Cancer control in the Caribbean island countries and territories: some progress but the journey continues.

Cancer causes a fifth of deaths in the Caribbean region and its incidence is increasing. Incidence and mortality patterns of cancer in the Caribbean reflect globally widespread epidemiological transitions, and show cancer profiles that are unique to the region. Providing comprehensive and locally responsive cancer care is particularly challenging in the Caribbean because of the geographical spread of the islands, the frequently under-resourced health-care systems, and the absence of a cohesive approach to cancer control. In many Caribbean countries and territories, cancer surveillance systems are poorly developed, advanced disease presentations are commonplace, and access to cancer screening, diagnostics, and treatment is often suboptimal, with many patients with cancer seeking treatment abroad. Capacity building across the cancer-control continuum in the region is urgently needed and can be accomplished through collaborative efforts and increased investment in health care and cancer control.

Reduced forced vital capacity is independently associated with ethnicity, metabolic factors and respiratory symptoms in a Caribbean population: a cross-sectional study.

BACKGROUND: Relationships between low forced vital capacity (FVC), and morbidity have previously been studied but there are no data available for the Caribbean population. This study assessed the association of low FVC with risk factors, health variables and socioeconomic status in a community-based study of the Trinidad and Tobago population. METHODS: A cross-sectional survey was conducted using the Burden of Obstructive Lung Disease (BOLD) study protocol. Participants aged 40 years and above were selected using a two-stage stratified cluster sampling. Generalized linear models were used to examine associations between FVC and risk factors. RESULTS: Among the 1104 participants studied a lower post-bronchodilator FVC was independently associated with a large waist circumference (- 172 ml; 95% CI, - 66 to - 278), Indo-Caribbean ethnicity (- 180 ml; 95% CI, - 90 to - 269) and being underweight (- 185 ml; 95% CI, - 40 to - 330). A higher FVC was associated with smoking cannabis (+ 155 ml; 95% CI, + 27 to + 282). Separate analyses to examine associations with health variables indicated that participants with diabetes (p = 0∙041), history of breathlessness (p = 0∙007), and wheeze in the past 12 months (p = 0∙040) also exhibited lower post-bronchodilator FVC. CONCLUSION: These findings suggest that low FVC in this Caribbean population is associated with ethnicity, low body mass index (BMI), large waist circumference, chronic respiratory symptoms, and diabetes.

Urgent need to strengthen and expand screening and other cancer control programs in the CARICOM Caribbean.

PURPOSE: With high mortality in breast, cervical, prostate, and colorectal cancers in Caribbean Community (CARICOM) countries, we examined cancer control initiatives including screening as well as the implementation of relevant international and regional mandates. METHODS: Secondary data were used to examine cancer control initiatives, which included the presence of national policies, programs, and screening services as well as the implementation of international and regional mandates. To identify the data, an on-line search was conducted using Google/Google Scholar. RESULTS: Data were available for 14 of the 15 full members of CARICOM. Although only six countries had distinct cancer control policies, strategies or action plans, all 14 had key elements of cancer control programs. Screening services were available in the 14 countries for cervical, in 12 countries for breast and in 11 for colorectal cancer. However, only four countries had screening policies. In addition, screening guidelines were available for cervical cancer in nine countries, in one country for breast and in none for colorectal cancer. Selected tobacco control policies were present in the 14 countries and immunization policies for human papillomavirus (HPV) in 13. Treatment services included chemotherapy in 10 countries and radiotherapy in six. Nine countries had palliative care services for patients with advanced disease. The countries were at different stages of implementation/compliance with international and regional mandates and frameworks. CONCLUSIONS: There is an urgent need to develop and implement comprehensive and customized cancer control policies addressing screening programs, treatment and palliative care.

Breast Carcinoma Receptor Expression in a Caribbean Population.

Trinidad and Tobago are islands in the Southern Caribbean with a unique mix of races within the population consisting of East Indian (EI) (37.6%), Afro-Caribbean (AC) (36.3%), mixed (24.2%), and Caucasian, Chinese, Lebanese, Syrian, Amerindian, and Spanish groups accounting for 1.9%. It makes it suitable for a comparison of breast carcinoma receptor expression within a fixed environment. This study included 257 women with an age range of 28 to 93 years (mean = 57.2, standard deviation = 15.0), peak age group of 51 to 60 consisting of 105 EI, 119 AC, and 33 mixed descent. Invasive ductal carcinoma accounted for 88%, invasive lobular 9.7%, and ductal carcinoma in situ 2.3%. The triple-negative rates were 24.8, 33.6, and 30.3% for EI, AC, and mixed races, respectively, with the Pearson's chi-square test revealing statistical significance for the AC versus EI ( p < 0.001); AC versus mixed ( p < 0.001); and EI versus mixed ( p = 0.014) groups. The overall estrogen (ER), progesterone (PR), and human epidermal growth receptor (HER) expression negative rates were 52, 64, and 79%, respectively. Chi-square test of the following combinations: ER +/PR +/HER + ; ER +/PR +/HER - ; ER -/PR -/HER + ; ER +/PR -/HER + ; ER +/PR -/HER - ; ER -/PR +/HER + ; ER -/PR +/HER- revealed no statistical differences ( p = 0.689).

No person left behind: Mapping the health policy landscape for genomics research in the Caribbean.

The Caribbean has long been an under-represented geographical region in the field of genomics research. Such under-representation may result in Caribbean people being underserved by precision medicine and other public health benefits of genomics. A collaboration among regional and international researchers aims to address this issue through the H3ECaribbean project (Human Heredity, Environment, and Health in the Caribbean), which builds on the lessons and success of H3Africa. The Caribbean project aims to target issues of social justice by encouraging the inclusion of diverse Caribbean communities in genomics research. This paper explores a framework for the ethical and socially acceptable conduct of genomics research in the Caribbean, taking account of the cultural peculiarities of the region. This is done in part by exploring research ethics issues identified in indigenous communities in North America, Small Island Developing States, and similar endeavours from the African continent. The framework provides guidance for interacting with local community leaders, as well as detailing steps for obtaining informed consent of all participants. Specifically, the authors outline the methods to ensure effective interaction and enforce full transparency with study participants to combat historical neglect when working with under-represented communities in the Caribbean.

Politics and political determinants of health policy and systems research funding in Latin America and the Caribbean.

Objectives and importance of study: The importance of health policy and systems research (HPSR) has been acknowledged since 2004 and was recognised by the United Nations World Health Assembly in 2005. However, many factors influence its development. This paper aims to analyse the impact of politics and political determinants on HPSR funding in selected countries of Latin America and the Caribbean. METHODS: Using a standardised protocol, we performed an analysis of available data and financing structures for health research and HPSR, based on research in eight countries, including interviews with key stakeholders (n = 42). RESULTS: Dollar depreciation and gross national product growth in the region may play a role in how governments fund research. There have been shifts in the political spectrum in governments, which have affected research coordination and funding in positive and negative ways. HPSR funding in some countries was dependent on budget decisions and although some have improved funding, others have regressed by decreasing funding or have completely cancelled financing mechanisms. Caribbean countries rely mainly on institutional funding. HPSR is recognised as important but remains underfunded; stakeholders believed it should be used more in decision making. CONCLUSION: Although HPSR is recognised as valuable for decision making and policy development, it does not have the financial support required to flourish in Latin America and the Carribean. Data on health research financing were not easy to access. There was little or no evidence of published reports or papers about research financing, health research funding, and HPSR funding in particular in the studied countries. Because of the fragility of health systems highlighted by the coronavirus disease 2019 (COVID-19) pandemic, HPSR should be of great relevance and value to both policy makers and funders.

Health Systems' Resilience: COVID-19 Response in Trinidad and Tobago.

Trinidad and Tobago, a small island developing state, has been ranked as number one in a report published by the University of Oxford that assessed responses to COVID-19 based on four of the six WHO criteria for rolling back COVID-19 "lockdown" measures. The key mitigation and containment strategies implemented by the country were evidence-informed and demonstrated an "all-of-government" approach. The COVID-19 health system response of this country demonstrates that although developing countries face many health system challenges, political will, evidence-informed decision-making, respect for science, and timely, coordinated, collaborative actions can strengthen the resilience and response of the health system during a health emergency.

Understanding and use of inhaler medication by asthmatics in specialty care in Trinidad: a study following development of Caribbean guidelines for asthma management and prevention.

STUDY OBJECTIVES: Following the development of the Caribbean Guidelines for Asthma Care, we examined the utilization of inhaled medications in asthmatic patients in Trinidad, West Indies. SETTING: Chest Clinic, Ministry of Health, Trinidad. PARTICIPANTS: Physician-diagnosed asthmatic patients who attended the Chest Clinic between July 1998 and August 2000. MEASUREMENTS AND RESULTS: A consecutive sample of patients who were > 7 years of age (n = 402) was interviewed about compliance with, understanding of, and use of inhaler medication. The inhaler technique of these patients was directly observed. Inhaled steroid therapy was prescribed in 83% of patients but were prescribed the least in elderly patients (63%) and children (62%). Salbutamol was prescribed in 98% of patients, and ipratropium and sodium cromoglycate were selectively prescribed in elderly men and children, respectively. Only 33% of patients used the inhaler correctly, and children and the elderly were the least efficient in its use. The use of a spacer device was advised in 19% of patients, including only 6% of the elderly patients. Explanations for different inhaler therapies were given to 62% of patients, and 53% of patients could describe these reasons. The reported 40% noncompliance rate among patients in the sample was primarily a result of long waiting periods at the pharmacy (58%) and the personal cost incurred on purchasing the medication (52%). CONCLUSIONS: Educating patients, with a focus on children and the elderly, in inhaler techniques and reinforcing understanding of asthma medications can improve asthma management in Trinidad. Asthma caregivers in the Caribbean should ensure the appropriate dissemination of the guidelines and should outline strategies for their implementation.

Hearing loss in steelband musicians.

OBJECTIVE: To determine the difference in hearing between a group of steelband musicians (pannists) and a control group. DESIGN, SETTINGS, AND SUBJECTS: We conducted a controlled cross-sectional pilot study consisting of 29 steelpan players and 30 control subjects from a steelpan orchestra (steelband) in the Otolaryngology Department of the Eric Williams Medical Sciences Complex. RESULTS: Significantly more steelpan players had a hearing loss than the control subjects at 3000 Hz, 4000 Hz, and 6000 Hz ( P < 0.01). chi 2 testing for trend demonstrated that the longer a steelpan player played his instrument the greater the hearing loss. CONCLUSION: These results indicate that pannists suffer permanent auditory damage from high-intensity sound levels and that preventative measures are required to prevent this hearing loss, particularly in younger players.

Sources of stress and psychological disturbance among dental students in the West Indies.

The aim of this study was to investigate sources of stress and psychological disturbance in dental students across the five years of undergraduate study at a dental school in Trinidad. Eighty-three percent of students completed a modified version of the Dental Environment Stress questionnaire (DES) and the Brief Symptom Inventory (BSI). On a scale ranging from 0 (not stressful) to 5 (highly stressful), overall mean DES scores for each of the five years of study were 1.58, 1.83, 2.65, 2.39, and 2.61 respectively, suggesting that levels of stress increase over the five years with a noticeable spike at the transition between the preclinical and clinical phases. Significant differences were found between specific stressors across the five years of study. Seven specific stressors and the stressor domains of Academic work and Clinical factors were more stressful for female students (t-test p < 0.05). The Global Severity Index of the BSI indicated that 54.8 percent of males and 44.2 percent of females were in the clinical range indicating significant psychological disturbance. Psychological disturbance was significantly associated with stress levels for male students (Spearmans rank correlation r = 0.56; p < 0.001), but not generally for female students. Further development is needed of dental educational programs that enhance students' psychosocial well-being.

Using a modified course experience questionnaire (CEQ) to evaluate the innovative teaching of medical communication skills.

SETTING: At the Faculty of Medical Sciences, The University of the West Indies, St Augustine first-year students take two courses in health communication. In the Centre for Medical Sciences Education students completed a course experience questionnaire. This instrument is potentially useful in evaluating innovative programmes and securing support for their development. CONTEXT: The Faculty of Medical Sciences, The University of the West Indies, St Augustine was the first of three campuses to introduce compulsory health communication courses in 1995. Using a modified form of the 25-item course experience questionnaire (CEQ25) (Broomfield & Bligh, 1998) normally employed in overall degree or course evaluation, this study developed a 30-item questionnaire (CEQ30) to test its applicability to the evaluation of medical communication skills teaching MEASURES: In 1997 - 1998 medical, dentistry, veterinary medicine and pharmacy students completed the original short form of the CEQ25 including five items specific to medical communication skills teaching. Students used a five-point Likert scale ranging from one, indicating that they strongly disagreed with the statement, to a score of five, reporting that they strongly agreed with the statement. Principal Components Analysis with Varimax rotation analysed the scale structure of the evaluation tool. RESULTS: The principal components factor analysis of responses (n = 165) broadly confirmed five of Broomfield and Bligh's six factors, but identified a sixth factor in their original instrument (appropriate assessment) that split into two, and a seventh factor, use of available materials and resources. CONCLUSION: The modified CEQ30 is a reliable instrument with which to evaluate a course in medical communication skills, and encourage reflection on teaching and course design. Its use is applicable to medical courses during overall curriculum change and innovation in a medical school.

Risk factors for urinary tract calculi in Trinidad.

OBJECTIVE: To identify risk factors for urinary tract stones in Trinidad and Tobago. METHODS: A consecutive series of patients presenting to institutions in Trinidad for the management of proven urinary tract calculi was interviewed by questionnaires designed to obtain data on age, gender, ethnicity, occupation, stone location, a family history of stone disease, a past history of certain medical diseases and a semiquantitative estimate of the magnesium intake in food, 'over the counter' drugs and drinking water. An equivalent number of patients attending the same institutions for follow-up and verified from hospital records as having a previous radiological diagnosis of urinary tract stones, as well as a group of asymptomatic members of the community working in the same area, underwent the same interview. Chi-square, anova and Kruskal-Wallis tests were used to examine differences between the groups. Multiple logistic regression analysis was used to determine persistence of the significance of these differences after controlling for confounding variables. RESULTS: Data sufficient for analysis were obtained for 122 previous and 102 prospective patients and 102 controls. The mean age of the patients was 32 years. The ratio of males to females was 0.9-1.8:1 for the affected groups, but significantly more males than females had calculi in the lower urinary tract (19%vs. 6%; P = 0.004). More patients (30%) than controls (7%) gave a positive family history of urinary tract stone disease (P < 0.001). Affected persons had a lower dietary magnesium intake (P = 0.003), which accounted for a significantly lower total magnesium intake (P = 0.02). Logistic regression analysis of the variables studied indicated that independent predictors of the disease were a positive family history (P = 0.001), total magnesium intake (P = 0.001) and age (P < 0.001). CONCLUSION: A low magnesium intake and a positive family history are highly predictive of urinary tract calculi in this population.

Use of food expenditure data to estimate household nutrient accessibity

The nutritional status of at-risk groups is usually monitored using health statistics. This approach has limitations as individuals are identified only after they have been afflicted by morbidity. In Jamaica, national surveys are carried out in which expenditure data on all consumption items are collected. We used these data to monitor food accessibility in at-risk groups. The identification of decreases in accessibility levels relative to requirements would enable timely intervention before there is a deterioration in nutritional status. We analysed the data from the survey of 3861 households conducted by Statistical and Planning Institutes of Jamaica in 1989. Using the food expenditure data, per capita energy and protein accessibility levels were determined. The mean energy and protein accessibility levels for the sample were 2170 Cals and 64 g, respectively. The results showed that the per capita accessibility levels of 20 percent and 9 percent of the households were less than half of requirments for energy and protein, respectively. The situation was worse in rural areas than in urban centres. However, the accessibility levels may have been underestimated as the data did not include meals bought and consumed away from the home, which may be significant to some households. We believe that the use of data from these surveys is a cost-effective way to monitor nutrient accessibility in Jamaica

Psychiatric disorder in systemic lupus erythematosus

The symptoms of systemic lupus erythematosus (SLE) may include altered mental function. The present study sought to examine whether the psychiatric disorders are due to the disease itself or to the stress of having a chronic disease. Forty-five SLE patients attending outpatient clinics at the Port of Spain General Hospital in Trinidad were compared with two control groups: patients with chronic debilitating diseases similar to SLE in terms of chronicity and treatment (n = 44) and non-diseased individuals (n = 48). The Structured Clinical Interview for DSM III-R was used to identify psychiatric disorders. Both the SLE and the chronic illness groups had more psychic illness (44 percent and 39 percent, respectively) when compared with the non-diseased controls (2 percent) (p<0.001). Major depression was the most common diagnosis among both diseased groups. However, the psychotic illnesses (schizophrenic-type psychosis and bipolar disorders) were more prevalent in the SLE group (11.1 percent vs 0 percent, p=0.02). These results indicate that major depression in SLE may be related more to the effects of a chronic illness than to SLE itself. However, the occurrence of psychotic symptoms may be related to SLE disease and needs further study.

Geohelminth infections in school-aged children in Jamaica

There is concern that geohelminthiasis may adversely affect the growth and development of children. The relevance of this in the Caribbean in unclear since in many territories the prevalence of geohelminths is unknown. We report the results of three surveys conducted in Jamaican primary schools located in areas at high risk for geohelminthiasis. The first was conducted in 12 Kingston schools and comprised children in grades 2 to 5 (age 7 to 10 years). The second and third surveys were conducted in rural areas with children in grades 2 to 5 and grades 4 and 5, respectively. Overall, 9244 children provided stool sample for analysis. The prevalence of Trichuris trichiura ranged from 42 per cent to 47 per cent among the surveys while that for Ascaris lumbricoides ranged from 15 per cent to 37 per cent . Children in grades 2 and 3 had lower T. trichiura prevalences than those in grades 4 and 5 in the first and second surveys (p<0.05 and p<0.005, respectively). In the second survey only, children in grades 2 and 3 had a lower prevalence of A. lumbricoides than those in grades 4 and 5(p<0.005). Most infections were light with approximately 1 per cent of the sample having heavy egg densities

Two-year mortality and its determinants following acute myocardial infarction in Trinidad and Tobago

The purpose of this study was to determine the occurrence of coronary artery disease risk factors in patients presenting with acute myocardial infarction(AMI) to a tertiary care institution in Trinidad and to determine the factors associated with increased mortality following AMI. All patients admitted to the Eric Williams Medical Sciences Complex (EWMSC) between January 1 and December 31, 1996, with a diagnosis of AMI were identified using the hospital admissions and discharge diagnosis databases. Demographic, clinical and laboratory variables were extracted from the hospital case records of patients with confirmed AMI. Sixty-one AMI patients (38 men) were admitted during the study period. Mean age of admittance was 60 ñ 11 years with an ethnic case mix of thirty-nine (62 percent) of East Indian descent, eight (13 percent) of African descent, twelve (20 percent) mixed ethnicity and three of Caucasian descent. Thirty patients (49 percent) were hypertensive. Thirty-two patients (53 percent) were diabetic and eighteen patients (30 percent) gave a history of cigarette smoking. The mean left venticular ejection fraction was 53 ñ 14 percent. The mean serum cholesterol from 29 patients was 228.2 ñ 49.0 mg/dl. Increasing age, female gender, an ejection fraction less than 40 percent, non treatment with streptokinase and in-hospital ventricular fibrillation were associated with poor survival. Multiple regression analyses identified three independent predictors of mortality. These were gender (p = 0.04), in-hospital ventricular fibrillation (p = 0.001) and an ejection fraction less than 40 percent (p = 0.02). Diabetes mellitus, hypertension, hyperlipidaemia and cigarette smoking were prevalent amongst patients presenting with AMI. Ventricular function was a major determinant of two-year mortality following AMI. Aggressive risk factor modification is recommended to prevent both first and recurrent coronary events.

Characteristics of Jamaicans who smoke marijuana before sex and their risk status for sexually transmitted diseases

Because of the high prevalence of marijuana smoking in Jamaica, it is important to know if this practice is associated with increased risk for STD infections. A national sample of 2,580 randomly selected Jamaicans, aged 15 to 49 years were administered a questionnaire to measure a number of health and behavioural variables. The results indicated that more persons who smoked marijuana before sex had a history of STD infections than non-marijuana smokers, the difference was significant among men (46 percent vs 26 percent, p < 0.001) but not among women (19 percent vs 8 percent, p = 0.09). There was no difference in age, however, more of the smokers were unmarried, poorly educated and unemployed than persons who did not smoke marijuana before sex. They were also more likely to engage in high risk sex behaviours and other risk taking behaviors than non-smokers. The results of multiple logistic analyses indicated that marijuana smoking before sex was an independent risk factor for STDs among men (Odd Ratio = 2.0, p = 0.04). Although it was not possible to determine if the association was causal, the increased risk for STDs among men who smoke marijuana before sex should be incorporated into the Jamaican STD/AIDS control programme by making special efforts to encourage condom use among marijuana smokers

The prevalence of seat belt use in Jamaica: an observational study

An observational cross-sectional survey showed that 21.1 percent of private motor vehicle drivers and 13.5 percent of front seat passengers voluntarily wore seat belts in Kingston, Jamaica, where there is no law requiring this. Rear passenger utilisation was not examined. Compared to males, females were significantly more likely to wear seat belts when driving but not as front seat passengers. Of all motor vehicles examined 10.1 percent were not equipped with seat belts. The oldest group of vehicles were mostly not fitted with seat belts. Drivers of older vehicles were significantly less likely to use seat belts even when the vehicles were equipped with belts. Implementation of legislation can reduce mortality, morbidity and costs from road traffic accidents which are relatively frequent in Jamaica. Male drivers, drivers of older vehicles and all passengers may require specific targeting in an educational and enforcement campaign should legislation, which is highly desirable, be implemented

Nutrition-related diseases and food and nutrition security in the Caribbean

Using questionnaires, data were collected from 14 member countries of the Caribbean Food and Nutrition Institute (CFNI) to determine the prevalence of nutrition-related diseases in the Caribbean and the programmes currently used to control or prevent them. Policies related to food/nutrition security and the strategies implemented to determine and ensure food availability at the household levels were also examined

Geohelminth infections and mental development in Jamaica

There have been many studies of the effects of various geohelminth infections on children's mental development and school performance. This chapter will describe several studies conducted in Jamaica that primarily examined the parasite T. trichiura. In the first study, the investigators looked at the effects of the most severe form of T. trichiura infections-Trichuris dysentry syndrome- on the mental development and cognition of young children. The second study investigated the effects of moderate to heavy Trichuris infections on the cognition of school children, and the third was a clinical trial that examined the effects of mild to moderate T. trichiura infections on school performance and on cognitive function