The chronic disease passport: an assessment of its effectiveness in improving hypertension control in Jamaicans

OBJECTIVE: To assess whether the Chronic Disease Passport (CDP) was effective in improving blood pressure control in patients in Montego Bay, Jamaica. DESIGN AND METHODS: A retrospective cohort study was conducted on a convenient sample of 264 patients aged 18-74 years with hypertension (HPT) who attended the Type 5 Health Centre in Montego Bay between May and July 2014. Blood pressure control was assessed at baseline and one year post exposure, using data from medical records. Knowledge, attitude and behaviour towards HPT and the CDP were gathered through an interviewer-administered questionnaire. In-depth semi-structured interviews were conducted with 6 persons who had received the CDP. RESULTS: Seventy-seven percent of respondents (n=204) were exposed to the CDP. At baseline HPT control was significantly better in the exposed group (20.7%), versus the non-exposed group (5.0%) (p<0.01). At the one year follow-up endpoint, there was no significant association between exposure to the CDP and HPT control with the relative risk of having a controlled SBP being significantly lower in the exposed group (RR = 0.44, 95% CI: 0.24, 0.81). Control of HPT among the exposed group also worsened by 17.3% (p<0.001), but remained unchanged for the non-exposed group. Participants cited medication supply as an issue of concern. CONCLUSION: Exposure to the CDP was not associated with better control of HPT. More research is needed to explore other impacting factors, including issues surrounding medication supply.

Non-communicable disease (NCD) risk factor survey 2014 among staff at one workplace in Barbados

OBJECTIVE: To investigate the prevalence of NCD risk factors at a specified workplace in Barbados. DESIGN AND METHODS: An interviewer administered questionnaire comprised of Core and some “Expanded” questions from the validated PAHO/WHO STEPS NCD Risk Factor Survey was conducted over a three-week period in June 2014 at a specified workplace. Standardized measurements were taken for height, weight, blood pressure, and hip and waist circumference. RESULTS: There was a 57.8% (70/121) response rate; 37.1% male and 62.9% female, with a mean age of 31.7 years (SD 8.0), age range 19 – 54. It was found that 95.7% of respondent staff had at least one of the identified risk factors; 76.9% of males and 54.5% of females were either overweight or obese. Most of the staff (91.4%) ate less than 5 servings of fruit and/or vegetables on average per day (88.5% males, 93.2% females). Comparison of study population with the Barbados population shows close correlations for most of the risk factors with some exceptions like binge drinking. Almost half of respondents (44.7%) (60.9% males, 29.2% females) engaged in binge drinking when compared to 25.3% and 5.4% in Barbadian males and females respectively in 2013. CONCLUSIONS: The study confirms a similar high prevalence of NCD risk factors among staff as observed among the Barbadian population. The study reveals opportunities to increase workplace health promotion and evidence-based national standards for the management of major NCDs through a primary care approach.

Non-communicable diseases risk factors survey 2014 among University of the West Indies staff, St. Augustine Campus, Trinidad & Tobago

OBJECTIVE: To determine the prevalence of NCD risk factors among University of the West Indies staff in Trinidad and Tobago. To compare these results with the country’s 2011 NCD risk factor survey. DESIGN AND METHODS: A cross sectional prevalence survey utilizing a self-administered questionnaire conducted during April-May 2014. The target population was all staff. Standardized measurements of cardiovascular fitness, weight, height and blood pressure were taken. Data was analyzed and results were compared to the national 2011 NCD survey. RESULTS: Participation was 24.9% (522/2100), 32.4% males (n=169) and 67.6% females (n=353). Among participants, 65.7% (95% CI 58.4, 72.9) of males and 64.7% (95% CI 59.6, 69.7) of females were either overweight or obese, 86.9% (95% CI 83.9, 90.0) ate <5 fruits and vegetables/day. Smoking prevalence was 13.1% (95% CI 7.9, 18.2) and 2.8% (95% CI 1.1, 4.6) for among males vs. females respectively while 39.1% and 7.6% were binge drinkers; One fifth of the participants had blood pressures >140/90, while 6.4% had blood pressures >160/100. The results were similar to the 2011 national risk factor profile. UWI staff smoked less but drank alcohol more frequently. UWI males were more obese and UWI women had higher blood pressure and higher cholesterol compared to the general Trinidad and Tobago population. CONCLUSION: The results confirmed a high prevalence of NCD risk factors among these staff as among the Trinidad and Tobago population. The study revealed opportunities to inform policy on strategies to positively impact the risk factors.

The prevalence of depression and the quality of life in hemodialysis patients and patients with chronic medical illnesses (CMIs) in the Bahamas

OBJECTIVE: To determine the prevalence of depression and the quality of life in hemodialysis patients and patients with chronic medical illnesses (CMIs) in the Bahamas. DESIGN AND METHODS: This study used a cross-sectional design with consecutive sampling. Data about sociodemographic characteristics, depression, and quality of life were collected using a sociodemographic questionnaire, the Beck Depression Inventory BDI-II, and the Short Form36 (SF 36) respectively. Data were analyzed using the Statistical Package for Social Sciences (SPSS). RESULT: 305 individuals (CMI: 106; Dialysis: 199) participated, 22 refused; 50.2% were males, 49.8% were female; mean age was 53.44 (ñ14.44); 45.9% were married; and 32.8% were unemployed for more than 2 years. The prevalence of depression was 43.7% for dialysis patients and 36.8% for CMI patients. Age of patients was associated with marital status, occupational status, ethnicity, and educational level. Hemodialysis patients were shown to have a lower quality of life than CMI patients. Linear regression analysis found that eight quality of life items were statistically significant predictor factors of the Beck score for the CMI and dialysis groups, and accounted for 45.5% of the variance. CONCLUSION: Although, these results did not necessarily demonstrate causality, patients receiving hemodialysis were as likely to be depressed as patients with chronic medical illness. Having to be on hemodialysis detracts significantly from patients’ quality of life.

National Strategic and Action Plan for the Prevention and Control of Non-Communicable Diseases (NCDS) in Jamaica 2013-2018

The document looks at strategic plan and action for the prevention and control of non-communicable diseases in Jamaica for the period 2013-2018. It gives an overview of non-communicable diseases - terminology, definitions and mechanisms; situation analysis; epidemiology; Jamaica's response to the non-communicable diseases programmes and progress; strategic plan and objectives; monitoring and evaluation, budgetary consideration and contingency actions.

Reforming primary medical care in our Caribbean communities, part 1: continuity of care and the healing interpersonal relationship. A position paper of the Caribbean College of Family Physicians

This brief paper highlights the demographic transition to CNCD, the poor success of our present model of care for CNCD and advocates for a re-focusing of our community medical services to provide through regional policy a focus on improved interpersonal continuity of care.

What proportion of hypertensive diabetics at Macoya Health Centre are achieving the JNC VII recommended blood target 130/80 mmHg?

INTRODUCTION :Despite widespread dissemination of guidelines advocating tight control, many patients with diabetes continue to have uncontrolled hypertension. We set out to determine what percentage of diabetics are achieving the target blood pressure of <130/80 at The Macoya Health Centre. METHOD: The standard criteria for this audit was adopted from the American Diabetes Association with some modifications according to the most updated evidence- based clinical guideline. JNCVII. From the period July 22nd to August 26th, 2010, all patients, records in the chronic disease clinic were examined. Inclusion criteria included: Diabetic patients with hypertension included in the nurses' diabetic register, patients' records without target organ damage must show that their blood pressure was recorded at least two different occasion before the drug therapy was commenced and patients' records show that the assessments for control of blood pressure were done within 3 consultations after diagnosis with hypertension. RESULTS: of the 342 records examined, 209 were found to be both diabetic and hypertensive. 199 were eventually selected for data analysis with 10 rejected since they did not fulfill the inclusion criteria. the average age of patients was 62.7 years. the were 87 female patients and 112 male patients. A total of 75 (37.7%) of all diabetics achieved this ideal control of 130/80mmHg. this made up 44 (39%) males and 31 (35.6%) females. Discussion: The NHS Diabetics Audit for 2007-2008 showed that only 30% of the people who had their blood pressure checked during the audit period achieved the desired target blood pressure. Standards of Hypertension care for diabetics patients at the Macoya Health Centre are definitely not optimal although they are as good as those reported by other audits. However with implementation of audit recommendations and greater awareness of physicians this can improve .....

Implications of the Central America-Dominican Republic-Free Trade Agreement for the nutrition transition in Central America

OBJECTIVES: To identify potential impacts of the Central America-Dominican Republic-Free Trade Agreement (CAFTA-DR) on food consumption patterns associated with the nutrition transition, obesity, and diet-related chronic diseases. METHODS: Examination of CAFTA-DR agreement to identify measures that have the potential to affect food availability and retail prices. RESULTS: CAFTA-DR includes agreements on tariffs, tariff-rate quotas (TRQs), and sanitary and phytosanitary regulations with direct implications for the availability and prices of various foods. Agreements on investment, services, and intellectual property rights (IPR) are also relevant because they create a business climate more conducive to long-term investment by the transnational food industry. Trade liberalization under CAFTA-DR is likely to increase availability and lower relative prices of two food groups associated with the nutrition transition: meat and processed foods. These outcomes are expected to occur as the direct result of increased imports from the United States and increased production by U.S. companies based in Central America, and the indirect result of increased domestic meat production (due to increased availability of cheaper animal feed) and increased production of processed foods by domestic companies (due to a more competitive market environment). CONCLUSIONS: CAFTA-DR is likely to further the nutrition transition in Central America by increasing the consumption of meat; highly processed foods; and new, non-traditional foods. The public health community should be more aware of the implications of trade agreements for dietary health. Governments and related stakeholders should assess the coherence between changes fostered by specific trade agreements with national policies on diet and nutrition.

Eumycetoma

Eumycetoma is a localized, chronic fungal infection of skin and subcutaneous tissues. It is characterized by tumefaction, abscess formation, draining sinuses, and sclerotia (grains) within the abscesses and fistulae. Treatment of eumycetoma is a challenge. Relapse rates are high even when a combination of surgical and medical approaches is utilized. Here we report a case of eumycetoma due to Exophiala jeanselmei arising on the foot of a man from Trinidad, West Indies.

Enfermedades cronicas y limitacion funcional en adultos mayores: estudio comparitivo en siete ciudades de America Latina y el Caribe / Chronic diseases and functional limitation in older adults: a comparative study in seven cities of Latin America and the Caribbean

OBJECTIVE. To identify the relationship between selected chronic diseases and the presence of disability in inhabitants 60 years old or older in seven cities of Latin America and the Caribbean. METHODS. In 2000 and 2001 a descriptive cross-sectional study was conducted with a sample of 10 891 persons 60 or older in seven cities: Bridgetown, Barbados; Buenos Aires, Argentina; Havana, Cuba; Mexico City, Mexico; Montevideo, Uruguay; Santiago, Chile; and Sao Paulo, Brazil. This research was part of the Salud, Bienstar y Envejecimiento (Health , Well-Being, and Aging) project (known as the "SABE project"). The dependent variables in the study were difficulty in performing basic activities of daily living, and difficulty in performing instrumental activities of daily living. Compiled from self-reports, the independent variables were : age, sex, educational level, living alone or with other person (s), self-assesed health, and the presence or not of hypertension, diabetes mellitus, cancer, chronic obstructive pilmonary disease, ischemic heart disease, cerebrovascular diseases, and osteoarthritis. The presence of depression and cognitive impairment in the participants was evaluated, and body mass index was also calculated. To compare the degree of influence of the different variables on disability, a standardized coefficient for each association was calculated. RESULTS. In the seven cities studied, the variables that showed a direct association with difficulty in carrying out basic activities of daily living and instrumental activities of daily living were: suffering from a higher number of noncommunicable diseases, from cerebrovascular diseases, from osteoarthritis, or from depression; being older; being female; rating one's own health as bad, and the presence of cerebrovascular diseases, osteoarthritis, or cognitive impairment. CONCLUSIONS. Our research provides the first systematized description of the associations between disability and chronic noncommunicable diseases in older adults in Latin America and the Caribbean. Difficulties that older adults have in carrying out instrumental activities of daily living are the first ones to appear. Therefore, follow-up mechanisms should be established that make possible the early detection of this disability (AU)

Chronic diseases - facing a public health challenge

Middle income countries like those in the Caribbean can feel proud of their achievements in health care. There has been a dramatic fall-off in infant mortality and crude mortality rates along with significant improvements in life expectancy at birth. However, these countries now find themselves grappling with the burden of chronic non-communicable diseases such as heart disease, stroke, hypertension, diabetes mellitus and cancer. There are good data to support the view that some of these diseases, in particular diabetes mellitus, have assumed epidemic proportions and there is concern that this fact may have been missed by many because of the surreptitious onset, as is the nature of the chronic diseases. The impact of this epidemic may have suffered because of the higher profile of more tropical issues like HIV/AIDS even though the former makes a larger contribution to morbidity and mortality statistics. It is now obvious that despite the impact of other factors, lifestyles changes are the major contributors to the epidemic. In populations of similar genetic stock, living in significantly different socio-economic circumstances, the impact of increased dietary salt, increasing obesity and decreased physical activity on the prevalence of hypertension, diabetes mellitus and lipid disorders is unequivocal. Data from the developed world, which has already been through this epidemic of chronic diseases, have shown that increasing technological advances in medical care is an efficient way to respond to the situation. A multi-sectoral approach is required to tackle this epidemic, including the provision of incentives for healthy eating and widespread opportunities for increased exercise and other physical activities. Continued research into the evolution of the epidemic, including reliable estimates via surveillance methods is a necessary component of our response. The problems and the solutions are not only the responsibilities of the health officials but must involve education, agriculture and other sectors of the economy. (AU)

Caring for the chronically III 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-laws were the main caregivers. Daughters-in-laws were especially instrumental in providing informal care in Indo-Trinidadians households, being 28 percent of caregivers in those households compared to 4 percent 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 percent), diabetes mellitus (9 percent) and arthritis (18 percent). The main concern which the caregivers reported was stress (50 percent). The study revealed that caregiving was perceived by mot 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 make reference to a government programme which trains young adults to work with the chronically ill elderly, in their own home. It make a case for the greater use of such young persons in order to relieve relatives of some of the burden of care.(Au)

Chronic disease control and compliance - the HOPE worldwide Jamaica experience

HOPE worldwide Jamaica has provided mobile curative and preventative services to fourteen rural government clinics since 1994. The patients records of 1,091 chronic disease patients, aged>30 years between January and December 1999 were reviewed. They were all above 30 years of age with an average age of 64 years; 81 percent were female and 60 percent were hypertensive, 16 percent diabetic and 24 percent had both diabetes and hypertension. There were 2,390 visits for hypertension, with an average of 2 visits per patient. Thirty-four per cent of patients had BP of < 140/90 mmHg while 43 percent had BP < 160/95 mmHg. Compliance was defined as daily consistency in taking prescribed medication. Forty-four per cent of hypertensive were non-compliant at the time of their visit. Anti-hypertensive treatment included thiazide diuretics (65 percent), reserpine (50 percent), ACE inhibitors (30 percent) and methyldopa (5 percent). There were 1,129 visits for diabetes, with an average of 2 visits for diabetes, with an average of 2 visits per patient. Twenty-four per cent of diabetic patients were controlled to fasting blood glucose FBG levels of <6.7 mmol/l and 38 percent controlled to (FBG) levels <8 mmol/l. Thirty per cent of diabetics were non-complaint at the time of their visit. The most frequently used oral hypoglycaemic agents were metformin (78 percent), glyburide (43 percent) and chlorpropamide (30 percent). Fourteen per cent of diabetics were on treatment with insulin 70/30 (12 percent) and lente insulin (2 percent). Electrocardiograms (ECG) were done on 24 percent (n=267) of patients in the previous two years. Thirty-six percent had evidence of left ventricular hypertrophy and 15 percent had evidence of ischaemic heart disease. The level of blood pressure and blood glucose control is inadequate, despite the provision of regular monitoring, surveillance and improved access to pharmaceuticals. It is perceived that poor socioeconomic conditions, lack of education, cultural beliefs, in addition to other factors, continue to militate against improved compliance and control.(Au)

Morbidity pattern of emergency room patients in Jamaica

OBJECTIVE: This study documents the morbidity pattern of diseases in patients presenting to the Accident and Emergency (A&E) Unit at the University Hospital of the West Indies in Jamaica. DESIGN and METHODS: Data were retrieved from a log book kept by the nursing staff in the A&E Unit at the UHWI. This SPSS software package was used to select 100 random days in 1997. All cases treated in the A&E Unit on those days were included in the study. Data collected included demographic data, discharge diagnosis and disposal. Diagnosis were coded and classified using the International Classification of Diseases - 9th edition coding system. RESULTS: In 1997, 16,798 patients were treated in the A&E Unit during the 100 random days selected, 4611 of these were seen. Twelve cases were excluded, as the diagnoses were unknown. Some patient had more than one diagnosis and therefore, 4762 diagnoses were made in 4599 patients. The mean age was 34ñ 24 (SD) years. The male to female ratio was 1.8:1. Injuries and poisoning accounted for 31 per cent of cases. Respiratory diseases were the next most prevalent (16.2 percent). Cardiovascular and digestive diseases accounted for 5.8 and 10.5 per cent of cases, respectively. Infectious diseases accounted for only 1.75 per cent of cases; 71.7 per cent of patients were discharged home, 23.5 per cent admitted and 4.2 per cent transferred to another institution. The mortality rate was 0.6 per cent. CONCLUSIONS: The pattern of diseases seen in this study demonstrates epidemiologic transition where injuries, cardiovascular and other chronic diseases are evolving as the most prevalent conditions seen. This is now seen frequently in the Caribbean and other developing countries. (Au)

Disseminated histoplasmosis detected by lingual and tonsillar erosions in an immunocompetent patient

BACKGROUND: Histioplasmosis is a usually asymptomatic fungal infection. In the immunocompetent patient, it leads to chronic disseminated infection. Mucosal involvement is common and can provide the diagnosis. CASE REPORT: A metropolitan Frenchman with a history of alcoholism and smoking and living in Guyana consulted for lingual and tonsil erosion. Squamous cell carcinoma was suspected but not confirmed at pathology. The patient had bi-apical infiltration on the chest x-ray and was treated empirically for tuberculosis. The diagnosis of histoplasmosis was reached when rare Histoplasma capsulatum were evidenced from a buccal swab. Itraconazole led to cure in 6 months. DISCUSSION: This case illustrates the importance of mucosal signs in the diagnosis of disseminated histoplasmosis in immunocompetent subjects. Histoplasmosis is rarely the cause of active infection in immunocompetent subjects. In these patients, the fungal infection generally progresses to chronic dissemination. Mucosal signs are frequent in this from but are rare in the case of cutaneous histoplasmosis. Itraconazole (200 mg/d) is indicated for 6 months. (AU)

Drug use, sexual behaviour and HIV risk of the homeless in Port-of-Spain, Trinidad

Data were collected from 88 homeless persons in Port-of-Spain, Trinidad to assess HIV risk. 68 percent of the sample were engaging in unprotected sex with multiple partners, 25 percent were exchanging sex for money, and 29.5 percent were regularly smoking crack cocaine. Many had two or more of these behaviours that put them at high risk of HIV infection. Females were significantly more likely to be sex traders, to engage in bisexual behaviour and to have a history of psychiatric illness. The relationship between psychiatric illness and HIV risk behaviours among homeless female persons is explored. Educational interventions are suggested to reduce the public health risks in this population.(AU)