Pilot Surveys of Ethics and Short-Term Medical Mission Work: University of Wyoming Agua Salada Clinic, Honduras

This research, performed in Agua Salada, Honduras, was done to help identify ethical issues perceived by the recipients of short-term medical missions and to examine how these issues differ between volunteers and patients. Using the four principles of medical ethics (non-maleficence, beneficence, autonomy, and justice) as a guide, patient-participants and brigade volunteers were surveyed using open-ended questions on the ethical aspects of taking western medicine to an underdeveloped region. Both the patient-participants (n=58) and brigade volunteers (n=12) agreed that medical missions should come to Honduras. Interestingly, with questions related to the benefit of medical mission work, volunteers were more likely to report benefit to themselves (60.3%) than to patients. In conclusion, patients and volunteers primarily share common perceptions of beneficence and justice while volunteers are more likely to be concerned with non-maleficence and undervalue indicators of autonomy.


Introduction
Medical missions are characterized by a group of people, travelling to a foreign country, seeking to provide medical services, education, or supplies to the people of that country. The nature of these missions varies; often being relief-, surgical-, or dental-oriented or aimed at providing general health services. [1] In recent years, these missions have shifted from a long-term commitment involving the building of structures and sustained medical services to a short-term model where volunteers provide temporary and transient services. [1] The "brigades" providing this care are largely comprised of western-trained and licensed physicians, nurses and other health care professionals whose primary goal is to provide services and education. [2] The nature of the services provided may also vary; one brigade may seek to provide care to those most in need, another might seek to provide services that simply are not available in their destination and yet another may seek to do the most good for the most people with simple and easily-treatable conditions. [3] In general, the intent of most volunteers on these medical missions is to improve the lives of patients in need of care in underdeveloped foreign countries. [3] Often, the volunteers themselves, a charitable organization, or both, pay for these trips. [2] Additionally, a majority of brigades work with non-governmental organizations (NGO) to facilitate these trips and maximize the benefits for everyone. [2] Conversely, a review of literature and informal survey of volunteers who have participated in medical missions reveal a multitude of ethical questions surrounding the services provided during short-term missions. Questions of who benefits, what kind of care to give, if money is being well spent and the overall impact on culture and health outcomes have been repeatedly asked. Issues of sub-standard care being given due to lack of resources, as well as communication barriers and lack of continuity often arise. Some efforts have been made to address these concerns through the development of sustainable mission models. At large, these models involve creating a common and specific mission, forming collaborations with local organizations and health workers, focusing on education, and ensuring that providers and supplies are appropriate while still remaining culturally sensitive. [2,4] In addition, one model suggests that evaluation of a project is essential to improving its design and implementation. [4] However, despite recent publications, overall there seems to be a clear paucity of literature involving a systematic review of the perspectives of the recipients of medical mission care, though "Anecdotally, experienced individuals in international development report that the communities give thanks… (For) caring to come, listen, and understand their lives." [5] The purpose of this research is to identify the ethical issues perceived by the local recipients of temporary, intermittent medical mission care and to examine how these ethical issues perceived by the recipients of this care differ from those perceived by the medical brigade volunteers who provided care.

Background
The College of Health Sciences Fay W. Whitney School of Nursing at the University of Wyoming (UW) has an established memorandum of understanding (MOU) with Shoulder to Shoulder (S2S), a NGO, which works solely in the Intibucá region of Honduras ( Figure 1). [6] UW sends 2-3 brigades each year to serve Agua Salada and its surrounding communities. The brigades have an established rapport within these communities with a mission to provide "primary health care, public health, dental care, nutrition, and education." [7,8] Recently (July 2012), UW and S2S, in conjunction with the communities in and surrounding Agua Salada, finished major construction on a health clinic located directly in Agua Salada. Prior to this construction, a makeshift clinic for each brigade was established in the Agua Salada Church. Current plans to finish all areas of this new clinic, including shelving, sinks, bathrooms, showers, a cooking and dining area, as well as landscaping, are under way. By completing this clinic, it is the hope of UW and S2S that the effort to increase health promotion and awareness while maintaining a continuity of health care services and disease prevention for things such as cardiovascular disease, mental illness, vaccinations, malnutrition, and severe respiratory illness can be met. [9]  The clinic setting(s), pre-and post-construction, is also intended to function as a practice and research site across the disciplines for UW faculty and students. [9] Additionally, Shoulder to Shoulder has a broad based approach to their aid efforts in Intibucá. They are involved in nutrition, water, education, literacy, scholarship, empowerment and research as well as health care in the area. They have several permanent clinics and a working relationship with the local and federal governments of Honduras. To add to this, many of the permanent employees of S2S are Hondurans that have received a western, post-high school education, thus making their efforts more culturally sensitive and responsive. [10]

Medical Ethics
When using ethics for a medical study, there are four principles that are included; nonmaleficence, beneficence, autonomy and justice (Table 1). [11] These four principles are widely accepted in Western medicine when dealing with beliefs about caring for the sick. [11] Each principle was an important factor within this study and was used to interpret both the brigade volunteer's perspective and the patients they served.

Methods
The data collected for this research, with UW Institutional Review Board (IRB) approval, was done in two groups: patient-participant and brigade volunteer. [12] Both surveys contained open-ended questions revolving around the ethical aspects of taking western medicine to an underdeveloped region and were asked in order to gain perspective from both parties. Because both groups surveyed were convenience samples, only descriptive statistics are used. The number of brigade volunteers is based on those who filled out the surveys. Additionally, because it is difficult to predict the amount of patients coming to the clinic during any given brigade, the number of patients surveyed was decided based on previous brigade numbers to reflect approximately 10-12% of an estimated population of 500 patients (desired n=50-60).

Patient-participants
The pre-construction clinic, where the data was collected, was set up in the Agua Salada, Honduras, church during the July 2011 medical brigade. For five days, patients within Agua Salada and the surrounding communities came to this clinic for care. During this five-day clinic operation, 598 A small area outside the church back entrance was set up for patient-participant interviews. Agua Salada is predominantly a Spanish-speaking region; therefore, an interviewer and interpreter were hired through contract with the Principal Investigator to conduct interviews. All interviews were recorded with audio equipment and conducted only after explanation and signature of consent was obtained for each participant, age 18 years or older. Both the survey and consent form were available in English and Spanish, with each participant receiving a Spanish copy of the consent form. Moreover, the consent form explained privacy, confidentiality, risks and benefits, as well as a brief explanation of the interview process and the intent of the research.
All participants were reminded (verbally and through the consent form) that their contribution was voluntary and, should they choose, they could end the interview at any time. Both confidentiality and privacy were maintained to best of the researchers' ability during interviews. Additionally, each patient-participant received a small incentive gift, a reusable tote bag valued at $3.00, for taking part in the survey. The involved risk was perceived as minimal and was no different from that of any average questions asked in a clinic setting. All participants (new and returning) were identified only by their age, gender, where they lived in proximity to the clinic, and their reason (such as diagnosis or treatment) for their clinic visit(s).

Brigade Volunteers
The brigade volunteer surveys consisted of a pre-and post-mission format with the same questions used in each. The surveys were set up and compiled through an office maintained on the UW campus; the Nightingale Center for Nursing Scholarship (NCNS).
[13] The type of software utilized through NCNS was World App Key Survey® (220 Forbes Road, Braintree, MA; 2011) with each survey having a start and stop date. Within each link, an electronic consent form preceding the surveys explained privacy, confidentiality, risks, benefits, and purpose of the study. All brigade volunteers were reminded that their contribution was voluntary and, should they choose, they could end the online survey at any time. Deadlines and purpose of the study were also explained. The pre-mission survey was open three weeks prior to the trip to Honduras and ended on the day before flight. The post-mission survey began one day after the return trip and ran approximately four weeks. Every brigade volunteer was sent an electronic invitation to each survey along with a designated link. Reminders were also sent electronically once the surveys were open. All volunteers were identified only by their age, gender, and profession or discipline.

Results
The patient-participants (n=58) interviewed for this research were new and returning clinic patients from various areas within and surrounding Agua Salada and ranged in ages from 18-80. The brigade volunteers (n=12) surveyed consisted of both UW and non-UW brigade members ranging in ages from 22-70. Most were from within the local Wyoming health care disciplines though other fields such as engineering and law were represented. In addition, people with no acquired degree, but intentions toward health care, were also volunteers. Those who completed both surveys (pre-and post-mission) were used in the final analysis. However, due to incomplete pairs of surveys (i.e. age, gender, profession, and/or definitive answers to specific questions) only the results of the post-mission survey are presented.
A summary of the results for each group are displayed in Table 2: Patient-participant Survey Results Summary and Table 3: Brigade Volunteer Survey Results Summary, respectively, and are presented by group below.

Patient-participants
The 58 patient-participants surveyed had a mean age of 43.2, 37 (63.8%) were female, 21 (36.2%) were male. There were 46 (79.3%) returning and 12 (20.6%) new patients surveyed; 25 (43.1%) were from Agua Salada and 33 (56.9%) were from surrounding communities. Reasons for visiting the clinic included headache (22.4%), aches and pain (39.7%), child or prenatal care (15.5%), vision (10.3%) heart conditions (3.4%) general care (24%) and other (48.3%; this category includes, various infections, non-medical reasons and generalized answers that do not fit a specific category); multiple responses were possible and recorded individually. Table 4 represents the most common medications used to treat these various ailments while Figure 3 lists the top 10 over-the-counter and prescription medications dispensed throughout the week.
In general, participants were pleased with the services provided (51, 87.9%) and stated everything was "fine or perfect." Suggested improvements included bringing more medications, a larger variety of medications (2, 3.4%), other specialists (5, 8.6%), more devices to do more tests (2, 3.4%), and other (8, 13.7%). In addition, several patient-participants (10, 17.2%) stated that things would improve with the building of the new clinic.

Brigade Volunteers
Volunteers were asked a series of questions similar to those asked of the patient-participants both before and following their involvement in the medical brigade; 12 brigade members responded to both surveys; however, due to inconsistencies in the pre-and post-mission surveys, only the results from the post-mission survey will be presented and discussed in this paper.
Beliefs about how the Hondurans managed their health care needs between clinics was also assessed; 6 (22.2%) respondents believed traditional methods were utilized, travel to other clinics (8, 29.6%), do what they can and teamwork (4, 14.8%), and local resources (2, 7.4%). Seven (25.9%) believed Hondurans would do nothing or leave their conditions unmanaged.
Volunteers had many suggestions for future improvements in organization including physical resources and volunteers (5, 25.0%), better tracking of patients and medications (5,25.0%), expanding the membership of the volunteer team (2, 10.0%), addition of more translators (2, 10.0%), creating a more efficient workflow (2, 10.0%), and expanding clinic hours later in the day (1, 5.0%). Finally, the new clinic being built was cited as being helpful and beneficial by 3 (15%) respondents.

Discussion
With the four principles of medical ethics as a guide [11], this research was intended to identify the ethical issues perceived by the local recipients of temporary, intermittent medical mission care and to examine how the ethical concerns perceived by the recipients of this care differ from those perceived by the medical brigade volunteers who provided care.

Beneficence
The first ethical question to address is whether the recipients perceive benefit from this short-term medical mission health care model. Every person surveyed, both patient-participants and brigade volunteers, responded that yes, medical brigades should go to Agua Salada, Honduras. The patients reported that the services and medications provided were important aspects to the care that was received and that providing care to economically challenged individuals was a good reason to provide the clinics. The patient-participants and the brigade volunteers both commonly referred to the extensive need for care and medical resources as the primary reason that medical brigades should go to Agua Salada. In the responses provided, the patients in Agua Salada do not generally recognize that volunteers gain some benefit from the experience, as well, one response indicated that the brigade members "like to protect the health of other individuals." In addition, the idea of reciprocity arose in one response stating that we should come because they come and support us. The brigade volunteers were more likely to report a sense of duty or moral obligation to provide care, while the recipients believed the volunteers to be inherently "very nice" or good people. In general, the act of being there seems to be adequate for the patients' belief that the volunteers are good.
Only 11 (22%) of the responses to the reasons and factors affecting a brigade volunteers decision to join the brigade involved helping the patient or providing care while 100% of the patient-participant surveys suggested patient care or community improvement as the reason why medical brigades come to Agua Salada. The recipients of the medical mission care did not report benefit to anyone, but themselves and their community. To some extent, both sides perceive that patients benefit from the care that is given and received during the clinics; however, the providers also get a sense of personal benefit from the experience. These benefits received by brigade volunteers are addressed primarily in the reasons why they chose to be a member of the brigade.
Adopting a model similar to that discussed in Suchdev, et al. (2007) addressing three major health issues (dental, GI parasites, and nutrition) in conjunction with promoting Spanish fluency through on-site education would help address the needs in the Agua Salada community. [4] This would also help define roles within the volunteer community who travels there while closing the discernable gap between each group regarding beneficence.

Non-maleficence
One patient-participant engaged the interviewers about the brigade run clinics by responding that services are intended "…to give these meds to all these rotting bodies, we may look nice, but we are all full of body aches and complaints." This patient is correct -headaches, other aches and pains, and access to medications emerged as a theme in reasons why patients come to the clinic; however, this was another source of concern for volunteers in the brigade. There were two suggestions for improvement to the clinic referring to having better medication dispensing procedures or efficiency, though the patients did not express a concern for the amount of waiting required to receive care.
While the patients wanted to see more medications available, the brigade volunteers wanted to make sure that they were dispensing the medications in a safe manner. This desire on the volunteers' part to do no harm was not necessarily recognized by the patients. Wall (2011) states that "one ethical question that medical volunteers may face is whether or not to provide a pharmaceutical or perform an intervention that is below the acceptable standard of care versus the alternative of doing nothing." [14] This may be a cultural difference in expectations for care and may reflect a difference in the care provided at the brigade-run clinics versus the Honduran-run facilities to which patients have access. As with beneficence, a gap in beliefs from the volunteers to the patient-participants exists, though further research would need to be done to confirm these results.
In other areas, recommendations from volunteers indicated desires to make the workflow more efficient (50% of responses) so patients are served more quickly and with less error.

Autonomy
The question of autonomy is an interesting development in this research. While none of the patient-participants or brigade volunteers reported any direct challenges to participants' autonomy, themes emerged in the responses to questions of how patients autonomously care for themselves when medical brigades are not available. The use of home remedies by patients seemed to be overestimated by the volunteers, 22.2% of volunteers responses indicated the use of herbal or home remedies while only 6.9% of patient-participant responses indicated their use. The incidence of patients failing to obtain care also seems to be overestimated in 25.9% of volunteer responses versus only 8.6% of patient-participant responses, though this may be due to differing perceptions of illness and health.
Furthermore, patient-participants reported traveling to other health centers for their medical care in 82.8% of responses, while brigade volunteers recognized this as the patient's choice in only 29.6% of responses. These differences are difficult to fully define, though it is clear that there seems to be a variance in the perception of patient autonomy.
Volunteers outwardly gave validation to cultural differences in their recognition of home remedies; however, they largely underestimated the patient's ability or desire to autonomously care for themselves in other recognizable ways.

Justice
The question of need also arose throughout the surveys of both patient-participants and brigade volunteers. Both sides recognized that the economic and health status of the people living in Agua Salada, Honduras, and the surrounding communities put them in a category of high need. This recognition by both parties may be considered an indication that the resources utilized for provision of health care in this area is appropriate and just.
Both volunteers and patients noted the value and distribution as being high quality. Neither questioned the allocation of resources, except in the concern of 9 (15.8%) patient-participants for brigades to bring more medications, more testing supplies, or a greater variety of specialists to provide care. In general, both groups recognized the system of justice that governs the distribution of resources.
Based on the results presented, it appears that the patients seen at this clinic have a basic understanding of justice and autonomy even if the actual definitions of each word may not be shared. However, is imposing this Western thought through education the direction medical brigades should turn? Isaacson, et al. (2010) discusses in reference to surgical procedures that those trained in developed nations, "assure patient autonomy and justice by disclosing reasonable risks, benefits, and alternatives." [3] Currently, the care given at the Agua Salada Clinic is free of charge and even though no surgical procedures are performed, many small invasive tasks, (i.e., wound cleaning, drainage and repair, and teeth cleanings) as well as treatment of many different ailments and disease states takes place during virtually every brigade. With Western thought in mind, the type of care provided in Agua Salada would suggest that patient education regarding ethics is needed, if not required.
Western medicine does not survive without these rules of autonomy and justice. Therefore, if we continue to take our medicine to underdeveloped regions, is it our duty to educate on the principles of medical ethics, including autonomy and justice or is disease state management enough? Seemingly, the more we educate to our way of medicine, the more we raise ethical questions.

Implications
When traveling to underdeveloped regions such as Agua Salada, Honduras to provide short-term medical care, ethical issues can always arise. Wall (2011) concluded that "medical volunteers in developing countries encounter different ethical problems than they do in their practice in the developed world." [14] Possible causes can be confusion from cross-cultural barriers and lack of resources and various types of education. The survey results presented here (Patient-participant and Brigade Volunteer) suggest a strong need to further examine the effects of doing no harm when dispensing medications. Furthermore, as discussed above, the implications of applying beneficence, autonomy and justice are all areas that may require a closer look when dealing with short-term medical mission care.
DeCamp (2011) argues that "research can be necessary, for example, to help identify health needs to be met during short-term work, to assess effectiveness of health interventions, and to monitor longer term health gains." [15] This type of research would make sense in a continued brigade support community such as Agua Salada and may also aid in decisions surrounding ethical education.
Finally, to better understand how the local community members think Western medications work, a question that still remains is what the local members of the community do with their medications after the brigade leaves; expanding on the question used in this research of what they do for care when the brigades are not there? Ideas include sharing with others, selling them, and using them in conjunction with traditional remedies, all of which imply the need for patient education. Conducting further research could also help confirm these theories.

Limitations
Because of the potentially unique relationships that the UW School of Nursing and S2S have with the communities they serve, there is some question of the generalizability of these results to other medical missions. Additionally, only patients and volunteers attending the clinic were surveyed and, therefore, may have biased the data. It should be noted that the questions utilized in the surveys were not piloted or validated in any way.

Conclusion
When evaluating differences in the perceptions of patients and volunteers in ethical terms, it seems that both primarily share common perceptions of beneficence and justice while volunteers are more likely to be concerned with elements of non-maleficence and tend to undervalue indicators of autonomy. The results of the research presented suggest that the four Western principles of medical ethics warrant further investigation in underdeveloped regions receiving short-term medical care. However, other questions arise on how to broach these areas and if imposing more Western concepts is always the right thing to do.
Ideas for future research would be more surveying, including short-term medical missions in other underdeveloped regions, which may help confirm or refute these initial findings, distribution of findings amongst those who provide care, and further surveys to determine if a change has taken place that either widens or closes the gap in brigade volunteer versus patient-participant perspective.