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)

Experiences and socialization of Jamaican men with multiple sex partners

One of the goals of the Acquired Immunodeficiency Syndrome (AIDS) control programme in Jamaica is to encourage persons to have a single sex partner. Before this can be achieved in men, it is important to identify the demographic characteristics as well as the sexual attitudes and socialization of men who have multiples sex partners. A national survey was conducted on sexual decision-making in Jamaica in which a random sample of 3,001 persons was selected for study and 2,580 (86 percent) interviewed 979 were men. The following analyses included the 769 men who where sexually active. Thirty-four percent (34 percent), 95 percent CI, 30.6-37.4 percent) of these men said that they were currently having sex with more than one woman. Although condom use was higher in men with multiple sex partners. 33 percent of them said that they never used condoms. Independent predictors of having multiple sex partners were: not being in a stable union; being raised by fathers only; and having a secondary school education. There was no significant association with church attendance or with occupation. Compared with other males, men who had multiple sex partners started having sex at an earlier age and were more likely to engage in high-risk sex behaviours such as having sex with prostitutes and abusing drugs prior to coitus. They were also more likely to believe in the use of sex as a means to control their partners and were less likely to think that being married or involved in a long-term relationship was important. These data must be taken into considerations by the AIDS control programme in Jamaica when formulating policies to promoted monogamy. There may also be a need to implement parenting support or education programmes for single men who raise their sons.(AU)

'Nuff Gal'? The practices of sexually active Jamaican men - abstract

A national survey was conducted in Jamaica comprising a random sample of 2580 persons aged 15 - 50 years. The sample comprised 979 men, of whom 920 (94 percent) had experienced sexual intercourse and 769 (79 percent) were sexually active in the previous year. 32 percent of the latter were having sex with more than one person. Their medium number of sex partners was 2 with the range being 2 to 10. Having multiple sex partners was associated with youth, being involved in a visiting relationship, not being raised by both parents and initiating sex at an earlier age. They also had significantly shorter relationships (2 vs 3 years) and more sex acts per month than monogamists. Men with multiple sex partners were more likely to engage in prostitution than monogamists while the prevalence of partner swapping and oral and anal sex was low. Although condom use was higher among men who had multiple sex partners, 33 percent of them never used condoms. There was no significant association between having sex with more than one person and either regular church attendance (at least once per week) or self-reported religiosity. The median age at first intercourse for all men was 15 years (range 6 - 30), the same as the age of their first partner. In only 33 percent of cases was the first partner someone with whom they had a relationship. The most common reasons for sex the first time were for the experience (59 percent), to express love (14 percent) and to "answer the call of nature" (14 percent) (AU).

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

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 (AU)

Working women's sexual risk taking in Jamaica

Although the rates of HIV are increasing among female populations in developing countries, there is little information available about factors influencing sexual risk taking among working class women. This paper describes some of the issues discussed by two groups of 58 women working in Jamaica: Informal Commerical Importers and women working in the Free Zone. These women discuss their economic vulnerability, expectations about the role of men as provides, multiple partners, perception of children as resources and concern about physical abuse as factors that could influence decisions about condom use. The implications of these findings are discussed for their impact of intervention programs targeting working class women in Jamaica.(AU)

Ganja smoking and sex in Jamaica - abstract

The characteristics and risk status for STD infections of Jamaicans who smoked marijuana before having sex were investigated. The study comprised 2580 individuals, aged 15 to 49 years, who were selected using a multi-stage random sampling technique. The results indicated that the prevalence of marijuana smoking before sex was higher among men (12 per cent) than among women (2 per cent). More Jamaicans who smoked marijuana before sex were unemployed and unmarried, had lower education levels and lived in poorer neighbourhoods than those who did not smoke. In addition, more of them were regular alcohol drinkers, took hard drugs and gambled. When their sex behaviour were examined, there was no difference in condom use; however, more marijuana smokers had multiple sex partners, had had STD infections and began having sex at an earlier age than the non-smokers. More male smokers had sex with prostitutes, viewed ponographic material and were involved in partner swapping than the men who did not smoke marijuana. The prevalence of anal and oral sex was higher in women who smoke marijuana before sex compared to the female non-smokers. The results of logistic regression analyses indicated (after controlling for the demographic and behavoral variables mentioned above (OR = 2.3, p<0.01) that men who smoked marijuana before sex had an increased risk of having STD infections. No increased risk was found in women who smoked marijuana before sex. Because of the high prevalence of marijuana smoking among men, it is important that their increased risk for STDs be considered by health authorities in the planning of STD/AIDS control programmes (AU)

The meaning of sexual partnerships: re-examining the Jamaican family system

This paper seeks to re-examine some of the fairly accepted notions about Caribbean family and mating relationships. The situation in Jamaica is similar to that found in most other Caribbean countries. Data from a recently concluded study in this country is therefore utilized in this review. Specifically, this paper looks at the phenomena of multiple partnerships, union stability and longevity, and the alleged evolution of relationships from a visiting to marital status. Data from detailed union histories of men and women, aged 15 to 50 years in Jamaica are presented. It is argued that the dominant pattern appears to be one in which serial, as distinct from simultaneous partnering is the norm, and that the average length of relationships is short. It is further suggested that marriage rates may in fact be falling, that marriage is not normally a terminal state for unions, and that they may be entered into only when they are not perceived to represent a threat to the economic networks useful and necessary for the organisation and rationalisation of resources. (Au)

Multisectoral approach to the delivery of health care in Jamaica

Examines the need for better integration of the public health sector with other sectors in the society. Critically examines the health status of the Jamaican population, the socio-economic environment and the development of health policy between 1950 and 1983. Five areas were researched for intersectoral co-ordination: Basic Services Programme for children jointly sponsored by UNICEF, PAHO and Government of Jamaica; the Pesticides Advisory Committee concerned with utilization of chemical and pesticides as it relates to plant protection, food storage and public health; the Nutrition Advisory Council which co-ordinates the development of food and nutrition policies; methods used for the efficient delivery of water; and methods used in the process of collaboration between the Ministries of Health and Education as attempts are made to include health concepts in school curricula and programmes. Concludes that almost all the projects and activities investigated have not performed as expected. Recommendations include the following: 1) clear goals and task specifications before the execution of any project or programme; 2) a common understanding and expectation of desired goals and objectives; 3) paying greater attention to the incorporation of potential beneficiaries into the planning and design stages of programmes. (Au)

Multisectoral approach to the delivery of health care in Jamaica

Examines the need for better integration of the public health sector with other sectors in the society. Critically examines the health status of the Jamaican population, the socio-economic environment and the development of health policy between 1950 and 1983. Five areas were researched for intersectoral co-ordination: Basic Services Programme for children jointly sponsored by UNICEF, PAHO and Government of Jamaica; the Pesticides Advisory Committee concerned with utilization of chemical and pesticides as it relates to plant protection, food storage and public health; the Nutrition Advisory Council which co-ordinates the development of food and nutrition policies; methods used for the efficient delivery of water; and methods used in the process of collaboration between the Ministries of Health and Education as attempts are made to include health concepts in school curricula and programmes. Concludes that almost all the projects and activities investigated have not performed as expected. Recommendations include the following: 1) clear goals and task specifications before the execution of any project or programme; 2) a common understanding and expectation of desired goals and objectives; 3) paying greater attention to the incorporation of potential beneficiaries into the planning and design stages of programmes.