Implementation of chronic disease risk factor surveillance in 12 Cuban municipalities.

Chronic non-communicable diseases have been called the pandemic of the 21st century and constitute a high-priority public health challenge; hence growing interest in chronic disease risk factor surveillance. Cuba is implementing decentralized risk factor surveillance in each of its municipalities as part of a strategy to address non-communicable diseases. Decentralized surveillance with this level of detail and explicitly designed to inform municipal and provincial decisionmaking is unprecedented in Cuba. We describe the methodology for planning and implementing measurement of major risk factors in 12 municipalities in 10 provinces, as part of Cuba's National Surveillance System. The results have facilitated timely use of information and evidence-based decisionmaking at the local level.

Diffusion of community empowerment strategies for Aedes aegypti control in Cuba: a muddling through experience.

Effective participatory strategies in dengue control have been developed and assessed as small-scale efforts. The challenge is to scale-up and institutionalize these strategies within dengue control programs. We describe and critically analyze the diffusion process of an effective empowerment strategy within the Cuban Aedes aegypti control program, focusing on decision-making at the national level, to identify ways forward to institutionalize such strategies in Cuba and elsewhere. From 2005 to 2009, we carried out a process-oriented case study. We used participant observation, in-depth interviews with key informants involved in the diffusion process and document analysis. In a first phase, the data analysis was inductive. In a second phase, to enhance robustness of the analysis, emerging categories were contrasted with Rogers' five-stage conceptual model of the innovation-decision process, which was eventually used as the analytical framework. The diffusion of the empowerment strategy was a continuous and dynamic process. Adoption was a result of the perceived potential match between the innovative empowerment strategy and the performance gap of the Ae. aegypti control program. During implementation, the strategy was partially modified by top level Ae. aegypti control program decision-makers to accommodate program characteristics. However, structure, practices and organizational culture of the control program did not change significantly. Thus rejection occurred. It was mainly due to insufficient dissemination of know-how and underlying principles of the strategy by innovation developers, but also to resistance to change. The innovation-diffusion process has produced mitigated results to date, and the control program is still struggling to find ways to move forward. Improving the innovation strategy by providing the necessary knowledge about the innovation and addressing control program organizational changes is crucial for successful diffusion of empowerment strategies. Issues highlighted in this particular experience might be relevant in the innovation-diffusion process of other complex innovations within health systems.

Intersectoral action for health at a municipal level in Cuba.

OBJECTIVE: To consider how Cuba's acknowledged achievement of excellent health outcomes may relate to how health determinants are addressed intersectorally. METHODS: Our team of Canadian and Cuban researchers and health policy practitioners undertook a study to consider the organization and practices involved in addressing health determinants in 2 municipalities (1 urban and 1 rural). The study included a questionnaire of municipal Health Council members and others involved in health and non-health sectors, key informant interviews of policy makers, focus groups in each municipality and examination of three common case scenarios. RESULTS: Regular engagement of different sectors and other agencies in addressing health determinants was quite systematic and comparable in both municipalities. Specific policies and organizational structures in support of intersectoral actions were frequently cited and illustrated in case scenarios that demonstrate how maintenance of regular linkages facilitates regular pursuit of intersectoral approaches. CONCLUSIONS: The study demonstrates the feasibility of examining processes of intersectoral action for health processes and suggests that further examination in evaluating factors such as training, particular practices, etc., can be a fruitful direction to pursue comparatively and with analytical designs.

Tobacco and alcohol use in Cuban women.

INTRODUCTION: Tobacco and alcohol are currently the most widely consumed legal psychoactive substances in the world. They represent a heavy burden for health and society in almost all populations. Increasing consumption of both substances is a trend observed in women. OBJECTIVE: Describe the profile of women aged ≥15 years residing in urban areas of Cuba with respect to tobacco and alcohol consumption. METHOD: Basic information on tobacco and alcohol consumption by Cubans aged ≥15 years in urban areas was obtained from the Second National Survey on Risk Factors and Chronic Diseases (2001), a national descriptive cross-sectional study, the objective of which was to determine the frequency and epidemiological characteristics of the urban population's main chronic disease risk factors. Sampling design was complex stratified multi-stage cluster. Of a sample of 23,743 individuals, 22,851 were surveyed, representative of 6.8 million Cubans. A questionnaire and structured interview were used. Variables were tobacco and alcohol use, as well as sociodemographic factors: sex, age, educational level, skin color, marital status, type of full-time employment and perceived economic situation. Prevalence, with 95% confidence intervals, and male:female prevalence ratios were estimated. RESULTS: Women who smoked were predominantly aged 40-59 years; had completed less than university education; of black skin color; divorced; laborers, service workers or managers, and with a perceived economic situation as very poor. Women who consumed alcohol were predominantly aged 15-59 years, had at least middle school education, of mestizo or black skin color, of marital status other than widowed; there was no typical profile for occupation or perceived economic situation. Women who were both smokers and alcohol consumers were predominantly 20-59 years, of black or mestizo skin color, of marital status other than widowed; with no typical profile for educational level, occupation or perceived economic situation. CONCLUSIONS: The first nationwide socioeconomic profile of Cuban women using tobacco, alcohol or both constitutes a baseline for comparison to results of a new national study now under way, permitting evaluation of trends over time and effectiveness of prevention and control efforts.

Network analysis as a tool to assess the intersectoral management of health determinants at the local level: a report from an exploratory study of two Cuban municipalities.

Intersectoral action on health determinants has long been recognized as an important factor in achieving better population health. Nevertheless, there is no process that provides empirical evidence to policy-makers on the extent of intersectoral collaboration. We aimed to fill this gap by conducting case studies in two municipalities in Cuba, a country well known for its intersectoral practice and good health outcomes. We surveyed an intentional sample of key members of Health Councils - virtual intersectoral spaces in Cuba - about links and related actions they had with other sectors on eleven health determinants. Using network analysis we were able to produce measures to evaluate and characterize the network of sectors. Findings show that the two municipalities were similar in reported importance of health determinants, extent of long-term engagement in intra-sectors actions and level of collaboration with other sectors for virtually all determinants. Municipalities also showed similar overall levels of collaboration for most determinants when considered as a network of different sectors (network density). However municipalities showed differences in the central role played by some sectors (centrality index). We further used the network analysis blockmodeling technique to typify the municipal Health Councils. We found that while one Health Council can be typified by a single well connected network structure, the other has two distinct structures with more sparse connections. We conclude that intersectoral collaboration can be assessed by the use of network analysis measurements. This approach is novel and provides evidence to decision-makers about their role and their effort towards collaboration in achieving better health outcomes.

Overweight, obesity, central adiposity and associated chronic diseases in cuban adults.

Introduction Prevalence of overweight and obesity is increasing worldwide in parallel with the growing burden of noncommunicable chronic diseases. According to the World Health Organization, in 2005 approximately 1.6 billion individuals aged ≥15 years were overweight and at least 400 million were obese; by 2015 these figures will almost double. Central distribution of adiposity has also been associated with higher rates of cardiovascular diseases and other conditions. Objective Determine the prevalence of overweight, obesity and central adiposity, and their association with noncommunicable chronic diseases and related lifestyle risk factors in Cuban adults. Methods The Second National Survey on Risk Factors and Chronic Diseases (ENFRENT II), conducted in 2000-2001, surveyed a representative sample of males and females aged ≥15 years using a stratified, multi-stage cluster sampling design. Data from a sub-sample of 19,519 individuals aged ≥20 years were analyzed and prevalence calculated for diabetes, hypertension, cardiovascular and cerebrovascular diseases, and for each of these variables in association with overweight, obesity and central distribution of adiposity, and with the presence of sedentary lifestyle, smoking, alcohol consumption, eating regular daily meals and daily breakfast. Results Estimated prevalence of overweight and obesity in the adult population was 30.8% (CI: 30.1-31.5) and 11.8% (CI: 11.2-12.4), respectively. Obesity prevalence was twice as high in women (15.4%; CI: 14.5-16.3) as in men (7.9%; CI: 7.3-8.6). Obesity was significantly more frequent in diabetics, hypertensives and people with heart disease, while central adiposity was significantly associated with a higher prevalence of diabetes mellitus, cardiovascular and cerebrovascular diseases, hypertension, obesity and overweight. Smoking and alcohol consumption were low among overweight and obese subjects, who exhibited a higher prevalence of irregular and inadequate eating patterns. Conclusions Prevalence of overweight, obesity and central adiposity, and comorbidity with diabetes mellitus, hypertension and heart disease, are growing public health problems in Cuba. A multi-sector strategy is needed to develop comprehensive food and nutrition policies and programs aimed at halting these trends, including interventions that encourage healthy eating patterns and regular physical activity in adults and children.

Smoking-attributable mortality in cuba.

Introduction Smoking is the main preventable cause of death worldwide. The World Health Organization estimates that smoking causes 5 million deaths annually, a figure that could double shortly if the present trend in tobacco product consumption continues. Objectives Estimate smoking-attributable mortality in the Cuban population and provide information needed to carry out effective public health actions. Methods This is a descriptive study using smoking prevalence and mortality data in Cuba for 1995 and 2007. Causes of death were grouped in three categories: malignant tumors, cardiovascular diseases and chronic respiratory diseases. Etiological fractions and attributable mortality were calculated by cause and sex. Results Of deaths recorded in 1995 and 2007, 15% and 18% of preventable deaths were attributed to smoking, respectively. In Cuba in 2007, smoking caused 86% of deaths from lung cancer, 78% of deaths from chronic obstructive pulmonary disease, 28% of deaths from ischemic heart disease, and 26% of deaths from cerebrovascular disease. Conclusions Smoking is responsible for high rates of preventable mortality in Cuba. There is willingness on the part of administrative and political authorities to discourage smoking, and more than half of smokers in Cuba wish to quit smoking. Given awareness that reducing smoking is the most effective means of decreasing preventable morbidity and mortality, the country is moving steadily toward concrete, sustainable steps leading to increased life expectancy and quality of life for the Cuban population.

Overweight, Obesity, Central Adiposity and Associated Chronic Diseases in Cuban Adults

Prevalence of overweight and obesity is increasing worldwide in parallel with the growing burden of noncommunicable chronic diseases. According to the World Health Organization, in 2005 approximately 1,6 billion individuals aged ¡Ý15 years were overweight and at least 400 million were obese; by 2015 these figures will almost double. Central distribution of adiposity has also been associated with higher rates of cardiovascular diseases and other conditions...(AU)

Cuba's health system: challenges ahead.

Cuba's exclusively public health system has been quite unique in pairing limited resources with excellent results. It continued to perform well during the economic crisis of the 1990s, and now that the hardships are being overcome, new opportunities are developing-as well as threats: (1) economic recovery should permit reinforcing of the system's effectiveness; (2) Cuba's increasing international solidarity in health also poses it corresponding challenges at home; (3) the ageing of the population necessitates adjustments to the health care system. However, the original principles of the health care system are not under question. Cuba can be considered a unique laboratory, and deserves more attention from the international public health community.

Uses of first line emergency services in Cuba.

OBJECTIVES: To rationalise the use of hospital emergency units, the Cuban health system developed from 1996 onwards an extra muros first line emergency system (FLES). We analyse the use of the FLES and its determinants, in order to develop proposals to channel inappropriate users to their family doctor. METHODS: In the FLES of an urban (Cerro) and a rural (Baracoa) municipality we collected, from July 1999 to June 2001, data on the moment of consultation, age and sex of the patient, referral status, motive of consultation, emergency classification, diagnosis and medical conduct. A variable "inappropriate use" was constructed. We used multivariate logistic regression to quantify the strength of the associations between patient characteristics, the night-time use, medical procedures, referral, and inappropriate use of the FLES. RESULTS: Over the 2 years observation period, 24879 and 59795 patient contacts were registered with the principal emergency policlinic in Baracoa and Cerro, respectively. In both municipalities the overall "inappropriate" use was almost 60%. There was no correlation with age and gender but inappropriate use was 50% more frequent during the day. Referred patients in both localities were up to 12 times more frequently hospitalized. CONCLUSION: Cuba's FLES attract patients that would be better attended by their family doctor. To strengthen his central position in the health system, one should strengthen the family doctor's technical platform, increase his permanence at the cabinet, and improve communication with the community on the rationale of the family doctor--FLES set up.

Cuba's international cooperation in health: an overview.

In the first years after Cuba's 1959 revolution, the island's new government provided international medical assistance to countries affected by natural disasters or armed conflicts. Step by step, a more structural complementary program for international collaboration was put in place. The relief operations after Hurricane Mitch, which struck Central America in 1998, were pivotal. From November 1998 onward, the "Integrated Health Program" was the cornerstone of Cuba's international cooperation. The intense cooperation with Hugo Chávez's Venezuela became another cornerstone. Complementary to the health programs abroad, Cuba also set up international programs at home, benefiting tens of thousands of foreign patients and disaster victims. In a parallel program, medical training is offered to international students in the Latin American Medical School in Cuba and, increasingly, also in their home countries. The importance and impact of these initiatives, however, cannot and should not be analyzed solely in public health terms.

An integrated ecosystem approach for sustainable prevention and control of dengue in Central Havana.

The authors developed and evaluated a comprehensive participatory ecosystem health approach for preventing the transmission of dengue, the most prevalent vector-borne disease in Cuba and the Latin America-Caribbean region. The integrated surveillance system central to this initiative encompassed three main subsystems (environmental; entomological; clinical-epidemiologic), relying on extensive community involvement. The study was conducted in Central Havana, Cuba. Indicators from each subsystem were selected and mapped using a GIS procedure providing instant visualization by city block in the municipality. To elucidate the factors affecting control and prevention efforts, perceived needs and risks, as well as knowledge, attitudes, and behaviors related to dengue, were assessed. Specific factors associated with the presence of mosquito breeding sites and risks of dengue were examined in a case-control study.

The functioning of the Cuban home hospitalization programme: a descriptive analysis.

BACKGROUND: Over the last decades hospital at home (HaH) programmes have been set up in many, mainly European, countries. The Cuban HaH programme is not hospital driven, but the responsibility of the first line health services, and family doctors play a pivotal role. METHODS: We analyse the structure and functioning of the Cuban programme. In this descriptive study, information was prospectively collected on HaH patients admitted between July 1st 2001 and June 30th 2002. RESULTS: Admission rates varied between areas from 0.014 to 0.035 per person per year (ppy). The < 1 y and 1-4 y age groups had the highest admission rates. In one area the follow-up of pregnancy problems led to high 15-24 y and 25-49 y female admission rates (0,070 and 0,058 respectively). Respiratory affections were the most frequent reason for admission (32,6%), followed by early hospital discharge (16,0%) and gynaeco-obstetrical problems (10.8%). The median length of stay varied from 5 to 7 days between regions and from 5 days (early discharge) to 7 days (gynaeco-obstetrical problems) in function of the reason for admission. On average an HaH episode entailed 1.4 and 1.6 contacts per patient-day with the family doctor and nurse respectively. CONCLUSION: Difference in admission criteria in function of geography, distance to the hospital, transport facilities, and staff factors, as well as differences in hospital policy on early discharge explain the observed variability. The programme plays an important role in the integrated approach to quality care in the Cuban health system, but could benefit from more uniform admission criteria.

Social and environmental determinants of Aedes aegypti infestation in Central Havana: results of a case-control study nested in an integrated dengue surveillance programme in Cuba.

OBJECTIVE: To characterize the social and environmental risk factors associated with the presence of Aedes aegypti in order to improve community dengue control. METHODS: A case-control study with 'cases' being households with entomologically confirmed A. aegypti infestation; personal interviews in Central Havana, a densely populated inner city area characterized by overcrowded housing and irregular water service. The participants were residents of 278 houses with infestation and 556 houses without infestation. RESULTS: Greater risk of infestation was associated with lack of preventive measures, such as no larvicide in the water tanks (OR = 2.21) and use of flower vases for religious practice (1.93), not being economically active (1.64), vulnerable populations with higher risks in households with older people (1.52) and households with children (1.94). CONCLUSIONS: Efforts to reduce infestations should continue to focus on water tank sanitation and improving housing conditions, but also engage community religious leaders to help promote safe practices. Vulnerable populations should be especially targeted by prevention activities. A surveillance programme can produce evidence to guide interventions.

Learning together: a Canada-Cuba research collaboration to improve the sustainable management of environmental health risks.

OBJECTIVE: To build a national Cuban capacity for training environmental health professionals directly linked to the needs of policy-makers and communities. PARTICIPANTS: The University of Manitoba and University of British Columbia collaborated with an established training centre in Cuba (the Instituto Nacional de Higiene y Epidemiologia--INHEM) and new centres in the Central (Santa Clara) and Eastern (Santiago) regions of the country. SETTING: Cuba. INTERVENTION: In the mid-1990s, a comprehensive curriculum (masters and diploma programs) was collaboratively developed, applying interactive teaching methods, and was delivered through a series of workshops and other interactions in Cuba, and short-term visits to Canada by Cuban PhD students. OUTCOMES: The collaboration was successful in fulfilling capacity-building targets (over 50 Masters graduates, 467 Diploma graduates, over 30 trained core faculty in all regional centres as well as new curriculum and new accredited regional programs). Alongside this, a number of collaborative community-based research projects were undertaken in all three regions (drinking water in Santiago; housing and urban renewal, and dengue control in Havana; and tourism-related effects, and effective intersectoral management of population health determinants in Santa Clara). CONCLUSION: The collaboration led to adopting new strategies for challenges such as a dengue epidemic in 2002, and new research on the effectiveness of intersectoral management of risks of particular interest to both Cuban and Canadian policy-makers. It triggered an ambitious collaboration between the Canadian-Cuban team and colleagues in Ecuador in order to build a similar national network there, built on South-South and North-South links.

Use of medical counseling for the prevention and control of smoking in the municipality of old Havana.

Physicians have an important responsibility for addressing smoking cessation and prevention with their patients. The objective of this study was to describe the use of physician counseling for the prevention and control of smoking and to predict its use according to physician characteristics. A cross-sectional survey of a random sample of 121 family physicians in one municipality of the city of Havana was used to address sociodemographic factors, years of practice in the community, smoking status, use of physician counseling in daily practice (ask, advise, and assist), and the role of physician counseling as an intervention. Summary statistics were used as well as canonical and discriminant analyses. The prevalence of smoking among the physicians was 18%. The smoking status of patients was determined "almost always" by 32% of doctors. Twenty-five percent asked their patients whether they intended to stop smoking; 35% recommended smoking cessation; and 38% gave advice on how to achieve this. More than half (58%) explored factors that might influence cessation in their patients, and 12% reported doing this "frequently." Physician characteristics were associated significantly with preventive behavior, with community involvement, and with the perceived value of physician counseling and smoking status. Physician responses were associated with actual practice in 82% of the cases. Predisposing, facilitating, and reinforcing factors for preventive behavior were strong determinants of active involvement by physicians in daily practice. Training of health professionals must include smoking cessation.

Estado nutricional de la población cubana adulta / No disponible

Fundamentos: El sobrepeso y la obesidad constituyen enla actualidad un importante problema de salud pública.En el marco de la Segunda Encuesta Nacional sobre Factoresde Riesgo y Afecciones Crónicas no Transmisiblesde la Población Cubana se llevó a cabo la evaluaciónnutricional mediante indicadores antropométricos.Métodos: Se usó un diseño muestral estratificado y porconglomerados polietápicos. Se encuestaron 22851 individuosde 15 años y más, a los efectos del presenteestudio solo se analiza la población mayor de 19 años.Se realizaron las mediciones del peso, estatura, circunferenciasde cintura y cadera y se calculó el índice de masacorporal y el índice cintura/cadera, la circunferencia dela cintura se utilizó para evaluar el riesgo de obesidadasociado con complicaciones metabólicas. Se presentanlas estimaciones puntuales y por intervalos con unaconfiabilidad del 95%Resultados: El 29,7% de los hombres y el 31,5% de lasmujeres presentan sobrepeso mientras que el 7,95% delos hombres y el 15,4% de las mujeres presentan obesidad,En relación con la distribución de la grasa corporal,aproximadamente la cuarta parte de la población presentaun patrón de adiposidad superior lo que indica unriesgo de asociación con algunas enfermedades crónicas.La distribución de la grasa centralmente incrementadaes más frecuente en aquellos individuos de menor nivelde instrucciónConclusiones: La prevalencia de sobrepeso y obesidadencontradas en el presente estudio muestra la magnituddel problema desde el punto de vista de la salud pública.Los resultados indican una disparidad por sexos

Introduction: Overweight and obesity are an importantpublic health issue. As a part of the Second NationalSurvey about risk factors and non-communicable diseaseswe carried out the nutrition assessment using anthropometricindicators.Methods: The analyses use cross-sectional data from anationally representative survey. A total of 22851 subjectsfrom more than 19 years of age were included. Subjectswere measured in the doctor's office by a trained assistant.Weight, height, hips and waist circunference weremeasured. The waist-hip ratio and body mass index werecalculated and were used to assess the risk of obesityassociated to metabolic problems. Estimates and 95%confident intervals are presented.Results: Overweight was present in 29.7% of men and31.5% of women while the prevalence of obesity was7.95% in men and 15.4% in women. In relation to fatdistribution, approximately 25% of the population hasupper fat body segment obesity. Central fat pattern wasmore frequent among low educated people.Conclusions: Based on the analyses presented, it isconcluded that overweight and obesity are a seriousproblem in the country. Results indicated disparity by sex

Shifting the demand for emergency care in Cuba's health system.

Cuba has developed a programme of quality improvement of its health services, which includes an extramural emergency care system in which polyclinics and general practitioner networks play an important role. Using routine health information from the decentralised first line emergency units (FLES) and from the hospital emergency service (HES) for the period 1995-2000, we evaluated the effects of the emergency care subsystem reform on the utilisation rates of first line and hospital services in Baracoa and Cerro, a rural and a metropolitan municipality, respectively. In the self-contained health system of Baracoa, the reform of the emergency subsystem resulted in a first phase of increased utilisation of the FLES, followed by a second phase of gradual decrease, during which there was an increased utilisation of general practitioners. In contrast, the overall results of the reform in Cerro were unclear. The proximity to a hospital seems to be the most important element in the patient's decision on which entry point to the Cerro health system to use. A potential adverse effect of the reform is an increased emergency services utilisation in situations where GP care remains below patients' expectations. Given the current world-wide trends in health-care reform, the organisational alternatives developed in the Cuban health system might remain specific to the local contextual setting.