Abstract
Cultural immersion/service-learning programs are an important tool to increase cultural competence among students. Adding a research component to an existing program provides students with the opportunity to further engage with the community and to learn basic research skills. This manuscript describes a community-based undergraduate research project in a rural area of Honduras. It also provides suggestions for integrating a research component into cultural immersion/service-learning programs.
Introduction
Cultural immersion/service learning programs are an important means of providing students with opportunities to develop cultural sensitivity, while also meeting important service needs of communities (Willard-Holt, 2001). Academic service-learning is a well established pedagogy in the education of future health care professionals. This teaching strategy incorporates community service as a means of helping students acquire new knowledge, develop professional expertise, and engage in civic activity (Redman & Clark, 2002). The concepts of community and service are an integral part of nursing education which has embraced the integration of service and community as an essential component of education (Hunt, 2007; Seifer & Vaughn, 2002). Students involved in academic service-learning projects develop an understanding of diversity and social responsibility while being offered the opportunity to provide service that addresses the needs of the community.
Developing countries such as Honduras provide students with many such opportunities. Honduras is one of the poorest countries in Central America (Meyer, 2009). Rural areas of Honduras lack basic necessities, such as clean water and adequate sanitation (Sano, 2009). These areas also lack basic health education resources and health knowledge (Moll, et al., 2007). While service activities can effectively address many of these issues, research is important to provide an evidence-based foundation for planning and implementing programming in a cultural immersion/service-learning setting. Integrating community-based research projects into cultural immersion/service-learning programs also provide students with an opportunity to learn and apply the research process. This article will discuss the preparation and implementation of an exploratory research study to understand rural Honduran women’s needs in relation to folic acid. This study was added to usual service-learning activities during a ten-day cultural immersion/service-learning program.
Planning
In its third year of programming, this cultural immersion/service-learning program works with an in-country network made up of community members in a medically underserved rural area of Honduras. The program partners with the Yojoa International Medical Center Foundation, a group of local health care professionals, educators, business people and others committed to the goal of building a medical center that will meet the health care needs of the population, regardless of ability to pay. The number of students involved each year has increased, with ten students participating the first year, twelve the second year, and fourteen in the third year. Twenty students are expected to participate in the 2011 program. Each program has provided unique and valuable cultural experiences for students.
During previous immersions, students have participated in educational lessons in elementary schools, worked in rural clinics, toured private and public hospitals, and worked as advocates for building a hospital in this underserved rural area of Honduras. These service-learning activities were planned and developed through primary and secondary community assessments and were well-received by the community. Students will continue to participate in these service learning activities during future immersions. Other service learning activities will be added each year as they are identified through continued primary and secondary community assessments.
In addition to these service learning activities, the instructors wanted to include a community-based research project to address one of the objectives of this liberal studies course, “Ability to engage in scientific inquiry and processes.” Planning and implementing an exploratory community-based research project met this need and the results of this study provide additional information for future service-learning activities. Community-based research also met Boyer’s (1996) long standing call for universities to participate in the scholarship of engagement. Research in the service-learning setting allows students to address real-world problems locally.
Planning for the Folic Acid Project
All students were involved in some aspects of the planning and implementation of this project (i.e. online discussion for a literature review, interviewing subjects). However there were some tasks that were completed by two students who took the class as honor students (developing the interview protocol, data analysis, dissemination of results).
The project began by reviewing the literature to learn more about the importance of folic acid during pregnancy and what is currently known about folic acid and neural tube defects in Honduras. This review played two important roles. It provided the basis for the study, and it also prepared students to better understand the community in which they would be working. Students and faculty members searched for and read articles and then shared their thoughts about the articles in an online discussion. The following information gained from the literature review was deemed as essential in establishing the need for the study and providing information needed for the development of a questionnaire and the educational component of the program.
Student- and Faculty-Generated Folic Acid Review of the Literature
Adequate intake of folic acid during the first 12 weeks of pregnancy is critical in decreasing the incidence of neural tube defects in newborns. Affected babies may be born with spina bifida in which the spinal cord is outside of the normal anatomy, or anencephaly where the infant is lacking part or all of the brain (Spinal Cord Medicine, 2003). It is difficult to estimate the number of cases of neural tube defects in Honduras due to the high number of in-home births. One author has estimated that there are 2.43 cases of neural tube defects per 1,000 births (Milla, et al., 2007).
In developing countries where health care infrastructure is lacking, neural tube defects such as these are difficult to treat and there is a high rate of death due to these defects. One study of select public health and social security hospitals in Honduras reported that 49% of deaths associated with birth defects were due to neural tube defects (Milla, Flores, Umaña, Mayes, & Rosenthal, 2007).
While neural tube defects may be difficult to treat in developing countries, fortunately they are easily prevented through public health measures. Like many other countries in the world, Honduras has approved the use of folic acid for all women of childbearing age for the prevention of birth defects.
The neural tube closes at three to four weeks gestation, so often by the time a woman learns that she is pregnant, it is too late to provide folic acid to prevent these defects. Instead, adequate intake of folate or folic acid must be consumed prior to conception (Buttriss, 2004). If the incidence of neural tube defects is to be decreased, it is important that all women of child bearing age begin consuming adequate amounts of folate or begin taking folic acid supplementation. However, there are barriers to these preventive actions in Honduras.
The first barrier to prevention efforts is knowledge. Wu, Brat, Milla, and Kim (2007) report that 45% of Honduran women in their study were familiar with folic acid and of this 45% only 25% reported proper pre-natal supplementation. Another study reported that 37.5% of Honduran women believed that folic acid was related to birth defects. Other reported causes of birth defects were alcohol intake (20.6%), and mystical, mythical, or religious causes (23%) (Milla, et al., 2007).
The second barrier related to increasing folate/folic acid consumption is the poverty in Honduras and its related effect on the typical Honduran diet, which lacks adequate folic acid. With over half of the population living in poverty, money for food is limited (World Health Organization, 2006). Hondurans typically consume rice, beans, natural fruit juices, tortilla, bananas or plantains, beef, and eggs on a daily basis (Edmonds, 2005). Folic acid fortification, an important and effective public health intervention employed by developed countries such as the United States has not been instituted in Honduras. Therefore, while tortillas made in the United States with folic acid enriched flour or rice are good sources of folic acid, in Honduras they are not. Of these typically eaten foods, only some varieties of beans and natural fruit juices are naturally high in folate (Whitney & Rolfes, 2005).
Creating an Interview Questionnaire
The review of the literature demonstrated the need for the study and provided guidance with the development of an interview questionnaire and an educational component of the program. The following research questions were addressed:
- What percentage of rural Honduran women in the Lake Yojoa Region report that they are knowledgeable about folate/folic acid?
- Is there an association between reported knowledge about folate/folic acid and reported consumption of a daily multivitamin?
- Is there an association between reported age and reported knowledge of folate/folic acid?
- Is there an association between reported number of children and reported consumption of a daily multivitamin?
After consultation with the in-country network, the questionnaire and research protocol were approved by the University’s Internal Review Board for research. The purpose of the interview questionnaire was to understand the folic acid education needs among rural Honduran women who are served in the clinics in the local area. This allowed students to go beyond what was in the literature for Honduras as a whole and better understand the needs of the specific group of women served. The questionnaire included demographic questions such as age, number of children, and ages of children. Participants were also asked if they had heard about folate or folic acid, and whether they took a multivitamin pill each day or on occasion. The two honor students, in collaboration with instructors wrote and then translated the interview questions into Spanish.
Activities for the Research Project during the Service-Learning Program
Interviewing Women
Women between the ages of 18 and 45 years of age who presented for care at one of three clinics in rural Honduras were invited to participate in the study. Interviews took place over a three-day period. All fourteen students participated in the interviewing process. Those that lacked Spanish speaking skills were teamed up with a Spanish-speaking student and played a role by recording responses. It was very interesting to observe the students in this process. In previous immersions some students had held back a bit from interaction. However the interview for the research provided students with a reason to approach and begin a discussion. In some instances, the discussion would extend beyond the interview, thus increasing the amount of interaction between students and Honduran natives.
This communication was important for some students in understanding “the other side” of communication difficulties. When reflecting on the barriers to communication during interviewing one student stated, “This got me thinking, what if I was the caregiver in charge? How would I help the person and obtain the needed medical information with a language barrier? It also got me thinking about being in the patient’s shoes.”
In addition to interviewing the women, students also participated in other service-learning activities in the three rural clinics. They assisted nursing staff with intake activities, gave immunizations and assessed the developmental level of children while engaging them in play in waiting rooms.
Providing an Educational Program
The review of the literature pointed to a knowledge deficit among Honduran women. In anticipation of this knowledge deficit, a folic acid educational component was also developed. Students created a DVD that focused on the potential for birth defects associated with a lack of folate/folic acid intake. The DVD presentation also provided information about the foods in the typical Honduran diet that are good sources of folate. The two honor students wrote and translated the script for the DVD. After review of the script by the course instructors, the DVD presentation was recorded in Spanish by a Spanish professor. An internal grant was used to purchase a portable DVD player. The grant also was used to pay for the recording of the DVD and to purchase folic acid supplements. Following the interviews, women were invited to view this educational DVD. Clinic personnel provided folic acid supplements to the women. The DVD player and DVD were left in Honduras for the clinics for continued educational use.
The educational aspect of this program was well-received. On reflection about the educational program, one student stated, “I did not know how the mothers were going to react to watching the video, but they all seemed very receptive and eager to watch. Many women were trying to crowd around because they all wanted to see, but we reassured them that we were going to be passing around the player and everyone was going to get a chance.”
Activities for the Research Project after the Service-Learning Program
Data Analysis/Results
Data were analyzed using PASW Statistics 17.0 using descriptive statistics. Pearson chi-square tests of independence were used to determine associations between variables. For analysis, the variable for number of children was divided into three groups. The first group contains those that reported zero children, the second group contains those that reported one to three children and the third group contains those subjects that reported having more than three children. This division was based upon the potential differences between women reporting having no children, women reporting having the number of children that was at or under the total fertility rate in Honduras (3.3 children) (UNICEF, 2010), and the women that reported having more children than the total fertility rate in Honduras. Reported age was divided into two groups based upon younger and older women of child bearing age, women 18-30 and women 31-45. Analysis of results was undertaken by the course instructors and the two honor students.
Students surveyed 137 women of childbearing age. Women were distributed between the three rural clinics with roughly one third being interviewed in each clinic (32%, 32%, & 36%). The sample was fairly young with a mean age of 27.3. Women reported 0 to 13 children and the mean number of children was 2.6.
Over half (61%) of the women reported that they knew about folate or folic acid and 37% of the women reported that they took a daily multivitamin. Just over half (56%) of the women reported that they took a multivitamin on occasion. A Pearson chi-square test for independence demonstrated that the proportion of women who reported taking a daily multivitamin and were knowledgeable about folate/folic acid differed significantly from the proportion of women who reported taking a daily multivitamin but were not knowledgeable about folate/folic acid ( N = 137) = 21.34, p < .05). Women who reported that they were knowledgeable about folate/folic acid had a higher than expected reported intake of a daily multivitamin (residual=4.6).
A Pearson chi-square test for independence demonstrated that the proportion of women who reported daily vitamin use differed significantly among women reporting zero, one to three, or greater than three children ( N = 136) = 7.812, p< .05). Women who reported zero children had a higher than expected reported intake of a daily multivitamin (residual 2.8).
A Pearson chi-square test for independence demonstrated that there were no statistically significant differences between the proportion of women who reported being knowledgeable about folate/folic acid and the proportion of women in the two age groups ( N = 137) = .289, p > .05).
Discussion of the Research Project
The mean number of children in the study sample (2.6) was lower than the 3.3 total fertility rate in Honduras (UNICEF, 2010). It was interesting to note that women reporting no children were more likely to take a daily multivitamin. This may be a reflection of the poverty in Honduras. Those with children may no longer have the resources to purchase multivitamins for daily use.
The results of this research demonstrated that the reported knowledge level of women in this sample of rural Honduran women was higher (61%) than reported in 2007 by Wu, Brat, Milla, and Kim (45%). Though more women reported being knowledgeable, the low daily vitamin supplementation intake of those that reported not being knowledgeable points to the importance of continued folate/folic acid education in rural Honduras for women of child bearing age. Education is limited in Honduras. Primary school from ages six to eleven is compulsory. According to UNICEF (2010), 96% of Honduran male children and 97% of Honduran female children attend primary school. However, it is unlikely that folate/folic acid plays a substantial role in health programming at the primary school level. Secondary school provides the next five years of schooling for students 12 to 16 years of age. UNICEF (2010), reports that 29% of male Honduran adolescents and 36% of female Honduran adolescents attend secondary school. This may be one of the reasons that age was independent of knowledge of folate/folic acid. Both younger and older adults have had limited educational opportunities.
Limitations of this Study
Students were asked to identify the limitations of this study. They identified the following limitations: lack of random sampling, problems that accompany self report, and potential communication difficulties. All women who attended the rural clinics in Honduras were invited to participate. This limitation does not allow generalization to all rural Honduran women. Women were interviewed in the waiting room of each clinic. Therefore their self-reported answers may have been influenced by others around them. Finally, while the students that were interviewing the women had fair Spanish speaking skills, there was the potential for miscommunication.
Applying the Results of the Research Project
While study limitations do not allow for generalizing to the larger Honduran population, one of the strengths of this study is that this data was obtained from the specific area where future immersions and service learning for this course will take place.
The results of this exploratory community-based research study were used to write a grant to provide additional resources for educating women in this rural area of Honduras. Further, this study and its results will be shared with the next student group that will be asked to identify additional areas of research needed. They will also be challenged to conduct future research with fewer limitations.
Future plans for this course include the use of a wiki (a webpage that allows all students in the class to edit a document) so that the class as a whole can write the literature review. While the discussion on WebCT was helpful, the use of a wiki will allow students to literally see the development of the review of the literature.
Conclusion
Adding an exploratory community-based research project to a cultural immersion/service-learning program adds a new dimension to the program. Students learn about the research process and faculty and students learn more about the population with which they are engaged. Please see Figure 1 for suggestions for adding a research project to a cultural immersion/service-learning program.
Faculty members found the implementation of this research project to be beneficial to students and intend to build on the research to better meet the needs of in-country partners. Conducting research with students was also beneficial to the faculty members in gathering data to use in a grant application to support future research endeavors. Finally, faculty members were rewarded by seeing the enriched learning that occurred with the addition of a research component to the program.
This community-based research project not only provided students with an opportunity to learn the research process, but students also valued seeing the relationship between the natural and social sciences. One student stated:
Service learning opportunities are an incredibly important component of a college career. Being part of a service learning project allowed me to develop both as an academic and a world citizen. Research done for this course demonstrates that the natural sciences and the social sciences are interconnected. Research in one area can lead to a greater understanding of the other. In addition, the research has real-life applications. In this service-learning project, I learned how certain aspects of the Honduran lifestyle can lead to health problems. Understanding how issues are interconnected is essential in order to find solutions to these problems. For example, since education is a large barrier to improving knowledge of folic acid/folate, educational programming (such as the DVD presentation) can be developed that focuses on the specific barrier.
Service learning projects inherently provide benefits to students as well as the community they serve. Embedded community-based research projects such as this one provide additional benefits to students in learning and applying basic research concepts. Students and faculty members learn more about their target population and are therefore better able to serve the community. The result is an enriching experience for all involved.
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About the Authors:
Professor Mary Jane Tremethick earned a Bachelor of Science degree in Nursing and a Master of Arts Degree in Community College Teaching from Northern Michigan University. She earned a Ph.D. in Community Health from the University of Tennessee-Knoxville. She completed a Post Doctoral Fellowship in Gerontology at Kansas State University. She has co-taught a cultural immersion/service-learning course in Honduras for the past three years. Email: mtremeth@nmu.edu
Professor Eileen Smit earned a Bachelor of Science in Nursing and a Master of Science degree in Psychiatric Mental Health Nursing from the University of Wisconsin-Madison. She is currently enrolled in the Family Nurse Practitioner program at Northern Michigan University. She has co-taught a cultural immersion/service-learning course in Honduras for the past three years.
Lauren Retzloff and Jessica Krol are undergraduate honor students at Northern Michigan University.