Social environment, morbidity and use of health care among people with diabetes mellitus in Trinidad.

BACKGROUND: This study aimed to identify social characteristics associated with higher levels of morbidity from diabetes and their relationship to health care utilization. METHODS: During a 6-month period 1149/1447 (79%) subjects admitted to Port of Spain Hospital, Trinidad with diabetes responded to a structured interview. Data collection included social factors, diabetes-related morbidity and health care utilization. Analyses were adjusted for age, sex, ethnic group and self-reported diabetes duration. RESULTS: Of 12 indicators of morbidity, nine were more frequent in subjects with no schooling compared with those with secondary education. At ages 15-59 years, nine morbidity indicators were less frequent among subjects in full-time jobs compared with those not in employment. The association of educational attainment was explained by confounding with age, sex, ethnic group and diabetes duration but five morbidity indicators were associated with employment status after adjusting for confounding. The type of water supply in the home was generally not associated with morbidity. Each of the indicators of lower socioeconomic status was associated with less use of private doctors and with more use of government health centres. CONCLUSIONS: Morbidity from diabetes was greater in groups with lower socioeconomic status. While morbidity associated with lower educational attainment was mostly explained by older age; the results suggested the possibility that diabetes may contribute to unemployment of those in the labour force. Private care was less accessible to social groups with higher levels of morbidity and the availability of government funded health services was important for reducing inequalities in health care utilization.

Diabetes care in middle-income countries: a Caribbean case study.

Many middle-income countries now have a high prevalence of diabetes and need to address the problem of providing care for people with diabetes within limited resources. This study evaluated standards of preventive care in primary settings in three Caribbean countries. We studied case records at 17 clinics in 15 government health centres and 17 private general practitioners' offices in Barbados, Trinidad and Tobago and Tortola (British Virgin Islands). A census of all attenders over a 4 to 7 week period identified 1661 attenders with diabetes mellitus, approximately two-thirds were women with a median age over 60 years. Overall 676/1342 (50%) had 'poor' blood glucose control (> or = 8 mmol l-1 fasting or > or = 10 mmol l-1 random). The proportion with BP > or = 160/95 mmHg or receiving treatment for hypertension was 943/1661 (57%), of whom 781/943 (83%) were prescribed drug treatment. Among those treated for hypertension only 181/781 (23%) had blood pressures < 140/90 mmHg. Surveillance for complications affecting the feet (11%) or eyes (2%) was not performed systematically in any setting. Only 533 (32%) had recorded dietary advice and 79 (5%) had recorded exercise advice in the last 12 months. To begin to address some of these problems at a regional level, we incorporated results from this survey into a series of workshops held in collaboration with health ministries in 10 Caribbean countries, with participants from 13 countries. At these workshops health care workers participated in the process of developing guidelines for diabetes management in primary care. The guidelines have subsequently been widely disseminated through health ministries and non-governmental organizations in the region. Further research is needed to evaluate the effectiveness of this approach, the constraints on diabetes care, and the most cost-effective means of addressing them.

Counting the cost of diabetic hospital admissions from a multi-ethnic population in Trinidad.

Many middle-income countries are experiencing an increase in diabetes mellitus but patterns of morbidity and resource use from diabetes in developing countries have not been well described. We evaluated hospital admission with diabetes among different ethnic groups in Trinidad. We compiled a register of all patients with diabetes admitted to adult medical, general surgical, and ophthalmology wards at Port of Spain Hospital, Trinidad. During 26 weeks, 1447 patients with diabetes had 1722 admissions. Annual admission rates, standardized to the World Population, for the catchment population aged 30-64 years were 1031 (95% CI 928 to 1134) per 100,000 in men and 1354 (1240 to 1468) per 100,000 in women. Compared with the total population, admission rates were 33% higher in the Indian origin population and 47% lower in those of mixed ethnicity. The age-standardized rate of amputation with diabetes in the general population aged 30-64 years was 54 (37 to 71) per 100,000. The hospital admission fatality rate was 8.9% (95%CI 7.6% to 10.2%). Mortality was associated with increasing age, admission with hyperglycaemia, elevated serum creatinine, cardiac failure or stroke and with lower-limb amputation during admission. Diabetes accounted for 13.6% of hospital admissions and 23% of hospital bed occupancy. Admissions associated with disorders of blood glucose control or foot problems accounted for 52% of diabetic hospital bed occupancy. The annual cost of admissions with diabetes was conservatively estimated at TT+ 10.66 million (UK 1.24 million pounds). In this community diabetes admission rates were high and varied according to the prevalence of diabetes. Admissions, fatalities and resource use were associated with acute and chronic complications of diabetes. Investing in better quality preventive clinical care for diabetes might provide an economically advantageous policy for countries like Trinidad and Tobago.