Tufts in Haiti: Public Health Research in the Milot Region

Edited by Elaine Siew

Over the past 3 years, Tufts Medical students and Masters in Public Health students have led public health projects in Milot, overseen by both clinical and public health faculty in collaboration with HSC physicians. The focus of these projects has been driven by HSC CEO, Dr. Harold Prévil and Dr. Mark Pearlmutter, Chair & VP Network Emergency Services, Steward Medical Group, who coordinates the Tufts/CRUDEM partnership. In designing the projects, Drs. Prévil and Pearlmutter took into consideration the healthcare needs and resources of HSC and the surrounding communities.

Initial projects included KAP (Knowledge, Attitude and Practice) surveys in maternal fetal medicine, nutrition, water safety, and pediatrics, as well as Cervical Cancer screening and correlation of VIA (direct visualization using acetic acid) with PAP smears and viral cultures. A common theme for each project is education of the community health agents based out of HSC. Initial results led the way for more targeted assessments, surveillance and interventional based projects.

The Tufts students spend most of the summer working on their respective projects alongside Tufts clinical and public health faculty. The students learn the value of working in resource challenged environments, which commonly involves a modification of their original project goals and expectations, while working under IRB based directives. The work over the past few years has resulted in various collaborative papers and poster presentations with both HSC and Tufts faculty/students authorship.

“I can’t think of a better way to enhance the health of Milot and its communities than to focus on academic projects that have been selected and fine tuned by Dr. Prévil in conjunction with Tufts faculty students,” said Tufts Faculty member and coordinator, Mark Pearlmutter, M.D. “The rotation is one of the more popular selections for international summer placements, due in large part to Dr. Prévil’s and CRUDEM’s support. All have gone out their way to ensure that the projects are supported and match the needs of both student development and the people of Milot.”

Summer Program Overview and Results
This summer, CRUDEM welcomed seven students from the Tufts University School of Medicine (Boston, MA) to Milot for 7-9 weeks to volunteer in the hospital and conduct public health projects in the surrounding communities. The students completed field research for four different research topics in the towns of Carrefour des Peres, Thibeau, Limonade, and Milot Center. The following descriptions highlight the details and results of their work:

Clean Water Access
High incidence of waterborne and diarrheal illnesses are largely attributable to the lack of access to safe drinking water and sanitation facilities, and represents a major point of concern in Haiti. To determine the safety of currently available drinking water, Tufts medical student Rose Yu assessed 58 public drinking water sites for coliform and E. coli, two bacteria that signify contamination. 81% of the 58 water sites surveyed were contaminated, which stresses the need for water treatment. In addition, 20 households were surveyed on their drinking water attitudes, beliefs, and practices. A better understanding of practices and acceptance of safe drinking water practices are essential before any infrastructure and technologies providing safe water can succeed. All households interviewed lived within 800 meters of a water source, treated their water, and valued the quality of their water highly. However, a significant amount of education on proper household water treatment is necessary, and it is a cost-effective way to provide safe water.

Hypertension
As little is known about hypertension in Haiti, the purpose of this study was to determine the prevalence of hypertension in the greater Milot community in Haiti, as well as evaluate knowledge and awareness of hypertension amongst study participants in this area. Three Tufts medical students, Logan Pierce, Alexander Shannon, and Julian Sonnenfeld, screened participants for Stage 1 (?140 systolic or ?90) and Stage 2 (?160 systolic or ?100 diastolic) hypertension based on two separate readings at least one week apart. Additionally, a survey was administered to each participant to gather certain demographic information as well as assess knowledge, attitudes, and beliefs about hypertension.

The estimated prevalence of hypertension in the sample was 36.4%. The data shows the expected trend between increasing age and higher blood pressure, as well as a higher prevalence of hypertension among the female participants in the study. There was little correlation between BMI and hypertension status. The results of the survey indicated a general lack of knowledge surrounding certain aspects of hypertension, most notably questions regarding associated symptoms and proper treatment. As a result, Tufts in Haiti recommends engaging Community Health Agents in an educational campaign targeting the general Haitian population (most importantly those with little or no schooling) and focusing on proper treatment and the asymptomatic nature of hypertension.

Maternal Health
According to the World Health Organization (WHO), the maternal mortality rate in Haiti is 300 women per 100,000 live births, 3 times that of the neighboring Dominican Republic and the highest in the western hemisphere. Many incidences of maternal mortality are preventable with the appropriate level of antenatal care during pregnancy, skilled care during childbirth, and continued care in the weeks immediately following delivery. Although there are many different causes of maternal mortality, the highest rates of maternal mortality are found in certain sub-populations of women: adolescent mothers, women living in poor or rural areas, women who have many closely spaced pregnancies, and women without access to prenatal care or a skilled birth attendant.

For this reason, this maternal health survey, led by Tufts medical student Amelia Curtis, focused on the age of mothers, spacing of children, and access to health care during pregnancy and delivery for mothers in the small communities surrounding Hôpital Sacré Coeur. A total of 142 women aged 17-85 years old were interviewed in Thibeau, Carrefour des Peres, and Limonade. Age at the time of first pregnancy ranged from 12 to 41 years old, with an average of 20.7 years old, and over 22.5% of women reported becoming pregnant before the age of 18. Median spacing between consecutive children was 3 years with a range of 1-14 years. Rates of prenatal care were high (80.1% of pregnancies followed by some level of prenatal care), but the quality of prenatal care was not measured and may be the subject of future studies. Less than 25% of recorded deliveries occurred in a hospital under the supervision of a doctor or nurse. Financial and transportation limitations were cited by many women as major obstacles to delivering outside of their own homes.

Childhood Nutrition and Health
Haiti has the highest under-five child mortality rate in the Western hemisphere. According to the WHO, inadequate nutrition underlies 53% of child deaths worldwide. The purpose of this research, led by two Tufts public health and nutrition students, Shelley Rollet and Elaine Siew, was to contribute to the reduction of childhood malnutrition and illness in the Milot region by providing data to inform the design and implementation of community health interventions. The students conducted child measurements and mother/caregiver surveys to learn about the prevalence of malnutrition, common feeding practices, and health status of the children.

The study measured three types of malnutrition: underweight (low weight-for-age), stunting (low height-for-age), and acute malnutrition/thinness (low weight-for-height for children under age 5; low BMI-for-age for older children). Out of a total 358 surveyed children below age 15, roughly two-thirds (69%) children were affected by at least one type of malnutrition of differing severity (mild, moderate, severe). 42% of mothers ended exclusive breastfeeding too early (before 6 months), which can put infants at risk for illness, compromised immunity, and disrupted growth.

Less than half (46%) of children aged 1-14 years who presented vaccination records had completed all required immunizations. In order to fight childhood malnutrition and illness at the local level, a multi-pronged, integrated approach is required, combining effective community outreach and monitoring, inpatient and outpatient nutrition therapy, and expanded partnerships with other nutrition-related organizations in the region.

Community Health Agent Trainings
In addition to the community-based public health projects, the Tufts in Haiti students conducted a series of five half-day workshops for an enthusiastic group of Community Health Agents from the Milot commune, in order to promote skill building and enhanced knowledge. The training topics included: Emergency First Aid, Hypertension and Urine Dipstick Analysis, Water Decontamination, Maternal Health, and Childhood Nutrition.