Caregivers' practices, knowledge and beliefs of antibiotics in paediatric upper respiratory tract infections in Trinidad and Tobago: a cross-sectional study

BACKGROUND: Antibiotic overuse and misuse for upper respiratory tract infections in children is widespread and fuelled by public attitudes and expectations. This study assessed knowledge, beliefs, and practices regarding antibiotic use for these paediatric infections among children's caregivers' in Trinidad and Tobago in the English speaking Caribbean. METHODS: In a cross-sectional observational study, by random survey children's adult caregivers gave a telephone interview from November 1998 to January 1999. On a pilot-tested evaluation instrument, respondents provided information about their knowledge and beliefs of antibiotics, and their use of these agents to treat recent episodes (< previous 30 days) of upper respiratory tract infections in children under their care. Caregivers were scored on an antibiotic knowledge test and divided based on their score. Differences between those with high and low scores were compared using the chi-square test. RESULTS: Of the 417 caregivers, 70% were female and between 18-40 years, 77% were educated to high school and beyond and 43% lived in urban areas. Two hundred and forty nine (60%) respondents scored high (>or12) on antibiotic knowledge and 149 (34%) had used antibiotics in the preceding year. More caregivers with a high knowledge score had private health insurance (33%), (p < 0.02), high school education (57%) (p < 0.002), and had used antibiotics in the preceding year (p < 0.008) and within the last 30 days (p < 0.05). Caregivers with high scores were less likely to demand antibiotics (p < 0.05) or keep them at home (p < 0.001), but more likely to self-treat with antibiotics (p < 0.001). Caregivers administered antibiotics in 241/288 (84%) self-assessed severe episodes of infection (p < 0.001) and in 59/126 (43%) cough and cold episodes without visiting a health clinic or private physician (p < 0.05). CONCLUSIONS: In Trinidad and Tobago, caregivers scoring low on antibiotic knowledge have erroneous beliefs and use antibiotics inappropriately. Children in their care receive antibiotics for upper respiratory tract infections without visiting a health clinic or a physician. Educational interventions in the community on the consequences of inappropriate antibiotic use in children are recommended. Our findings emphasise the need to address information, training, legislation and education at all levels of the drug delivery system towards discouraging self-medication with antibiotics in children.

Hormone replacement therapy - knowledge, attitudes and practices of women attending a gynaecology outpatient clinic in Trinidad

A questionnaire was used to assess the knowledge, attitudes and practices of a sample of 218 outpatients attending the Port of Spain General Hospital Gynaec Outpatient Clinic. The questionnaire investigated women's knowledge of menopause, risks and benefits of Hormone Replacement Therapy (HRT), their attitudes concerning HRT and menopause as well as practices of postmenopausal women with respect to HRT. Comparisons were made between women of differing menopausal status, educational background and ethnicity. The results showed that overall knowledge was lacking regardless of menopausal status, ethnicity or educational background. Less educated women were more inclined to believe that HRT was inappropriate prinicpally because they regarded the menopause as a natural process (p = 0.023). Only 24 percent of postmenopausal women were practicing some from of HRT. A minority (7 percent) had previously been undergoing the therapy but had stopped. Most postmenopausal women (69 percent) simply never considered treatment because the majority had never heard about HRT. The main source of patient information was from the clinic they were attending. This study reveals low awareness of menopausal information and therapeutic options in a Trinidadian population. A targeted education programme may substantially fill this void.(Au)

The impact of the women's centre of Jamaica foundation programme for adolescent mothers on repeat pregnancies

A random sample (n=260) of primiparous Jamaican adolescent mothers (12-16 years old) who gave birth in 1994 in the parishes of Kingston and St Andrew, St Catherine and Manchester was selected from vital records and interviewed in 1998 for this historical cohort study. Among programme participants, the incidence of repeat pregnancy was 37 percent compared with 60 percent among non-participants. Programme participation reduced the risk of one or more repeat pregnancies by 45 percent with 95 percent confidence interval (0.22, 0.91). Programme participants were also 1.5 times (1.005, 2.347) more likely to complete high school than non-participants; however, this effect did not achieve statistical significance. The results confirmed that the WCJF Programme exerts a considerable effect on the incidence of repeat pregnancy among participants. The benefits of programme participation were greatest among residents of the Kingston Metropolitan Area from single parent, female headed households with average incomes below J$10,000, who wanted to continue their education after the first live birth.(Au)

Formal handling routines in Jamaican infants. Knowledge, attitudes and behaviour

This study aimed to determine the frequency of use and the knowledge, attitudes and behaviour regarding the Formal Handling Routines (FHR) in rural and urban Jamaican infants. Analysis was made of the area of residence and educational level of the caregivers. The study included 194 caregivers, thirty-three community rehabilitation workers (CRWs) and 30 health care workers (HCWs). Depending on the level of understanding of the respondents, questionnaires were either self-administered or a personal interview was conducted. Caregivers with tertiary education differed significantly from the other caregivers both in frequency of use of the FHR and knowledge, attitudes and behaviour. Caregivers with tertiary education used the routine much less and had more negative attitudes towards it. This might be due to their better financial position, which allowed them to have helpers who cared for their children. HCWs also had significantly more negative beliefs about the FHR than CRWs and caregivers. It is possible that HCWs carried over their knowledge, attitudes and behaviour to the caregivers but if they did, it did not influence the majority of caregivers.(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)

Breast-feeding and weight change in newborns in Jamaica

This study was conducted to examine weight change of breast-fed infants during the first week and through the first 24 days of life, and to evaluate the effect of breast-feeding factors and maternal characteristics on early weight change in infants. The weights of 21 infants were recorded on day 1 (day of birth), and on days 3, 7, 10, 17, and 24, and the data analysed to evaluate weight change over the period. Multiple regression analysis was used to assess whether birth weight as well as maternal and breast-feeding factors were significant predictors of weight on day 24. Nineteen of the 21 infants gained weight between days 1 and 3, and 20 infants gained weight between days 3 and 7. All infants gained weight over the 24-day period and their weights at day 7 and day 24 were significantly different (P <0.05 and P <0.01, respectively) from their birth weights. Multiple linear regression analysis showed that significant (P < 0.01) predictors of weight gain by day 24 included birth weight, mother's educational level, whether the baby cried before feeding, and length of feeding time periods. This is the first study of weight change in the early days and weeks of life of exclusively breast-fed newborn infants in Jamaica. The infants showed significant weight gain during the study period and weight gain was affected by certain maternal and breast-feeding factors. (AU)

Relationship of health-related quality of life to symptom severity in diabetes mellitus: a study in Trinidad and Tobago

Our objective was to estimate the effect of greater symptom severity in diabetes mellitus on measures of health-related quality of life in a cross-sectional design in 35 government primary care health centres in Trinidad. Data were gathered on 2,117 subjects with clinical diabetes and analysed for 1,880 (89 percent). For each scale of the short form 36 (SF-36) questionnaire (a generic measure of health-related quality of life), scores were presented by quartile of symptom severity, measured using the Diabetes Symptom Checklist. Mean (SD) SF-36 scores were 44 (10) for the physical component score (PCS) and 45 (12) for the mental component score (MCS). Greater severity of diabetic symptoms was associated with lower scores on each of the subscales of the SF-36. Comparing lowest and highest quartiles of DSC score, the adjusted difference in PCS was -11 (95 percent confidence interval -12 to -9) and for MCS -16 (-18 to -14). Our results provide standardised data for health related quality of life in relation to severity of illness from diabetes, these might be used to aid the evaluation of relevant interventions.(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)

Nutrition and education: a randomized trial of the effects of breakfast in rural primary school children

Hunger during school may prevent children in developing countries from benefiting from education. Although many countries have implemented school feeding programmes, few of these have been rigorously evaluated. We conducted a randomized, controlled trial of giving breakfast to undernourished and adequately nourished children. The undernourished group comprised 407 children in grades 2-5 in 16 rural Jamaican schools (weights-for-age < - 1SD of the National Centre for Health Statistics references) and the adequately nourished group comprised of 407 children matched for school and class (weight-for-age > - 1SD). Both groups were stratified by class and school, than randomly assigned to breakfast or control groups. After the initial measurements, breakfast was provided every school day for one year. Children in control group were given one-quarter of an orange and the same amount of attention as children in breakfast group. All children had their heights and weights measured and were given the Wide Range Achievement Test before and after the intervention. School attendance was taken from the school's registers. Compared with the control group, height, weight, and attendance improved significantly in the breakfast groups. Both groups made poor progress in Wide Range Achievement Test scores. Younger children in the breakfast group improved in arithmetic. There was no effect of nutritional group on the response to breakfast. In conclusion, the provision of a school breakfast produced small benefits in children nutritional status, school attendance, and achievement. Greater improvements may occur in more undernourished populations; however, the massive problem of poor achievement levels requires integrated programmes including health and educational inputs as well as school meals.(AU)

A case-control study of aggressive and pro-social Jamaican school boys

We examined the correlates of behaviour of 102 aggressive and 103 pro-social boys, selected by peer and teacher ratings, from grades 5 and 6 in 10 primary schools in urban Kingston and St. Andrew. The children were given in-depth questionnaires, school achievement test (WRAT) and verbal ability tests (Peabody Picture Vocabulary Test). Their parents were also given questionnaires. Interobserver and test retest reliabilities were established for all questionnaires and tests. Interviewers were unaware of the boys' groups. The aggressive group was significantly older (mean 11.1 years; t-test p<0.1). The aggressive group had significantly lower scores on both the number of possessions and the housing rating (proxies for socio-economic status); they showed significantly lower scores on spelling, arithmetic, reading and verbal IQ, and considered themselves less bright than the pro-social boys. Preliminary analyses indicate that, as expected, the aggressive boys fought more and used knives more compared with the pro-social boys. They reported receiving significantly more punishment at home. The aggressive group indicated that they saw significantly more family fights. All differences remained significant when socio-economic status was controlled in analyses of covariance except that the difference in the arithmetic scores was no longer significant. Many of these patterns are similar to those reported elsewhere.(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)

Social environment, morbidity and use of health care among people with diabetes mellitus in Trinidad

BACKGROUND: This study aimed to identify social characteristics associated with higher levels of morbidity from diabetes and their relationship to health care utilization. METHODS: During a 6-month period 1149/1447 (79 percent) subjects admitted to Port of Spain Hospital, Trinidad with diabetes responded to a structured interview. Data collection included social factors, diabetes-related morbidity and health care utilization. Analyses were adjusted for age, sex, ethnic group and self-reported diabetes duration. RESULTS: Of 12 indicators of morbidity, nine were more frequently in subjects with no schooling compared with those with secondary education. At ages 15-59 years, nine morbidity indicators were less frequently among subjects in full-time jobs compared with those not in employment. The association of educational attainment was explained by confounding with age, sex, ethnic group and diabetes duration but five morbidity indicators were associated with employment status after adjusting for confounding. The type of water supply in the home was generally not associated with morbidity. Each of the indicators of lower socioeconomic status was associated with less use of private doctors and with more use of government health centres. CONCLUSIONS: Morbidity from diabetes was greater in groups with lower socioeconomic status. While morbidity associated with lower educational attainment was mostly explained by older age; the results suggested the possibility that diabetes may contribute to unemployment of those in the labour force. Private care was less accessible to social groups with higher levels of morbidity and the availabiltiy of government funded health services was important for reducing inequalities in health care utilization.(AU)

Lifestyle in Curacao: smoking, alcohol consumption, eating habits and exercise

The Curacao Health Study was carried out among a randomized sample (n = 2248, response rate = 85 percent) of the adult non-institutionalized population in order to assess aspects of lifestyle that may pose health risks. Factors examined were tobacco and alcohol use, eating habits and exercise behaviour. Outcome variables were cross-tabulated by gender, age and socioeconomic status. 17.1 percent of the participants were smokers and 20.5 percent regular drinkers, including 6.3 percent of the men who consumed alcohol excessively (4 or more glasses of alcohol a day). 75 percent of the participants did not excercise regularly, 37 percent did not eat vegetables daily, and half did not eat fruit daily. Other poor eating habits were the addition of extra sugar and salt to prepared food by 33 percent and 20 percent of the participants, respectively. On the whole, men had less healthy lifestyles than women, with the exception of execise behaviour. People of high socioeconomic status (SES) drank less alcohol, and exercised more often than those of low SES. Considering the high prevalence of diabetes mellitus and hypertension in the Caribbean, research of lifestyle factors in other Caribbean countries is required to facilitate the development of regional prevention and intervention programmes. (AU)

Are clinical criteria just proxies for socioeconomic status? A study of low birth weight in Jamaica

OBJECTIVE: To determine if the clinical risk factors for low birth weight are independent of socioeconomic risk factors in a population based sample from a developing country. DESIGN: Survey data from patient reported socioeconomic measures and their most recent pregnancy history. SETTING: A national sample of randomly selected households in Jamaica. SUBJECTS: All women aged 14-50 in the household who had a pregnancy lasting seven months in the past five years (n = 952). MAIN OUTCOME MEASURE: Birth weight. RESULTS: Clinical risk factors for low birth weight, such as parity age, are independent of socioeconomic determinants, such as consumption and where a mother lives. Women who are nulliparous, 35 or older, poor, or living in certain areas are more likely to have lower birth weight children than those that do not have these characteristics (t statistics > 2.0). The addition of socioeconomic factors to the multiple regression does not alter the estimates for the clinical risk factors for low birth weight. Thus, the effect of being nulliparous can be offset by being in the highest consumption quintile and, conversely, the risk of being older will be compounded if women are poor. CONCLUSIONS: Both clinical and socioeconomic risk factors should be used to target women at risk. In terms of the quality of care, this study links clinical and socioeconomic risk factors to poor outcomes. Further studies are needed, however, to link the quality of care at various locations to these outcomes.(AU)

Social economics of childhood glucocorticoid stress response and health

This study examines socioeconomic conditions, psychosocial stress, and health among 264 infants, children, adolescents, and young adults aged 2 months to 18 years residing in a rural Caribbean village in Dominica. Fieldwork was conducted over a 9 year period (1988-1996). Research methods and techniques include salivary cortisol radioimmunoassay (N = 22, 438), systematic behavioral observation, psychological questionnaires, health evaluation, medical records, informal interviews, and participant observation. Analyses of data indicate complex relations among socioeconomic conditions, stress, and health. Household income, land ownership, parental education, and other socioeconomic measures are weakly associated with child illness. There is no evidence that apparent material benefits of high socioeconomic status such as improved housing, diet, work loads, and access to private health care have important direct effects on child health in this population. However, social relationship, especially family environment, may have important effects on childhood psychosocial stress and illness. Abnormal glucocorticoid response profiles, diminished immunity, and frequent illness are associated with unstable mating relationships for parents/caretakers and household compositon. We suggest that family relationships and concomitant stress and immunosuppression are important intermediary links between socioeconomic conditions and child health.(AU)

Lifestyle, education, and prevalence of hypertension in populations of African origin. Results from the International Collaborative Study on Hypertension in Blacks

Lifestyle Incongruity has been shown to be associated with elevated blood pressure in various developing societies. We sought to test this model in a international collaborative study of hypertension in populations of African origin. Data were available for 4770 men and women, aged 25-74, from Africa, the Caribbean, and the United States. The main effects of lifestyle score (LSS) and education on hypertension prevalence were explored, as well as interaction predicted by the Lifestyle Incongruity model. Significant interactions were observed, but only the U.S. men conformed to the pattern predicted. For this group, adjusted ORs for LSS were 4.45 among low-education and 0.71 among high-education subgroups (risk OR = 0.16, 0.03-0.84 95 percent CI). The Lifestyle Incongruity model therefore received limited support. The model was designed to describe processes in societies experiencing modernization and opportunities for lifestyle differentiation, conditions that may not have been met in some sites.(AU)

Characteristics of HIV-infected pregnant women in the Bahamas

The Commonwealth of the Bahamas has one of the highest rates of acquired immunodeficiency syndrome (AIDS) in the English-speaking Caribbean. A seropositive study of the pregnant women attending antenatal clinics in New Providence in 1990-91 showed that of 3,914 pregnant women tested, 2.9 percent were human immunodeficiency virus (HIV) infected. Women born in the Bahamas constituted 79.2 percent of the women tested; 17.7 percent were born in Haiti. The rate of HIV infection was 2.5 percent in the Bahamian women as compared with 4.5 percent in those born in Haiti. The highest incidence was in women aged 25-34 years and in women who had multiple pregnancies. There was a significant association with a history of crack cocaine use by the Bahamian women. There was also a significant association between a lack of education and HIV infection in this group. There was a lower rate of condom use among women with less education and also among women in common-l

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).