brownsville city limit. Settled in the 1960s by immigrants from Mexico eager for homes and a stake in the United States, the community is officially classified a colonia, defined by the Texas Secretary of State as “a residential area along the Texas-Mexico border [lacking] some basic living necessity:” these include potable water, sewage, electricity, paved roads, and safe and sanitary housing. Texas recognizes some 1500 colonias. Cameron Park, the largest and most densely populated, is exemplary of its class, its history dominated by the amenities it has lacked. For decades, electrification was sporadic, multiple homes shared a single water tap, and open sewers lined dirt roads. When heavy rains turned those roads to mud, emergency services, garbage collection and mail delivery ceased. School children labored to reach a bus stop. In those days, health care ranked below controlling the stray dogs that menaced pedestrians.

service-learningIn 1998, health services improved when Frontera de Salud (www.fronteradesalud.org) turned its attention to Cameron Park. Frontera is a volunteer service organization of medical, nursing and health profession students that originated at the University of Texas Medical Branch (UTMB) at Galveston. The organization’s student founders had become familiar with the colonia while training at the Brownsville Community Health Center (BCHC), a federally qualified health center serving the southern half of Cameron County. Frontera had recently begun a volunteer effort aimed at alleviating the then two-year backlog of BCHC patients awaiting well-woman exams. This effort has continued as six times a year, teams of 15 to 20 medical, nursing, and health occupation students make the 600 mile round-trip from the health sciences campus in Galveston to the Rio Grande Valley of south Texas to conduct weekend clinics at the BCHC, providing pelvic and breast exams to un- and underinsured women, over 1500 exams to date.

Soon after the clinical operation took hold, the volunteers expanded their mission to include community-based services in Cameron Park. The colonia initiative started modestly. The clinic offers well-woman clinics on Saturday mornings at BCHC. In the afternoons, in the first months of the community outreach, the students arranged their equipment on tables in a hall adjacent to the parish church to screen residents for hypertension and diabetes and offer counsel. The initial response was disappointing. The first Saturday, no one came for screening. At first blush, this reluctance appeared to confirm received notions of the community’s attitude toward health. Local health care providers who were not located in the colonia, frequently frustrated by their patients’ non-compliance with therapy and counsel, had intimated to the students that residents of these low socio-economic communities, (primarily Mexican-American communities) take little regard, or responsibility, for their health and are beset by fatalismo, the belief that illness is fated by God. A similar presumption had under laid the students’ lectures on campus wherein the subtext suggested that advising lifestyle changes to control chronic disease was futile since the subjects of such advice are generally recalcitrant to change and did not take responsibility for their own health.

service-learningFrontera’s first impression of Cameron Park seemed verification of that assumption. But as the students persisted in their outreach and became better acquainted with the community, a different, more accurate picture emerged. As they later learned, a few years before the students’ introduction to Cameron Park, a consortium of health science center scientists had targeted the community for a research study, a central component of which was blood assays of children to assess nutrient levels. The researchers intimated they would return to share results and remedy deficiencies but neither results nor remedies materialized The disappointed community was thus inclined to shun the students’ proffered help, fearing it would lead to further exploitation.

Still, they persisted, sitting patiently at their tables, awaiting a response and, as it turned out, building trust. For as the volunteers returned time and again, regularly and as promised, manifesting no intention beyond caring for the community’s well-being, perceptions changed. On the part of the colonia, suspicion waned. On the students’ part, prejudices—held, if never admitted—gave way to understanding and solidarity. In particular, false impressions of fatalismo and disinterest dissipated. The health professions students and the people of the colonia developed a bond so that, by the time the outreach celebrated its first anniversary, upwards of 50 Cameron Park residents were attending the Sunday morning “health fairs;” services had expanded to include diabetic foot assessments, screening for depression and domestic violence (in addition to the blood pressure and blood glucose checks), and health education and wellness counseling; the fairs themselves had moved out of the parish hall and into Proyecto Digna’s (501(c)(3) advocacy organization based in Cameron Park) new community center.

Moreover, as a further manifestation of the outreach’s acceptance, residents began requesting home visits for those who, through frailty or reluctance to publicize their maladies, were unable to attend the health fairs. As an index of the colonia’s needs, those maladies are instructive. They ranged from stitches embedded in the face of an injured worker unable to afford their removal following an emergency room visit to an elderly resident with a physical examination classic for aortic stenosis whose grandchildren summoned the students to their shared home to address her frequent fainting spells. In these, and numerous other cases, the volunteers were able to provide remedy, whether the painstaking tweezing out of sutures in a patient’s cramped living room or a persistent, and ultimately successful effort to obtain life-saving surgery.

service-learningThe joint effort and the residents own self-care practices are well-illustrated in the students’ home visits. The home visit program arose spontaneously as residents, hearing of the ‘student doctors and nurses’ presence, began requesting visits to house-bound family members and those too shy or wary of public attention to attend health fairs. This was still early in the process of civic improvements and the visits were complicated by the lack of street signs and, more fundamentally, the students’ ignorance of the colonia’s rules of social concourse. The students were relieved then when, on the occasion of their initial summoning to a resident’s home, one of the women of the colonia who had been assisting them with the health screenings offered to show the way and act as interpreter, culture guide and—as she always carried a thick stick to ward off stray dogs—bodyguard.

As they later learned, their guide (call her Catalina) was one of a group of Cameron Park residents trained as a community health worker (CHW, known locally as promotores de salud) under a now defunct cancer prevention program. This was the students’ first acquaintance with CHWs and the system of community-based preventive healthcare that for decades in places like Cameron Park had been struggling to be born. Catalina proved the catalyst for Frontera’s investment in that system. Realizing that the CHWs offered a solution to the screening conundrum (referring residents to clinical management was unlikely to lead to care; referring them to a self-management program involving promotores as the conduits of care could), the students began to organize, step-by-step and in tandem with Proyecto Digna, a healthcare delivery system based on disease prevention and control. First, they reactivated the Cameron Park CHWs, arranging for their re-certification; they then funded their further training on chronic disease self-management. Soon, a cadre of five promotores began assisting the volunteers’ with the health fairs (now re-dubbed healthy living events in token of their expanded reach) and home visit program and also began conducting home visits and follow-up on their own, reinforcing the health professions students’ self-management counsel. Meanwhile, Proyecto Digna undertook to recruit a full-time community nurse to oversee the CHWs and supervise the prevention and control program.

service-learningCoordination of these social services with healthcare had an additive effect. Among other benefits, it led to improved access to care. The satellite clinic in Cameron Park, staffed by family practice providers, was already seeing a large volume of unsponsored patients (in keeping with the BCHC’s commitment to stretch resources to the maximum to accommodate the un- and underinsured). Enrollment of Cameron Park residents in funded programs not only eased their own access to the clinic, it also leveraged access for unfunded neighbors. Finally, in partnership with the University of Texas Health Science Center Houston School of Public Health (UT-SPH) regional campus in Brownsville, the Frontera/PD alliance joined with the county in upgrading the local park to include a walking trail, soccer field, basketball court and family picnic area, all well-lit and enclosed with a security fence: this in addition to the paved roads, sewage, sidewalks and street lights secured through the advocacy of Proyecto Digna. This healthy living infrastructure now also includes additional exercise spaces, distributed throughout the colonia, and a large community garden down the street from the PJD healthy living center.

The consequence of this integrated effort—coordinated across a variety of agencies (individual, grassroots, administrative, academic and political)—is evident in the evolution of the student volunteer screening, education and counseling activities. These have been transformed from well-meaning, but often futile exercises that served mainly to indict failures of the healthcare system into “healthy living events” integrated into a comprehensive health delivery system: 1) rooted in prevention, 2) exercised through local action, and 3) aimed at root causes to 4) ameliorate social determinants of health.

All residents have access to that system: self-management classes; aerobics, salsa dancing, and walking groups; healthy eating events; cooking demonstrations, etc. The more motivated are encouraged to become health leaders themselves, e.g. hosting ‘healthy kitchen’ (cocinas de salud) demonstrations for which they earn incentive remuneration as well as their neighbors’ goodwill. Those with, or at evident risk for, disease are referred to the community nurse, who, besides following them regularly at the PJD facility, arranges periodic home visits by the CHWs as well as appointments at the Cameron Park clinic subsidized, as necessary, by Proyecto Digna and Frontera.


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