Original Articles

By Ms. Rachel Whitney , Dr. Michael Stevens , Dr. Gonzalo Bearman
Corresponding Author Ms. Rachel Whitney
Virginia Commonwealth University, 1915 E. Main St Apt D322 - United States of America 23223
Submitting Author Ms. Rachel E Whitney
Other Authors Dr. Michael Stevens
Virginia Commonwealth University, Dept of Infectious Disease, - United States of America

Dr. Gonzalo Bearman
Virginia Commonwealth University, Dept of Infectious Disease, - United States of America


Honduras, Obesity, Medical relief, Brigade, Rural, Dermatology

Whitney R, Stevens M, Bearman G. Medical Relief Services In Rural Honduras: An Assessment Of Healthcare Needs And Delivery With A Comparison Of Two Neighboring Communities. WebmedCentral PUBLIC HEALTH 2010;1(11):WMC001146
doi: 10.9754/journal.wmc.2010.001146
Submitted on: 10 Nov 2010 01:28:38 PM GMT
Published on: 10 Nov 2010 07:03:25 PM GMT


Background: Rural Honduras has limited access to healthcare. Medical brigades are a common occurrence in extremely underserved areas. In 2008 and 2009, the VCU Honduras Outreach Medical Brigada Relief Effort (HOMBRE) administered a Needs Assessment Survey (NAS) in the towns of Coyoles and La Hicaca, two proximal yet geographically distinct areas. In 2010, the Adult Health Initiative (AHI) database was developed with a formal data collection tool employed by the team in the same towns.

Objective: To perform a descriptive analysis of the 2010 AHI database and compare the results with the NAS from 2008 and 2009 of the same Yoro regions.

Methods: A descriptive analysis of the AHI database was performed for Coyoles and La Hicaca. Univariate analysis and multivariable modeling was performed to assess predictors for health conditions and medical relief services rendered across the two populations. Clinical data, diagnoses, and treatments recorded in the AHI database were compared to the NAS for a descriptive assessment of the medical services delivered.

Results: 491 individual patient encounters were recorded in the AHI database. There were 338 patients from Coyoles, and 153 from La Hicaca. By univariate analysis, residents of La Hicaca had a greater odds of normal body weight and a decreased odds of obesity, heartburn, and receipt of analgesics, proton pump inhibitors (PPI)/H2 blockers, and multivitamins (MVIs) than residents of Coyoloes. Multivariable modeling associated receipt of analgesic medications with obesity across both populations. 

Conclusion: The 2010 AHI database suggests that demographic differences exist between two geographically proximal yet distinct communities.  Residents of La Hicaca are less likely to be obese while Coyoles has an increased prevalence of obesity and gastrointestinal complaints. The predominant health concerns of 2008/9 were met by the 2010 campaign. Dermatological problems, both infectious and non-infectious, were highly prevalent in both communities, but more so in Coyoles. These data are useful for further planning and delivery of healthcare in rural Honduras.


Much of rural Honduras has limited access to healthcare. For the past several years faculty and students from the VCU School of Medicine have provided clinical care to rural Honduran populations through the Honduran Outreach Medical Brigada Relief Effort (HOMBRE). Many of these brigades have taken place in the Departmento de Yoro, a region of northern Honduras. Yoro is a large area and encompasses the geographic extremes of developed flatlands and rural mountains. Two towns in Yoro, and their respective surrounding villages, were selected as the focal points for a needs assessment survey (NAS) delivered by the HOMBRE teams in 2008 and 2009; the town of Coyoles, located in the flatter region of Yoro, and La Hicaca, located in the more rural, mountainous area (Illustration 1, [1]). This assessment was a formal, structured interview administered by members of the care team to 70 participants in 2008, and 101 participants in 2009 [Stevens MP, et al. Needs Assessment for 6/08-6/09 HOMBRE Medical Relief Trip: Yoro Region. Richmond: Virginia Commonwealth Univ; Nov 2009].

In 2010 we employed a formal data collection tool at the point of patient care. Each patient data form was completed by the provider and team at the time of patient encounter. The AHI database included information on basic health demographics of this population, as well as recorded the symptoms, diagnoses, and treatments delivered during the 2010 brigade.


The study aim was to provide a descriptive analysis of the 2010 AHI database. We compared two different yet geographically proximal communities for differences in patient characteristics, symptoms, diagnoses and treatments. Also, we compared the 2010 patient services rendered to that of the 2008 and 2009 NAS to evaluate areas of new or unmet needs.


A standardized data collection tool was employed at both clinic sites. At both sites, demographic data was collected at the clinic intake station and included gender, age, blood pressure, height, and weight. Mean height, weight, and body mass index (BMI) were calculated by gender and by site. There were, additionally, 25 medical variables included in the AHI database: clinic location, BMI, osteoarthritis, headache, analgesics prescription, home PT handout and educational handout given, diabetes mellitus (DM) screening, random blood glucose, diagnosis of DM, diagnosis of tinea pedis, tinea corporis, tinea cruris, and atopic dermatitis, albendazole or anti-fungal cream prescription, multivitamin, PPI/H2 blocker,  ibuprophen, or acetaminophen given, epigastric pain, heartburn, and dental consult. Providers also recorded individual patient dermatologic and medical complaints when indicated. In La Hicaca, owing to the small volume of patients, all variables were recorded by the individual provider at the point of care following the initial intake assessment. In Coyoles, in response to the large patient volume, clinical encounters were completed at 4 stations, with each station focusing on a different set of health concerns. The stations included a dermatologic and musculoskeletal complaints station, a gastrointestinal complaints and anti-helminthic therapy station, a diabetes and blood pressure screening station, and finally, a station for any remaining medical concerns. All adult patients rotated through each station sequentially. For either site, the same data collection form was employed. All data were entered daily on mobile computers by two medical team leaders (MS and GB).

A descriptive analysis of the AHI database was performed. Frequency counts, percent response per variable and mean values were calculated, when applicable, for all variables across both encounter sites. For dermatologic complaints, we categorized these into two diagnostic categories: dermatophyte infections or other dermatologic conditions as documented by the provider at the point of care. Univariate and multivariable model analyses were performed to compare health assessments and encounters between the two different populations.

The chi-square test was used to test the difference between the two sites. The analysis was done using the SAS software (version 9.2, SAS Institute, Inc., Cary, NC). The multivariable analyses were done using the JMP software (version 8.0, SAS Institute, Inc., Cary, NC).

Finally, a descriptive analysis between the 2010 AHI database variables and the 2008 and 2009 NAS from the same sites was completed. The NAS was employed during the 2008 and 2009 HOMBRE brigades. The NAS consisted of 29 variables, including questions about home environment, access to healthcare, health practices, and health concerns. We categorized the NAS responses into the following clinical categories: water sanitation, nutrition, education, prenatal care, delivery, post-partum care, service too far away, cost, transport, anxiety/depression, alcoholism, breathing problems, diabetes, hypertension, and infections. We then cross referenced those diagnostic categories to the data elements in the 2010 AHI database for similarity, overlap and discordance.


Population characteristics

There were 491 participants in the 2010 AHI survey, 69% (n=338) were from the Coyoles area, and 31% (n=153) were from the La Hicaca area. General characteristics of the overall population included a mean age of 42 and a mean blood pressure of 124/80 mmHg. Of the 491 participants, 77% (n=379) were female and 23% (n=112) were male. Males had a mean age of 50, mean height of 63 cm, mean weight of 140 pounds, and mean BMI of 23. Females had a mean age of 40, mean height of 58 cm, mean weight of 134 pounds, and mean BMI of 25.8.

Medical variables

Demographics, medical conditions, and treatments for the populations of Coyoles and La Hicaca are summarized in Illustration 2. BMI, DM screening, dermatophyte infections, presence of gastroesophageal reflux disease (GERD), dental consults, and medications were significantly different between the two regions.

Dermatologic concerns 

Dermatologic complaints were recorded on the data assessment form. Fifty-two percent (n=92) of all dermatological complaints were related to infection, accounting for 54% of dermatologic complaints at Coyoles and 80% at La Hicaca. A further breakdown is detailed in Illustration 3. Of the non-infectious complaints, the most frequently reported issues were pruritis (6%, n=28) and heat rash (2%, n=12).

Univariate Analysis

Mean weight, the diagnosis of GERD, and medications prescribed differed between the two communities in the univariate model. Patients from La Hicaca were associated with a decreased odds ratio for obesity, extreme obesity, diagnosis of GERD and receipt of analgesics, MVIs, and PPI/H2 blockers. These relationships are detailed in Illustration 4.

Multivariable Analysis

Significant univariate variables were assessed by multivariable analysis. In a multivariable model, obese patients were less likely to receive analgesics at the time of medical encounter (p=<0.0001, OR=0.287).

Missing Data

Overall, for the Coyoles area, there was a 4.2% (n=393) missing data rate, and for La Hicaca a 6.6% (n=304) missing data rate. The bulk of the missing data for Coyoles came from assessment of whether an educational handout was given and a random blood glucose was drawn.  With these variables excluded, the missing data rate dropped to 1.5 % (n=143). For La Hicaca, the majority of missing data came from assessment of educational handout given and diagnosis of diabetes. With these variables excluded, the missing data rate dropped to 2.7% (n=124).

Descriptive Analysis of Needs Assessment

In 2008 and 2009, a NAS was conducted in the Yoro region of Honduras, focusing on the areas in and around Coyoles and El Caril (both just outside of the city of Olanchito), as well as La Hicaca. Predominant health concerns expressed by participants included water sanitation, nutrition, DM, hypertension, and infection. Diagnoses and treatments detailed in the 2010 AHI database were compared with the health and diagnostic concerns documented by the 2008 and 2009 NAS (Illustration 5). We assessed whether the treatments and evaluations of the 2010 brigade matched the concerns listed in 2008 and 2009. Water sanitation, a prevalent concern in the NAS, was matched with both medical evaluation for epigastric and gastrointestinal discomfort and concerns about infection with intestinal helminths. Nutritional concerns were evaluated and addressed by measurement of BMI and prescription of multivitamins. Concerns about diabetes were addressed by screening for diabetes and by measuring random blood glucose, and by providing home glucose monitoring strips and lancets for known diabetics. Concerns about hypertension were addressed by blood pressure screening. Lastly, concerns about infectious diseases from 2008 and 2009 were addressed by careful clinical assessment and treatment, when applicable, of any infectious condition reported by the patients, including dermatologic issues. Concerns listed in the NAS that could not be associated with the AHI database were education, prenatal care, delivery, post-partum care, service too far away, cost, transport, anxiety/depression, alcoholism, and breathing problems.


Delivery of healthcare to rural and underserved nations is a continuing challenge. The World Health Organization’s current Honduran statistics document only 6 doctors for every 10,000 inhabitants, and even fewer community and public health workers for this decidedly underserved population [2].

Medical relief trips to Honduras are common and often focus on delivery of care to rural communities. Physicians, residents and medical students affiliated with Virginia Commonwealth University travel to Honduras through the HOMBRE program [3]. These brigades serve to expose students, residents and faculty to the delivery of healthcare in resource-poor settings. In addition, our brigade attempts to meet public health needs within a given geographic region, through such efforts as obesity and diabetes screening, delivery of anti-helminthics, and provision of home water filters for increased access to potable water.

Similar relief efforts in Honduras are aimed at developing effective needs assessment tools [4]. The 2008-2009 NAS and 2010 AHI database are part of a continuing effort at exploring the Yoro region of Honduras, and how future brigades traveling to these towns might adapt to best serve the needs of this population.

Analysis of the 2010 AHI Honduras database suggests that similar health concerns exist across Coyoles and La Hicaca. However, notable differences exist between the two communities. There is a decreased prevalence of obesity in La Hicaca with an increased prevalence of obesity and heartburn in the area of Coyoles. This is likely related to the geographic differences of the two areas. Coyoles is located in a flatter, more developed region of Honduras, with greater access to transportation and processed food, while La Hicaca and its surrounding villages are located in the mountains surrounding Coyoles, and is much more rural and isolated.

Sociodemographic predictors of health in Honduras have been previously described. In a similarly focused study, Smith et al describe differing prevalence and intensity of helminthic infections in Honduras based on geography and socio-demographic variables [5].Obesity in Latin America has also been previously studied. A study by Kain et al examining obesity trends in Latin American countries observed that overall rates of obesity are lowest in the poorest countries, including Honduras. However, obesity in the population increases most for countries rising from poverty, especially for more urban areas within these countries [6]. Filozof et al supports these findings, adding that the dietary changes and decline in physical activity related to urbanization are a possible explanation for obesity in these regions [7].

The NAS-AHI database comparison suggests that the predominant concerns expressed by the population of the Yoro region were addressed, albeit indirectly, by the 2010 AHI. Although not expressed as a significant concern in the NAS, the AHI database revealed dermatological problems, both infectious and non-infectious, to be widespread in this population, especially in patients from Coyoles. This relationship between geography and prevalence of dermatologic complaints has not yet been extensively studied for Central America.

While helpful, periodic health brigades cannot fully address the fundamental needs of resource poor populations. Needs assessment surveys are important for focused and efficient medical relief care. However, data from the NAS may not be sufficient. The AHI database provides additional and more specific clinical data that may be useful for future trips as they aim to better prepare and serve these areas in the coming years. While the NAS highlighted infectious concerns in general, the AHI database identified dermatophyte infections and scabies as predominant diagnoses. In addition, the AHI database provided important objective health measurements. For example, geographic differences in BMI and weight-related health issues, such as heartburn should be taken into consideration during future brigade planning. These data suggest that Coyoles, more so than La Hicaca, would benefit from education about nutrition and exercise, and the advantages that maintaining a lower weight can have on one’s health.

Prior investigators have highlighted strategies for health related education in resource poor settings. Rennert et al show that using community health workers (CHW) to educate and treat local populations can be a very effective means of providing care. This is especially true when the system involves initial education and continued evaluation of the CHW, along with implementing this system in areas where the need is greatest [8]. The communities of Coyoles and La Hicaca are ideal for CHWs given their rural locations and significant health concerns. Where applicable, radio broadcast education also proves to serve as an effective means of education [9]. Furthermore, Babamoto et al. documented greater improvement in health status, dietary habits, physical activity, and a greater odds of decreasing BMI for Hispanics when educated by a CHW versus a standard urban clinic [10]. Thus, a future consideration for the HOMBRE brigade, in addition to expansion of the clinical program, is education of patients on health related matters, possibly through collaboration with local CHWs. However, cultural, financial, and geographic restrictions of these areas must be considered when attempting these novel public health and education programs. 

Limitations of the study include missing data points for both locations, which can present as an incomplete picture of the demographics, symptoms, and diagnoses of the region. Also, patients included in the database may not be representative of the Honduran community at large. A difference in clinical encounter mechanism existed between the two sites, with the possibility that more data was recorded at Coyoles. It is possible that this led erroneously to a perceived increase in the prevalence of GI complaints, et cetera. As data at Coyoles were collected by a team approach rather than by one individual provider, collection and misclassification bias is possible. However, the volume of patients was decreased at La Hicaca, allowing each provider ample time to perform and document a thorough encounter evaluation. Last, we employed a simple descriptive analysis to assess congruencies in health needs and delivery between the 2008/2009 NAS and the 2010 AHI database. As a result, a quantifiable coefficient measure was not possible.

Our study has several strengths. We utilized the same, simple and easy to use data collection form for both sites thus minimizing data collection misclassification. In addition, data entry at the point of care was employed, minimizing recall bias. Last, our database had a large sample size, allowing for power to detect significant differences in all statistical tests employed.

Our study adds to the current body of literature on medical relief services in rural Honduras.  We also highlight that, although not a common concern when measured by the 2008 and 2009 NAS, dermatologic conditions were highly prevalent diagnoses in 2010. Our results confirm that even within developing, resource poor countries, communities closer to urban areas are prone to increased rates of obesity and related health consequences. Despite commonality in many of the healthcare needs across rural Honduras, we suggest that future Honduran medical brigades be aware of nuances in health pressures, resulting from differences in urbanization, as they attempt to deliver health services across geographically proximal communities. Rural Honduran communities, particularly in the Yoro region, would be well served by relief services seeking to address not only common musculoskeletal, infectious diseases, and dermatologic complaints, but also by attempting to increase awareness, through education, about obesity and its associated health risks, especially in urban settings. 


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