Gender-based violence: don’t ask, don’t tell, don’t care

OBJECTIVE: Our goal was to highlight the ongoing disparity, promote discussion, and advocate for further funding to examine the factors associated with sexual violence to target prevention rather than intervention. DESIGN AND METHODS: We compared prevalence, incidence, and economic burden of sexual violence to other major public health issues in the US: cardiovascular disease, cancer, and diabetes. We compared the public funding allocated to an issue as a proxy of the social priority of addressing the issue. Finally, we calculated the ratio of public funding to economic disease burden. RESULTS: [Table]. CONCLUSION: Public funds allocated to sexual violence were a fraction of those allocated to other major public health issues such as cardiovascular disease, cancer, and diabetes despite similar incidence, prevalence, and economic burden between them. While sexual violence was similarly prevalent and costly to these other major public health issues, it received a fraction of public funds.

Psychological autopsy as a method of investigating suicide in Jamaica [Abstract]

OBJECTIVE: To assess the usefulness of the psychological autopsy in the Jamaican setting for investigating the characteristics of suicides in respect of psychiatric diagnoses and stressful life events. METHODS: The study was conducted in the parishes of Kingston, St.Andrew and St.Catherine, Jamaica. All suicide cases occuring between January 1 and December 31, 1998, were identified on the basis of police records. After obtaining informed consent the autopsy process initiated by interviewing key informants identified by relatives. Semi-structured interviews to assess mental state and stressful life events were conducted by a psychiatrist and supplemented by a review of case notes. A structured questionnaire was used to assess sociodemographic characteristics. An assessment of mental status prior to death was done and DSM IV criteria used to classify psychiatric disorders. Thiry-two suicides were studied using the psychological autopsy method. There was overwhelming willingness among key informants to be interviewed. RESULTS: The approach was fairly time consuming; interviews ranged from forty-five minutes to four hours (mean of 2 hours) having to be extended at times to allow for expression of emotions by informants. The method allowed for fairly easy retrospective formulation of psychiatric diagnosis (90 percent of victims) and for the elucidation of comorbidity. Substancial levels of stressful life events were also exposed. Many relatives expressed relief at being able to discuss these deaths with a neutral person. CONCLUSIONS: The psychological autopsy approach has provided valuable insights into the epidemiological and psychosocial context of suicide occurrence in these three Jamaican parishes. It has potential for ongoing surveillance and in the planning of prevention programmes. Its use among community mental health professionals should be evaluated. (AU)

Diabetes, lower extermity amputations and podiatry

We are all worried and simultaneously frustrated by the increasing prevalence of diabetes mellitus (DM) throughout the world and the anticipated increase in diabetes-associated complications, including lower-extremity amputations (LEAs). At the same time, we realize that primary prevention programmes for both Types 1 and 2 diabetes, and/or a "cure" are both still a few years into the future; and secondary (controlling blood glucose, blood pressure, and blood lipids) and tertiary (detecting complications early and treated appropriately) prevention programmes have been scientifically and economically validated. However, even with this knowledge, we are frustrated by two things: the "gap" between what we all should be doing and what is actually happening in daily clinical and public health practice; and between information we need about important and practical health services research questions about LEAs, e.g. how often should we really be examining the feet of someone with diabetes and with what methodology. With this background, where do podiatric health care professional fit into efforts to address diabetes-related LEAs? While certainly the rigour and completeness of podiatric training programmes in many countries legitimize their more active role in preventive care practices for people with DM, my own experience is that the podiatry community has skills, interests, abilities relevant to LEAs, beyond care. Both within academic centres and from practice, podiatrists have added and can add to the understanding and knowledge base about diabetes-related lower extermity disorders. Further, based on experiences with the CDC-NIH supported National Diabetes Education Programme (NDEP), podiatrist have embraced and enhanced general secondary prevention and public awareness activities about diabetes. Podiatrists have demonstrated their thoughtfulness and "power" by addressing a very large United States of America governmental agency - the Health Care Financing Administration (HCFA) - to begin to seriously address prevention programmes for diabetes-related LEAs, i.e. changing policies. While there are and will always be tensions within and among various diabetes disciplines, "today's podiatry is not your father's podiatry".(Au)

Controlling Hypertension among African-Caribbean patients

The older age groups of African-Caribbean people are at particular risk of hypertension and stroke, and comprise the original migrant group who came to the UK in the 1955's and 1960's as young adults. This raises questions of the significance of traditional cultural beliefs and practices for health behaviours and medication use. AIMS: to examine 1) the cultural beliefs and medication practices of African-Caribbean and "white" hypertensive patients treated by general practices in Lambeth and 2) GPs awareness of the beliefs of African-Caribbean patients. METHODS: Case note review and semi-structured interviews with 60 hypertensive patients treated by general practices in Lambeth, and with 22 GPs from the study practices. RESULTS: Most African-Caribbean patients were aware of the risk of high blood pressure, although often adopting a fatalistic attitude. They had high levels of uncontrolled blood pressure and reported low levels of adherence with the prescribed medication (16/30 regularly "left off" the medication or took a reduced dose). Major reasons were concerns about possible present or future side-effects, fears of becoming "addicted" or "dependent" on the drugs, worries about mixing tablets with alcohol, and questioning their needs for the drugs. Familiarity with traditional herbal remedies increased worries about power of prescribed drugs and formed an alternative resource for managing illness. "Cerasee"(Momordica charantia) obtained from the local market was often taken for blood pressure problems and perceived as "natural" and less harmful than prescribed drugs. GPs were not aware of African-Caribbean patients' beliefs and medication practices, with implications both for prescribing and patients's interpretation of the information provided for their own self management. Feedback of the study findings was helpful to GPs in reducing cultural barriers to communication and managing this patient group. CONCLUSIONS: Low levels of compliance with treatment is likely to contribute to uncontrolled blood pressures among African-Caribbean population, while health promotion strategies require to take account of cultural beliefs and practices prevalent among the older generation of African-Caribbean people. Further work is planned (with Kings) to examine the use of herbal remedies among larger population samples, the phytochemical properties of Momordica charantia obtained from different outlets and its possible hypotensive effects. (AU)

The dietary fatty acids of patients with coronary artery disease and control in Curacao: implications for primary and secondary prevention

Patients with coronary artery diseases are advised to augment their dietary linoleic acid intakes at the expense of saturated fatty acids. We investigated whether the dietary linoleic acid intake of 57 patients with coronary artery disease (47 males, 10 females; ages 61 ñ 10 years) in Curacao is higher as compared with 77 controls (51 males, 26 females; ages 56 ñ 7 years). For this, we measured plasma cholesterol ester fatty acids, which reflect the dietary fatty acid composition of the preceeding weeks. Patients with coronary artery disease and controls had minor differences in cholesterol ester fatty acids. Their cholesterol ester linoleic acid content suggests that the dietary polyunsaturated/saturated fatty acid ratio is far below 1. Comparison with data reported for the the Netherlands, Greenland and Crete showed that the dietary fatty acid composition in Curacao is typically Western with a high intake of saturated fatty acids, a low intake of monounsaturated fatty acids and the consumption of linoleic acid as the predominant polyunsaturated fatty acid. Intake of long chain polyunsaturated fatty acids from fatty fish is low. Reduction of dietary saturated fatty acids, augmentation of fish consumption, and an increase of the O-linolenic/linoleic acid ratio are likely to be of benefit to both primary and secondary prevention from coronary artery disease in Curaco.(AU)

Management of heart failure in the Caribbean

Heart disease and in particular, heart failure, has become the number one cause of death in most Caribbean countries, following the epidemic increase in obesity, hypertension and diabetes. The most common cause of heart failure is uncontrolled hypertension. Effective management demands major health care expenditure with relatively unrewarding long term results. The priority for Caribbean countries must be primary and secondary prevention with emphasis on weight reduction, blood pressure control and a healthy life-style, to avoid the high costs of drugs and tertiary care. (AU)

Emerging evidence of the effectiveness of nutrition services

Despite lack of uniformity of data, emerging evidence of the effictiveness of nutrition services in outpatient services , prenatal services, among diabetic and hypertensive patients indicate that nutrition services can lead to dietary change and subsequently to improved health outcomes and ultimately to decreased health care costs

Can diabetes mellitus be prevented? - abstract

Many secondary and tertiary interventions have proven effective in preventing the complications of diabetes mellitus. Of note, The Diabetes Control and Complications Trial has established that intensive treatment of diabetes mellitus with the goal of normo-glycaemia delays the development and slows the progression of renal failure. Screening and photocoagulation for macular oedema and proliferative retinopathy are highly effacious at reducing the progression of these complications to blindness. It is estimated that more than half of the non-traumatic amputations in diabetics can be prevented by appropriate education, footcare and early intervention for trauma, ulcer and infection. Patients and purveyors of care to patients with diabetes mellitus should institute these interventions in their patients to reduce the long-term effects of hyperglycaemia. At present, however, there are no interventions which have been proven to prevent development (primary prevention) of diabetes mellitus. Several large scale trials (Diabetes Prevention Trial - Type 1 Diabetes (DPT-1), European Nicotinamide Diabetes Intervention Trial (ENDIT), European Insulin Trial (EUROINS) are underway to try and prevent IDDM by administration of nicotinamide or insulin to individuals with increased risk of developing diabetes mellitus. Large scale studies of primary prevention studies of NIDDM are planned or are underway. Primary prevention of diabetes mellitus is intuitively attractive. Chronic disease models indicate that the delaying of the onset of diabetes mellitus enhances the effect of intensive treatment on reducing complications, and that the combined approach is more effective than either alone. It is appropriate to allocate research resources to large-scale clinical trials of diabetes primary prevention at this time. Trials of immunomodulation of the natural history of IDDM is supported by work in animals and pilot studies in man. Epidemiological studies suggest that lifestyle interventions such as diet and exercise may prevent development of NIDDM in susceptible individuals, and drugs that affect insulin secretion and/or action are also potential candidates for primary prevention of NIDDM (AU)

Growth monitoring: the role of community health volunteers

A community volunteer programme was initiated in rural Jamaica in May 1990. The main aim of the programme was to monitor the growth of children less than 36 months of age through community health volunteers (CHVs) and improve their nutritional status. At the end of the second year the programme was evaluated to determine effectiveness. The results of the evaluation indicated that almost all (95.6 percent) of the children were covered by the CHVs. In addition the participation rate was high (78.5 percent). However, only 50 percent of the children were adequately covered. Nonetheless, 81 percent of them gained adequate weight. Indeed, malnutrition levels declined by 34.5 percent. The annual cost per child per year for the total programme was fairly moderate (US$14.5) with growth monitoring accounting for nearly half (42.7). The results suggest that CHVs can play an important role in primary health care programmes in developing countries(AU)

Colorectal cancer: prospects for prevention

Primary prevention has too often been elusive and mythical with regard to the activities of a physician. Colorectal cancer appears too often as an exceptionally opportunity. New information about the epidemiology, the development of a better method of testing for occult blood and the flexible fiberoptic endoscopic has made mass screening for precursors of an early stage of cancer of the colon practical and cost effective (AU)