Depression and diabetic control amongst a chronic disease clinic in Trinidad

Objectives: The goals of this study were to evaluate the relationship between two outcomes; depression and uncontrolled diabetes as well as to determine the prevalence and associated factors of these two main outcomes amongst diabetics attending a chronic disease clinic in Trinidad. Research Design and Methods: A cross-sectional study utilizing a researcher-administered questionnaire with a sample of 239 diabetic patients from the St Joseph Enhanced Health Centre. The Patient Health Questionnaire was used to determine the presence of depression whilst history from patients and laboratory data from the files were used to determine the HbA1C and other factors. Results: Depressed patients had increased odds for uncontrolled diabetes (OR 8.24 95%CI 3.37-20.17 p <0.000). Mann-Whitney U testing showed significant differences between the median and variance of the HbA1C between the depressed and non-depressed group, with the depressed group having a median HbA1C 9.0% and the non-depressed group a median of 7.1%. Prevalence of depression was 23.4% in this population and 59.4% of patients had HbA1C >7.0%. Factors associated with increased odds for depression were females, unemployment, no exercise and treatment with insulin. Decreased odds for depression was associated with religious participation, frequent exercise, compliance with medication and Afro-Trinidadian ethnicity. With respect to uncontrolled diabetes, housewives and those on insulin had increased odds whilst single persons and those who comply with medications had decreased odds for uncontrolled diabetes. Conclusions: The presence of depression is associated with 8x increased odds of uncontrolled diabetes, with depressed persons having higher average HbA1Cs than non-depressed. Persons treated with insulin had increased odds of both depression and uncontrolled diabetes whilst those compliant with medication had lowered odds for both.

Detecting alcoholism in primary care among Trinidadians: using the CAGE and AUDIT-C screening tools

OBJECTIVES: To measure the proportion of attendees in a primary care setting consuming alcohol at levels which put them at risk of alcohol-related harm using the CAGE and AUDIT-C Screening tools. DESIGN AND METHODS: A cross-sectional study was used. The population consisted of all adults ≥18 years in a primary care setting. The CAGE and Alcohol Use Disorders Identification Test (AUDIT-C) screening tools were administered to 865 randomly selected participants. RESULTS: Of the 865 participants entered into this study, 514 participants drank alcoholic beverages. Furthermore, 142 (27.6%) were found to be CAGE positive (≥2) where more men (100, 11.5%) than women (42, 4.9%) were CAGE positive. A larger proportion of South-East Asians 60 (11.7%) were found to be CAGE positive than Africans 51 (9.9%) (ρ = 0.6221). For the AUDIT-C, 460 individuals participated with a response rate of 89.5%. With the score ≥ 4 in men, among the male drinkers 150 (32.6%) of the AUDIT-C screens were positive. For women, with the score ≥ 4, 100 (21.7%) of those who drank alcohol, screened positive. A larger proportion of South East Asians 101 (39.2%) were found to be AUDIT-C positive than Africans 105 (42%) (ρ = 0.7893). The Cronbach Alpha values for AUDIT-C and CAGE were 0.792 and 0.636 respectively. CONCLUSION: The CAGE screening tool identified 27.6% of the participants attending primary care facilities to be at risk of developing alcohol related disorders (ARDS). AUDIT-C identified 48.6% of participants to be at risk of developing an ARDS.

A parenting intervention delivered at routine primary health visits improved child cognitive development and parenting knowledge

OBJECTIVE: Several agencies have recommended integrating early child development interventions with health services. We developed and evaluated a parent training programme integrated into primary health visits. DESIGN AND METHODS: A cluster randomised trial conducted in Jamaica, Antigua and St Lucia with health centre as the unit of randomization. Fifteen centres were randomised to control (n=250 mother-child pairs) and 14 to intervention (n=251). Participants were recruited at the 6-8 week child health visit. Intervention was provided at routine health visits from age 3-18 months and comprised short films of child development messages followed by discussion and demonstration led by community health workers, and mothers’ practice of activities. Nurses distributed message cards and a few play materials. Primary outcomes were child development, measured 2 weeks after the 18 month visit, with the Griffiths Mental Development Scales and the Communicative Development Inventory (CDI). RESULTS: 85% of enrolled children were tested (control = 210; intervention=216). Loss did not differ by group. Multilevel analyses showed significant intervention benefits for cognitive development, (3.09 points; 95% CI 1.31, 4.87), effect size 0.30 SD. There were no benefits to language or hand and eye subscales, or CDI vocabulary score. Of six secondary outcomes there was a significant benefit to parenting knowledge, treatment effect 1.59 (95% CI 1.01 to 2.17), effect size 0.40. CONCLUSION: An innovative parenting intervention, requiring no additional clinic staff or mothers’ time, can be integrated into health services, with benefits to cognitive development and parent knowledge.

Instrument N° 2. HRH Program Evaluation Questionnaire: Expanded version

This instrument serves as the core document for evaluation and description of the HRH program selected. In order to complete the information requested, use the documents, reports, evaluations, budgets and HRH data available for program evaluation. Attached is a sample (fictional) of a rural health physician program from Canada. This document should be completed by the Director of HRH or the equivalent person in the Health Authority who has access to national information and is in consultation with the national institutions. (AU)

Prediction of 10-year coronary heart disease risk in Caribbean type 2 diabetic patients using the UKPDS risk engine

OBJECTIVE: Primary prevention of Coronary Heart Disease (CHD) in diabetic patients should be based on absolute CHD risk calculation. This study was aimed to determine the levels of 10-year CHD risk in Caribbean type 2 diabetic patients using the diabetes specific United Kingdom Prospective Diabetes Study (UKPDS) risk engine calculator. SUBJECTS AND METHODS: Three hundred and twenty-five (106 males, 219 females) type 2 diabetic patients resident in two Caribbean Islands of Tobago and Trinidad met the UKPDS risk engine inclusion criteria. Records of their sex, age, ethnicity, smoking habit, diabetes duration, systolic blood pressure, total cholesterol, HDL-cholesterol and glycated haemoglobin were entered into the UKPDS risk engine calculator programme and the absolute 10-year CHD and stroke risk levels were computed. The 10-year CHD and stroke risks were statistically stratified into <15%, 15-30% and >30% CHD risk levels and differences between patients of African and Asian-Indian origin were compared. RESULTS: In comparison with patients in Tobago, type 2 diabetic patients in Trinidad, irrespective of gender, had higher proportion of 10-year CHD risk (10.4 vs. 23.6%, P<0.001) whereas the overall 10-year stroke risk prediction was higher in patients resident in Tobago (16.9 vs. 11.4%, P<0.001). Ethnicity-based analysis revealed that irrespective of gender, higher proportion of patients of Indian origin scored >30% of absolute 10-year CHD risk compared with patients of African descent (3.2 vs. 28.2%, P<0.001). CONCLUSIONS: The results of the study identified diabetic patients resident in Trinidad and patients of Indian origin as the most vulnerable groups for CHD. These groups of diabetic patients should have priority in primary or secondary prevention of coronary heart disease.

Herbal self-medication at primary health care facilities in Trinidad

A letter to the editor is presented in response to the article regarding herbal self-medication at Primary Health Care Facilities in Trinidad, which appeared in previous issue.

Emergency medical training for health promoters in Central and South America

Underserved regions in the developing world are challenging areas to provide emergency medical care. As populations in these often remote or isolated districts may have minimal access to regular health care, contacts with medical providers are frequently episodic and driven by an acute condition. Health promoters—practitioners who provide basic medical care and promote public health in numerous countries across Central and South America, Asia and Africa—help to fill this void. Typically, health promoters are certified through a formal training program in their country and come from the same population as the clients they serve, which helps them form a link between their community and the dominant health care system in the region (1-2). Access to health and social services in regions served by health promoters is usually minimal, resulting in high morbidity and mortality associated with preventable diseases. Health promoters strive to improve the overall health of these communities by supplementing and improving the curative, preventive, and promotional aspects of the existing health system.

Health sector challlenges and responses beyond the Alma-Ata declaration: a Caribbean perspective

Primary health care (PHC) is defined as "essential health care based on practical, scientifically sound, and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination." For the effective delivery of PHC to occur, it must be undergirded by a national health system infrastructure that has five key components: (1) development of health resources, such as manpower, facilities, equipment and supplies; (2) organized arrangement of health resources through the establishment of national health authorities, the provision of national health insurance, and the integration of public and private health services; (3) delivery of health care through the media of primary, secondary and tertiary health services; (4) economic support through sources, such as public financing and foreign aid; and (5) management through strong leadership, policy formulation, regulation and monitoring and evaluation (AU)

Perceived efficacy of herbal remedies by users accessing primary healthcare in Trinidad

BACKGROUND: The increasing global popularity of herbal remedies requires further investigation to determine the probable factors driving this burgeoning phenomenon. We propose that the users' perception of efficacy is an important factor and assessed the perceived efficacy of herbal remedies by users accessing primary health facilities throughout Trinidad. Additionally, we determined how these users rated herbal remedies compared to conventional allopathic medicines as being less, equally or more efficacious. METHODS: A descriptive cross-sectional study was undertaken at 16 randomly selected primary healthcare facilities throughout Trinidad during June-August 2005. A de novo, pilot-tested questionnaire was interviewer-administered to confirmed herbal users (previous or current). Stepwise multiple regression analysis was done to determine the influence of predictor variables on perceived efficacy and comparative efficacy with conventional medicines. RESULTS: 265 herbal users entered the study and cited over 100 herbs for the promotion of health/wellness and the management of specific health concerns. Garlic was the most popular herb (in 48.3% of the sample) and was used for the common cold, cough, fever, as 'blood cleansers' and carminatives. It was also used in 20% of hypertension patients. 230 users (86.8%) indicated that herbs were efficacious and perceived that they had equal or greater efficacy than conventional allopathic medicines. Gender, ethnicity, income and years of formal education did not influence patients' perception of herb efficacy; however, age did (p = 0.036). Concomitant use of herbs and allopathic medicines was relatively high at 30%; and most users did not inform their attending physician. CONCLUSION: Most users perceived that herbs were efficacious, and in some instances, more efficacious than conventional medicines. We suggest that this perception may be a major contributing factor influencing the sustained and increasing popularity of herbs. Evidence-based research in the form of randomized controlled clinical trials should direct the proper use of herbs to validate (or otherwise) efficacy and determine safety. In the Caribbean, most indigenous herbs are not well investigated and this points to the urgent need for biomedical investigations to assess the safety profile and efficacy of our popular medicinal herbs.

Glycaemic responses after ingestion of 3 local carbohydrate-based foods in West Indian patients with type-2 diabetes mellitus

Summary - BACKGROUND & AIM: Previous studies suggest that inadequate glycaemic control in diabetic patients might be related to the type of carbohydrates the patients consume regularly. Thus, we aimed to assess glucose and insulin responses after diabetic and non-diabetic subjects ingested 3 commonly consumed carbohydrate-based foods. METHODS: Thirty-eight type-2 diabetic and 27 non-diabetic subjects were studied in 3 different occasions of 7 days apart. On each day of the study, anthropometric indices were measured and after collecting fasting blood samples, subjects randomly consumed bread, roti or rice within 10 min. Subsequently 7 ml of venous blood samples were collected at 60, 90, 120 and 150 min for determination of glucose and insulin responses. RESULTS: Although the diabetic patients were older than the healthy subjects (P < 0.05), both subjects had similar weight, body mass index and waist and hip circumferences (P > 0.05). The mean fasting and post meal plasma glucose concentrations for the 3 test foods were higher in diabetic patients than the corresponding values for the healthy subjects (all; P < 0.001). Generally, roti elicited the highest total incremental glucose responses in the diabetic patients irrespective of ethnic group (P < 0.05). CONCLUSION: There were variations in glucose and insulin responses to the 3 test foods. However, roti elicited the highest postprandial hyperglycaemia and should therefore be discouraged in regular dietary plan of diabetic patients.

Immunization manual for health professionals

The surveillance of vaccine preventable diseases has been very successful and had been recognised at the highest levels. Trinidad and Tobago was awarded 1st place in 2001 for surveillance of EPI diseases by PAHO/WHO at the Caribbean EPI managers meeting. The ultimate hallmark of a successful immunization programme is demonstrating that vaccine reduces the incidence of diseases therefore routine surveillance must be an important activity in any immunization programme. Surveillance can be termed "watchdog of the EPI". The immunization coverage for all antigens have exceeded 89 percent for all antigens. There is no room for complacency. The levels of immunization coverage must be sustained at over 95 percent so that vaccine preventable diseases will not have any human loss. In addition, let us continue to maintain our efforts to eliminate other diseases such as neonatal tetanus, diptheria, rubella, measles, polio and pertussis. In light of these successes, let us continue to increase our coverage, and prevent missed opportunities at all health facilities, clinics and schools, or wherever vaccination is being administered. New initiatives are needed to reach families in difficult circumstances, areas of severe social privation, mobile families and those in remote areas. It is also important to identify pockets of unimmunized children in urban populations and have them vaccinated. Immunization is a safe and highly effective method of preventing morbidity and mortality due to vaccine preventable diseases and is well established as a most cost effective programme in Public Health

Immunization manual for health professionals

This third edition contains details of important changes and additions. The Immunization Schedule for Trinidad and Tobago now reflects children being immunized as early as possible in life, and incorporates additional vaccines such as Pentavalent vaccine DPT/Hepatitis/Haemophilus influenzae type b.(DPT-Diptheria/Pertussis/Tetanus). The introduction of new combination vaccines improves the ability of the immunization programme to deliver safe and effective vaccines to infants and children, with fewer injections. Another change is that all persons will now receive Adult Diptheria Tetanus (Adult DT) vaccine instead of Tetanus Toxoid (TT) vaccine. MMR vaccine will be given to susceptible post-natal women, and all persons 19-45 years of age (Foreword)

Annual report of the Chief Medical Officer for the years 2000 and 2001

The annual report of the Chief Medical Officer gives an overview of the activities of the Ministry of Health for the years 2000 and 2001. It aims to provide reliable information on the health situation and the health care system in Barbados during this period.

Equity and the goal of health for all

There is a basic difference between the causes of diseases in population. We know that cigarette smoking causes cancer of the lung. If everyone in a population smoked, some would develop cancer, but we would never be able to identify tobacco as an etiologic factor. However, if one is seeking to enhance the health of populations, which is the main focus of public health, one has to be concerned with the distribution of the problems and the factors that influence such distribution in those populations. In the late 1970s the countries of the Caribbean, where I come from, were very advanced in their thinking about the steps to be taken to deal with population health issues, and they actually elaborated concepts that were very similar to those that subsequently were included under the heading of "primary health care." I found later that the Caribbean countries were not alone and that there was considerable ferment in public health circles in Latin America about the social causes of disease and the link between health and the various measures to achieve social progress. Health figured in the Pan American efforts to build a better future for the Americas. It could not have come as much of a surprise to the health authorities of this part of the world when the 30th World Health Assembly of the World Health Organization (WHO), in 1977, called for social justice and set Health for All as a goal. It is no accident that the main proponent and advocate of Health for All, Halfdan Mahler, of Denmark, was a man with a strong social conscience and was a firm believer in the possibility of galvanizing the world's nations to see the indecency of the differences in health that existed within and between nations (AU)

Glycaemic control and cardiovascular risk factors among patients with Type 1 diabetes mellitus in Trinidad [abstract]

Healthcare providers working at the primary care setting are often faced with the challenges of providing standard medicare in the absence of adequate resources and facilities. We assessed long-term glycaemic control and cardiovascular risk factors among patients with Type 1 diabetes mellitus at primary care clinics in an attempt to suggest an intervention programme to prevent long-term diabetic complications. Twenty-five (14 females, 11 males, mean age: 53.7 ñ 3.2 years) patients with Type 1 diabetes mellitus (mean (SE) duration: 15.7 ñ 2.0 years) attending two primary care clinics in Trinidad were studied after an overnight fast. Weight, height, waist and hip circumferences and blood pressure were measured and blood sample was taken for glucose, glycated haemoglobin, total cholesterol, triglyceride, HDL-cholesterol, LDL-cholesterol and creatinine determinations. There were no significant differences in the glycaemic exposure and the measured cardiovascular risk factors between male and female patients (p> 0.05). However, more than one-half (56 percent) of the patients had truncal obesity while 96 percent had glycated haemoglobin levels> 7.0 percent. The prevalence rates of hypercholesterolaemia (84 percent), hypertriglyceridaemia (28 percent) and increased LDL-cholesterol levels (88 percent) were high. About 48 percent of the patients had diastolic blood pressure> 83mmHg while 40 percent had total-cholesterol/HDL-cholesterol ratio greater than 6. We report that patients with Type 1 diabetes mellitus attending primary care clinics in Trinidad had poor glycaemic control and high levels of classical cardiovascular risk factors. These patients are at great risk of progressing to cardiovascular disease and therefore efforts at strict glycaemic control and protection against long-term diabetic complications should be intensified at primary care levels. (AU)

The institutional aspects of health sector reform: whither primary care? [abstract]

In recent years, there has been a great deal of discussion about the need for health sector reform. Most of the general discussions have centred around the need for ensuring equity, efficiency, effectiveness and quality, financial sustainability and intersectoral action and community participation. In practice, however, the large majority of the official efforts have focussed on health finance reform, as the several governments in the region have sought to cope with what has been defined as the health resource gap: that is, the difference between available revenues and rising health costs. In addition, the focus of most reform efforts has largely been on improving the health delivery systems. So far, there has been insufficient attention given to those factors affecting the demand for health and health care. Since one of these factors is likely to be the reform package itself, it is critical to seek to assess and evaluate the impacts of the reforms implemented. In this paper, it will be argued that socio-economic circumstances, as well as particular health finance reforms may be significantly changing the character of the demands for health care. It will be also suggested that to the extent that the inefficiency and ineffectiveness of the primary health care system has negatively contributed to the changing character of health demands, it may be necessary to raise questions about the current locus, viability and strength of the ideals of the primary care approach to health care. In this discussion, case material and data from selected countries in the Caribbean will be presented. (AU)

Development of primary health care in Jamaica

The development of primary health care in Jamaica is explored, tracing its early roots to the abolition of the slave trade, the collapse of estate-based services after emancipation and the subsequent establishment of the Island Medical Services in 1875. Most developments in the health sector occurred after World War I in response to the high infectious disease mortality rates. The Rockefeller Foundation was asked to assist with the control of hookworm, tuberculosis, malaria and yaws. Its recommendation led to the growth of public health programmes (eg environmental health, public health nursing, community midwifery) alongside community-based curative services run by hospitals. The most significant period of development occurred in the 1970s when the various vertical programmes were integrated into the current primary care system. Jamaica was integral in the development of the World Health Organization's Alma Ata Declaration on Primary Health Care, tabling the "Jamaican Perspective on Primary Health Care" which set out its goal that all citizens should be within 10 miles walking distance of a primary health care facility. At the close of the twentieth century, the health reform process led to the development of regional health authorities aimed at integrating the management of primary and secondary care under four Regional Boards of Health. This has led to a change in the role of the central Ministry of Health to one of policy-making, health promotion, setting standards, monitoring and evaluation of the quality of health care. (AU)

Why youths stay away from health centres: an assessment of youth health needs and health care services utilization

OBJECTIVE: To determine the extent to which the primary health care services meet the needs of adolescents in the North-West Health Region, Trinidad. DESIGN and METHODS: A systematic sample of Government and Government assisted elementary, secondary and technical/vocational schools in the North-West was included in the study. Between January and February of 1999, self administered questionnaires were completed by 300 students in the 11 to 19 age-group randomly selected from the schools' sample. RESULTS: Only 23.6 percent of the sample went `most often' to Health Centres `at some time' - 167 (56 percent) - the major source of discomfort was the lengthy waiting period (82.7 percent) while 22 percent felt that the attitude of the deliverers of the service was either poor or very poor. Young people requested that the community health administration provide a range of services that include sport and recreation (50.7 percent), educational programmes (48.6 percent), sex education (36.1 percent), career guidance (34.8 percent), counselling (30.7 percent). They preferred these services to be delivered in a building specially designed for that purpose. CONCLUSIONS: The health services currently being provided do not meet the needs of the youth. Their preference is for a mix of services that would focus on their physical, emotional and social needs. This would require a multisectoral collaboration and the participation of youth in the planning and development of such an initiative. (Au)