1. Introduction

The phenomenon of short-term medical service trips has grown substantially over the last several decades [1]. Medical service trips, traditionally referred to as medical missions, medical brigades, or global health experiences, involve clinicians based in developed nations who travel to underserviced communities in developing countries to provide limited primary health care [2,3]. Clinicians choose to participate in these trips for a variety of reasons: [4] from religious obligation, to professional and personal development, to altruistic instincts, to the desire for a working holiday that allows for a more authentic experience of the local culture than would be otherwise possible.

Resources on these trips are generally limited to point-of-care testing, including urinalysis, urine pregnancy testing, and glucometer testing. There is limited availability of advanced laboratory testing and imaging, and this generally requires referral to either a private hospital or to the public hospital, which may be a considerable distance from the community.

Considering the popularity and prevalence of these global health experiences, there have been limited descriptions in medical literature of the epidemiology that clinicians can expect to encounter on these trips. Previous studies have suggested that clinicians visiting Latin America see both symptomatologies that are similar to that of primary care practice in North America, but also a greater prevalence of minor conditions that are endemic to tropical, rural, and under-resourced environments [5]. However, it is crucial to the preparation of Western clinicians that intend to deploy on a medical service trip to be informed of the symptomatology they are likely to encounter.

The objective of this article is to describe the common symptom clusters encountered by primary care mobile medical service trips in five distinct regions in Latin America. This descriptive study improves the understanding of the common symptomatology that Western clinicians assess and treat on primary care mobile medical service trips in underserviced regions in Latin America and has implications for the preparation and appropriate training for these types of trips.

2. Methods

3. Results

A total of 22,977 patients were assessed by clinicians across all sites, and 32.9% of these patients were male. The average age of all patients seen was 36 years. The number of service trips, number of patients, gender, and ages of patients assessed in each region are presented in Table 2 . Most patients seen on the trips had multiple diagnoses.

The top diagnostic categories are presented for the five regions in Table 3 . In all regions, general pain was the most common symptom category, and included general pain, back pain, and nonspecific headache. General pain was reported by 14.5–22.1% of all patients assessed, substantially higher than the other diagnostic categories. Upper respiratory complaints, not including asthma and COPD, made up the second most common complaint with 8.3–13.2% of patients presenting with this sign. The prevalence of diabetes and hypertension was substantially lower in the rural Napo region than on trips in Quito, Quetzaltenango, and Monti Cristi, whereas complaints like diarrhea, menstrual complaints, urinary complaints, pruritus, and anemia were similar across the five regions. Aggregated, the tracked diagnostic clusters accounted for 71–78% of all diagnoses made. All other diagnoses made by clinicians accounted for 22–29% of total diagnoses, and of these, no individual uncategorized diagnosis made up more than 1% of all diagnoses.

4. Discussion

The major strength of this study is its large data set, which allowed for the analysis of diagnoses from over 20,000 patients assessed on mobile medical service trips. The majority of symptomatology seen on primary care global health experiences in the five described regions was easily classified into the above symptom clusters. The most common six clusters were general pain, upper respiratory tract symptoms, skin disorders, eye irritation, dyspepsia, and nonspecific abdominal complaints. The most common complaints were similar at all sites, with the exception being that Quito and Monti Cristi brigades saw more hypertensive patients than Napo region. Other important conditions are specifically listed due to their importance to chronic disease management (hypertension, diabetes, and anemia) or public health importance (pregnancy, vaginal discharge and diarrheal disease), despite their overall low prevalence on the brigades.

There is little quantitative literature available concerning short-term medical service trips in Latin America. It is useful, however, to compare these results to those described in a large longitudinal study of over 2500 patients seen on short-term medical service trips in Honduras [5]. The authors also clustered the diagnoses into similar categories: general pain (headache, back pain, body pain) accounted for 17.1%; upper respiratory complaints (fever, cough, cold) 22.3%; dyspepsia (stomach pain) 10.4%; nonspecific abdominal (parasites and worms) 19%; rash/itchy skin 8.1%; and eye symptoms 4%. These proportions are similar to those observed in this study. Together, these six symptom clusters in the Honduras study totaled 80.9% of the complaints assessed.

These results are also similar to those of an observational study of 788 patients seen on a short-term service trip in rural Western Haiti [7]. Of those patients assessed, 39.8% were diagnosed with general pain or headache, 24% with “acid” (dyspepsia), 17.4% with parasites, 13.2% with eye symptoms, 8.2% with hypertension, and 7.4% with anemia. In this study, specific case definitions were used, and a diagnosis of parasites was defined by a patient’s complaint of passing worms, nonspecific gastrointestinal complaints (pain, bruxism, loss of appetite, insomnia), or clinical signs of malnutrition. General pain ranged from such complaints as joint pain, to generalized pain without evidence of serious disease, to apparent osteoarthritis.

The clustering of diagnoses into broad categories serves a valuable purpose. In most instances on low-resource mobile service trips, confirmatory testing is not available for pathologic diagnoses like gastritis, esophagitis, and peptic ulcer disease; or for microbiologic diagnoses like streptococcal pharyngitis, salmonella dysentery, giardia diarrhea, parasitic abdominal pain, or chlamydia cervicitis. Dermatologic diagnoses for scabies, tinea, and impetigo that are commonly seen on mobile medical service trips are either rarely seen in North American settings, or are outside of the scope of practice of clinicians who do not practice comprehensive primary care. Therefore, the diagnostic accuracy of a specific diagnosis is often in question. Previous studies of dermatologic diagnoses have shown diagnostic accuracy to be very poor when it has been specifically assessed [6,7].

In the absence of confirmatory diagnostic testing, the described results suggest that the approach of clinicians to patient management on low-resource medical service trips should tend toward syndromic management. This would mean movement toward an algorithmic diagnosis based on patient symptomatology, and toward the treatment that is most likely to be efficacious and reasonable given the epidemiology of the region. The above diagnostic categories represent a reasonable starting point, since these clusters encompass over 70% of the diagnoses encountered in these selected trips.

This descriptive study has several limitations. While our data involve five disparate regions in Latin America, one cannot therefore conclude that these results are generalizable to other parts of Latin America and the Caribbean. Furthermore, the diagnoses reported in this study are those of the independent clinicians participating in the service trips, and there were no case definitions or independent confirmation of their reported diagnoses. This further reinforces the choice to discuss broad categories of symptomatology, rather than make false presumptions of the prevalence of specific diagnoses. There may also be overlap between certain reported symptom clusters, including dermatologic conditions, and abdominal conditions. In particular, this might occur when a diagnosis of “parasites” could be reasonably classified as diarrhea, nonspecific abdominal complaints, or dyspepsia. Finally, the symptomatology seen on medical service trips is unlikely to represent the epidemiology or demographics of the population as a whole. This is the case for a variety of reasons, including bias toward patients who are available during the day, access to a Community Health Promoter, access to transportation to the clinic site, and cultural factors influencing the likelihood of patients presenting for medical care.

It is worthwhile to discuss the gap in the literature regarding follow-up on patients seen and managed presumptively based on symptoms or a syndrome. While Timmy Global Health maintains a robust referral system to associated partner hospitals for semi-urgent and urgent conditions, there continues to be little data on the natural history and effectiveness of treatment for more benign conditions. Given the apparent differences in patient responses to history taking, medication-seeking behavior, treatment adherence, cultural challenges, and other epidemiological concerns, it cannot be assumed that conventional Western management of common primary care conditions will have the same effectiveness as in a North American setting. A search of the literature found no studies that quantitatively conducted follow-up assessments on patients seen and empirically managed on Latin American short-term medical trips.

Mobile medical service trips serving Latin America should have clear guidelines for treating common patient symptomatology. This framework should include, at a minimum, a rational algorithm for managing upper respiratory complaints, dyspepsia, nonspecific abdominal pain, dermatologic complaints, and general pain. The above results will be useful in training and educational programs for clinicians who are involved in global health experiences, as well as the creation of practice guidelines that are applicable in low-resource areas. As the literature on short-term medical service trips evolves, it is expected that appropriate guidelines for syndromic management will reflect the results of quantitative follow-up studies. Further research is needed to develop treatment and management protocols that will streamline and improve the quality of care of underserviced patient populations in Latin America.

Conflict of interest

None declared.

Acknowledgements

Timmy Global Health gave explicit permission for use of the relevant database information for study purposes. This was provided as an anonymized data set. Muz Ahmed (B. Eng) is the software programmer responsible for the development of the electronic medical record system. He was responsible for extracting the information from the database necessary for data analysis, and received no financial compensation.