Quality of life and labour force participation in people living with HIV: The TREVI study in Barbados and The Netherlands

OBJECTIVE: The TREVI study compared cohorts of persons living with HIV in Barbados and The Netherlands to investigate the impact of living with HIV on health-related quality of life, cognitive functioning and labour force participation. SUBJECTS AND METHODS: Cross-sectional cohorts were recruited from the Ladymeade Reference Unit, Barbados (n = 129) and the Outpatient Clinic of Erasmus Medical Centre, Rotterdam, The Netherlands (n = 315). RESULTS: The Barbados cohort was younger (mean age 37years) and more gender mixed (58% male) than the Dutchcohort (48 years; 87% male). Both cohorts were well controlled with respect to viral load (> 90% undetectable HIV virus). Unemployment was similar (31% vs 35%) but Dutch respondents reported greater job satisfaction and less anxiety. The Barbadian cohort scored better in self reported quality of life, physical functioning, general health perception, happiness, cognitive functioning and depression. Dementia assessed on the International HIV Dementia Scale scale was equivalent (10.8 ± 1.0 vs 10.8 ±1.3). Dutch clients were more likely to have disclosed their status to sexual partners, family, or work colleagues. Barbadians were more likely to have been hurt by the reaction of friends to their HIV status (36% vs 17%). CONCLUSIONS: The TREVI study revealed higher perception of health, happiness and quality of life among an HIV cohort living in Barbados. Willingness to disclose HIV status and perceptions of stigma and workplace satisfaction were better among the Dutch cohort. Both recorded similar levels of educational attainment and unemployment. The social, workplace and psychological support needs of persons living with HIV are therefore distinct between these two countries.

Los escenarios sociales en America Latina y el Caribe / The social setting in Latin America and the Caribbean

A wide range of sources have pointed out the magnitude and depth of the social problems that trouble Latin America and the Caribbean and the risks that these problems pose for democracy. Although there are other issues that merit consideration, this article briefly outlines nine key social problems: 1) the increase in poverty, 2) the impact of poverty, 3) unemployment and informal employment, 4) deficiencies in public health, 5) problems in education, 6) the newly poor, 7) the erosion of the family, 8) increasing crime, and 9) the perverse cycle of socioeconomic exclusion. Solving these problems must not be delayed. It is urgent to move to a comprehensive view of development that achieves a different balance between economic and social policies, and that recognizes the indispensable role of these policies in achieving truly sustainable development. At stake are problems that not only concern resources, but also priorities, levels of equity, and the organization of society. Facing up to this poverty and inequity requires an in-depth assessment of these economic policies' social consequences, of the crucial subject of Latin American inequity-the greatest in the world-and of the role of social and public policies (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)

Patient perception and satisfaction with health care professionals at primary care facilities in Trinidad and Tobago

This paper endeavours to identify the background characteristics of health centre users in Trinidad and Tobago and their perceptions of the efficiency of the services provided. Multistage sampling was employed to select 1451 users. Data were obtained during structured interviews on regular clinic days. Of the people using the health centres, 80.4 percent were unemployed and 75.9 percent were women. People aged over 60 accounted for 25.4 percent of the sample. Users included a disproportionately high number of persons from the lower socioeconomic categories. The proportions of persons of different ethnic and religious groups closely reflected those in the country's general population. Approximately 74 percent of the interviewees were satisfied with the performance of the doctors in the health centres. For nurses the satisfaction rating was about 10 percent higher. The greatest needs for improvement were perceived to be in pharmacists' and doctors' services, with particular reference to waiting times.(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)

Social inequalities in morbidity from diabetes mellitus in public primary care clinics in Trinidad and Tobago

Associations between soci-economic status and non-communicable diseases in middle income countries have received little study. We conducted an interview survey to evaluate the asociations of morbidity with social conditions among people attending government primary care health centres with diabetes mellitus in Trinidad. Data collected included morbidity from hyperglycaemia, foot problems, visual problems and cardiovascular disease, as well as social demographic variables. Of 622 subjects, 35 percent were aged > or = 65 years, 54 percent were Indo-Trinidadian, 13 percent had no schooling, only 11 percent were in full-time employment, and 33 percent had no piped drinking water supply in the home. Prevalent symptoms included itching, reported by 215 (35 percent), nocturia in 315 (51 percent), burning or numbness in the feet in 350 (56 percent), and difficulty with eyesight in 363 (58 percent). A morbidity summary score was used as dependent variable in regression analyses. Comparing those with no schooling with those with secondary education, the mean difference in morbidity score was 1.77 (95 percent CI 1.15-2.39), attenuated to 0.71 (0.06-1.37) after adjusting for age, gender, ethnic group and diabetes duration. The equivalent differences for those with no piped water supply in the house, compared with those with, were 0.53 (0.17-0.88) and 0.57 (0.24-0.89). For the unemployed, compared with those in full-time jobs, at ages 15-59 years difference were 0.85 (0.14-1.56) and 0.58 (-0.11-1.27). We conclude that morbidity in persons with diabetes is associated with indicators of lower socio-economic status and that this association is partly explained by confounding with older age, female gender, longer duration of diabetes and Indo-Trinidadian ethnic group. A negative association between socio-economic status and morbidity from diabetes contributes to a justification for investment of public health resources in the control of diabetes and other non-communicable diseases(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)

Gender and life-cycle differentials in the Impact of Health employment in Jamaica - abstract

The impact of health on labour market work is analyzed using the 1989 Jamaican Survey of Living Conditions data set. In contrast to most economic studies which focus on retirement, we investigated this relationship for individuals aged 15-80 years old and find that poor (self reported) general health has a significant effect on both the entry and retirement decision. Although women reported a higher incidence of poor health, the impact of ill-health is larger for males than for females. Results are robust to an alternative measure of health status based on activities of daily living. These latter estimates indicate that while any limitations affect the employment behaviour of males, only severe limitations affect the behaviour of females. (Au)

Patient satisfaction at health centres in Trinidad and Tobago

The aim of this paper is to identify background characteristics of health centre users in Trinidad and Tobago and their perceptions of the services provided. Multi-staged sampling was used to select 1,500 health centre users throughout the country. Data were obtained using structured interviews conducted on regular clinic days. Results show that there is an overwhelmingly large percentage of unemployed persons (80.4 percent) and women (75.9 percent) among the users of health centres. The elderly is well represented, with 25.4 percent of the sample being over 60 years of age. Also occupational status of family wage earners and educational attainment levels of respondents reflect a disproportionately higher number from lower socio-economic groupings among health centre users. On the other hand, proportions of different ethnic and religious groups among the respondents bear a striking similarity to the general population of Trinidad and Tobago. Respondents appear to be generally satisfied with the services of the health centres. When the categories for <

Suicides in Trinidad and Tobago: associations with unemployment, crime and emigration

Death by suicide is an important public problem and efforts to identify its causes are needed so as to facilitate its prevention. Although mental illness is an established risk factor, the role of socioeconomic factors has not been explored. We, therefore, conducted an investigation to determine whether suicides in Trinidad and Tobago are related to social distress. Using national statistics for the period 1978 - 1992, associations were examined between suicide rates and unemployed, serious crimes and emigration rates. Over the 15-year period examined, there was a 319 per cent increase in male suicide rates, from 4.96/100,000 in 1978 to 20.76/100,000 in 1992. The rate in females was fairly constant remaining below 8/100,000 throughout the period. Over the same period there was a 51 per cent increase in serious crime, an 89 per cent increase in male unemployment and a 33 per cent increase in female unemployment. However, there was a fall in the rate of permanent emigration. Male, female and total suicide rates were significantly associated with serious crimes and unemployment (male, female and total). However, there was no association with emigration. The results of multiple regression analyses indicated that female unemployment was an independent predictor of male suicides while crime was an independent predictor of female suicides. Because of the design, the present study could not determine whether the observed associations were causal. However, the results suggest that at least some suicides in Trinidad and Tobago, during the period examined, may have been due to social distress. Programmes to ease this distress should have a positive effect on the suicide rate (AU)

Work, gender, and culture in the Jamaican community health aide programme

This dissertation explores the relationship among the organization of work in primary health care, the workplace culture of the Jamaican community health aides, and their domestic culture. Collected during twelve months of fieldwork in St. James parish in 1987 and 1988, the data include field notes from participant observation with community health aides, transcrips of tape recorded interviews with twenty aides, and information found in manuals and reports of the Ministry of Health and the Department of Social and Preventive Medicine at the University of the West Indies. National and international political and economic forces, the position of women in Jamaica, and contradictions in primary health care policy coverage in the Jamaican health service where they shape the organization of work in primary health care and give rise to the constraints and possibilities the community health aides find in their work. Fraught with conflicts and ambiguities, the organization of work in primary health care provides the space for, and necessitates, the workplace culture that emerges in the ideology and daily practices of the community health aides. With women predominating at every level in primary health care in Jamaica, domestic culture is a resource in the aides' response to the organization of their work and the workplace culture that emerges. Four features define the community health aides' workplace culture: 1) the aides'ability to construct an identity as mediators between the health service and the community from their marginal position in the hierarchial organization of primary health care; 2) the aides' ability to negotiate a compromise between the competing demands for staff in the health centers and community work, a compromise they turn to advantage in maintaining their claim to unique knowledge of their communities; 3) the aides' ability to cope, on the basis of their commitment to primary health care and their empathy with people, with material contradictions in their workplace; the permeability of the aides' workplace to their domestic culture which supports them in their struggle for control over their work and a better daily life while it enhances the delivery of primary health care. (AU)

Anticipated child loss to migration and sustained high fertility in an east Caribbean population

Development today is mainly accompanied by rapid utilization and, where possible, high rates of migration to industrialized countries. At the same time, the expected demographic transition has often not materialized despite decreases in death rates. Child-to-woman ratios in St. Vincent and the Grenadines are related to the educational attainment of women in a census district, the percentage of men engaged in agriculture, whether the district has direct access to the outside world through a port or airport, and, when the other variables are controlled, the stability of the district's population. Those districts with the greatest stability of population had the lowest child-to-woman ratios, suggesting that the anticipated loss of children to migration may be an important factor in maintaining high reproductive rates (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)

Malnutrition in children attending a Barbadian polyclinic

Given the relatively high standards of living in Barbados, indicated by the per capita income of U.S. $3.500, level of education and health care, and the activities of the National Nutrition Centre since 1972, it was felt that the prevalence of malnutrition (8.8 percent) reported in the 1981 National Health and Nutrition Survey was still relatively high. It was, therefore, decided to determine the prevalence of malnutrition in a clinic and factors associated with the nutritional status of the children. Weights and ages of all children 6-42 months of age on clinic records were noted. Then the parents or guardians of 104 children (52 malnourished or index and 52 normal or comparison) attending the clinic were interviewed. Anthropometric measurements (weight, height and head circumference) of the 104 children were taken; and information from both their clinic records and their mothers' maternity records was noted. In the index group (46 percent) mothers were employed compared with 40 (77 percent) in the comparison group, a difference that was statistically significant. There were 20 and 39 houses in the index group with piped water in the house and in poor state of disrepair respectively compared with 37 and 49 in the comparison group, differences that were significant at the 1 percent and 5 percent level respectively. The comparison group had significantly more households with gas stove (50), kitchen appliances (31), telephone (30) and refrigerators (42), than the index group: gas stove (41), kitchen appliances (18), telephone (19) amd refrigerator (31). In the study 22 children in the index group compared with all 52 children in the comparison group were receiving their first solid food too early and too late respectively; these differences were statistically significant. In the present diet, significantly larger numbers of children in the comparison group were receiving milk and cereal, 38 and 32 children respectively, than in the index group, 25 and 21 children. However, significantly more children (18) in the index group were receiving bush teas than the comparison group, 2 children. In the index group 21, children had low birth weights (i.e. 2500g) compared with 1 child in the comparison group. Similarly, more children (34) in the index group than the comparison group (21) were ill; and 23.1 percent of the index sick children had 3 or more episodes compared with 3.8 percent in the comparison group. All these differences were significant at p<0.001. In addition to those factors already mentioned, there are a number of other factors thought to be associated with poor nutritional status but which were not found to be so in this study. For example, there was no difference in the level of educational attainment of mothers in the index group (19 primary, 33 post-primary) and the comparison group (19 primary, 33 post-primary). Further, both groups had a similar family size: index 6.7 and comparison 6.3. Other factors not associated were presence of male head (50.0 percent index, 63.5 percent comparison); working male head and mothers' age and union status. Yet it should be noted that there was a tendency for the comparison group to have higher values than the index group. It was concluded that: (1) the socioeconomic or standard of living conditions in the comparison group were better than those of the index groups indicated by mother's employment, mean household income, crowding, better housing and household amenities such as gas stove, refrigerator and telephone. (2) Feeding practices in the comparison group were generally better than in the index group as indicated by dilution of milk formula, age first solid foods were given and receiving cereals and milk in their diet (3) children who are sick and have frequent episodes of illnesses are more likely to have low nutritional status; and (4) children with normal birth weights are more likely to have better nutrition status (AU)