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.

Neighbourhood socioeconomic characteristics and blood pressure among Jamaican youth: a pooled analysis of data from observational studies.

INTRODUCTION: Neighbourhood characteristics are associated with several diseases, but few studies have investigated the association between neighbourhood and health in Jamaica. We evaluated the relationship between neighbourhood socioeconomic status (SES) and blood pressure (BP) among youth, 15-24 years old, in Jamaica. METHODS: A pooled analysis was conducted using data from three studies (two national surveys and a birth cohort), conducted between 2005-2008, with individual level BP, anthropometric and demographic data, and household SES. Data on neighbourhood SES were obtained from the Mona Geo-Informatics Institute. Neighbourhood was defined using community boundaries from the Social Development Commission in Jamaica. Community characteristics (poverty, unemployment, dependency ratio, population density, house size, and proportion with tertiary education) were combined into SES scores using principal component analysis (PCA). Multivariable analyses were computed using mixed effects multilevel models. RESULTS: Analyses included 2,556 participants (1,446 females; 1,110 males; mean age 17.9 years) from 306 communities. PCA yielded two neighbourhood SES variables; the first, PCA-SES1, loaded highly positive for tertiary education and larger house size (higher value = higher SES); while the second, PCA-SES2, loaded highly positive for unemployment and population density (higher value = lower SES). Among males, PCA-SES1 was inversely associated with systolic BP (ß-1.48 [95%CI -2.11, -0.84] mmHg, p < 0.001, for each standard deviation unit increase in PCA-SES1 score) in multivariable model accounting for age, household SES, study, BMI, fasting glucose, physical activity and diet. PCA-SES1 was not significantly associated with systolic BP among females (ß -0.48 [-1.62, 0.66], p = 0.410) in a similar model. Associations for PCA-SES2 was assessed using linear splines to account for non-linear effects. The were no significant associations between systolic BP and PCA-SES2 among males. Among females, higher PCA-SES2 (i.e. lower SES) was associated with higher systolic BP at spline 2 [z-score -1 to 0] (ß4.09 [1.49, 6.69], p = 0.002), but with lower systolic BP at spline 3 [z-core 0 to 1] (ß-2.81 [-5.04, -0.59], p = 0.013). There were no significant associations between diastolic BP and PCA-SES1, but PCA-SES2 showed non-linear associations with diastolic BP particularly among males. CONCLUSION: Higher neighbourhood SES was inversely associated with systolic BP among male Jamaican youth; there were non-linear associations between neighbourhood SES and systolic BP among females and for diastolic BP for both males and females.

Knowledge, Beliefs and Practices of Patients with Diabetic Retinopathy at the University Hospital of the West Indies, Jamaica.

To determine the knowledge, beliefs and practices of patients with diabetic retinopathy attending the Retina Eye Clinic at the University Hospital of the West Indies. A prospective study was done using a questionnaire with a sample population of 150 patients. The questions included their knowledge about the frequency of their eye examination, the relevance of exercise and a healthy diet, the role of the ophthalmologist and their views on the importance of compliance with medications for diabetes and hypertension. One hundred and fifty patients were recruited. Sixty six percent (99/150) were females and 34 % (51/150) males. The ages ranged from 29 to 83 years (mean ± SD, 56.1 ± 10.3) years. Type II diabetes was more common; 63 and 79 % of females and males respectively. A minority (19.8 %) obtained tertiary education. The mean % knowledge scores were 86 ± 14 for males and 82.8 ± 16.4 for females (p = 0.260). Prior to attending the retina clinic, 50 % were unaware of the need for annual eye examinations. Compliance with medication, exercise and a special diet was seen in 73, 40.3 and 49.7 % respectively. Current knowledge scores were good. However, knowledge about the timing and frequency of eye examinations prior to attending the retina clinic was inadequate. Correct knowledge and beliefs did not correspond to a high level of compliant practices.

Certification of Coroners cases by pathologists would improve the completeness of death registration in Jamaica.

OBJECTIVES: Describe the completeness and quality of Jamaica's 2008 vital registration mortality database. STUDY DESIGN AND SETTING: Multiple sources (hospitals, police, forensic pathologists, Coroners courts) were used to validate deaths registered as occurring in 2008. A 10% random sample was examined to evaluate the quality of certification and coding. Jamaica, a middle-income country of 2.7 million, began vital registration in 1877; however, the mortality database was considered of limited use, and the study was commissioned to understand the problem. RESULTS: Of 19,286 deaths identified, 76% were registered by 31.12.2009 for inclusion among 2008 demographic returns. Registration was highest among deaths not requiring autopsy (94%) and lowest among Coroners cases (22%) with only 41% of deaths among 15-44 year-olds registered. The leading causes of death were cerebrovascular disease, diabetes mellitus, and homicide. Fifteen percent were coded to ill-defined causes of death. Recoding the sample increased mortality from prematurity, pregnancy complications, homicide, selected cardiovascular disorders, and human immunodeficiency virus/AIDS. CONCLUSION: Delays registering Coroners cases, certification and coding errors, introduced biases into the disease profile limiting the data's value in informing clinical care. Issuance of medical certificates by pathologists who investigate Coroners cases and training physicians and coders would eliminate most underreporting and improve data quality.

Vital registration and under-reporting of maternal mortality in Jamaica.

OBJECTIVE: To identify why vital registration under-reports maternal deaths in Jamaica. METHODS: A cross-sectional study was undertaken to identify all maternal deaths (during pregnancy or ≤42 days after pregnancy ended) occurring in 2008. Data sources included vital registration, hospital records, forensic pathology records, and an independent maternal mortality surveillance system. Potential cases were cross-referenced to registered live births and stillbirths, and hospital records to confirm pregnancy status, when the pregnancy ended, and registration. Medical certificates were inspected for certification, transcription, and coding errors. Maternal mortality ratios (MMRs) for registered and/or unregistered deaths were calculated. RESULTS: Of 50 maternal deaths identified, 10 (20%) were unregistered. Eight unregistered deaths were coroners' cases. Among 40 registered deaths, pregnancy was undocumented in 4 (10%). Among the other 36, 24 (67%) had been misclassified (59% direct and 89% indirect deaths). Therefore, only 12 (30%) registered maternal deaths had been coded as maternal deaths, yielding an MMR of 28.3 per 100 000 live births (95% confidence interval [CI] 12.3-48.3), which was 76% lower than the actual MMR of 117.8 (95% CI 85.2-150.4). CONCLUSION: Under-reporting of maternal deaths in Jamaica in 2008 was attributable to delayed registration of coroners' cases and misclassification. Timely registration of coroners' cases and training of nosologists to recognize and code maternal deaths is needed.

Gender differences in the effects of urban neighborhood on depressive symptoms in Jamaica / Diferencias entre sexos en los efectos del vecindario urbano sobre los síntomas depresivos en Jamaica

OBJECTIVE: To explore the mental health effects of the urban neighborhood on men and women in Jamaica and the implications for urban planning and social development. METHODS: A cross-sectional household sample of 2 848 individuals 15-74 years of age obtained from the Jamaica Health and Lifestyle Survey 2007-2008 was analyzed. Secondary analysis was undertaken by developing composite scores to describe observer recorded neighborhood features, including infrastructure, amenities/services, physical conditions, community socioeconomic status, and green spaces around the home. Depressive symptoms were assessed using the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Bivariate and multivariate methods were used to explore the associations among gender, neighborhood factors, and risk of depressive symptoms. RESULTS: While no associations were found among rural residents, urban neighborhoods were associated with increased risk of depressive symptoms. Among males, residing in a neighborhood with poor infrastructure increased risk; among females, residing in an informal community/unplanned neighborhood increased risk. CONCLUSIONS: The urban neighborhood contributes to the risk of depression symptomatology in Jamaica, with different environmental stressors affecting men and women. Urban and social planners need to consider the physical environment when developing health interventions in urban settings, particularly in marginalized communities.

OBJETIVO: Explorar los efectos del vecindario urbano sobre la salud mental de los hombres y las mujeres de Jamaica, y sus implicaciones en materia de planificación urbana y desarrollo social. MÉTODOS: Se analizó una muestra transversal de hogares que incluyó a 2 848 personas de 15 a 74 años de edad y que se obtuvo de la Encuesta sobre Salud y Estilo de Vida en Jamaica, realizada los años 2007 y 2008. Se llevó a cabo un análisis secundario mediante la elaboración de puntuaciones compuestas para describir las características del vecindario registradas por el observador, incluidos las infraestructuras, los equipamientos y los servicios, las condiciones físicas, la situación socioeconómica de la comunidad y las zonas verdes próximas al hogar. Se evaluaron los síntomas depresivos mediante el Manual Diagnóstico y Estadístico de los Trastornos Mentales (DSM-IV). Se utilizaron métodos bifactoriales y multifactoriales para explorar las asociaciones entre el sexo, los factores del vecindario y el riesgo de padecer síntomas depresivos. RESULTADOS: Mientras que no se observaron asociaciones en los residentes de zonas rurales, los vecindarios urbanos se asociaron con un mayor riesgo de padecer síntomas depresivos. En hombres, la residencia en un vecindario con infraestructuras deficitarias aumentó el riesgo; en mujeres, la residencia en una comunidad informal o un vecindario no planificado aumentó el riesgo. CONCLUSIONES: El vecindario urbano contribuye a aumentar el riesgo de sintomatología depresiva en Jamaica. Los estresantes ambientales que afectan a los hombres y las mujeres son distintos. Es necesario que los planificadores urbanos y sociales tengan en cuenta el entorno físico cuando elaboren las intervenciones de salud en entornos urbanos, en particular en las comunidades marginadas.

Gender differences in the effects of urban neighborhood on depressive symptoms in Jamaica.

OBJECTIVE: To explore the mental health effects of the urban neighborhood on men and women in Jamaica and the implications for urban planning and social development. METHODS: A cross-sectional household sample of 2 848 individuals 15-74 years of age obtained from the Jamaica Health and Lifestyle Survey 2007-2008 was analyzed. Secondary analysis was undertaken by developing composite scores to describe observer recorded neighborhood features, including infrastructure, amenities/services, physical conditions, community socioeconomic status, and green spaces around the home. Depressive symptoms were assessed using the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Bivariate and multivariate methods were used to explore the associations among gender, neighborhood factors, and risk of depressive symptoms. RESULTS: While no associations were found among rural residents, urban neighborhoods were associated with increased risk of depressive symptoms. Among males, residing in a neighborhood with poor infrastructure increased risk; among females, residing in an informal community/unplanned neighborhood increased risk. CONCLUSIONS: The urban neighborhood contributes to the risk of depression symptomatology in Jamaica, with different environmental stressors affecting men and women. Urban and social planners need to consider the physical environment when developing health interventions in urban settings, particularly in marginalized communities.

Factors affecting study efficiency and item non-response in health surveys in developing countries: the Jamaica national healthy lifestyle survey.

BACKGROUND: Health surveys provide important information on the burden and secular trends of risk factors and disease. Several factors including survey and item non-response can affect data quality. There are few reports on efficiency, validity and the impact of item non-response, from developing countries. This report examines factors associated with item non-response and study efficiency in a national health survey in a developing Caribbean island. METHODS: A national sample of participants aged 15-74 years was selected in a multi-stage sampling design accounting for 4 health regions and 14 parishes using enumeration districts as primary sampling units. Means and proportions of the variables of interest were compared between various categories. Non-response was defined as failure to provide an analyzable response. Linear and logistic regression models accounting for sample design and post-stratification weighting were used to identify independent correlates of recruitment efficiency and item non-response. RESULTS: We recruited 2012 15-74 year-olds (66.2% females) at a response rate of 87.6% with significant variation between regions (80.9% to 97.6%; p < 0.0001). Females outnumbered males in all parishes. The majority of subjects were recruited in a single visit, 39.1% required multiple visits varying significantly by region (27.0% to 49.8% [p < 0.0001]). Average interview time was 44.3 minutes with no variation between health regions, urban-rural residence, educational level, gender and SES; but increased significantly with older age category from 42.9 minutes in the youngest to 46.0 minutes in the oldest age category. Between 15.8% and 26.8% of persons did not provide responses for the number of sexual partners in the last year. Women and urban residents provided less data than their counterparts. Highest item non-response related to income at 30% with no gender difference but independently related to educational level, employment status, age group and health region. Characteristics of non-responders vary with types of questions. CONCLUSION: Informative health surveys are possible in developing countries. While survey response rates may be satisfactory, item non-response was high in respect of income and sexual practice. In contrast to developed countries, non-response to questions on income is higher and has different correlates. These findings can inform future surveys.

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)

Health sector challenges and responses beyond the Alma-Ata Declaration: a Caribbean perspective

Al igual que el resto del mundo, el Caribe ha sido testigo del drástico paso de las enfermedades nutricionales y transmisibles a las enfermedades no transmisibles y crónicas. No obstante, en el Caribe este cambio ha coincidido con una nueva dinámica, creada por la emergencia de enfermedades transmisibles -como la infección por el VIH/sida- junto con los problemas relacionados con el envejecimiento, las enfermedades cardiovasculares, la violencia y las lesiones, entre otros. En este artículo se hace una revisión de la historia de la atención sanitaria en el Caribe, los retos y enfoques del sector salud y la nueva orientación en la atención primaria de salud (APS). Las observaciones se basan en trabajos publicados. En el Caribe, la Declaración de Alma-Ata sirvió como importante punto de giro y ofreció orientación, apoyo y dirección a medida que los países perfilaban sus servicios de salud para satisfacer sus necesidades. La creatividad y el ingenio surgieron como rasgos distintivos del enfoque caribeño en la reestructuración de la APS, ante los retos económicos, sociales, culturales, de recursos humanos y de políticas que enfrentaban. El fortalecimiento de de la capacidad institucional, la extensión de los programas sociales, los esquemas nacionales de seguros de salud, los programas específicos de promoción de salud y la ampliación de la investigación en apoyo al desarrollo de políticas continúan evidenciando el esfuerzo caribeño para responder a los cruciales retos epidemiológicos. A pesar de esos retos, se han establecido alianzas dentro y fuera del Caribe. Además, la Carta del Caribe para la Promoción de la Salud ha servido como elemento crítico para el desarrollo de la APS.(AU)

Health sector challenges and responses beyond the Alma-Ata Declaration: a Caribbean perspective

Al igual que el resto del mundo, el Caribe ha sido testigo del drástico paso de las enfermedades nutricionales y transmisibles a las enfermedades no transmisibles y crónicas. No obstante, en el Caribe este cambio ha coincidido con una nueva dinámica, creada por la emergencia de enfermedades transmisibles -como la infección por el VIH/sida- junto con los problemas relacionados con el envejecimiento, las enfermedades cardiovasculares, la violencia y las lesiones, entre otros. En este artículo se hace una revisión de la historia de la atención sanitaria en el Caribe, los retos y enfoques del sector salud y la nueva orientación en la atención primaria de salud (APS). Las observaciones se basan en trabajos publicados. En el Caribe, la Declaración de Alma-Ata sirvió como importante punto de giro y ofreció orientación, apoyo y dirección a medida que los países perfilaban sus servicios de salud para satisfacer sus necesidades. La creatividad y el ingenio surgieron como rasgos distintivos del enfoque caribeño en la reestructuración de la APS, ante los retos económicos, sociales, culturales, de recursos humanos y de políticas que enfrentaban. El fortalecimiento de de la capacidad institucional, la extensión de los programas sociales, los esquemas nacionales de seguros de salud, los programas específicos de promoción de salud y la ampliación de la investigación en apoyo al desarrollo de políticas continúan evidenciando el esfuerzo caribeño para responder a los cruciales retos epidemiológicos. A pesar de esos retos, se han establecido alianzas dentro y fuera del Caribe. Además, la Carta del Caribe para la Promoción de la Salud ha servido como elemento crítico para el desarrollo de la APS.

Health sector challenges and responses beyond the Alma-Ata Declaration: a Caribbean perspective / Retos y respuestas del sector salud más allá de la declaración de Alma-Ata: una perspectiva Caribeña

Al igual que el resto del mundo, el Caribe ha sido testigo del drástico paso de las enfermedades nutricionales y transmisibles a las enfermedades no transmisibles y crónicas. No obstante, en el Caribe este cambio ha coincidido con una nueva dinámica, creada por la emergencia de enfermedades transmisibles -como la infección por el VIH/sida- junto con los problemas relacionados con el envejecimiento, las enfermedades cardiovasculares, la violencia y las lesiones, entre otros. En este artículo se hace una revisión de la historia de la atención sanitaria en el Caribe, los retos y enfoques del sector salud y la nueva orientación en la atención primaria de salud (APS). Las observaciones se basan en trabajos publicados. En el Caribe, la Declaración de Alma-Ata sirvió como importante punto de giro y ofreció orientación, apoyo y dirección a medida que los países perfilaban sus servicios de salud para satisfacer sus necesidades. La creatividad y el ingenio surgieron como rasgos distintivos del enfoque caribeño en la reestructuración de la APS, ante los retos económicos, sociales, culturales, de recursos humanos y de políticas que enfrentaban. El fortalecimiento de de la capacidad institucional, la extensión de los programas sociales, los esquemas nacionales de seguros de salud, los programas específicos de promoción de salud y la ampliación de la investigación en apoyo al desarrollo de políticas continúan evidenciando el esfuerzo caribeño para responder a los cruciales retos epidemiológicos. A pesar de esos retos, se han establecido alianzas dentro y fuera del Caribe. Además, la Carta del Caribe para la Promoción de la Salud ha servido como elemento crítico para el desarrollo de la APS.