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.

The assessment of empathy and the quality of interpersonal communication by standardized patients in an OSCE: an exploratory study [abstract]

Emphatic communication is a critical aspect of medical interviewing. While there are a number of theoretical perspectives on empathy, in the medical context Feignhny (1995) describes, empathy as, "a physician's cognitive capacity to understand a patient's needs, an affective sensitivity to a patient's feelings, and a behavioural ability to convey empathy to a patient". From this definition, the most direct and valid assessment of empathetic concern is likely to come from the patients own perspective. The development of empathy in students is critical in the provision of quality undergraduate medical attention. At the St. Augustine Campus of the Faculty of Medical Sciences, the skills laboratory programme has the responsibility for developing basic clinical competencies in medical students in years 1 to 3, including empathetic concern. However, as yet, there are no formal intervention programmes. A standardized patient (SP) programme is maintained in which a core of volunteers is trained to work with the students and to perform in the role of patient at the annual OSCE at the end of year 3. In the 1999 OSCE, the SPs were asked to assess the quality of the interpersonal communication of students. These ratings were compared with those of experts raters at key stations. In the 2000 OSCE, the study was expanded to include an assessment of empathy using the Adjective Check List. The key research questions for the study focused on the relationship between empathy and student individual characteristics and performance in traditional assessments. It was found that empathetic communication as practised in the OSCE and as assessed by the SPs was related to gender but unrelated to performance in traditional assessments in the Phase examinations and admission scores. There was evidence that students with high admission scores were likely to score lower in some aspects of empathy as perceived by the SPs. Recommendations for the development and assessment of attitudes are provided. Issues centring on design intervention programmes for developing empathetic concern in students are discussed. (AU)

A study of the acquisition of interviewing skills by medical students in a focused small group course [abstract]

St. George's University School of Medicine matriculates two separate classes of 250 students each year. Clinical interviewing and communication skills are taught in "small groups" of 9-11 students by experienced physician educators using standardized simulated patients. During each 90-minute session, a student acts as the interviewer and receives feedback from both physician and patient as well as also observing interviews by colleagues. Nine such sessions occur over a 9-month period. There is evidence of overall efficacy of the Clincial Skills course from an OSCE administered at the end of the two-year course in Basic Sciences, but this study attempts to define the efficacy of these small group sessions. The study compares, by means of videotaped recordings, the skills of volunteer freshmen medical students before and after 3 small group sessions, and compares this group to a similar group of students who had completed all 9 sessions. These recordings were rated by two independent observers, unaware of the students experience, using a new interview rating scale derived from a combination of three previously validated scales. The characteristics of this scaleproved to be reliable and valid within the limits of this study. Student performance improved significantly after three sessions in terms of interview content, non-verbal communication and interpersonal skills. Further improvement occured in the first two at the end of the course, but there appeared to be a deterioration in interpersonal skills. This was similar to the results in previous studies. The focussed small group course in interviewing and communication skills at St. George's University is effective in improving student skills, but continuing efforts are needed to ensure that their interpersonal skills are optimized and maintained. (AU)

The important concepts in the management of microbial keratitis

Eye practitioners in the Caribbean must be aware of the issues involved in the management of microbial keratitis. A comprehensive literature review is presented in order to outline appropriate management strategies and to identify when referral may be indicated. (AU)

Perceptions about mental illness among pre-clinical medical students in Trinidad and Tobago

Perceptions about mental illness among medical practitioners are likely to determine their capacity to recognise, treat appropriately and refer patients who have mental health problems. It is therefore important that training of medical students in psychiatry is undertaken with knowledge of their attitudes to mental health disorders. We determined the perceptions of 108 pre-clinical medical students (69 males, 39 females; mean age 22 years) toward mental illness in Trinidad and Tobago by analysing their responses to a questionnaire based on a case vignette of a young man with a paranoid psychotic illness. 88 percent felt that medical treatment in hospital was the best means of treating the illness and 86 percent suggested that discharge should be conditional on regular visits to a doctor. 89 percent however opposed the patient's marrying into their families and 85 percent to his teaching their children. This was associated significantly with having a personal relationship with someone having a mental illnes (p < 0.03). Surprisingly, 25 percent believed that mental illness could be caused by supernatural forces, particularly females who were almost twice as likely as males to express this belief.(AU)

The social worker: a member of the primary care team?

The primary health care team at present does not include social workers as routine members. If however, we, accept the World Health Organisation definition of health, which includes social well being, then it follows that the social worker should be considered as a member of the health team to attend to this aspect of health in the service delivery mix. This paper presents the experience of a social worker assigned to the August Town/Hermitage Type III health centre during the period March 1995 to February 1996 and her contribution to patient welfare. The expected roles of the social worker and his or her contribution to the health team are outlined.(AU)

The Jamaican body's role in emotional experience and sense perception: feelings, heart, minds and nerves

When Jamaican speak of feelings, they literally mean feelings: physical sensations. Emotions, which emerge through social interaction, comprise an unmarked subset of feelings. They can affect the mind in ways that are actualized in behavior. Emotions affect other parts of the body as well, in ways that follow from an equilibrium model of health. Non-emotional feelings index bodily disequilibrium rather than causing it. An example of such is seen in nerves: a chronic feeling-complaint that comes about when the nerves, associated with perception and sensation, are weakened, and which entails visual dimness, jumpiness, and joint trouble. Although exacerbated by certain social situations and often used in social commentary and manipulations, nerves is experienced and treated as a physical rather than a socially-based disorder. By studying the bodily dimension of nerves and other feelings we may gain insight into the ways in which the body serves as a source of culture (e.g., nerves culture) as well as into how culture influences bodily experience. We may broaden our understanding of the complex interplay between the bodily and mental dimensions of people's lives.(AU)

Working women's sexual risk taking in Jamaica

Although the rates of HIV are increasing among female populations in developing countries, there is little information available about factors influencing sexual risk taking among working class women. This paper describes some of the issues discussed by two groups of 58 women working in Jamaica: Informal Commerical Importers and women working in the Free Zone. These women discuss their economic vulnerability, expectations about the role of men as provides, multiple partners, perception of children as resources and concern about physical abuse as factors that could influence decisions about condom use. The implications of these findings are discussed for their impact of intervention programs targeting working class women in Jamaica.(AU)

Gender and age variations in the self-image of Jamaican adolescents

The purpose of the study was to investigate the relationships among gender, age, and self-image of adolescents attending three secondary schools in Jamaica. The relatively few studies that have been done regarding self-perceptions of these youths are not only dated but have utilized a unidimensional conceptualization of the self. The Offer Self-Image Questionnaire which employs a multidimensional construct of the self was administered to a sample of 174 Jamaican adolescents ranging in age from 14 to 18 years (M=15.90 years, SD=1.21). Results revealed statistically significant effects for both gender and age. Gender was found to be significant on one self-image dimension: Morals, while age differences were evident on six dimensions: Social Relationships, Morals, Sexual Attitudes, Mastery of the External World, Vocational and Educational Goals, and Emotional Health. The results in some instances were contrary to those of past research. Discussion focused on cultural socialization and other factors affecting youth in Jamaican society.(Au)

The nature of interpersonal violence in Jamaica and its strain on the national health system

A random prospective study of 640 victims (76.6 percent) in the 15-39-year-old age group) of interpersonal violence (IPV) at the Kingston Public Hospital was conducted over three months. About 87.5 percent of the aggression on males and 74.5 percent on females was committed by males. However, there was more female/female than female/male violence. Weapons used ranged from guns to a variety of cooking wares, though knives were used most frequently (34.8 percent) for stabbing 48 percent of the victims. Head, neck and upper limb were the main sites of injury; only 13.4 percent of all the injured had complications, and 63 percent of these required hospitalization. Family members and acquaintances contributed to about 84 percent of the violence. Instinctive spontaneous aggression aimed at maiming the victim characterizes IPV in Jamaica. The Jamaican taxpayer bears 90-94 percent of the cost of managing trauma injuries. These costs should be recovered from the assailants, even in the form of blood donations and community service. (AU)

Social integration of the physically disabled in Barbados

An emergent concern with the rehabilitation and social integration of disabled people in developing nations has created a need to identify cultural beliefs and behaviours which may affect the integration of the disabled into normative social roles. The focus of this study is the social integration of physically disabled adults among the nonelite, coloured population of Barbados, West Indies. This paper analysed the role participation of 30 physically disabled adults within the context of Barbadian beliefs and behaviours related to the disabled and to the 'normal' adult. Although village Barbadians do not expect the physically disabled to fulfill normative roles, some disabled individuals in this study do perform adult activities, such as maintaining employment and engaging in sexual relationships. However, very few of them participate in the reciprocal relationships among peers and neighbours through which village Barbadians achieve status and 'respect' as adults. (AU)

Psychiatric morbidity and related factors in West Indian students

An analysis of certain clinical and demographic variables was performed on patients seen in each of four years by psychiatrists at the University of the West Indies Mona Campus Health Services. A serial sample of 169 patients was also surveyed. A 50 percent sample of final year students was used as a control group. Personality disorders and related neurotic syndromes were commonest. Alcohol and drug addiction were absent. Contributory life stresses included male-female relationships, relating to parents, general relationships, and academic and identity problems. More of the patient sample had frequent previous emotional complaints than the control group. Passive dependency was the single greatest clinical problem and correlated highly with male-female life stresses. The common nature of dependency and its predisposition to decompensation amidst male-female difficulties are striking and could reflect the pressure of the West Indian family structure. The pattern seen reflect academic, developmental and cultural factors which are of importance in treatment and prevention (AU)

The buccra-massa and the little man's broker in a Jamaican sugartown: implications for community health education

In societies that have been historically stratified by class, interclass communication is frequently hampered by behaviors of higher status people that lower status people interpret as denigrading. To escape what they perceive as denigration, lower status people may attempt to avoid interclass interaction, and, when it is unavoidable, adopt such strategies as not making direct eye contact, saying very little except what they think the higher status people want to hear (including flattery), and using a lower status peer as an intermediatry. Such behavioral patterns have important implications for the design of health services programs. This paper presents a case study of such interaction difficulties observed during 13 months of anthropological research in a Jamaican town. The lower status people in the town of Haversham (a pseudonym) refer to this avoidance behavior as the 'buccra-massa'. The antonym of buccra-massa is 'buck-the-massa'. "Buck-the-massa' is characterized by being able to look higher status people in the eye and boldly engage them in conversation. Lower status people who are known for bucking-the-massa are frequently used as intermediaries in cross-class interactions. Because Havershamins refer to higher status men as 'big men and to lower status people in Haversham, 'little men's brokers'. the author argues that the buccra-massa and buck-the-massa behavioral traditions had their roots in the complex and extreme social inequalities of the slavery period in Jamaica. It is further argued that economic difficulties in Jamica since the slavery period have contributed to the persistence of these behavioral dynamics to the present day. The buccra-massa/buck-the-massa behavioral complex is often manifested in health care settings in Jamaica. Thus, the author suggests that the little man's broker can be very useful in promoting less threatening and therefore more effective interactions between the clients and the staff of health and other human service programs. He notes that while staff members often view brokering behavior as trouble making, many of the clients they wish to serve view this same behavior as bucking-the-massa. It is a mistake, according to this analysis, to ignore the little man's broker. As this case of Jamaica shows accomplished brokers can choose to exert their extensive influence against utilization of services offered by specific programs (AU)

Effect of psychosocial stimulation on mental development of severly malnourished children: an interim report

The effect of adding psychosocial stimulation to the treatment of severly malnourished children was studied. The study period covered children from the time they left the hospital to 24 months later. The children's developmental levels (DQs) were compared with those of two other groups who were in the hospital - an adequately nourished group with diseases other than malnutrition, and a severely malnourished group who received standard hospital care only. The children receiving intervention had structured play sessions in the hospital and were visited weekly for 2 years after returning home. During the visits paraprofessionals showed mothers how to continue structured play with their children. The malnourished children who did not receive intervention showed a marked deficit in developmental level compared with that of control children throughout the study. The control children showed a decline in developmental level with age, which is characteristic of disadvantaged children. The children receiving intervention showed marked improvements and by 24 months were ahead of the children who did not receive intervention in every subscales. Both groups of malnourished children remained behind the control children in nutritional status and locomotor development. (AU)

Sources and symptoms of stress among a sample of Jamaican secondary school teachers

This exporatory investigation examined the sources and symptoms of stress experienced by secondary school teachers drawn from a random sample of New Secondary and Traditional High schools throughout Jamaica. The instruments used were a 23-item measure of Teachers' Experience of stress Symptoms (TESS) which comprised the criterion measure: and the independent variable consisted of groupings which emerged from a factor analysis of 60 items tapping sources of stress, as well as selected biographical and demographic variables. The data obtained from 470 respondents (162 males and 308 females) were subjected to the following procedures: 1. ORTHOGONAL FACTOR ANALYSES with varimax rotation grouped the 60 source of stress items into five factors identified as 'Interaction among Staff Members', 'Students' Indiscipline', 'Job Pressures', 'Inadequate Rewards', and 'Poor Working Conditions'. All five factors were significantly related to the criterion measure (TESS). STEPWISE MULTIPLE REGRESSION analysis for the total sample yielded 'Poor Working Conditions', 'Students' Indiscipline', and 'Job Pressures' in that order, as the best predictors of the criterion (TESS). For the male sub-sample, 'Poor Working Conditions', and 'Job Pressures' surfaced as the best predictors of the criterion, while 'Interaction among Staff Members' was the only variable making any significant contribution to the criterion for the female sub-sample. ANALYSIS OF VARIANCE revealed that there were no statistically significantly differences emerging for teachers working in girls', boys' or co-educational schools on the experience of stress symptoms. Teachers at coeducational schools did however experience significantly greater stress from 'Interaction among Staff Members' and 'Inadequate Rewards'. CORRELATION ANALYSIS revealed that the teachers' sex, age, academic speciality and the grade levels of students taught were significantly related to the criterion (TESS). Teachers at New Secondary schools experienced significantly more stress than Traditional High school teachers from certain sources viz: 'Interaction among Staff Members', 'Students' Indiscipline', 'Inadequate Rewards', and 'Poor Working Conditions'. Corporate area teachers also found certain sources, viz: 'Interaction among Staff Members', 'Students' Indiscipline', 'Inadequate Rewards' and 'Poor Working Conditions', more stressful than their non-Corporate Area counterparts. Female teachers not only experienced significantly more symptoms of stress (p<.001) but also found 'Students' Indiscipline', 'Job Pressures', 'Inadequate Rewards' and 'Poor Working Conditions' to be more stressful than male teachers.(AU)

Parent-child interaction and teenage pregnancy - an urban study

One hundred pregnant teenagers and 100 non-pregnant school girls were studied in an effort to determine whether there was any significant difference in the interaction the girls had experienced with their parents. The hypothesis was that the girls who experienced satisfactory parent-child interaction were less likely to become pregnant than girls who did not experience good parent-child interaction during their "growing-up" period. An interaction index was compiled in order to provide a parent-child interaction score for each teenager and thus a definite point of comparison for the two groups. Other variables were also included to examine the differences if any in the quality of their interaction with their parents. The results revealed that the mother-child interaction score for the two groups was quite different, as also was the father-child interaction score. The mean mother-child and father-child interaction scores were significantly higher for the school girls than they were for the pregnant girls. Although there were fewer father-figures among the pregnant girls, where these girls came from two parent families, their mean father-child interaction score was still lower than the mean father-child score for the school girls. In addition to these findings, the variables which were designed to give additional information about the nature of the parent-child interaction generally indicated that the school girls had experienced more satisfactory interaction with their parents than had the pregnant girls (AU)

Psychosocial functioning of mothers of malnourished children

The relationship between infant malnutrition and maternal psychosocial behavior was explored by comparing mothers of malnourished children with mothers whose children were matched for age and family income but were not malnourished. The mothers were interviewed and asked to describe their relationships with their children, their children's fathers, extended families, friends, and employers. The mothers of malnourished children described more chronically disrupted lives. Their housing conditions and employment records reflected disorganization. They had fewer social contacts except with extended families who supervised excessively. The fathers of their babies were either not present or unsupportive. Relationships were more stereotyped, transient, and focused on material aspects. The mothers' narcissistic concerns took precedence over the needs of their children. Nearly all the mothers, including the controls, had suffered severe deprivation in childhood. Some mothers of malnourished children were apathetic and dependent, whereas others were manipulative and evasive. These findings were consistent with "failure-to-thrive" in affluent countries.(AU)

Correlates of adolescent marijuana use as related to age, sex and ethnicity

This study examines the interactive effects of background factors and personality/attitudinal and perceived environmental dimensions on adolescent drug behaviour. Data were collected during home interviews using a structured interview schedule. The sample consisted of 403 British West Indian black, American black and white adolescents, ranging in age from 13 to 17. Results suggested that two processes, nonconformity to conventional middle class values at both the personality/attitudinal and institutional level and modeling of familial and peer drug use account in large part for adeolescent drug behaviour. The majority of correlates of adolescent drug behaviour were similar in different sex, age and ethnic groups. (AU)