Applying the Stages of Change model to Type 2 diabetes care in Trinidad: a randomised trial.

OBJECTIVE: To improve glycaemic control among Type 2 diabetics using patient-physician consultations guided by the Stages of Change (SOC) model. DESIGN AND METHODS: A randomised trial was conducted. After ensuring concealment of allocation, Type 2 diabetics were randomly assigned to receive the intervention or the control. The intervention consisted of identifying each patient's Stage of Change for managing their diabetes by diet, exercise and medications, and applying personalised, stage-specific care during the patient-physician consultations based on the SOC model. Patients in the control group received routine care. The variables of interest were effect on glycaemic control (measured by the difference in HbA1c levels) and patients' readiness to change (measured by identifying patients' SOC for managing their diabetes by diet, exercise and medications). RESULTS: Participants were primarily over age 50, male and Indo-Trinidadian. Most had received only a primary school education and over 65% had a monthly income of $320 USD/month or less. Sixty-one Type 2 diabetics participated in each arm. Three patients were lost to follow-up in the intervention arm. After 48 weeks, there was an overall increase in HbA1c of 0.52% (SE 0.17) and 1.09% (SE 0.18) for both the intervention and control groups respectively. There was a relative reduction in HbA1c of 0.57% (95% CI 0.07, 1.07) with the intervention group compared to the control (p = 0.025). For exercise and diet there was an overall tendency for participants in the intervention arm to move to a more favourable SOC, but little change was noted with regards medication use. CONCLUSIONS: The result suggests a tendency to a worsening of glycaemic control in this population despite adopting more favourable SOC for diet and exercise. We hypothesized that harsh social conditions prevailing at the time of the study overrode the clinical intervention.

Serum creatine kinase and lactate dehydrogenase activities in patients with thyroid disorders.

BACKGROUND AND OBJECTIVES: There is the recognition of a pattern of elevations of serum enzymes in hyperthyroid and hypothyroid patients. The aims of this study were to determine the activities of serum creatine kinase (CK) and lactate deydrogenase (LDH) in thyroid disorders, and to evaluate the relationship between CK, LDH and FT4, and TSH levels. MATERIALS AND METHODS: In this retrospective study, thyroid function tests, serum CK and LDH activities were obtained from the medical records of newly diagnosed hyperthyroid and hypothyroid patients attending the Endocrinology Clinic at the University Hospital of the West Indies from 2005- 2009. RESULTS: Elevation of CK activity was found in 5 patients (28%, 5/18) with overt hypothyroidism and in 12 patients (24.0%, 12/50) with subclinical hypothyroidism. The mean CK activity in subclinical hypothyroid patients was 179.80 ± 125.68 U/L compared with 389.901 ± 381.20 U/L in overt hypothyroid patients. The elevation of LDH activity was found in 6 patients (33.3%, 6/18) with overt hypothyroidism and in 37 patients (74.0%, 37/50) with subclinical hypothyroidism. In the hypothyroid patients, a positive correlation was found between CK activity and TSH (r = 0.292, P = 0.015), and a negative correlation between CK activity and FT4 (r = - 0.325, P = 0.007); and between FT4 and TSH (r = - 0.371, P = 0.002). CONCLUSION: The significant elevation in serum CK and LDH activities indicates that these can be used as parameters for screening hypothyroid patients but not hyperthyroid patients.

The prevalence of domestic violence within different socio-economic classes in Central Trinidad.

OBJECTIVES: Domestic violence is a medical and social issue that often leads to negative consequences for society. This paper examines the association between the prevalence of domestic violence in relation to the different socio-economic classes in Central Trinidad. The paper also explores the major perceived causes of physical abuse in Central Trinidad. SUBJECTS AND METHODS: Participants were selected using a two-stage stratified sampling method within the Couva district. Households, each contributing one participant, were stratified into different socioeconomic classes (SES Class) and each stratum size (or its share in the sample) was determined by the portion of its size in the sampling frame to the total sample; then its members were randomly selected. The sampling method attempted to balance and then minimize racial, age, cultural biases and confounding factors. The participant chosen had to be older than 16-years of age, female and a resident of the household. If more than one female was at home, the most senior was interviewed. RESULTS: The study found a statistically significant relationship between verbal abuse (p = 0.0017), physical abuse (p = 0.0012) and financial abuse (p = 0.001) and socio-economic class. For all the socio-economic classes considered, the highest prevalence of domestic violence occurred amongst the working class and lower middle socio-economic classes. The most prominent reasons cited for the physical violence was drug and alcohol abuse (37%) and communication differences (16.3%). These were the other two main perceived causes of the violence. The power of the study was 0.78 and the all strata prevalence of domestic violence was 41%. CONCLUSIONS: Domestic violence was reported within all socio-economic class groupings but it was most prevalent within the working class and lower middle socio-economic classes. The major perceived cause of domestic violence was alcohol/drug abuse.

The elderly in Trinidad: health, social and economic status and issues of loneliness.

OBJECTIVES: To determine the general health and social status of elderly persons surveyed in Trinidad and to explore issues of loneliness. METHOD: An island-wide survey of persons aged 65 years and older was conducted in early 2002 in Trinidad Eight hundred and forty-five (845) elderly persons were chosen using systematic random sampling. The main survey instrument for data collection was a questionnaire that included structured as well as open-ended questions. The subjects were chosen in a house-to-house survey conducted in all eight counties in Trinidad. Elderly people who were unable to comprehend the questions were excluded from the survey. RESULTS: Those selected ranged in age from 65-102 years and represented all the ethnic groups in Trinidad. These elderly persons lived in a wide range of housing situations. The majority lived in the homes of family members (57%) and 16% lived on their own. A large proportion (80%) had at least one chronic medical problem, although 44% reported their health as "fairly good" or "good". More than a half of the males (53%) and 67% of the females were taking at least one prescribed medicine. The main sources of income were old age pension (85%) and National Insurance (15%). Thirty-three per cent reported feelings of loneliness. This figure includes 28% of those who did not live alone. CONCLUSION: The data revealed that across all ethnic groups more than one-third of the sample reported themselves to be in fair to good health. Many of these elders were lonely because their relatives were quite occupied with their own affairs.

Malaria and its vectors in the Caribbean: the continuing challenge of the disease forty-five years after eradication from the Islands.

OBJECTIVES: Given the occurrence of autochthonous malaria in non-endemic island countries in the last 10 years, this study evaluates the risk factors for malaria transmission in the malaria "endemic and "non-endemic" countries of the Caribbean region. DESIGN: Data on imported and autochthonous malaria for the 27-year period (1980-2006) were gathered from surveillance units in the 21 Caribbean Epidemiology Centre (CAREC) Member Countries (CMCs) via the CAREC epidemiology unit. Anopheles mosquito data were also gathered from various sources. The vector and malaria data were correlated to determine the current risk of malaria transmission. RESULTS: Imported cases. For the 26-year period (1980-2005), there were 897 reported cases in the CMC islands. Jamaica (38.4%) > Trinidad and Tobago (19.5%) > Bahamas (15.8%) > Cayman Islands (12.5%) were mostly affected. Only the smallest CMCs eg Anguilla and British Virgin Islands reported no imported malaria. Indigenous malaria. Over the same time period, malaria was seen mainly in the three mainland countries of Guyana (514 386 cases) > Suriname (275 361) > Belize (85 313). However, for the period 1995-2005, Belize and Guyana reported reduction in case numbers of 84% and 54% respectively. At the same time, Suriname reported a cyclical pattern of reported cases resulting in 77% increase in cases between 1995 and 2005. "Non-endemic" CMCs such as Trinidad and Tobago, and Bahamas, did report autochthonous malaria. In 2006/7, Jamaica reported 340 P falciparum cases, coming just 1-2 years after a massive 505% increase in imported malaria in the region--88% in Jamaica. Anopheles spp: There was a rich diversity of Anopheles mosquitoes--29 spp. in CMCs. Mainland CMCs and nearby island countries had most spp. recorded. Smaller countries with limited ecological niches such as St Kitts, Anguilla, Turks and Caicos Islands (TCI) and Bermuda had little or no Anopheles spp. Two main Anopheles axes were identified--An albimanus in the northern CMCs and An aquasalis in the southern Caribbean. CONCLUSION: All the essential malaria transmission conditions--vector, imported malaria organism and susceptible human host--now exist in most CMCs. A call is now made for enhanced surveillance, vector control and anti-malaria skills to be established in CMCs, in particular in: Recognizing the possible impact of climate change on the spread of anopheles and malaria transmission. Improving vector control skills for anopheles in CMCs. Strengthening malaria surveillance skills. Upgrading malaria therapy and prophylaxis. Emphasizing malaria prevention and educationfor all community and professional sectors.

A knowledge, attitude and practices study of the issues of climate change/variability impacts and public health in Trinidad and Tobago, and St Kitts and Nevis.

OBJECTIVE: To determine the level of understanding of the issues of climate change (CC)/variability (CV) and public health by populations of St Kitts and Nevis (SKN) and Trinidad and Tobago (T&T) and to find whether respondents would be willing to incorporate these values into strategies for dengue fever (DF) prevention. DESIGN AND METHODS: Using a cluster sampling system, representative samples of the communities of SKN (227) and T&T (650) were surveyed for responses to a questionnaire document with questions on the impact of climate variability on health, the physical environment, respondents' willingness to utilize climate issues to predict and adapt to climate variability for DF prevention. Data were analyzed by Epi Info. RESULTS: Sixty-two per cent SKN and 55% T&T of respondents showed some understanding of the concept of climate change (CC) and distinguished this from climate variability (CV). With regard to causes of CC, 48% SKN and 50% T&T attributed CC to all of green houses gases, holes in the ozone layer burning of vegetation and vehicular exhaust gases. However some 39.3% SKN and 31% (T&T) did not answer this question. In response to ranking issues of life affected by CC/CV in both countries, respondents ranked them: health > water resources > agriculture > biodiversity > coastal degradation. The major health issues identified for SKN and T&T respondents were: food-borne diseases > water-borne diseases > heat stresses; vector-borne diseases were only ranked 4th and 5th for SKN and T&T respondents respectively. There was in both countries a significant proportion of respondents (p < 0.001) who reported wet season-related increase of DF cases as a CC/CV link. Respondents identified use of environmental sanitation (ES) at appropriate times as a method of choice of using CC/CV to prevent DF outbreaks. More than 82% in both countries saw the use of the CC/CV information for DF prevention by prediction and control as strategic but only 50-51% were inclined to become personally involved. Currently, only 50% SKN and 45% T&T respondents claimed current involvement in DF vector surveillance and control in the last two days. CONCLUSION: Despite the fact that knowledge and attitudes did not always coincide with practices of using ES for DF prevention, in both countries, even with CC/CV tools of prediction being available, it seems that respondents could be persuaded to use such strategies. There is a need for demonstration of the efficacy of CC/CV information and promotion of its usefulness for community involvement in DF and possibly other disease prevention.

A knowledge, attitude and practices study of the issues of climate change/variability impacts and public health in Trinidad and Tobago, and St Kitts and Nevis / Un estudio de conocimientos, actitudes y prácticas (CAP) de los problemas del cambio climático/variabilidad de los impactos y salud pública en Trinidad y Tobago y St Kitts Nevis

OBJECTIVE: To determine the level of understanding of the issues of climate change (CC)/variability (CV) and public health by populations of St Kitts and Nevis (SKN) and Trinidad and Tobago (T&T) and to find whether respondents would be willing to incorporate these values into strategies for dengue fever (DF) prevention. DESIGN AND METHODS: Using a cluster sampling system, representative samples of the communities of SKN (227) and T&T (650) were surveyed for responses to a questionnaire document with questions on the impact of climate variability on health, the physical environment, respondents' willingness to utilize climate issues to predict and adapt to climate variability for DF prevention. Data were analyzed by Epi Info. RESULTS: Sixty-two per cent SKN and 55% T&T of respondents showed some understanding of the concept of climate change (CC) and distinguished this from climate variability (CV). With regard to causes of CC, 48% SKN and 50% T&T attributed CC to all of green houses gases, holes in the ozone layer burning of vegetation and vehicular exhaust gases. However some 39.3% SKN and 31% (T&T) did not answer this question. In response to ranking issues of life affected by CC/CV in both countries, respondents ranked them: health > water resources > agriculture > biodiversity > coastal degradation. The major health issues identified for SKN and T&T respondents were: food-borne diseases > water-borne diseases > heat stresses; vector-borne diseases were only ranked 4th and 5th for SKN and T&T respondents respectively. There was in both countries a significant proportion of respondents (p < 0.001) who reported wet season-related increase of DF cases as a CC/CV link. Respondents identified use of environmental sanitation (ES) at appropriate times as a method of choice of using CC/CV to prevent DF outbreaks. More than 82% in both countries saw the use of the CC/CV information for DF prevention by prediction and control as strategic but only 50-51...

OBJETIVO: Determinar los niveles de comprensión de los problemas del cambio climático (CC)/ variabilidad (CV) y salud pública por parte de las poblaciones de St Kitts y Nevis (SKN) y Trinidad y Tobago (T&T), y averiguar si los encuestados estarían dispuestos a incorporar estos valores en las estrategias para la previsión de la fiebre del dengue (FD). DISEÑO Y MÉTODOS: Usando un sistema de muestreo por conglomerados, muestras representativas de las comunidades de SKN (227) y de T&T (650) fueron encuestadas mediante un cuestionario en el que se les pedía responder preguntas sobre el impacto de la variabilidad del clima sobre la salud, el ambiente físico, y la disposición de los encuestados a aprovechar las cuestiones del clima para predecir y adaptarse a la variabilidad climática a fin de prevenir la FD. Los datos fueron analizados mediante Epi Info. RESULTADOS: Sesenta y dos por ciento de los encuestados de SKN y el 55% de los de T&T, mostraron cierta comprensión del concepto de cambio climático (CC) y fueron capaces de diferenciarlo de la variabilidad climática (CV). En relación con las causas del CC, el 48% (SKN) y el 50% (T&T) atribuyó el CC a los gases de efecto invernadero, los agujeros en la capa de ozono, la quema de la vegetación, y los gases de escape de vehículos.

Caring for the chronically ill elderly in Trinidad: the informal situation.

This paper comments on research data, from a survey, which sought to determine the health and social circumstances of persons in Trinidad who were providing informal care for the chronically ill elderly during the period, March to August 1998. The research also sought to ascertain the main concerns of the caregivers in their caregiving role. One hundred caregivers in North, Central and South Trinidad were chosen using a convenience sampling method. Caregivers selected had to be at least eighteen years old and residing in their own homes or in the home of the cared. The caregivers ranged in age from 20-89 years. Eighty two percent of the caregivers were females. Wives, daughters and daughters-in-law were the main caregivers. Daughters-in-law were especially instrumental in providing informal care in Indo-Trinidadian households being 28% of caregivers in those households compared to 4% for daughters-in-laws in Afro-Trinidadian households. Fifty percent of the caregivers reported their health to be good. The main health conditions reported by the others were hypertension (14%), diabetes mellitus (9%) and arthritis (18%). The main concern which the caregivers reported was stress (50%). The study revealed that caregiving was perceived by most of these caregivers to be extremely stressful. Daughters, daughters-in-law and wives bore the greatest burden of care and desired greater assistance from family members and friends. The paper makes reference to a government programme which trains young adults to work with the chronically ill elderly, in their own home. It makes a case for the greater use of such young persons in order to relieve relatives of some of the burden of care.

Caring for the chronically ill elderly in Trinidad: the informal situation

This paper comments on research data, from a survey, which sought to determine the health and social circumstances of persons in Trinidad who were providing informal care for the chronically ill elderly during the period, March to August 1998. The research also sought to ascertain the main concerns of the caregivers in their caregiving role. One hundred caregivers in North, Central and South Trinidad were chosen using a convenience sampling method. Caregivers selected had to be at least eighteen years old and residing in their own homes or in the home of the cared. The caregivers ranged in age from 20-89 years. Eighty two percent of the caregivers were females. Wives, daughters and daughters-in-law were the main caregivers. Daughters-in-law were especially instrumental in providing informal care in Indo-Trinidadian households being 28 of caregivers in those households compared to 4 for daughters-in-laws in Afro-Trinidadian households. Fifty percent of the caregivers reported their health to be good. The main health conditions reported by the others were hypertension (14), diabetes mellitus (9) and arthritis (18). The main concern which the caregivers reported was stress (50). The study revealed that caregiving was perceived by most of these caregivers to be extremely stressful. Daughters, daughters-in-law and wives bore the greatest burden of care and desired greater assistance from family members and friends. The paper makes reference to a government programme which trains young adults to work with the chronically ill elderly, in their own home. It makes a case for the greater use of such young persons in order to relieve relatives of some of the burden of care.

Transformations in maternity services in Jamaica.

Analysis of the current organization and delivery of maternity care in Jamaica profits not only from an assessment of recent health issues but from consideration of the development of maternity services over the past century. Historical analysis indicates that a critical element in public health policy has been the effort to encourage use of biomedical obstetrical care and to eliminate the lay midwife. However, while women increasingly patronize hospitals, the delivery of services has deteriorated, resulting in widespread client dissatisfaction. Economic contingencies have contributed to the decline in maternity services, but health personnel manifest the ideology prevalent throughout the colonial era equating social irresponsibility with health complications. The cultural construction of illegitimacy and maternity is shown to be a dimension of class relations having an impact on health policy throughout Jamaica's history.

Good managers for good health services.

PIP: This article outlines progress in the preparation of nurses, doctors and other professionals for managerial roles in the health services of several Caribbean countries. It is expected that there will be solid gains in effectiveness and efficiency during the next few years as the new managers' influence is felt and that the prospects for primary care and health for all will consequently be enhanced. The difficulties of running the health services of the Caribbean vary from country to country. In Jamaica, financing the health sector is a major problem. Inadequate funds mean that there are shortages of drugs and other medical supplies in the public hospitals and that up-to-date equipment is scarce or unavailable. These problems are compounded by the steady exodus from the sector of doctors, registered nurses and other health professionals. In 1978 at the Caribbean Health Ministers' Conference, management problems were identified as the principal health issue for all categories of health workers and lack of training in effective and efficient management was blamed. During the 1960s, short courses for health staff aimed at improving administration were conducted under the auspices of the Faculty of Social Sciences and the Extramural Department of the University of the West Indies. Advanced nursing education was established in 1966, and a program for middle and senior managers in the Department of Management Studies was begun. Since 1977 the Administrative Staff College of Jamaica has been preenting general management and project management programs for health workers. In 1984 the University of the West Indies began a program for health workers in an integrated format leading to The Diploma in Health Management. It can be taken on a full-time basis for 1 year or part-time for 2 years. Members of the Faculties of Medical Sciences and Social Sciences participate in teaching. Unusual features of the coursework are student workshops; modular division of the 5 main courses; utilization of lecturers from other institutions; participation of experienced health managers; and a 3-week field placement.^ieng