Correlates of bone mineral density among postmenopausal women of African Caribbean ancestry: Tobago women's health study

Population dynamics predict a drastic growth in the number of older minority women, and resultant increases in the number of fractures. Low bone mineral density (BMD) is an important risk factor for fracture. Many studies have identified the lifestyle and health-related factors that correlate with BMD in Whites. Few studies have focused on non-Whites. The objective of the current analyses is to examine the lifestyle, anthropometric and health-related factors that are correlated with BMD in a population based cohort of Caribbean women of West African ancestry. We enrolled 340 postmenopausal women residing on the Caribbean Island of Tobago. Participants completed a questionnaire and had anthropometric measures taken. Hip BMD was measured by DXA. We estimated volumetric BMD by calculating bone mineral apparent density (BMAD). BMD was >10% and >25% higher across all age groups in Tobagonian women compared to US non-Hispanic Black and White women, respectively. In multiple linear regression models, 35-36% of the variability in femoral neck and total hip BMD respectively was predicted. Each 16-kg (one standard deviation (SD)) increase in weight was associated with 5% higher BMD; and weight explained over 10% of the variability of BMD. Each 8-year (1 SD) increase in age was associated with 5% lower BMD. Current use of both thiazide diuretics and oral hypoglycemic medication were associated with 4-5% higher BMD. For femoral neck BMAD, 26% of the variability was explained by a multiple linear regression model. Current statin use was associated with 5% higher BMAD and a history of breast feeding or coronary heart disease was associated with 1-1.5% of higher BMAD. In conclusion, African Caribbean women have the highest BMD on a population level reported to date for women. This may reflect low European admixture. Correlates of BMD among Caribbean women of West African ancestry were similar to those reported for U.S. Black and White women.

Obstetric care and severe pregnancy complications in Latin America and the Caribbean: an analysis of information from demographic health surveys

OBJECTIVE: To compile, consolidate, and analyze information obtained in surveys conducted by the MEASURE DHS [Demographic and Health Surveys] program, concerning obstetric care and pregnancy complications for women in Latin America and the Caribbean, in the five years before the survey. METHODS: This exploratory study utilized data from demographic surveys carried out in the 1990s in seven countries of Latin America: Bolivia, Brazil, Colombia, the Dominican Republic, Guatemala, Nicaragua and Peru. The study describes the characteristics of the women who were interviewed and of the obstetric care that they received in the five years before the respective survey, and it also estimates the occurance of prolonged labor and of hemorrhagic, hypertensive, and infectious complications in those five years. RESULTS: The median number of prenatal consultations ranged from 4.7 in Bolivia to 6.6 in the Dominican Republic. More than 40 percent of deliveries in Guatemala, Peru, and Bolivia were attended by traditional midwives, relatives, or other persons without formal training. The highest rates of deliveries performed in health care facilities (>90 percent) were in the Dominican Republic and Brazil. In Guatemala, Peru, and Bolivia more than 45 percent of deliveries were at home. The highest rate of cesarean delivery was in Brazil (36.4 percent), and the lowest rates (<12 percent) were in Peru and Guatemala. The rate of pregnancy complications reported by the women surveyed was 16.7 percent in Brazil, 17.9 percent in Guatemala, 42.1 percent in Colombia, 42.5 percent in Nicaragua, 43.0 percent in the Dominican Republic, 51.7 percent in Bolivia, and 51.8 percent in Peru. CONCLUSION: The reported occurance of severe pregnancy complications in the surveys we examined was well above the 15 percent rate reported in other scientific literature, suggesting that these complications may have been overestimated in the MEASURE DHS surveys. Prior validation of the questionnaires used for data collection is extremely important in the generation of high-quality data (AU)

Using household surveys and other information sources to study health equity in Latin America and the Caribbean

There are many types of household surveys. The discussion that follows will focus on what is know as "general-purpose household surveys." Such surveys were devised to study household expenditures (and/or income), job and occupational conditions, education of the members of the household (both highest level of attainment and current enrollment), conditions of the dwelling, and access to and utilization of services, including health services. The surveys usually also include a few questions on self-assesment of health status and the presence of health problems. Some of the surveys also include modules for special population groups such as children and women of reproductive age. The modules may cover such topics as immunizations, prevalence of diarrhea, upper respiratory tract illnesses in children, complete birth histories for women, and women's use of contraceptive methods. While they almost never have information on expenditures or income, they do include data about conditions of the dwelling, education, crowding, and other characteristics. These data allow some limited analyses of the relationships that health-seeking behaviors, health outcomes, and access to and utilization of some types of health care services have some aspects of the social and economic determinants of inequalities (AU)

Measuring and analyzing activities of daily living and quality of life in community elderly residents [abstract]

The rapid growth of the elderly population as well as the ongoing change in family structure is of public health concern in Japan. Before one can attempt to solve the problem of providing support to the elderly community residents, some assessment of their health status must be undertaken. We measured the activities of daily living (ADL), quality of life (QOL) and SF-36 score of about 716 elderly residents aged 65 years and over by interviewing them at home. The items of our survey included ADL, QOL (PGC), SF-36 scores, the elderly health-awareness, attitude, daily activities and other related subjects. Comparisons were then conducted in regard to the scores on the individual subscales of the SF-36 of residents with each of the diseases and the national-norm scores for Japan. ADL of the people who responded, "go out very often", was 99.9, followed by 98.6 for "occasionally", 87.4 for "seldom". ADL of the people who responded, "able to do shopping for daily necessities", was 99.7 while for "unable" it was 81.1. QOL of the people who resonded that their health status was "excellent" was 98.6, followed by 12.7 for "very good", 11.4 for "good", 8.3 for "not very good" and 7.1 for "not good". About the differences in SF-36 scores standardized with the national-normscores for Japan, only "role limitations due to physical problems" was -0.17 in males; "role limitations due to physical problems" was-0.19, "pain" was -0.10, and "mental health" was -0.01 in females. The survey revealed the prevalence of poor health among those ADL (QOL) showing 8090 (78). From this it may be concluded that ADL, QOL and SF-36 scores are very useful indices for us to rate the elderly patients' health status level, thus enabling us to consider what support is required by them. (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)

Factors associated with having general medical "check ups" in a Caribbean country

OBJECTIVES: To determine the extent to which general `check ups' were sought by adult Jamaicans and to identify the demographic and health factors that would characterise individuals who utilized this service. DESIGN and METHODS: A national survey was conducted comprising Jamaicans age 15-50 years. Subjects were selected using a random sampling technique and respondents were interviewed using a structured questionnaire that included a number of demographic, health and behaviour variables. Multiple regression analyses were used to identify the independent predictors of having general 'check-ups'. RESULTS: Of the 3001 persons identified for study, 2580 persons were interviewed (86 percent). Nine hundred and twenty-six (926) (35.9 percent; 95 percent C1, 34.1-37.8 percent) persons said that they had general medical `check -ups. Of those who had check-ups, 33 percent had them at least once every 6 months, 34 percent every year and 33 percent less frequently. The independent predictors of having a check-up were being well educated (p<0.001, maried (p,0.001), more religious (p<0.001), female gender (p=0.001), being satisfied with life (p=0.009) and over 20 years of age (p=0.03). CONCLUSIONS: Having general medical `check-ups' was not an uncommon behaviour in this sample. More research is needed to further characterize and understand this phenomenon since this could be a route for improved preventive medicine and health education. (Au)

Adolescents' access to health care and the constraints they face in acquiring good health

In this study adolescents' access to health care is analyzed, based on a survey done in two secondary schools. Two hundred adolescents 14 -19 years old were selected. A pretest and a focus group were used in the formulation of a quantitative and qualitative questionnaire. Questions were identified by number in order to maintain confidentiality. Data were collected over a 2 week period, and analyzed manually by a prepared coding system and by using the computer program SPSS. Results showed that adolescents' main health problems were preventable, mostly stress and tension related. The health services available were utilized. Seventy eight point five percent of respondents accessed the private services, and 61.0 percent of the sample had health insurance. Access to contraceptive source was over the counter (65.0 percent), from pharmacies (53.0 percent), from medical sources and 12.0 percent from supermarkets. Adolescents utilized health services for general health problems, but accessed services for sensitive areas such as contraceptives from an additional source. The study has demonstrated that adolescents' access is constrained when relating to reproductive health.(Au)

A 4-year evaluation of blood pressure management in Trinidad and Tobago

This paper reports a 4-year evaluation of government primary care services in Trinidad and Tobago. The sample included 16 primary care health centres in Trinidad and Tobago with cross-sectional surveys of adult attenders in 1994 and 1998. Data were obtained from clinic records including details of processes of care, drug utilisation and blood pressure (BP) control. Intervention following the initial survey was by means of reports to the Ministry of Health and annual training workshops for medical officers. Data were analyzed for 1759 adult attenders at study clinics (981 in 1994 and 778 in 1998). Most attenders had blood pressure recorded (96 percent in 1994 and 98 percent in 1998). Among 1176 subjects with hypertension (BP > or = 160/95 mm Hg or treated with drugs) the proportion with dietary advice ever recorded increased from .139/662 (21 percent) in 1994 to 185/514 (36 percent) in 1998, and recording of exercise advice increased from 36 (5 percent) in 1994 to 99 (19 percent) in 1998. Among subjects treated with drugs, use of Brinerdin decreased from 191/625 (31 percent) in 1994 to 29/486 (6 percent) in 1998, while use of diuretics, beta-blockers, calcium antagonists and ACE inhibitors increased. The proportion of patients with blood pressure adequately controlled (<160/95 mm Hg) was 338 (51 percent) in 1994 and 297 (58 percent) in 1998 (odds ratio 1.39, 95 percent confidence interval 0.96 to 2.00). An audit study used to inform health care policy, staff training and clinical practice may contribute to improving processes of hypertension management in a middle-income country like Trinidad and Tobago.(Au)

Nutrition, anaemia, geohelminth infection and school achievement in rural Jamaican primary school children

OBJECTIVE: To determine whether nutritional status, anaemia and geohelminth infections were related to school achievement and attendance in Jamaican children. DESIGN: A cross-sectional study using a randomly selected sample. SUBJECTS: Eight hundred children aged 9-13 years randomly selected from those enrolled in grade 5 in 16 primary schools in rural Jamaica. RESULTS: The mean height for age of the children was -0.37 z-score +/-1.0 s.d. with 4.9 percent having the heights for age < -2 s.d. of the NCHS references. Anaemia (Hb < 11 g/dl) was present in 14.7 percent of the children, 38.3 percent were infected with Trichuris trichiura and 19.4 percent with Ascaris lumbricoides. Achievement levels on the Wide Range Achievement Test were low, with children performing at grade 3 level. In multilevel analyses, controlling for socioeconomic status, children with Trichuris infections had lower achievement levels than uninfected children in spelling, reading and arithmetic (P < 0.05). Children with Ascaris infections had lower scores in spelling and reading (P < 0.05) Height for age (P < 0.01) was positively associated with performance in arithmetic. Ascaris infection (P < 0.001) and anaemia (P < 0.01) predicted poorer school attendance. CONCLUSION: Despite mild levels, undernutrition and geohelminth infections were associated with achievement, suggesting that efforts to increase school achievement levels in developing countries should include strategies to improve the health and nutritional status of children(AU)

Distribution of intraocular pressure: the Barbados Eye Study

OBJECTIVE: To provide data on the distribution of intraocular pressure (IDP) in a predominantly black population, which has a high prevalence of open-angle glaucoma. DESIGN: Population-based prevalence study. SETTING AND PARTICIPANTS: Participants (N = 4601) (age range, 40-84 years) who had undergone applanation tonometry measurements in the Barbados Eye Study. Self-reported race was 93 percent black, 4 percent mixed (black and white), and 3 percent white or other. DATA COLLECTION: A standardized protocol included applanation tonometry and other ocular measurements, fundus photography, demographic data, and an interview. MAIN OUTCOME MEASURES: The average of 3 IDP measurements at the Barbados Eye Study visit was used to compare IDP by self-reported race. Descriptive data on IDP by age, sex, glaucoma status, and cup-disc ratio were examined in the black population. RESULTS: The IDP was highest in the population of African origin. The mean (+/-SD) IDP values for black, mixed, and white participants were 18.7 +/- 5.2, 18.2 +/-3.8, and 16.5 +/- 3.0 mm Hg, respectively. An IDP greater than 21 mm Hg was present in 18.4 percent, 13.6 percent and 4.6 percent of the black, mixed and white participants, respectively. In analyses that were adjusted for age, sex, and glaucoma status, such values were 5 times as likely in black than white participants and 3.5 times as likely in mixed race participants (p < .01). Among the black participants, the mean IDP increased approximately 1 mm Hg for every increase in 10 years of age. After excluding persons with any type of glaucoma, suspected glaucoma, or a history of glaucoma treatment, women had significantly (P < .01) higher IDP values; however, no significant IDP trends by sex were evident in the group with glaucoma. The IDP was also positively associated (P < .05) with vertical cup-disc ratios. After 2 visits, the IDP remained 21 mm Hg or less in 21 percent of the persons with glaucoma vs 64 percent of those without glaucoma. CONCLUSIONS: In the black participants, the IDP was higher than in the white participants. The IDP was also associated with age and cup-disc ratios. The results showed that open-angle glaucoma and a high IDP alone have a different distribution by sex; although open-angle glaucoma was more frequent in men, ocular hypertension was more frequent in women. These data have implications for the detection and causation of open-angle glaucoma in this high-risk population.(AU)

Factors associated with the initiation of breast-feeding in the Dominican Republic

The determinants of initiating breast-feeding vary among different populations, but knowledge of them is of fundamental importance for guiding programs to promote breast-feeding. Data from the Demographic and Health Survey of 1991 in the Dominican Republic were used to identify factors associated with the initiation of breast-feeding in a random sample of women of reproductive age. Approximately 93 percent of 2714 mothers reported having begun to breast-feed their live-born child who was currently under 5 years of age, and that percentage had not changed substantially in the past 5 years. A logistic regression analysis was done in which odds ratios were calculated as measures of association. Women who had suffered some type of illness during pregnancy (odds ratio = 2.3), those whose child had a low birth-weight (odds ratio = 2.9), primiparas (odds ratio = 1.9), and those with medium (odds ratio = 1.6) or high (odds ratio = 2.1) income levels showed a significantly higher risk of not starting to breast-feed. These women should be considered priority groups by breast-feeding promotion programs (AU)

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 4 to 7 week period identified 1661 attenders with diabetes mellitus, approximately two-thirds were women with a median age of over 60 years. Overall 676/1342 (50 percent) had 'poor' blood glucose control (> or + 8 mmol 1-1 fasting or > or = 10 mmol 1-1 random). The proportion with BP > or = 160/95 mmHg or receiving treatment for hypertension was 943/1661 (57 percent), of whom 781/943 (83 percent) were prescribed drug treatment. Among those treated for hypertension only 181/781 (23 percent) had blood pressures , 140/90 mmHg. Surveillance for complications affecting the feet (11 percent) or eyes (2 percent) was not performed systematically in any setting. Only 533 (32 percent) had recorded dietary advice and 79 95 percent) had recorded exercise advice in the last 12 months. To begin to address some of these problems at the 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 of diabetes care, and the most cost-effective means of addressing them (Au).

Morbidity from diabetes mellitus in Trinidad: identification of vulnerable groups

To evaluate health problems experienced by people with diabetes mellitus in Trinidad we conducted an interview survey of 622 randomly selected patients attending 17 government health centres. We enquired after typical symptoms of diabetes mellitus and combined the responses into a score which was used as the dependent variable in multiple regression analyses. Itching was reported by 215 (35 percent), polyuria 315 (51 percent), burning or numbness in the feet 350 (56 percent) history of foot ulcer 69 (11 percent) previous minor amputation 29 (5 percent), major amputation 10(2 percent), difficulty with eyesight 397 (64 percent), vision reduced to light perception only in both eyes 32 (5 percent). A past stroke was reported by 55 (9 percent), heart attack by 54 (9), and other heart trouble 103 (17 percent). Increasing burden of illness was associated with increasing age, Indo-Trinidadian ethnic background, environmental factors such as absence of piped water supply and social factors, e.g., not being employed in full-time work. Hyperglycaemic symptoms were more strongly associated with lower socio-economic status while foot and eye symptoms were associated with lower socio-economic status and increasing duration of diabetes. Cardiovascular disease was associated with increasing age and Indo-Trinidadian ethnic-origin. We concluded that people with diabetes mellitus in Trinidad experience high levels of symptoms and illness. The elderly, those with longer duration of disease, the unemployed and persons of Indo-Trinidadian ethnic background were more vulnerable to the above complications of diabetes mellitus (AU)

A health profile of Curacao: results from the Curacao health study - abstract

Based on the outcomes of the Curacao Health Study, a health profile of the adult non-institutionalized population of Curacao was drawn. A randomly drawn sample of 2248 participants has been surveyed in face-to-face interviews. Data were collected on the prevalence of chronic disorders and functional limitations, and on the subjects' self-perceived health. Of the total sample 58.8 percent reported to be suffering from one or more chronic disorders. The most prevalent chronic conditions are hypertension (14.5 percent), arthrosis and arthritis (11.1 percent), dizziness (10.85 percent), chronic back problems (10.1 percent) and psychological problems (9.6 percent). As regards functional limitations, 4.7 percent of the total sample have very serious visual disabilities and 1.4 percent are (practically) deaf; the prevalence of limitations in activities of daily living can be estimated at 0.3 to 2.8 percent, depending on the kind of activities that are taken as a criterion. A general conclusion is that women, the elderly and individuals from the lower socio-economic strata (SES) are relatively disadvantaged as regards health. The disadvantage for women and individuals from the lower SES applies to both their physical and their mental health. Ageing is soley related to a worsening of the physical health status. The subjective health perceptions of the participants are in accordance with their more objective health status; women, individuals from the lower SES and the elderly have a relatively poorer perceived health. The particular value of these profiles lies in their usefulness for the establishment of priority areas in health policy, by identifying relatively disadvantaged groups who need specific attention (AU)

Rise in prevalence of genital ulcers among STD clinic attenders in Jamaica: significance for HIV transmission - abstract

Two cross-sectional surveys were undertaken to estimate the prevalence of genital ulcer disease (GUD) in all clients presenting at the Comprehensive Health Centre in Kingston, Jamaica with a new STD complaint. The first survey done in 1983 involved 23,050 clients (men 11,948; women 11,102). The second survey in 1990 involved 1,001 clients (men 517; women 484). All clients were screened for syphilis and in 1990 for HIV. Culture for herpes virus was done on a subsample of 103 persons seen in 1983, but in the main, diagnoses were clinical. In 1983, GUD was found in 1,571 clients, an overall prevalence of 6.8 percent (men 1,110, 9.3 percent; women 461, 4.2 percent). Of those with GUD, genital herpes was diagnosed in 267 (17 percent); syphilis in 203 (12.9 percent); chancroid in 195 (12.4 percent); viral warts in 89 (5.7 percent); lymphogranuloma venereum in 65 (4.1 percent) and granuloma inguinale in 55 (3.6 percent). A diagnosis could not be made in 697 (44.5 percent) cases. All conditions were significantly higher in men (p<0.001) except for syphilis which was higher in women (p<0.05) and viral warts, where there was no significant difference. In 1990, GUD was found in 128 clients, an overall prevalence of 12.8 percent (men 95, 18.2 percent; women 33, 6.8 percent). Of clients with GUD, syphilis was diagnosed in 24 (18.8 percent); chancroid in 17 (13.3 percent); genital herpes in 10 (7.8 percent); viral warts in 8 (6.3 percent); lymphogranuloma venereum in 5 (3.9 percent) and granuloma inguinale in 3 (2.3 percent). A diagnosis could not be made in 61/128, 47.6 percent of cases in 1990. The prevalence of HIV was 28/1,001 (3.2 percent). A significant association was found between GUD and HIV infection (men with current GUD: OR 7.3, CI1.4 - 72; women with history of "bad blood" (syphilis): OR 6.6, CI 1.3-30). Overall prevalence rates of GUD were significantly higher in 1990 than in 1983 for both sexes (p<0.001), as well as total rates for each sex (males p< 0.001, females p<0.004) (AU)