A comparison of outcome for stroke patients in Barbados and South London.

BACKGROUND AND AIMS: Little is known about the poststroke outcome in Caribbean populations. We investigated differences in the activities of daily living, level of social activities, living circumstances and survival for stroke patients in Barbados and London. METHODS: Data were collected from the South London Stroke Register and the Barbados Register of Strokes for patients with a first-ever stroke registered between January 2001 and December 2004. The ability to perform activities of daily living was measured by the Barthel Index and level of social activities by the Frenchay Activities Index. Living circumstances were categorised into private household vs. institutional care. Death and dependency, activities of daily living and social activities were assessed at three-months, one- and two-years using logistic regression, adjusted for differences in demographic, socioeconomic and stroke severity characteristics. RESULTS: At three-months, a high level of social activities was more likely for the Barbados Register of Strokes (odds ratio 1.84; 95% confidence interval 1.03-3.29); there were no differences in activities of daily living; and Barbados Register of Strokes patients were less likely to be in institutional care (relative risk ratio 0.38; 95% confidence interval 0.18-0.79). Following adjustment, Barbados Register of Strokes patients had a higher risk of mortality at three-months (relative risk ratio 1.85; 95% confidence interval 1.03-3.30), one-year (relative risk ratio 1.83; 95% confidence interval 1.08-3.09) and two-years (relative risk ratio 1.82; 95% confidence interval 1.08-3.07). This difference was due to early poststroke deaths; for patients alive at four-weeks poststroke, survival thereafter was similar in both settings. CONCLUSIONS: In Barbados, there was evidence for a healthy survivor effect, and short-term social activity was greater than that in the South London Stroke Register.

Public health education in Barbados

Most [Caribbean] countries have grossly understaffed health promotion units, and while there are many initiatives, whether individual, non-governmental or governmental, they are often uncoordinated and unsustained. This chapter will review some of the broader Caribbean health promotion efforts in the literature and some of the local efforts in Barbados, and address the approaches most likely to have an impact on the major Caribbean health priorities.

A comparison of acute and long-term management of stroke patients in Barbados and South London.

BACKGROUND: To compare health care utilisation between stroke patients living in a middle-income country with similar patients in a high-income country in terms of the type and amount of health care received following a stroke. METHODS: Data were collected from the population-based South London Stroke Register (SLSR) and the Barbados Register of Strokes (BROS) from January 2001 to December 2004. Differences in management and diagnostic procedures used in the acute phase were adjusted for age, sex, ethnic group, living conditions pre-stroke and socio-economic status by multivariable logistic regression. Comparison of subsequent management was made for 3 months and 1 year post-stroke. RESULTS: Patients in BROS were less likely to be admitted to a hospital ward (OR 0.22; 95% CI 0.13-0.37), but the difference for the lower use of brain scans in BROS was smaller (OR 0.62; 95% CI 0.25-1.52). Additional adjustment for stroke severity (Glasgow Coma Score) showed that BROS patients were more likely to have a swallow test on admission (OR 2.95; 95% CI 1.17-7.45). BROS patients were less likely to be in nursing care at 3 months (OR 0.37; 95% CI 0.17-0.81), and less likely to be receiving speech and language therapy at 3 months (OR 0.10; 95% CI 0.03-0.33) and 1 year (OR 0.05; 95% CI 0.00-0.55). CONCLUSIONS: The lower use of hospital admission and nursing care at 3 months suggests that in Barbados, family and friends take greater responsibility for patient care around the time of the stroke and in the medium term thereafter.

Differences in risk factors between black Caribbean patients with stroke in Barbados and South london.

BACKGROUND AND PURPOSE: Risk of stroke is higher in black Caribbeans in the United Kingdom compared with black Caribbeans in their country of origin. We investigated if these differences were caused by variations in prior-to-stroke risk factors. SUMMARY OF REPORT: Data were collected from the South London Stroke Register (SLSR) and the Barbados Register of Strokes (BROS). Differences in prevalence and management of stroke risk factors were adjusted for age, sex, living conditions prestroke, stroke subtype, and socioeconomic status by multivariable logistic regression. Patients in BROS were on average older (mean difference 4 years) and more likely to have a nonmanual occupation. They were less likely to have a prestroke diagnosis of myocardial infarction (OR, 0.39; 95% CI, 0.19 to 0.77) or diabetes (OR, 0.65; 95% CI, 0.46 to 0.92) and were less likely to report smoking (OR, 0.31; 95% CI, 0.19 to 0.49). They were also more likely to receive appropriate prestroke antihypertensive (OR, 1.88; 95% CI, 1.21 to 2.92) and antidiabetic treatment (OR, 3.33; 95% CI, 1.44 to 7.70) and less likely to receive cholesterol-lowering drugs (OR, 0.19; 95% CI, 0.05 to 0.71). CONCLUSIONS: The higher risk of stroke in black Caribbeans in the United Kingdom might be caused by a higher prevalence of major prior-to-stroke risk factors, differences in treatment patterns for comorbid conditions, and less healthy lifestyle practices compared with indigenous black Caribbean populations.

All-cause mortality after diabetes-related amputation in Barbados: a prospective case-control study.

OBJECTIVE: To determine the mortality rate after diabetes-related lower-extremity amputation (LEA) in an African-descent Caribbean population. RESEARCH DESIGN AND METHODS: We conducted a prospective case-control study. We recruited case subjects (with diabetes and LEA) and age-matched control subjects (with diabetes and no LEA) between 1999 and 2001. We followed these groups for 5 years to assess mortality risk and causes. RESULTS: There were 205 amputations (123 minor and 82 major). The 1-year and 5-year survival rates were 69 and 44% among case subjects and 97 and 82% among control subjects (case-control difference, P < 0.001). The mortality rates (per 1,000 person-years) were 273.9 (95% CI 207.1-362.3) after a major amputation, 113.4 (85.2-150.9) after a minor amputation, and 36.4 (25.6-51.8) among control subjects. Sepsis and cardiac disease were the most common causes of death. CONCLUSIONS: These mortality rates are the highest reported worldwide. Interventions to limit sepsis and complications from cardiac disease offer a huge potential for improving post-LEA survival in this vulnerable group.

Poststroke survival for black-Caribbean populations in barbados and South london.

BACKGROUND AND PURPOSE: There are variations in mortality rates for stroke in black communities, but the factors associated with survival remain unclear. METHODS: The authors studied population-based stroke registers with follow up in South London (270 participants, 1995 to 2002) and Barbados (578 participants, 2001 to 2003). Differences in sociodemographic factors, stroke risk factors and their management, case severity, and acute management between London and Barbados were studied. Survival analysis used Kaplan-Meier curves, log-rank test, and Cox proportional hazards model with stratification. RESULTS: There were 1411 person-years of follow-up. Patients in Barbados had poorer survival (log-rank test P=0.037), particularly those with a prestroke Barthel index scores between 15 and 20 (1-year survival, 56.4% versus 74.3%; P<0.001). This disadvantage remained significant (hazard ratio [HR], 1.99; 95% CI, 1.23 to 3.21, P=0.005) after adjustment for age and year of stroke and stratification for stroke subtype and socioeconomic status (SES). After stratification by SES, clinical stroke subtype, and Glasgow Coma Score, and adjustment for other potential confounders, additional factors reducing survival were untreated atrial fibrillation (AF; HR, 8.54; 95% CI, 2.14 to 34.08, P=0.002), incontinence after stroke (HR, 2.64; 95% CI, 1.79 to 3.89), and dysphagia (HR, 2.25; 95% CI, 1.57 to 3.24). Patients not admitted to the hospital had improved survival (HR, 0.35; 95% CI, 0.21 to 0.58). Interaction terms between location and Barthel score, location and AF, and location and transient ischemic attack were included in the final model to reflect the greater difference in survival with a high Barthel score of 15 or more, absence of untreated AF, and having untreated transient ischemic attack. CONCLUSIONS: Black-Caribbean people with stroke living in Barbados have worse survival than similar patients in South London, particularly if they have good mobility before the stroke. Further exploration and refinement of measurement of confounding factors such as SES and poststroke management along with exploring the cultural/environmental differences between the communities is required to understand these stark differences.

Estimation of the risk of stroke in black populations in Barbados and South London.

BACKGROUND AND PURPOSE: The incidence of stroke in black populations is a public health issue, but how risk varies between black communities is unclear. METHODS: Population-based registers in South London (SLSR) and Barbados (Barbados Register of Strokes [BROS]). Stroke incidence estimated by age group, gender and stroke subtype from January 1995 to December 2002 (SLSR), and October 2001 to September 2003 (BROS). Incidence rate ratios [IRR] estimated adjusting for age and sex. RESULTS: Two hundred and seventy-one cases registered in SLSR and 628 cases in BROS. Average age of stroke was 66.1 years (SD 13.7) in SLSR and 71.5 years (SD 14.9) in BROS (P<0.001). The incidence rate/1000 population in SLSR was 1.61 (European adjusted; 95% CI, 1.41 to 1.81) and 1.08 (world adjusted; 95% CI, 0.95 to 1.21). For Barbados incidence rates were 1.29 (European adjusted; 95% CI, 1.19 to1.39) and 0.85 (world adjusted; 95% CI, 0.78 to 0.92). Overall IRR for SLSR: BROS adjusted for age and sex was 1.26 (95% CI, 1.09 to 1.46). Statistically significant subtype differences included total anterior cerebral infarction (IRR, 1.82; 95% CI, 1.23 to 2.69), posterior cerebral infarction (IRR, 2.12; 95% CI, 1.28 to 3.53), primary intracerebral hemorrhage (IRR, 1.56; 95% CI, 1.03 to 2.35) and subarachnoid hemorrhage (IRR, 5.04; 95% CI, 2.54 to 9.97). CONCLUSIONS: The risk of stroke in black Caribbeans is higher in South London than Barbados, and particularly so for specific stroke subtypes. The risk in Barbados approaches that in the white population in South London and strokes occur at an older age. Whether environmental factors mediate these differences in migrant populations requires further study.

Prevalence and risk factors associated with obesity in the elderly in Barbados.

This article's objective is to examine the epidemiology of obesity in the urban elderly population of Barbados. A random sample of adults >/= 60 years underwent comprehensive interviews and measurement of their weight, height, and waist circumference (WC). Outcomes of interest were obesity (body mass index [BMI] > 30 kg/m2), high-risk WC (men >/= 102 cm; women >/= 88 cm), and high risk of disease comorbidity (from BMI and WC criteria). Total, 1,508 persons participated (80% response). Women had higher rates of obesity (31% vs. 11.9%), high-risk WC (61.9% vs. 13.9%), and disease co-morbidity risk (51.1% vs. 17.5%) compared to men. Multivariate regression confirmed female gender as an independent predictor of outcomes (p < 0.001). Other predictors were less consistent: self-reported fair/poor health status and eating two (vs. three) meals daily were associated with obesity, whereas semiprofessional occupation and unmarried status predicted high-risk WC. Obesity is highly prevalent among elderly Barbadians. Public health interventions must target this group, particularly women.

Exercise, blood sugar, blood pressure, and cholesterol levels in a Caribbean population.

This study used a population-based sample of 407 Seventh-day Adventists in Barbados to determine the relationship between physical activity, blood sugar, hypertension, and cholesterol levels. A systematic random sampling technique was used to select participants: 37.6% were male and 62.4% female. No significant association was found between exercise and the outcome variables: blood sugar, blood pressure, and cholesterol levels of participants. However, females appeared to be more sedentary when compared to males. A significant association was seen between weekly exercise and triglycerides, but only in male participants.

Historical and current predictors of self-reported health status among elderly persons in Barbados.

OBJECTIVE: To understand the relative contribution of past events and of current experiences as determinants of health status among the elderly in the Caribbean nation of Barbados, in order to help develop timely public health interventions for that population. METHODS: The information for this prevalence study was collected in Barbados between December 1999 and June 2000 as part of the "SABE project," a multicenter survey in seven urban areas of Latin America and the Caribbean that evaluated determinants of health and well-being in elderly populations (persons 60 and older). We used ordinal logistic regression to model determinants of self-reported health status, and we assessed the relative contribution of historical socioeconomic indicators and of three current modifiable predictor groups (current socioeconomic indicators, lifestyle risk factors, and disease indicators), using simple measures of association and model fit. RESULTS: Historical determinants of health status accounted for 5.2% of the variation in reported health status, and this was reduced to 2.0% when mediating current experiences were considered. Current socioeconomic indicators accounted for 4.1% of the variation in reported health status, lifestyle risk factors for 7.1%, and current disease indicators for 33.5%. CONCLUSIONS: Past socioeconomic experience influenced self-reported health status in elderly Barbadians. Over half of this influence from past events was mediated through current socioeconomic, lifestyle, and disease experiences. Caring for the sick and reducing lifestyle risk factors should be important considerations in the support of the current elderly. In addition, ongoing programs for poverty reduction and increased access to health care and education should be considered as long-term strategies to improve the health of the future elderly.

Historical and current predictors of self-reported health status among elderly persons in Barbados

OBJECTIVE. To understand the relative contribution of past events and of current experiences as determinants of health status among the elderly in the Caribbean nation of Barbados, in order to help develop timely public health interventions for that population. METHODS. The information for this prevalence study was collected in Barbados between December 1999 and June 2000 as part of the "SABE project," a multicenter survey in seven urban areas of Latin America and the Caribbean that evaluated the determinants of health and well-being in elderly populations (persons 60 and older). We used ordinal logistic regression to model determinants of self-reported health status, and we assessed the relative contribution of historical socioeconomic indicators and three current modifiable predictor groups (current socioeconomic indicators, lifestyle risk factors, and disease indicators), using simple measures of association and model fit. RESULTS. Historical determinants of health status accounted for 5.2 percent of the variation in reported health status, and this was reduced to 2.0 percent when mediating current experiences were considered. Current socioeconomic indicators accounted for 4.1 percent of the variation in reported health status, lifestyle risk factors for 7.1 percent, and current disease indicators for 33.5 percent. CONCLUSIONS. Past socioeconomic experience influenced self-reported health status in elderly Barbadians. Over half of this influence from past events was mediated through current socioeconomic, lifestyle, and disease experiences. Caring for the sick and reducing lifestyle risk factors should be important considerations in the support of the elderly. In addition, ongoing programs for poverty reduction and increased access to health care and education should be considered as long-term strategies to improve the health of the future elderly (AU)

The relationship of internalized racism to body fat distribution and insulin resistance among African adolescent youth.

This study examined the relationship of internalized racism (INR) and hostility to body fat distribution and insulin resistance in black adolescent children age 14-16 years on the Caribbean island of Barbados. Questionnaire data on psychosocial variables and anthropometric measurements, together with a fasting blood sample, were obtained from 53 low-birthweight and 119 normal-birthweight adolescents. Insulin resistance was calculated using the homeostasis model assessment (HOMA). Spearman correlation analyses showed that both INR (r = 0.244) and hostility (r = 0.204) were significantly (p < 0.05) correlated with waist circumference in girls but not boys. Among girls, age- and birthweight-adjusted mean levels of BMI and waist circumference were greater for those with high levels of INR and hostility compared to those with low levels of both variables. In multiple logistic regression analyses, a high INR remained independently associated [odds ratio = 3.30 (95% CI = 1.30-8.36); p = 0.012] with having an elevated HOMA value in models that included age, income, birthweight, hostility, physical activity and family history of diabetes. The results of the current study show that the positive relationship between INR and metabolic health risk seen in African-Caribbean adults also exists in African Caribbean adolescent youth independent of birthweight.

Dialysis in Barbados: the cost of hemodialysis provision at the Queen Elizabeth Hospital

OBJETIVO: El objetivo de este estudio fue analizar el costo, para los servicios sanitarios, de la hemodiálisis realizada en el Queen Elizabeth Hospital de St. Michael, Barbados. MÉTODOS: Realizamos un análisis de costos desde el punto de vista del hospital terciario objeto de este estudio, con protocolos para el tratamiento que se basan en las prácticas actuales para establecer el punto de acceso vascular (preparación quirúrgica) y el mantenimiento de la diálisis. Los datos relativos a los costos y pacientes fueron recogidos desde el 1 de abril de 1998 hasta el 31 de marzo de 1999. Fueron estudiados 64 pacientes y se realizó un total de 7 488 sesiones de hemodiálisis durante el estudio. Los costos analizados han sido los de mano de obra, farmacéuticos, suministros (para diálisis y para otros fines), costos de hospitalización, laboratorio y otros servicios complementarios, y costos indirectos tales como la ingeniería, limpieza, lavandería y administración. RESULTADOS: Se calculó como costo de cada tratamiento de hemodiálisis una cifra de US$ 156,64 durante el primer año, y US$ 145,55 en años sucesivos. El costo total anual por paciente fue de US$ 18 327,22 en el primer año de diálisis, incluida la preparación quirúrgica, y de US$ 17 029,54 en lo sucesivo. Los costos directos (determinados por la utilización de recursos por el paciente y los costos de mano de obra para médicos y personal de enfermería) representaron el 80,7% del costo total. Los gastos principales fueron los suministros relacionados con la diálisis, la mano de obra, y los costos indirectos. CONCLUSION: Estos resultados son importantes, habida cuenta de las limitaciones en los recursos económicos en los servicios sanitarios de los países del Caribe, junto con el aumento de la prevalencia de la insuficiencia renal en dichos países. Se recomienda la realización de nuevos análisis para estudiar el suministro de los servicios de terapia de sustitución renal en Barbados y trazar planes para extender y optimizar estos servicios.

Explanations for the high risk of diabetes-related amputation in a Caribbean population of black african descent and potential for prevention.

OBJECTIVE: Diabetes-related lower-extremity amputation (LEA) rates are elevated in blacks compared with whites in the U.S., but are lower in African Caribbeans in the U.K., whereas anecdotal reports suggest high rates in the Caribbean. We aimed to establish the incidence and risk factors for diabetes-related LEA in a Caribbean population. RESEARCH DESIGN AND METHODS: We conducted an incident and prospective case-control study of case patients (individuals with diabetes having a LEA) and community-based control subjects (individuals with diabetes without a LEA) in Barbados, West Indies. Participants completed an interview and examination of risk factors for amputation, including footwear use. RESULTS: The overall 1-year incidence of LEA (n = 223) was 173 per 10(5) population and 936 per 10(5) population with diabetes (557 per 10(5) for minor amputation and 379 per 10(5) for major amputation). Women had higher amputation rates than those reported in the Global Lower Extremity Amputation Study, apart from the U.S. Navajo population. Independent risk factors for all diabetes-related LEAs were poor footwear (odds ratio [OR] 2.71 [95% CI 1.23-5.97]), elevated GHb (1.40 per percent increase [1.26-1.57]), peripheral neuropathy (1.05 per volt increase [1.03-1.08]), and peripheral vascular disease. CONCLUSIONS: Diabetes LEA rates in Barbados are among the highest in the world. Inadequate footwear independently tripled amputation risk. Education of professionals and patients, particularly about footwear and foot care, coupled with improved diabetes clinical care, is key to reducing amputation risk in this population.

Incidence and case fatality rates of first-ever stroke in a black Caribbean population: the Barbados Register of Strokes.

BACKGROUND AND PURPOSE: Estimation of stroke incidence among black populations outside the USA and the UK has been hampered by the lack of community-based studies. We aimed to document the incidence of first-ever stroke in Barbados, a Caribbean island with a population of 268,000 people. METHODS: A national community-based prospective register of first-ever strokes, using multiple overlapping sources of notification, was established. RESULTS: During the first year, 352 patients (95.2% black) were registered, 142 males and 210 females (59.7%), with a mean age of 72.5 years (range 24 to 104; SD 14.8). Cerebral infarction (IS) occurred in 81.8%, intracerebral hemorrhage (ICH) in 11.9%, subarachnoid hemorrhage (SAH) in 2.0%, whereas 4.3% of strokes were unclassified (UC). The crude annual incidence rate for the black population was 1.40 (95% CI: 1.25,1.55) per 1000 (1.35 standardized to the European population) for all strokes, 1.20 (1.07,1.34) for IS, 0.18 (0.12,0.23) for ICH, and 0.03 (0.01,0.05) for SAH. Lacunar infarction (LACI) accounted for 50.7% of IS among the black population, whereas 15.6% and 26.8% were caused by total anterior circulation infarction (TACI) and partial anterior circulation infarction (PACI), respectively. At 7 and 28 days, respectively, case fatality rates for blacks were 13.1% and 27.8% for all strokes, 46.3% and 58.5% for ICH, 7.6% and 21.7% for IS, 32.6% and 65.1% for TACI, and 2.1% and 9.0% for LACI. CONCLUSIONS: Stroke incidence among the black population of Barbados is lower than among African-origin populations in the USA and UK. Lacunar infarction is the predominant stroke subtype.

Diabetes in the English-speaking Caribbean.

Rates of diabetes mellitus in the English-speaking Caribbean have been rising in recent years, and they are projected to continue climbing in the new millennium. Prevalence rates across countries of the African diaspora mirror levels of Western acculturation, and available data emphasize the importance of obesity as a modifiable risk factor. The population-based Barbados Eye Studies have provided new information about the burden of ocular complications of diabetes such as retinopathy and lens opacities. Diabetes was shown to increase the risk of lens opacities, and 14% of prevalent cataract was attributed to diabetes. Persons with type 1 diabetes were particularly at increased risk of retinopathy, as a result of longer durations of illness and poor glycemic control. Other Caribbean studies have suggested that glycemic control in patients evaluated in various clinical settings is suboptimal, which raises important concerns about quality of care. Diabetics are at increased risk of mortality compared with nondiabetics, and that mortality risk increases with higher baseline levels of glycosylated hemoglobin, even among nondiabetics. These data highlight the need for urgent attention to public health and clinical strategies to prevent diabetes in unaffected persons as well as to prevent or reduce the burden of complications among those who are affected. Among the measures that should be adopted to stem the flood of diabetes in the Caribbean region are lifestyle interventions to promote better nutrition and to increase exercise; patient education, particularly about the central role of diabetes self-management; and the multidisciplinary team approach in the provision of care.