The St. Mark’s Community Health Project (SMCHP) is an NGO working in the St. Mark Parish, of Grenada, in a community known as Coast Guard. Working in Grenada has expanded my knowledge and understanding about the theory and methodology of community-based approaches, to field research, as it relates to public health and preventative medicine. The team is made up of students, sociologists, nurses, and public health professionals working together to train and equip lay community health workers (LCHW) with the tools and skills necessary to educate their neighbors about general breast health education, breast cancer awareness, and seeking clinical consultation in order to help bridge the gap between the community and the health care system. Grenada ranks 23rd in the world for the number of women who die from breast cancer.¹ This is exceptionally high for an estimated population size of 106, 000 people in 2013.² The community-based approach addressing this disparity is an innovative model that rectifies and enhances the current health system in Grenada.

The primary objective of the SMCHP is to implement a community-based approach to address health disparity issues and gaps as it relates to breast health. This model acts as a focal point of entry into the health care system and the move towards primary health care in Grenada. In this project, breast health is the primary concern with an understanding that all women are at risk for breast cancer, and all health issues are interrelated-considering the holistic view of health. Traditional research models engage the community with the intent to collect data to publish research findings. Given this research methodology --what action steps are being implemented to address the long-term underlying issues and findings? (Figure 1).

Figure 1 Lay Community Health Workers (LCHWs) identifying lumps on breast models.

During a home health assessment visit, accompanied by a LCHW, the homeowner questioned our motives saying, “What is your purpose? All your questions and surveys solve nothing for my family, nothing changes`”. We sat down with the home owner to explain the purpose of the visit, and the importance of the health assessment document in question, in addition to explaining the importance of knowing the family health history and background information. The following week, the LCHW visited the family and met with the women of the house to talk about signs, symptoms, and risks of breast cancer. The following week the LCHW taught the women, of the household how to do a breast self-examination using a breast model to show the proper procedure to identify lumps.

What makes this project unique is the underlying philosophy of a community-based approach to address health disparities. The integration of LCHWs into the primary health care system is the only way a community-based model will become sustainable. This integration, subsequently, increases the awareness and early detection of breast cancer. In Grenada, ten women from the St. Mark Parish were trained in the clinical and social dimensions of the project. For the next six months, the LCHWs will be responsible for eight to nine homes in their case load. This approach will ultimately impact and improve the lives of women in the community of Coast Guard.

Using a health assessment document, the women were taught how to engage and connect with residents while discussing health, education and employment history. The second week of training covered modules on breast education, signs, symptoms, abnormalities, self-examination, and how to perform breast examinations on a client. Through the training the LCHWs learned to assess, systematically, the health needs of the Coast Guard community. Towards the end of each week the LCHWs were paired together, with a member from the research team, and sent out into the community. They became liaisons involved with the direction, quality, accessibility of health service, and treatment of each family, particularly the women, in their caseload.

Walking through the streets of Coast Guard and working with the LCHWs has enlighten, shaped, and redefined my perception and understanding of public health, medical sociology, and health care delivery. During my internship studies our research team has met with government officials, physicians, and nurses, including the Minister of Health, the honorable Dr. Clarice Modeste, in an effort to work towards the sustainability and integration of the community-based model approach into the current health care system (Figure 2 & 3).

The SMCHP provides a systematic frame work for the advancement and promotion of primary health care for the citizens of Grenada. In 1978 the World Health Organization and the United Nations Children’s Fund executed the implementation of the Alma Ata Declaration with an agenda focused on primary health care. The International health and development conference meeting hosted representatives from 134 countries and 67 NGOs to formulate the rights-based (community-based) approach, declaring it a fundamental human right for all people, especially in developing countries, to have access to basic health services.³ Cultural traditions, or norms, may discourage dialog about breast cancer or the need to seek treatment. Due to the lack of knowledge, many women have refused treatment or sought out clinical intervention when it is too late. The community-based approach uses local knowledge to redefine cultural standards and dissolve social stigmas and conceptualizations related to breast health, while encouraging social dialog as it relates to health and wellness⁴ (Figure 4).

Figure 2 SMCHP team meeting with the Minister of Health and Government Officials of Grenada.

Figure 3 Student interns Kellina Langaigne (Left) and Figure 3. Precious Ezeamama (Right) meet with the Minister of Health, the Honorable Dr. Clarice Modeste.

Figure 4 Breast health education training with LCHWs

Grenada is an opportunity I do not take lightly.⁵ This has been a once in a life time educational experience. My participation has included the following activities: attending weekly planning meetings; applying for and receiving research grants; submitting proposals to Institutional Review Boards; creating the LCHW training modules; assisting with LCHW training; conducting health assessments and breast health education in the field; meeting with the staff and elected officials from the Ministry of Health and the District Wellness Council of Grenada; and finally providing the invocation for the LCHWs orientation and graduation ceremony.

For the SMCHP the starting point is women’s health with a focus on breast cancer. LCHWs are responsible for sharing the skills and knowledge, they have learned with the women in their caseload. This prevents life-threatening situations that can be avoided with early intervention, which in turn promotes community self-reliance through participation. The future hope is to expand this model to focus on other chronic illnesses such as diabetes, high blood pressure, hypertension, prostate cancer, and so forth.

To be a part of a group of researchers who are redefining the role of public health and social medicine in a developing country, such as the sustainability of this project is secure with the help of government officials endorsing the program and the proper resources made available to the LCHWs. Part of the training included the initiation of a Health Committee. The LCHWs will meet once a month in order to plan the future of the project, and foster collective responses to pressing health issues. Part of my responsibility was to organize the health committee meeting agenda which included monthly goals, prospective health-related events, and discussion questions (Figure 5).

The tasks of the health committee includes: organizing community meetings, disseminating information, conduct breast education training sessions, and interface with government and larger health systems. As volunteers presented the agenda format to the LCHWs they were enthused and receptive to the tasks. Afterwards they conducted the first Health Committee meeting as the research team observed and provided feedback (Figure 6).

On the third week of training the LCHWs visited the homes assigned to their caseload. This time around they performed breast exams during their home visits using the resources, and education they received throughout the training. After regrouping some had mixed feelings when we learned that two of the LCHWs found lumps, in women, from two different house-holds in Coast Guard. In addition a lump was found on one of the LCHWs during the clinical breast education training sessions.

A research project of this caliber is something usually read about in a global health magazine or debate about in a bioethics bowl competition. Student researchers are fortunate to have spent their summer as a student intern in Grenada and realized my passion for global health studies and medicine. Getting to know each one of the LCHWs and my research team, on a personal basis, has been eye opening and life changing. The things done, seen, and the people met have been a unique educational experience. The women we have trained to become LCHWs will support, educate, and save the lives of many women, in Coast Guard, who are unknowingly suffering from breast cancer. This task would not have been accomplished without community participation in shaping the direction and impact of primary health care (Figure 7).

Figure 5 "Health Matters" television show appearance with the St. Marks Community Health Project research team

Figure 6 LCHWs on their way to do home visits in Coast Guard, Grenada

Figure 7 Precious Ezeamama, performing blood glucose testing at Community Health Fair in Munich, Grenada

None.

The author declares no conflict of interest.

1. World Health Rankings. Grenada top 50 causes of death. 2011.
2. United Nations Department of Economic and Social Affairs- Population Division. World Population 2012. 2012.
3. Declaration of Alma-Ata. International Conference on Primary Health Care, Alma-Ata, USSR; 1978. p. 6–12.
4. Creating Sustainable Community Health. St. Mark’s Community Health Project. 2014.
5. Wadler BM, Judge CM, Marianne P, et al. Improving Breast Cancer Control via the Use of Community Health Workers in South Africa: A Critical Review. Journal of Oncology. 2011;2011(2011):8.