Inequalities in health in Latin America and the Caribbean: descriptive and exploratory results for self-reported health problems and health care in twelve countries

Objective: To explore and describe inequalities in health and use of health care as revealed by self-report in 12 countries of Latin America and the Caribbean. Methods: A descriptive and exploratory study was performed based on the responses to questions on health and health care utilization that were included in general purpose household surveys. Inequalities are described by quintile of household expenditures (or income) per capita, sex, age group (children, adults, and older adults), and place of residence (urban vs. rural area). For those who sought health care, median polishing was performed by economic status and sex, for the three age groups. Results: Although the study is exploratory and descriptive, its findings show large economic gradients in health care utilization in these countries, with generally small difference between males and females and higher percentages of women seeking health care than men, although there were some exceptions among the lower economic strata in urban areas. Conclusions: Inequalities in self-reported health problems among the different economic strata were small, and such problems were usually more common among women than men. The presence of small inequalities may be due to cultural and social differences in the perception of health. However, in most countries included in the study, large inequalities were found in the use of health care for the self-reported health problems. It is important to develop regional projects aimed at improving the questions on self-reported health in household interview surveys so that the determinants of the inequalities in health can be studied in depth. The authors conclude that due to the different patterns of economic gradients among different age groups, and among males and females, the practice of standardization used in constructing concentration curves and in computing concentration indices should be avoided. At the end is a set of recommendations on how to improve these sources of data. Despite their shortcomings, household interview surveys are very useful in understanding the dimensions of health inequalities in these countries (AU)

Attitudes of patients and staff to the implementation of an open door policy in a psychiatric unit of a general hospital [Abstract]

OBJECTIVE: To document the changing attitudes of staff and patients to the implementation of an open door policy (ODP) in the custodial psychiatry unit at the University Hospital of the West Indies. METHOD: The implementation of the changing therapeutic activities between October 2000 and January 2001 was followed using qualitative methods. Patients, their relatives and staff were interviewed around the time of implementation of each changing activity, and their attitudes documented. Patients attitudes to the transformed ward were sampled from May 2001 using the Verona Satisfaction Scale. The ODP had five separate components. The first was the opening of the main gate of the ward, which took place in October 2000. This was followed by a rationalization in stages of patients clinical status and their assignment to specific therapeutic activities. The implementation of daily therapeutic community group meetings was followed shortly afterwards by the implementation of an art therapy programme and other occupational activities. The opening of the Occupational Centre was the final phase of the programme in June 2001. RESULTS: The initial response of staff members to the opening of the main gate was angry and hostile with acts of passive resistance. Patient response was cautious but favourable, and they soon took advantage of leaving the ward unacompanied. Demarcation of the patients into groups of clinical severity soon allowed the staff to rationalize therapuetic activities for the patients. Both staff and patients were cooperative to this change. Implementation of the therapuetic community group meetings had a profound resocializing effect on patients and staff. Finally, the implementation of the art and activity therapy was warmly received by the patients, and proudly acclaimed by the staff. Analysis of the Verona Satisfaction Scores indicated a general acceptance and appreciation by the patients. CONCLUSIONS: The general consensus has been that the ward atmosphere was positively transformed by the ODP with patients being more satisfied with their care and being less hostile in their interactions with staff. Staff have cooperated with the changes, and have expressed appreciation of the benefits derived from the process. (AU)

Factors in the onset of schizophrenia: a comparison between London and Trinidad samples

Objective: Sociodemographic factors play an important role in the genesis of mental disorders. High rates of unemployment and other social factors have been reported previously among African-Caribbeans with schizophrenia in London. The aim of the present study was to compare these factors in Trinidad with London African-Caribbeans. METHOD: Using internationally-defined criteria, patients with first-onset schizophrenia were recruited in both countries, and information on the onset of symptoms, help-seeking, pathways into care, premorbid personality and educational and employment status were collected. These two samples are compared on a number of these factors. A total of 56 cases of first-onset of psychosis coming into contact with psychiatric services in Trinidad were studied. Of these, 46 cases were diagnosed as having schizophrenia using the CATEGO program. Over a period of 2 years, 38 African-Caribbean patients with schizophrenia were recruited in London. RESULTS: African-Caribbean patients with schizophrenia in London were more likely to be admitted for perceived threat to others and to have shown loss of interest and serious neglect and to have assaulted others. A lower proportion were admitted via a psychiatrist and a higher proportion by the police. The unemployment rate among the London sample of African-Caribbeans was much higher than in the general population, whereas this was not the case for the Trinidad patients. CONCLUSION: These findings are discussed in the context of culture and aetiology of schizophrenia, and suggestions with regard to future research are made. (AU)

First-contact incidence rate of schizophrenia on Barbados

BACKGROUND: The incidence rate for broad schizophrenia among second-generation African-Caribbean people in the United Kingdom has been reported as high. Ethnicity, migration and psychosocial stressors have been suggested as causal factors. AIMS: To determine the incidence of schizophrenia for the whole population of Barbados using an identical methodology to two previous studies in Trinidad (Bhugra et al, 1996) and London (Bhugra et al, 1997). METHOD: A 12-month study of all persons in the 18-54-year age group presenting with a psychosis for the first time was carried out on the population of Barbados. Information was collected using the World Health Organization screening and measurement instruments. RESULTS: On an island of just over a quarter of a million, 40 out of the 53 patients that met the inclusion criteria were categorized as S+ (narrow) schizophrenia, giving an incidence rate of 2.8/10,000 (95 percent Cl 1.97 - 3.7). The incidence rate for broad schizophrenia was calculated at 3.2/10,000 (95 percent Cl 2.3 - 4.1), which is significantly lower than the comparable rate for London's African-Caribbeans of 6.6/10,000 (95 percent Cl 4.5 - 8.7). CONCLUSIONS: The very high rate for broad schizophrenia among African-Caribbean people in the UK is probably due to environmental factors. (AU)

A behaviour risk factor survey in Jamaica

A population based probability sample of 958 persons (454 males and 504 females) aged 15 to 49 years was surveyed in Jamaica in late 1993 for lifestyle and behaviour risk factors. Demographic characteristics of the sample were comparable to the general population. 60 percent of persons visited a private doctor the last time that they were ill. Based on self-reporting, 18 percent of the women and 8 percent of the men had never their blood pressure taken. 40 percent of the women had never had a Papanicolaou smear, 29 percent had never had a breast examination and 33 percent said that they were overweight compared with 18 percent of men. Smoking cigarettes and marijuana was more common among men (36 percent) than women (11 percent) as were drinking alcohol (79 percent of men, 41 percent of women) and heavy alcohol use (30 percent of men, 9 percent of women). Injuries requiring medical attention in the previous five years were reported by 40 percent of the men and 15 percent of the women. 34 percent of the men and 12 percent of the women regularly carried a weapon and 18 percent of the sample had participated in or witnessed at least one violent act in the previous month. Most of the people interviewed used a contraceptive method; 10 percent were not sexually active. Significantly more men than women had two or more sexual partners in the previous year (54 percent vs 17 percent, p<0.001) or reported ever having a sexually transmitted disease (29 percent vs 9 percent, p<0.001). Younger persons were more sexually active and more likely to use condoms during the most recent sexual intercourse. Higher socio-economic status and educational level generally had a more positive effect on health behaviour. This survey provides vital information relevant to planning health promotion campaigns and assessing their success.(AU)

Cyclofem/Cyclo-Provera: emerging countries' perspective

Cyclo-Provera, the original name of the combination of 25 mg medroxyprogesterone acetate and 5 mg estradiol cypionate, later known as Cyclofem and hereafter referred to MPA/E2C, has proven its use- effectiveness (pregnancy rate less than 1 percent) in routine service delivery conditions. Overall, the life-table discontinuation rates at 1 year ranged from 33.5 percent to 71.8 percent. Only a third of total discontinuations were attributable to the injectable contraceptive method, thus raising the importance of service delivery issues related to its continued use. The results of introductory trials in Mexico, Indonesia, Thailand, Tunisia, Jamaica and, more recently, Brazil, Colombia, Chile and Peru have demonstrated that MPA/E2C is a highly effective contraceptive that could be offered as an alternative to current fertility regulation methods for many women around the world. In addition, the results of studies were the basis for the approval of MPA/E2C by local health authorities and its inclusion in the Ministries of Health Family Planning Programs.(Au)

Sociocultural variations in help-seeking behaviour for everyday symptoms and chronic disorders

In this study, we test the assumption that sociocultural differences in use of health services will occur only below a certain level of illness severity. Data are derived from the Curacao Health Study (N = 2248). Subjects' educational level and degree of proto-professionalisation were used as indicators of their sociocultural background. Differences in the likelihood of seeking professional care for several common health problems were analysed, and were compared with the help seeking behaviour for chronic disorders. As hypothesised, more highly educated and proto-professionalised people were less likely to seek care for everyday symptoms. In addition, proto-professionalisation was accompanied by a greater likelihood of using over the counter medication. Increasing empowerment of patients appeared to lead to increase self care for everyday symptoms. When conditions reached a more serious stage, the difference in help-seeking behaviour disappeared. For most of the chronic conditions studied, the higher educated and more proto-professional treatment as the less advantaged groups. However, there was a difference as to the type of professional consulted for chronic health problems. Proto-professionalised individuals more often received specialist treatment, probably because they were better equipped to persuade GPs to refer. The adverse side of patient empowerment may be increasing consumerism.(AU)

Evaluation of a pilot study for breast and cervical cancer screening with Bradford's minority ethnic women; a community development approach, 1991-93

The objectives were to provide information about breast and cervical cancer and related screening services to minority ethnic women, to enable them to make well informed decisions and choices; to adopt a health education strategy based on a community development approach, augmented by a local publicity campaign; and to evaluate both the direct and indirect effects of this project. To this end a community development intervention study was made over 18 months from October 1991 to March 1993 in Bradford, a multicultural city with 87,000 residents from minority ethnic groups. The subjects of the study were 1,628 women from minority ethnic groups in three geographical areas of Bradford. A stratified sample of 1,000 women (670 South Asian, 163 African-Caribbean, 96 Eastern European and 71 other) was interviewed at the beginning of the project and six months after the health promotion intervention. Two specifically trained Health Promotion Facilitators from minority ethnic groups undertook community development work within three neighbourhoods in Bradford with the largest minority ethnic populations. There were group sessions in both formal and informal settings, which included the health education about breast and cervical cancer and the associated screening programmes. These sessions were in the women's preferred languages and audio-visual material and a specially designed teaching pack were used. There were significant differences in the baseline levels of knowledge about cervical cancer and breast cancer and breast across the different minority ethnic groups. The South Asian women had the lowest levels of knowledge and also showed the most significant improvements. Significant increases in attendance for cervical smear and breastcancer screening were self-reported. These were confirmed by anecdotal views of local health professionals. In addition, a local self-help group for South Asian women was established; also the contacts with other related organisations and professionals has help to raise the issues of ethnically sensitive services within the voluntary and statutory sectors. A community development approach to health promotion is particularly valuable in communities with low levels of knowledge about a disease/s or health service provision. Community development approaches often produce outcomes that had not been predicted. (AU)

Cross-cultural differences in maternal evaluation of children's body shapes

OBJECTIVE: This study investigated cultural variation in mothers attitudes to children's body shape. METHOD: One hundred and thirty-one mothers from five cultural groups attending a pediatric clinic were approached, and data obtained from 114. Background information was obtained, including weight and height for themselves and their children. Mothers completed the Eating Attitudes Test (EAT-26) and rated drawings of children for attractiveness and health, using Likert scales, scored 1-7. RESULTS: Mothers from the different cultural groups and their children had similar average body weight. However, UK mothers found slimmer girls attractive compared to mothers from South Asia, the Mediterranean or the Caribbean regions, and sub-Saharan Africa (P<.05). The differences occurred within the mid-range (median scores for all ethnic groups 4-5). South Asian mothers presented to the pediatric clinic with more worries about their children not gaining weight and growth (p>.01). DISCUSSION: These findings have implications for understanding cultural variation in the acquisition of attitudes to body shape, and these attitudes influence medical seeking help (AU).

The challenge for women with a drug-abusing family member: the Jamaican perspective

The abuse of alchol and other drugs presents a multiplicity of problems for the abuser, family members and the wider community. The psychosocial, as well as the economic, probelms can produce an environment of chaos and misery. Women in families in which there is an abuser are challenged in a variety of ways and, depending on the severity of the situation and their capacity to cope, they may confront the problem, seek help or withdraw from it. The present article reviews the impact of drug abuse within the family on Jamaican women from the viewpoint of treatment and rehabilitation specialists and the women themselves and on the basis of case histories and the work experience of the author. Although there have been efforts through demand reduction strategies and culturally relevant treatment and rehabilitation programmes to control the epidemic of drug abuse, the specific needs of women have been left largely unattended. Both men and women are however critical in the fight against drug abuse and women have skills and experience that can contribute to making such programmes achieve their desired objectives. Addressing their needs would not only help them, but also the family and the wider community. In order to address these needs effectively with the limited resources available, however, a credible basis for action has to be established, which can only be done by research and analysis so that the issues can be clearly defined and a plan of action developed.(AU)

The influence of family support on compliance in the management of diabetes

Diabetes mellitus is one of the leading causes of death and disability among adults, affecting approximately 12 percent of the adult population 35 years and over. Effective metabolic control through the use of pharmacological and non-pharmacological treatment is essential to ameliorate and/or avoid or delay acute and long term complications. This cross-sectional study was conducted to determine influence of family support on compliance, observing whether there was any variation with certain demographic variables. Information was obtained from a purposive sample of seventy diabetics attending weekly diabetic clinics at the Community Health Centre of the Department of Social and Preventative Medicine and the University Hospital of the West Indies. The survey instrument used was a questionnaire and data was collected from a single interview. Patients were found to be more compliant with medication than with diet or exercise, recording lower levels of family support with exercise than with encouragement to take medication or to observe dietary restrictions. All patients reported some level of family support. No patient with a low score for family support recorded a high level of compliance. No significant statistical association was found between levels of family support and age, sex, income and education, or between family support and compliance. However, there was found to be a significant association between compliance and the state of glycaemic control of patients, indicating that patient compliance is a most important factor in management of the disease. Indications are that family support is an important factor in influencing compliance, however, individual influences such as the patient's attitude, judgement and experience are critical factors which influence compliance. (AU)

The level of compliance of individuals screened for cardiovascular disease by the Heart Foundation of Jamaica

This study was conducted on persons who attended the Heart Foundation for screening for cardiovascular disease. The study was done so as to determine the level of compliance among respondents who were given advice/treatment as a result of this visit. Two questionnaires were administered to gather data. The first questionnaire was administered when the respondent visited the Heart Foundation of Jamaica clinic. This questionnaire collected demographic data and information on the respondents knowledge about the risk factors for the development of heart disease. The second questionnaire was sent to the respondents three weeks after they received their medical results. The second questionnaire sought to ascertain what treatment/advice if any the respondents had been given and whether or not it had been complied with. A total of 145 persons completed the first questionnaire. Seventy one percent of the sample was female. Of the 145 respondents (33 persons - 22.8 percent) were between 50-59 years old although ages ranged from 4-94 years. Seventy nine respondents (54.5 percent) were educated up to the level of primary/all age school. Most of the respondents correctly identified the risk factors that could lead to the development of heart disease. Only 65 (45.5 percent) returned to the second questionnaire which had been sent by mail with a stamped self addressed envelope enclosed. Of these 65 persons 32 (49.2 percent) had been given further advice/treatment. Most of these respondents (78.1 percent) complied to the treatment/advice that was given. In this study, no association was found between level of compliance and knowledge of risk factors, family support, educational level, gender and social class. Also age did not influence compliance. Of the respondents to the second questionnaire, 90.8 percent (59 persons) felt that they had benefited by using the services offered by the Heart Foundation of Jamaica. (AU)

Incidence of psychotic illness in London: comparison of ethnic groups

The objective is to compare annual incidences of psychosis in people from different ethnic groups as defined in the 1991 census. The setting was the catchment area of district psychiatric hospital. The design included all people aged 16 to 54 years who made contact with a wide range of community and hospital services between 1 July 1991 and 30 June 1992 were screened for psychotic symptoms. Patients with such symptoms were interviewed face to face to collect information on demography, ethnic group, psychiatric history and symptoms, drug use, and how care had been sought. A key informant, usually a close relative, was also interviewed. The main outcome measures entailed age standardised incidence of schizophrenia and non-affective psychosis according to the ninth edition of the International Classification of Diseases in each ethnic group. The results showed that ninety three patients took part, of whom 38 were assigned a certain or very likely diagnosis of schizophrenia (15 in white population, 14 in black, seven in Asian, and two in others). The age standardised annual incidence of schizophrenia was 2.2 (95 percent confidence 1.5 to 2.9) per 10,000 of the population. The incidence ratio for schizophrenia in all ethnic minority groups compared with the white population was 3.6 (1.9 to 7.1); the corresponding figure fon non-affective psychosis was 3.7 (2.2 to 6.2). The conclusions were that raised incidences of schizophrenia were not specific to the African Caribbeans, which suggests that the current focus on schizophrenia in this population is misleading. Members of all ethnic groups minority groups were more likely to develop a psychosis but not necessarily schizophrenia. The personal and social pressures of belonging to any ethnic minority group in Britain are important determinants in the excess of psychotic disorders found (AU)

The painful crisis of homozygous sickle cell disease: clinical features

The details of onset, perceived precipitating factors, associated symptoms, and pain distribution in the painful crisis of homozygous sickle cell (SS) disease have been prospectively recorded in 183 painful crises in 118 patients admitted to a day-care centre in Kingston, Jamaica. Painful crises developed most frequently between 3 p.m. and midnight, most commonly affected patients aged 15-29 years, affected the sexes equally, and were not obviously influenced by menstrual cycle. Of the perceived precipitating factors, skin cooling occurred in 34 percent, emotional stress in 10 percent, physical exertion in 7 percent, and pregnancy in 5 percent of women of child-bearing age. Cold as a precipitant was not less common in patients with more subcutaneous fat. Pain affected the lumbar spine in 49 percent, abdomen in 32 percent, femoral shaft in 30 percent, and knees in 21 percent. There was a highly significant excess of bilateral involvement in limb and rib pain. Recurrent painful crises occurred in 40 patients but showed no evidence of involving similar sites on successive occasions. Abdominal painful crises were associated with abdominal distention in 18 ( 31 percent) and with referred rib pain in a further 15 (26 percent) of crises. Fever was common even in apparently uncomplicated painful crises, suggesting that fever is characteristic of the painful crisis itself after and not necessarily indicative of infection. Following investigation and treatment in a day-care centre, over 90 percent of patients returned home (AU)

Risk indicators of childhood undernutrition in Kingston, Jamaica

In Jamaica, early childhood undernutrition remains a problem; however, the health of all children cannot be monitored due to limited resources. Therefore, there is a need for the early identification of children at risk of undernutrition. A simple screening instrument for use by paraprofessionals in the primary health care system was developed. We conducted a case-control study using 649 children, aged 6 to 48 months. The cases were undernourished (weight-for-age less than 80 percent of the reference) and identified from a survey. The children's guardians were given a questionnaire comprising 31 variables thought to be associated with undernutrition and which were present from 6 weeks of age. Nine variables were significantly associated with undernutrition. Multiple logistic regression analysis indicated that low birth weight, short birth spacing, being born at home, poor ante-natal and post-natal clinic attendance, overcrowding and a lack of household possessions were independent predictors of undernutrition. Using these variables, a simple scoring system was developed to identify high risk children. It had a sensitivity and specificity of 56 percent and 76 percent respectively and a positive predictive values of 31 percent. This simple screening instrument should be easy to use in the primary health care system. However, its low sensitivity indicates that it is difficult to identify children who are at risk of undernutrition from 6 weeks of age. Subsequent high morbidity and poor child care which were not measured may account for some of the missed cases. (AU)

Science and spirit: health care utilization in rural Jamaica

This study uses an analysis of health care utilization in a rural community in eastern Jamaica, to evaluate health care development in this Caribbean country and suggest new approaches which could improve the effectiveness of health development programs. To make sense of health-seeking strategies it is necessary to look first at the various components of the health care system and their interconnections with the cultural, social, economic, and political realms. This problem is approached through the use of Kleinman's tripatite model of health care systems, which focuses on three interconnecting sectors. Within the popular sector, the realm of self-medication and family based care, there are a variety of options which people use in the early stages of illness. The professional biomedical sector, which includes the government health services and private doctors, plays a vital role when illness does not respond to self - treatment. However, structural ineffeciencies and economic barriers limit access to biomedical treatment, especially for the poorest individuals. The folk sector comprise of a variety of alternatives, public and private, ranging from church - based faith healing to several types of folk practitioners and the African-drived Kumina cult. Spirtual beliefs, which have taken shape through the evolution of Jamaican folk religion, continue to exert a profound influence of health care decision-making. Pattern which emerge from the analysis of numerous cases suggest the health-seeking strategies can be better understood when analyzed not as choices between systems, but as steps in a complex iterative process of coping with illness. The relative balance among the various factors affecting health care decisions changes at different stages of the process. The preponderence of chronic illness in rural Jamaica means that many people cycle continually through the illness and the health-seeking process. There has been a dearth of creative planning aimed at addressing chronic illness, which has become the most important health problem in Jamaica. To better respond to the changing needs of the population, planners and administrators must look for more effective methods of managing chronic illness, including strategies for prevention and treatment(AU)