Accessing Our Future Through Service

By Perdita Henry

Healthy Futures of Texas mission focuses on science-based education and advocacy efforts that empower young people, women, and families to make the best decisions for their futures. And while our work centers on Texas, Big Decisions curriculum has made it to communities around the world.

Ahead of this year’s Accessing Our Future event—live streaming Wednesday, October 21, on YouTube, register and donate here—we wanted to ensure that everyone knows about the magnificent work of this year’s awardees. These three outstanding leaders work tirelessly to ensure that communities, both near and far, have the knowledge necessary to make the best decisions for their futures. Through their work, they remind us that every person in the state, the nation, and the world, has dreams that need nurturing, and goals that deserve a chance to be met.

Ruth Berggren, MD, MACP, is the recipient of the Janet P. Realini Trailblazer Award for her outstanding work taking the Big Decisions curriculum international.

What drew you to the Big Decisions curriculum and inspired you to use it in your programs?

This choice dates back to around 2009. We had a community partnership with Good Samaritan Community Services.

Adelita Cantu, PhD, RN, at the School of Nursing, and I approached Good Sam about community service learning opportunities for students. Our vision was that our students could create a fun, interactive summer camp activity to improve nutrition and exercise. Our perception was that our priorities (preventing obesity and diabetes) would be the same as those of the West Side community served by Good Sam.

When we interviewed the parents at Good Sam, they valued the health and nutritional status of their children, but they articulated a pressing concern. One mother said, “help me prevent my teenager from becoming a father at age 14.”

The starting point of all community service is engaging with the partner population to identify a real need. One that the served population articulates, rather than one we impose to fulfill our perceived priorities. Answering this call led us to discussing the Big Decisions curriculum with Healthy Futures of Texas Founder, Janet Realini, MD, MPH. She was a little skeptical at first that medical students would ever have time to properly implement Big Decisions, but our students gamely came to the preparatory workshops, and did an excellent job of learning both the content and the implementation approach. Thus, we embraced Big Decisions on our journey of delivering relevant, participatory, community-responsive health education. It was a great decision, to implement Big Decisions at Good Sam. They later got Big Decisions training for their own counsellors too, so it did not have to depend on the presence of our students.

What surprised you about the responses of the populations you serve—including the medical students—when they receive sexual health education?

You’d think med students would naturally know how to talk to youth about reproductive health. Turns out they have a lot of book learning (and maybe personal experience), but zero preparation for talking about emotionally sensitive subjects. And reproductive health is not just emotionally sensitive, but politically too. So, teaching reproductive health effectively requires a lot more preparation for health professional students than you might think.

The next surprise was truly pleasant: our students really develop confidence and self-efficacy once they have the proper tools and skills to teach Big Decisions. They experience extraordinary gratitude from their served populations, whether in San Antonio, Guatemala, Dominican Republic, or Uganda. They are sometimes overwhelmed when they see how much it means to the empowered young people with whom this knowledge is shared. And this motivates our students to be better learners in medical and nursing schools, because now they know the power of effective health communication skills. It motivates them to be community-minded, civically engaged, and service-oriented healers.

You’ve taken Big Decisions to Uganda, Guatemala, Haiti, Nicaragua, Ecuador, and the continent of Africa. How does sexual health education empower urban and rural communities internationally?

We started our international implementation in Guatemala—at a home for young girls who had been removed from their families by the equivalent of our Child Protective Services. These young women and girls were being cared for by religious nuns, and we worried the nuns might object to “Sex Ed” under their roof. But they sat in on some of the sessions (for which the manual had already been translated into Spanish), and even insisted on a condom demonstration. The nuns, and our students, saw the profound expression of gratitude from the girls, who said things like, “No one ever told us these things about our bodies before,” and “Thank you for seeing us as people with potential to be more than what we are today.” The nuns not only endorsed this work, they invited us back again and again because they saw how the young women’s lives and dreams were being affirmed and empowered by the experience.

In Haiti, Jason Rosenfeld, DrPH, MPH, and I started a program of Community Health Clubs after the post-earthquake cholera outbreak of 2010-2012. We were implementing a curriculum on Water, Sanitation and Hygiene (WASH) to help prevent deaths due to diarrheal illness. It was a six-month curriculum culminating in a public graduation ceremony.

Several thousand WASH health club graduates wanted to continue to improve their health and the lives of their communities, so we offered them choices on topics like nutrition, kitchen gardens, or emergency preparedness. They chose the Big Decisions curriculum, which they call (in Kreyol “Gwo Desizyon”). The participatory, modular nature of Big Decisions made it highly adaptable to the Haiti context. With permission from Healthy Futures and Dr. Realini, we translated the manual and educational materials into Kreyol and they continue to be used. In 2014, a medical student named Samy Bendjemil observed the Haiti health clubs, and then took the concept to Burkina Faso, West Africa. Burkina health clubs are still working on WASH and female literacy, but they see Big Decisions as a goal they want to implement once the manual is translated into French.

Every year, the Center for Medical Humanities and Ethics helps to fund, prepare, and organize a medical team to work in Uganda over the summer break. The students visit the same sites annually and have established a longitudinal relationship with a high school that was experiencing a surge in teen pregnancies. Our students, prepared by none other than Dr. Realini herself, trained several high school leaders and educators, so they could continue the Big Decisions curriculum themselves. The very first year of implementation nearly eliminated teen pregnancy at that school, and we hope to support the continuation of this ongoing work. One of our graduates from the Long School of Medicine, Jaclyn Boozalis, MD, presented these outcomes at the Consortium of Universities in Global Health and wrote up this experience for publication—she graduated with an MD with Distinction in Global Health. She aspires to use this experience as a frame of reference for her life-long career of medical service to underserved populations around the world. This is but one example of how our implementation of Big Decisions has profoundly affected the professional identities of our health professional students.

The country (outside of the US) where we have perhaps made the longest lasting investment in training trainers has been Ecuador. In partnership with the Cachamsi medical Spanish immersion program founded by Jorge Duchicela, MD, Dr. Rosenfeld at our Center, mentored a whole year-abroad immersion program for student doctor, Garrett Kneese. He helped found Proyecto Riosueño, which aims to integrate Spanish Big Decisions into the local high school’s standard curriculum. Garrett was joined by another student, Eithan Kotkowski, and Dr. Realini, in Ecuador for a month in 2019. They rolled out an intensive training of trainers with a rigorous program of monitoring and evaluation to set the program up for long term success. This experience has also been submitted for peer review publication.

One of the important aspects of Big Decisions, and something that makes it amenable to international work, is that it is so empowering to youth. Big Decisions encourages them to have, and to work towards, their own hopes and dreams. In low-income countries where not everyone has access to the most basic education, young people don’t often have a caring community of adults who can encourage them to have dreams for their lives.

Big Decisions is modular, replicable, portable, non-judgmental and profoundly inclusive. In Haiti, the session on healthy and unhealthy relationships always has a huge impact—and can even be triggering for some people—because many young people in Haiti have never had any one talk to them about the difference between healthy and unhealthy relationships. They have their eyes opened and, in many cases, this enables them to make the changes they need to move forward towards their life goals more effectively.

How do you use Big Decisions curriculum to ensure that those you educate in resource poor communities abroad always maintain their autonomy?

First and foremost, we never enter a community to impose Big Decisions. We always offer it as part of a broader discussion on ways we can be of service to an under-resourced population. We try and understand the local priorities, religious mores, and sexual norms for young people. In Nicaragua for example, another country where Dr. Realini travelled with us to supervise the training of trainers, there were some religious communities that did not want their kids to learn reproductive anatomy. But they greatly valued the teaching on Goals and Dreams; how to define and defend one’s own limits (learning to say a CLEAR NO), and the distinction between healthy and unhealthy relationships. For those communities, we adapted the curriculum and tried to honor the integrity of the community while sticking as closely as possible to the Big Decisions key messages. This is also known as cultural humility, working with any population that differs from our own. Cultural humility is a key take-away for our students when they implement this curriculum that empowers others.

Finally, we honor and foster the autonomy of poor communities through the training of trainers, and by not charging fees for the education we deliver. We don’t want others to depend on us to return every year to deliver the teaching activities to new groups of youth. Rather, we want local facilitators, teachers, and youth leaders to continue training their peers. In this way, the knowledge and behavior changes that are catalyzed by Big Decisions are perpetuated indefinitely.

The COVID-19 pandemic prevented us from visiting all our international sites in 2020, but thanks to the training of trainers, the work can continue to the extent permitted by local pandemic restrictions. This is perhaps one of the final lessons and most beautiful aspects of delivering an empowering teaching methodology. The ripple effects of Dr. Realini’s initial vision are potentially endless. Big Decisions, ultimately, is designed to foster human flourishing in any community in the world.