Introduction

The world’s porous borders have made local health issues international concerns. Demand for global health education in the United States (US) is growing due to the international perspective on health issues, as well as students’ desire for a broader health outlook within their professional training [1]. Lencucha and Mohindra (2014) posited that increased interdisciplinary training outside of traditional health science disciplines would advance global health as a comprehensive field. Building Healthier Communities (BHC) requires the delivery of interdisciplinary public health services and robust programs in partnership with low-resource communities facing public health challenges [2]. With this interdisciplinary global health training in mind, a Clemson University (CU) faculty of Dominican origin developed a study abroad research program in the Dominican Republic (DR). This research program had the dual purpose of promoting global health skills among students, while assisting a low-resource community’s local efforts to improve their own health and well-being. Las Malvinas II (hereafter referred to as Las Malvinas), is a small and low-resourced community located in Santo Domingo, capital city of the Dominican Republic (DR).

Las Malvinas BHC initiative was premised in this descriptive study upon the Global Health Education Framework’s [3] ideals of territorial and trans-territorial partnerships to promote a healthier community. The BHC project multi-dimensional partnerships incorporated an emphasis on a pro-active community role in the planning and implementation processes and were built on local community assets to promote sustainability. With this pro-active community role in mind Las Malvinas project incorporated the following strategies, (1) A bi-national university partnership (Clemson University [CU] and Universidad Iberoamericana [UNIBE]); (2) a community-academic partnership (active involvement of Las Malvinas II Neighborhood Association and UNIBE); (3) translation of evidence-based initiatives from the US to the DR; (4) consultation with the CDC on culturally and linguistically adapting the CHAnGE protocol; (5) interdisciplinary undergraduate and graduate students and faculty involvement at CU and UNIBE; (6) mixed methods research to conduct a Community Health Assessment (CHA); and (7) collaborative development of a Community Health Improvement Plan (CHIP). The aims of this descriptive study is to examine the value of multi-level partnerships to foster a BHC process in a low-resource setting in the Dominican Republic (DR). This report describes theoretically driven processes through which these partnerships facilitated the accomplishing of proposed goals and selected process outcomes, the lessons learned, as well as the partnerships challenges and opportunities.

Las Malvinas BHC process was informed by three theoretical approaches framed into the CHAnGE protocol. These frameworks are the Socio-ecological Model [4], the Assets-based Community Development (ABCD) [5], and the Healthy Communities Movement [6,7]. The Healthy Communities Movement, originally developed by the CDC, emphasizes that no one community sector can successfully generate a healthier community. The foremost component of this approach is providing opportunities for the voices of the entire community to be heard. In this way, community mobilization allows for the incorporation of unique community values, creating a more aligned vision of the future of one’s community [8]. Another underlying premise of the Healthy Communities movement is that empowered citizens, effectively partnered with invested organizations, can transform their community and its members [9]. This descriptive study depicts the process followed by CU to assist Las Malvinas II Neighborhood Association and UNIBE in fostering valuable partnerships to promote engagement, strategic planning, assets identification, and capacity-building initiatives for community members and local partners. Tenants from all three theoretical frameworks guided the CHA design, as well as the BHC process at Las Malvinas. The following section expands on the importance of community engagement and partnerships for developing a BHC.

Role of Community Engagement

Government and academic institutions should not dictate to a studied community what to do and how to do it. Instead, impetus to become a healthier community must arise from within the community itself [8]. Community engagement can be described as “…the process of working collaboratively with and through groups of people affiliated by geographic proximity, special interests, or similar situations to address issues affecting the well-being of those people…. It often involves partnerships and coalitions that help mobilize resources and influence systems, change relationships among partners, and serve as catalysts for changing policies, programs, and practices.” [10], pp.9 Community engagement can take many forms and have diverse partners, including organized groups, agencies, institutions, or individuals. Collaborators may have diverse types and levels of engagement in the community, such as health promotion, research, or policymaking [11]. Importantly, celebration and recognition of community members’ efforts fosters meaningful community engagement, while supporting enthusiasm and determination [8].

Role of partnerships

BHC requires a thorough examination of the complex social determinants of health (SDOH) by relying on collaborative interactions between disciplines. According to the World Health Organization, health includes physical, mental and social well-being [12]. The circumstances in which community residents live, work, and grow are shaped by the distribution of currency, resources, and power [2]. Ultimately, the outcomes of these factors’ distribution within different sectors (e.g., work, health, education, community institutions and organizations, and community at large sectors) greatly affect a community’s health and well-being. Therefore, a blending of professions with various skills, resources, and knowledge is indispensable to build a healthier community.

Collaborations between the community, its organizations, and academic institutions often bring expanded reach and success to a project than might have not occurred in isolation. Partnerships imply mutually sharing both resources and responsibility, while requiring that each partner relinquish some element of control. Hence, there must be sufficient mutual respect and trust between partners to work together productively [13]. Visovsky and colleagues [14] posited that in addition to building trust among the community, partnerships with organizations, institutions, and local businesses promote creative community development perspectives. Individual partners bring different strengths to the table that overlay other partners’ weaknesses by promoting creative ways of problem solving [15].

The Global Health Education Framework [GHEF]

Without mutual assistance between the community, academic, and other partners who supply missing resources, the progress and durability of community-based programs or interventions would be limited. Community partnerships can be national or international in nature. International partnerships in particular allow cross-cultural consideration, while implementing large-scale policy changes or assisting populations of different cultures [3]. Lencucha and Mohindra posited that health is interconnected with international and transnational development. The authors added that multidisciplinary health approaches have changed the way the world views healthcare, from its former consideration as a luxury to the current perspective of health as a human right [1]. This paradigm shift has produced a proliferation of frameworks incorporating this modern day viewpoint. Taking increasing globalization into account, Bozorgmehr and colleagues developed the Global Health Education Framework (GHEF). The GHEF seeks to address the SDOH needs all across the planet [3].

The GHEF categorizes the SDOH with a socio-ecological perspective, viewing the environment from a microscopic to a macroscopic level. GHEF addresses three dimensions of global health: territorial, inter or trans-territorial and supra-territorial dimensions. The territorial dimension examines the SDOH as bound by its country borders. The trans-territorial dimension focuses on health issues beyond the nation-state. This view not only encompasses Western medical philosophies, but also seeks to address health care equity and policy in non-Western countries. Finally, the supra-territorial dimension focuses on globalization’s impact [3].

This report describes the development of multi-faceted community-institutional partnerships at the territorial and trans-territorial levels to promote health and well-being improvement in a low-resource community in the Dominican Republic. These partnerships sought to foster community engagement through the incorporation of local assets to build a healthier community. Through these partnerships, Las Malvinas leaders and affiliate institutions were able to facilitate multidisciplinary research and interventions aimed at achieving sustainable improvement in community health and well-being in this community. The first step in the BHC process was the completion of Las Malvinas CHA [16]. This CHA explored community perspectives on SDOH related with five public health priorities (i.e., sanitation, education, vaccine-preventable diseases, chronic diseases, and unwanted pregnancies) previously identified by Las Malvinas leadership. It also oriented the identification of initiatives to address the SDOH framed in a Community Health Improvement Plan (CHIP) which was developed in collaboration with Las Malvinas II Coalition in 2017 (hereafter referred to as the coalition).

Methods

The Context

Occupying the island of Hispaniola, the Dominican Republic (DR) has established itself as the economic engine of the Caribbean, with a region-leading GDP of over $150 billion [17]. This figure continues to grow, as the country boasted a Gross Domestic Product growth rate of 7%, the highest in the entire Western Hemisphere. However, this burgeoning wealth belies deep problems [18], as political corruption diverts much of this income to the elites, perpetuating structural inequality. This inequality is reflected in the DR’s Gini coefficient, ranking it in the bottom half of the world [19]. Wealth disparity greatly affects citizens as the national government outlays less than 5% of its budget in education. Inequity is not only experienced in income and education, but also in access to adequate sanitation; over half the country lacks access to clean water and functioning toilets [20].

Las Malvinas is situated in the Northern Santo Domingo province, which include the capital city. This community vividly illustrates the issue of income disparity many Dominicans face. In this resource-scant community, the majority of citizens live off subsistence wages ($RD 2,771, compared with the national average of $RD 16,051). Most residents have minimal educational levels; nearly one-third are illiterate [21]. In addition to these marginal economic and educational prospects, industrial waste contaminates the streets and water supplies, burdening an already inadequate sanitation system [22]. These combined factors contribute to the poor health status of the community. UNIBE has collaborated with Las Malvinas for more than 10 years through service-learning interventions and advocacy to improve overall health while encouraging local development. This ongoing partnership has effectively highlighted community health issues. In 2015, UNIBE and Las Malvinas expanded their partnership to include CU, a U.S.-based university.

Cultural and linguistic adaptation of the CDC CHAnGE’s protocol

A Community Health Assessment (CHA) served as the basis to initiate a BHC process at Las Malvinas. A CHA is a systematic examination of the health status indicators for a given population used to identify key problems and assets in a community [2]. Community engagement and collaborative participation are essential ingredients to design and implement a CHA. The CDC’s Healthy Communities Program (HCP) offers a variety of approaches and tools to foster long-lasting partnerships to prevent chronic diseases and to reduce health gaps [23]. One of these tools is the Community Health Assessment and Group Evaluation (CHAnGE protocol) protocol, which was culturally and linguistically adapted for the design of Las Malvinas CHA [2]. The protocol’s adaptation process included changing questionnaires to incorporate SDOH with selected priorities, and translation into Spanish of research protocols and data collection instruments. Mixed methods research protocol and procedures were by CU and UNIBE Institutional Review Boards.

A socio-ecological perspective of health [4] informed the utilization of five sectors (i.e., community organizations and associations, community-at-large, work, health, and education sectors) to identify research participants, as well as to identify actions for improvement. An assets-based approach5 was reflected in that all three methods of data collection used in the CHA (interviews, focus groups and a Geographical Information Systems household survey) included questions to explore community assets at three levels. Level 1 included the gifts, skills, and capacities of the individuals living in the community; Level 2 represents citizens’ organizations/networks through which local people pursue common goals; and Level 3 assessed the institutions present in the community, such as local government, hospitals, education, and human service agencies. A Healthy Communities Movement [6,7] guided the participatory selection of the SDOH, as well as the incorporation of community engagement and capacity-building as overarching approaches for the development and implementation of a CHA and a CHIP.

In accordance to the GHEF, community-institutional partnerships developed in Las Malvinas BHC process were categorized in this report into two of the three dimensions of global health, territorial and trans-territorial. At the territorial level, Las Malvinas partnerships included community organizations and associations; governmental, non-governmental, and private organizations; and UNIBE. At the trans-territorial level, Las Malvinas partnerships included a partnership between CU and UNIBE, as well as between CU and the Las Malvinas community directly. The results section will address the relevance of these partnerships for the successful completion of actions in the BHC project.

Results

Las Malvinas BHC project is a multi-disciplinary and cross-cultural intervention engaging students of CU and UNIBE in a holistic approach to public health research that recognizes the importance of social, political, and economic systems to health behaviors and outcomes. The project includes an interdisciplinary and participatory model of research, in which community leaders were engaged in the research process through a partnership between CU, UNIBE, and a local non-profit organization. Figure 1 includes a summary of the methods and processes followed to complete Las Malvinas CHA and CHIP.

Systems, assets, and resources must come from within the community in order to create a sustainable community-wide intervention [5]. Las Malvinas CHA included identification of community assets through qualitative and quantitative methods. The process included incorporating individual, community and institutional assets identified by Las Malvinas residents into an assets map, as well as into the CHIP. These assets included skills in construction, cosmetology, mechanics, leadership, etc.

Value of partnerships for building a healthier Las Malvinas

Partnerships are essential to obtain community intervention’s desired sustainable effects [24]. The goals of the partnership among Las Malvinas II Neighborhood Association, CU, and UNIBE were to facilitate sustainable social and community development of this community, with the end goal of improving the overall health and well-being of its residents. All three theoretical models that guided this project design (i.e., the Socio-ecological Model, the Healthy Communities Movement, and Assets-based Community Development) [4-7] emphasize the importance of partnerships as a driving force behind any successful health intervention.

Bozorgmehr and colleagues posited that responses to health issues come through international interdependency. This interdependency is built upon the foundation of intra-communal, inter-communal, and international partnerships [3]. Partnerships are essential in identifying opportunities within communities to resolve health-oriented problems and permitting the use of innovative multidisciplinary approaches. In 2015, representatives from UNIBE met with representatives from CU and requested support to advance a more structured and sustainable community development effort at Las Malvinas. As a result, Las Malvinas BHC project incorporated partners beyond the borders of the community, by extending these partnerships cross-country to the United States. Table 1 shows Las Malvinas partnerships based on two levels of the GHEF (i.e., territorial and trans-territorial).

Territorial Level Partnerships

At the territorial level, Las Malvinas partnerships included community organizations and associations, governmental, non-governmental, and private organizations, and UNIBE. The territorial-level partnerships within Las Malvinas were crucial for driving community engagement and pulling viable resources to, from, and within the community. However, in a setting where poverty deepens, few or no mainstream private companies and financial institutions invest. Therefore, public and philanthropic capital are the primary investments that help stabilize this community. Collaborative partnerships amongst the territorial organizations, businesses, and government sectors are necessary to bolster financial and logistical support [25]. The program alliances with the DR government are crucial for the administration of community resources, funding for intervention projects, accessing health education services, and provision of technical assistance. These inter-institutional alliances were formalized through the formation of Las Malvinas Coalition. The coalition must continue working collaboratively to sustain and strengthen their alliance by targeting the public health priorities (i.e., sanitation, education, vaccine preventable diseases, chronic diseases, and unwanted pregnancies) identified in the CHA, while implementing strategies and actions identified in the CHIP.

Trans-territorial Partnerships

Global dilemmas mandate the need for trans-territorial partnerships [3]. At the trans-territorial level Las Malvinas’ partnerships grew beyond the walls of the community and the DR country borders, to include a partnership between the CU Creative Inquiry team and UNIBE. Through this partnership, CU contributed by applying global health principles to adapt evidence-based BHC approaches and methods from the US to the DR context [2,6,7]. These global health principles prioritize improving health equitably.

Las Malvinas BHC project has facilitated collaboration among selected departments and programs within CU including, engineering; planning, environment and preservation; and geospatial technology departments. Selected departments further engaged through interdisciplinary student-led initiatives. These interdisciplinary institutional partnerships also provided participant students’ opportunities for diverse training outside of traditional health science disciplines, advocacy, and leadership development. Student exposure to non-traditional and holistic health approaches contributes to advancing global health as a more comprehensive field [1]. The achievement of lasting, influential health improvements in Las Malvinas will continue to require a united effort. For this reason, it is necessary to sustain the established interdisciplinary territorial and trans-territorial partnerships, to facilitate involvement of a variety of disciplines and professions into ongoing efforts to improve the health and well-being of this community.

The BHC project process in the underserved community of Las Malvinas reflect the importance of collaborations among academic, governmental and non-governmental institutions with community leaders to facilitate a community building and development process. The formation and nurturing of a partnership that links the technical and financial support of CU (trans-territorial partnership) and UNIBE (territorial partnership) with Las Malvinas II Neighborhood Association is facilitating the development of new territorial partnerships between the community and governmental and non-governmental organizations, which now are part of the coalition which developed the CHIP in 2017.

Las Malvinas Community Health Improvement Plan (CHIP)

In March 2017, representatives from CU, UNIBE, Las Malvinas II Neighborhood Association, other community representatives, governmental and non-governmental organizations, all engaged in a strategic planning workshop to develop a Community Health Improvement Plan (CHIP) that integrated findings from the CHA. A coalition also emerged during this planning process. The CHIP offers a balance between long-ranging strategic opportunities for health improvement and achievable short-term goals [2]. Adopting the CHIP in Las Malvinas facilitated strategic inclusiveness, thereby incorporating the assets of more individuals, groups, and organizations within the community. Inclusiveness is essential to develop a clear vision of what community members want their community to become, thus providing a valid foundation for a holistic and comprehensive sustainable development plan for Las Malvinas.

The ongoing implementation of the CHIP guides efforts to improve the health and well-being of the citizens of Las Malvinas. The CHIP included those assets and strengths identified in the CHA. The CHIP also included strategies and actions addressing identified SDOH, such as the lack of a primary health care clinic, contamination of the nearby Ozama and La Isabela rivers, trash accumulation in the streets and stagnant water. Additionally, the CHIP promoted increasing long-term and sustainable partnerships for community development. CU students, led by the first author, returned to Las Malvinas in 2018, to further the partnership with UNIBE and Las Malvinas’ leadership. Adding Boston University as a partner, the CU and UNIBE students conducted positive youth development and engagement research. The purpose of these research activities were to explore youth’s perspectives on the SDOH and methods to engage them in CHIP planning and interventions. The research approach included focus groups and a photo voice project. Las Malvinas have achieved positive process outcomes through the BHC project thus far. These process outcomes are detailed in the discussion section. The commitment and ongoing efforts of local leaders in collaboration with the coalition have shaped the achievement of these process outcomes. The following section will detail lessons learned, challenges and opportunities for the development of successful community-institutional partnerships for Las Malvinas BHC project.

Discussion

Las Malvinas BHC process have facilitated important process outcomes for this community. Las Malvinas II Neighborhood Association secured initial funding from the municipality, through a participatory budget contest, to initiate the construction of a primary health clinic. In addition, a more proactive engagement among the neighborhood association, local school, and key governmental institutions is providing needed services and resources insufficiently offered in the past, such as water provision, trash removal, and construction of a water pipeline to the community. The governmental institutions included the ministries of public health (MINSA) and education (MINERD), the CAASD, and the municipal government. Las Malvinas BHC process included factors that assisted collaborative research and interventions, as well as those that posed challenges to successful collaboration. Following, lessons learned from, challenges and opportunities for Las Malvinas BHC are discussed.

Unleashing human potential by engaging voices and talents of the community: Community leaders

Building a healthier community is a multidisciplinary process that relies on the talents of a variety of individuals in both, local and international domains. For a BHC to be successful partners must unleash human potential by engaging community voices and talents [25]. An essential component for Las Malvinas BHC project has been the engagement of respected and well-integrated community members with credibility and visibility. This project benefited from the presence of a local neighborhood association and school. These two institutions brought vital assets and played crucial roles, taking ownership of the processes to improve the health and well-being of their community. For example, a community leader who is a member of the neighborhood association instituted a sport and cultural club providing space for healthy recreation for youth, as well as developing summer camps in partnership with a local non-profit organization. These camps provided occasions for youth competition in track, soccer, and other sports, serving to enhance the overall community environment. In addition, a dance school and an arts and crafts workshop were established at Las Malvinas, in collaboration with a governmental and a non-governmental organization. These community initiatives exemplified how leaders of the neighborhood association are essential assets for the sustainability of this BHC process.

Building essential relationships and trust: Proxy trust

A BHC process requires partners’ capacity to build relationships and trust [25]. However, the most frequently mentioned challenge to conducting effective community-based research are a lack of trust and perceived lack of respect, particularly between academic representatives and community members. A common challenge to build the necessary trust among partners are the power differentials that exist among researchers and community members. A long history of research from which there was no perceived benefit and no result feedback to the community has contributed to this mistrust [26]. These power differentials must be addressed systematically to succeed in a BHC enterprise, in a way that community representatives identify themselves as “Equal partners” through shared ownership and control of the BHC process [27]. One of the key elements for successful achievements of the proposed research and programmatic goals of Las Malvinas BHC project has been the high level of trust and regard of this community towards UNIBE. UNIBE institutional investment within Las Malvinas has forged a strong bond of confidence between them and community members. Las Malvinas has welcomed the CU faculty leader and students due to their association with UNIBE. This proxy trust [28] has paved the way for U.S. students to be productive in action research endeavors within this community.

Building communities that skillfully address community problems in collaboration with governmental partners: Availability of funding and sustainability

An important facilitator for the launch of this BHC project has been the addition of governmental and non-governmental affiliate organizations through territorial partnerships. Support of government institutions in the DR is required to create a lasting and sustainable impact through systems development and maintenance. This effort included meeting the Public Health Area Director, a representative from the Ministry of Environment, as well as a representative from the Office of the President. These outreach efforts brought in government support to address some of the many environmental issues affecting Las Malvinas. Without government support for building expansion, sewage improvement, or water sanitation, these projects cannot be fully endorsed. As the government oversees, approves, and potentially funds all construction, its involvement is required. Although government partners are advancing relevant infrastructure development initiatives, availability of funds to execute identified infrastructure development and improvement projects poses a constant challenge. The proactive attitude of Las Malvinas II Neighborhood Association, through a participatory budget contest facilitated by the local municipality, secured funds for the construction of a primary health care clinic, as well as the Ministry of Education’s purchase of a large land parcel for a new and enlarged school. Additional funds and joint planning between responsible government institutions will contribute toward achieving additional priorities identified by this community.

Mobilizing creativity and resources of the community toward a shared vision for the future: Community members time constraints and changes in community structure

Developing healthy communities requires the engagement and participation of community members towards developing a shared vision of their future. However, a BHC is a time-consuming and long-term process [23]. Community partners’ time availability presents an ongoing challenge for the achievement of actions identified in the CHIP. This limitation includes the time required to establish and maintain trusting relationships. Las Malvinas continues to grow, as more families move into the community. Changes in the diversity population require a persistent effort to nurture a sense of community among newcomers, while fostering community engagement among all residents to ensure an inclusive BHC process.

Study Limitations

Limitations of this study include that, as a descriptive case study, casual inferences cannot be derived from its findings. In addition, the partnership-building processes, as well as research and intervention methods applied to Las Malvinas may not be generalizable to other communities in the DR and around the world. However, these findings may guide further research and interventions to promote healthier communities by fostering multidimensional partnerships in low-resource Dominican communities. This descriptive case report did not include subjective measures on the community’s and its partners’ experiences on the BHC process. However, the goal of this study was to describe the chain of events that made possible the development of multi-dimensional partnerships at Las Malvinas, as well as the research and interventions derived from these partnerships, and its corresponding process outcomes. Lastly, this BHC process did not include supra-territorial dimension level partnerships, as per the GHEF [3]. These supraterritorial level partnerships would correspond to collaborations that encompass research or interventions to address regional or global mechanisms through which SDOH influence health outcomes for Las Malvinas [29]. While currently beyond the scope of this BHC project, the authors hope that this descriptive case study will serve as a motivation to promote partnerships that address SDOH at the level of low-resource communities in developing nations.

Conclusion

Las Malvinas BHC interdisciplinary project focused on a small low-resource community located in the DR capital of Santo Domingo. These community-institutional partnerships’ dual ambition was to develop participating students’ global health skills, while simultaneously supporting the community of Las Malvinas in their health and well-being improvement efforts. The CDC’s Community Health Assessment and Group Evaluation (CHAnGE) protocol2 was linguistically and culturally adapted through the collaborative effort of CU and UNIBE students and the Las Malvinas II Neighborhood Association. Las Malvinas BHC project promotes an interdisciplinary and holistic approach to community health and well-being improvement. The project focuses in five public health priorities identified in collaboration with community leaders-sanitation, education, vaccine preventable diseases, chronic diseases, and unwanted pregnancies. These priorities were framed within five sectors in the socio-ecological spectrum-work, health, education, community organizations, and community at large-. Based on the GHEF [3], partnerships developed in this community-building effort were analyzed and categorized as territorial-level partnerships (Las Malvinas community leaders, neighborhood association, local school, UNIBE, governmental and non-governmental organizations), as well as trans-territorial partnerships (CU). Partnerships between sectors within the community, outside Las Malvinas’ city limits, and ultimately beyond the borders of the DR, encouraged the exchange of assets, theories, and innovation in order to identify and begin remedying SDOH, with the objective of improving the overall health and well-being of the Las Malvinas community. Several of the process achievements resulting from this BHC project demonstrate the value of mutually beneficial alliances at the territorial and trans-territorial dimensions. They also highlight the impact of pro-active community inventory of local assets in devising and implementing sustainable interventions for community health and well-being improvement.

Acknowledgement

We would like to acknowledge the many contributions of all Clemson University and Iberoamerican University (UNIBE) students involved in the design and implementation of this Building a Healthier Community project; the stakeholders involved in the Dominican Republic including Ruben Darío Gomez, Community Services Coordinator Iberoamerican University (UNIBE); Sobeida Familia, Joceline Ramirez, Bernardo Martinez, and Edilberto Trinidad Ramos from Las Malvinas II Neighborhood Association; Tamara Valdez San Pedro, Fundación Eco-ambiental Dominicana; Vanessa Alba Caminero, Gerdau Metaldom; and, Dr. Onofre Rojas, Director Mancomunidad del Gran Santo Domingo.

Funding

Research conducted with financial support from Clemson University’s Creative Inquiry Program, Service Learning Alliance, and Critical Thinking 2 Project.

Conflict of Interest

The Authors declare that there is no conflict of interest.

To access research materials related to this publication please contact Dr. Arelis Moore de Peralta at ared@clemson.edu.

Figure 1: Building a Healthier Las Malvinas II: Community Health Assessment (CHA). Dominican RepublicSummary of Methods and Processes Fall 2015 – Fall 2017.

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