Continuing Medical Education [viewpoint]

The Caribbean needs a specialized Continuing Medical Education Unit and the structure that would enhance most of this is a University of the West Indies Faculty of Medical Sciences' Outreach Department of Continuing Medical Education. (AU)

The changing role of the family practitioner in the Caribbean

Family medicine has its origin in 15th Century England, when apothecaries filled the gaps in British health care of that time. The discipline has had a checked history and in the West Indies in 1984 the poor health care situation resulted in the University of London establishing a college, The University College of the West Indies, to produce general practitioners to work in the islands of the Caribbean. Over the past 50 years the role of family practitioner has changed to the extent that the same educational institution, now the Faculty of Medical Sciences of the University of the West Indies, produces family doctors with post graduate training equal to that in all of its other post graduate programmes. Over 40 percent of Family Medicine in the Caribbean today must be preventive in one or more of its many forms. The role of educating and counselling in an ever more influential market society is an essential preventive function, as is the need for screening and case findings. The challenge is to view every encounter with the patient as an opportunity for some necessary screening or prevention. In addition there is the need for management skills, not only to facilitate the best use of increasingly complex health services, but in many cases to protect the patient from these. Essential to the care of patients with urgent problems, those with chronic diseases and those with psychological and behavioural problems, is the mystique of the doctor-patient relationship. This powerful tool is built on understanding and trust, it facilitates communication, motivation and partnership in health care. It is the core of modern family medicine where ethical issues and clinical decision are worked out jointly by doctor and patient. This changing role of the family physician occurs in response to the availability of specialists in both primary and secondary care. The future will be shaped by the family physicians who are motivated to record and analyze their observations and experiences in this unique speciality. Research in family medicine is essential for further understanding and definition of the discipline, and only the family physician can set the scene for this.(AU)

Headaches in persons attending polyclinics in Barbados

Headache is a very common problem in the community, but only a small proportion of people who have it presents to the health services. In the Caribbean little is known of its prevalence, the resulting morbidity or the nature of self care used. This paper reports on a survey of 679 adults who attended three polyclinics as patients, or accompanying young, elderly or acutely ill relatives. 68.9 percent reported having experienced a headache in the previous month. Headaches were more prevalent among respondents aged 25-44 years (78.6 percent) than among those in other age groups; in women (73 percent) than in men; in those living in households of four or more people (72 percent) than in those living in smaller households; in those whose family members were reported as using alcohol, tobacco or marijuana singly or in combination (70-72.5 percent) compared to those whose families did not use any of these substances (55 percent); and in those whose family members were reported as having allergy, asthma and migraine (72.5 to 77.1 percent). No significant association was shown in relation to employment. 18.4 percent of the respondents visited the doctor for their headache. In the clinical evaluation of these patient, the number of costly investigations may be reduced by attention to the epidemiological variables such as age and gender, domestic factors such as stress, and family disease such as migraine, asthma and allergy.(AU)

Obesity in food handlers

The objective of this study was to determine whether obesity is an occupational hazard in food handlers. 309 persons who presented to two Barbadian group General Practices for food handling certification were studied. The results demonstrate that a majority (55.3 percent) of food handlers had grade 1 obesity or overweight (BMI > 25 kg/sq m). The prevalence in men 67/104 (64.4 percent) was as great as in women 104/175 (59.4 percent). Overweight was high in the relatively young age groups, 30-39 (60.9 percent), 40-49 (75 percent) and 50-59 (69.7 percent). Among the food handlers it was seen more frequently in those with sedentary lifestyles (76/116; 65.5 percent) and in those who had worked more than 10 years in the food handling industry (91/140; 65 percent). No association was found between overweight and use of alcohol or tobacco, but among the food handlers studied were many who demonstrated inaccurate perception of their body image, with 74 of the 190 (39 percent) who thought their weight to be normal, actually classified as overweight. Obesity or overweight is most likely and occupational hazard in food handlers. They work in an industry that is growing rapidly in Barbados as tourism services expand and as the local population adopts the lifestyle of eating out more often. Food handlers are required by law to be certified annually as fit to work. It is important that doctors recognize the threat of obesity and use the opportunity of this annual examination to screen and intervene for this hazard.(AU)

Obesity in food handlers

The object of this study was to determine whether obesity is an occupational hazard in food handlers. 309 persons who presented to two Barbadian group General Practices for food handling certification were studied. The results demonstrate that a majority of food handlers were obese (55.3 percent), more so than in population studies despite the relatively young age of the sample. The men 67/104 (64 percent) were just as obese as the women 104/175 (59.4 percent) and obesity was seen in the relatively young age groups, 30-39 (60.9 percent), 40-49 (75 percent) and 50-59 (69.7 percent). Among food handlers obesity was seen more frequently than in those with sedentary lifestyles 76/116 (65.5 percent) and in those who worked more than 10 years in the food handling industry 91/140 (65 percent). No association was found between obesity and use of alcohol or tobacco, but among the food handlers studied were many who demonstrated inaccurate perception of their body image, with 74 of the 190 who thought their weight to be O.K. actually measuring as obese (39 percent). Obesity is most likely an occupational hazard in food handlers. They work in an industry that is growing rapidly in Barbados as tourism services expand and as the local population adopts the western lifestyle of eating out more often. Food handlers are required by law to be certified annually as fit to work. It is important that doctors recognize the threat of obesity and use the opportunity of this annual examination to screen and intervene for this hazard. (AU)

Obesity in food handlers

The object of this study was to determine whether obesity is an occupational hazard in food handlers. 309 persons who presented to two Barbadian group General Practices for food handling certification were studied. The results demonstrate that a majority of food handlers were obese (55.3 percent), more so than in population studies despite the relatively young age of the sample. The men 67/104 (64 percent) were just as obese as the women 104/175 (59.4 percent) and obesity was seen in the relatively young age groups, 30-39 (60.9 percent), 40-49 (75 percent) and 50-59 (69.7 percent). Among food handlers obesity was seen more frequently than in those with sedentary lifestyles 76/116 (65.5 percent) and in those who worked more than 10 years in the food handling industry 91/140 (65 percent). No association was found between obesity and use of alcohol or tobacco, but among the food handlers studied were many who demonstrated inaccurate perception of their body image, with 74 of the 190 who thought their weight to be O.K. actually measuring as obese (39 percent). Obesity is most likely an occupational hazard in food handlers. They work in an industry that is growing rapidly in Barbados as tourism services expand and as the local population adopts the western lifestyle of eating out more often. Food handlers are required by law to be certified annually as fit to work. It is important that doctors recognize the threat of obesity and use the opportunity of this annual examination to screen and intervene for this hazard.

Headaches in patients attending polyclinics in Barbados

679 adults attending three polyclinics in Barbados were interviewed using a standardised pre-coded questionnaire. 468 (68.9 percent) reported having a headache in the past month, and these were tabulated with variables such as age, gender, number of persons living in the home, the use of alcohol, cigarettes, marijuana and cocaine by family members, and the presence of migraine, allergy, and asthma in family members. The results demonstrate that headache was more prevalent in women, and in those aged 25 - 44 years, but there was no relationship between headace and employment, or headaches and the use of alcohol, cigarettes and other substances by family members. As the number of persons in the household increased, so did the occurrence of headaches, there being a three-fold increase in headaches between person living alone or with one other person and those with five in the household. There were more headaches (313/93) in those who reported migraine in the family, and also more headaches (158/47) in those reporting an upper respiratory allergy in their families. Eight-six persons with a headache in the past month (18.4 percent) would visit their doctor for this, a higher percentage than reported from other countries, while 313 (66 percent) reported self-medication with over the counter medicines. The study confirms, as have epidemiological studies in other countries, that a vast majority of persons with headaches do not present to the health services. In the clinical evaluation of the person with a headache, costly investigation may be reduced by attention to epidemiological variables such as age and gender, and domestic factors such as stress, migraine and allergy. (AU)

Referrals in family practice: a retrospective study of referrals - abstract

This study took a retrospective look at referrals from a primary care physician to secondary and tertiary institutions during three years of post-graduate training, July 1988 to September 1991. The aims were to assess the types of referrals made, their outcome and the degree of communication that existed between the specialities. Of the 151 referrals made, 41 (27.15 percent) were males and 110 (72.85 percent) were females; a male : female ratio of 1 : 2.7. The age of referral followed the population distribution with the majority 37.77 per cent in the reproductive age group 15 - 44 years. Most of the referrals went to the departments of Surgery, Accident and Emergency, Opthalmology and to the Nutritionist. The surgical disciplines received 37.75 per cent of the referrals while 5.96 per cent went to the medical disciplines. Compliance with referrals was found to be 78.15 per cent, with 13.25 per cent of the patients requiring admission to hospital at the time of referral. Emergency management on referral was required in 19.21 per cent of cases, whilst 63.58 per cent of the patients had an out patient follow-up appointment. Resolution of the problem occurred in 42.38 per cent of patients. Ninety-five per cent [95.36] of the patients returned to the primary care setting after referral, although communication from the specialties was documented in only 11.92 per cent of the referrals. The remainder of information on referral outcome was verbal in 69.54 per cent while in 18.54 per cent of cases there was no documentation on referral outcome (AU)

A Descriptive study of the family physicians' use of radiology in Barbados - abstract

A descriptive study of family physicians' use of radiology in Barbados was carried out. This study examined a total of 691 X-rays, a 10 percent systematic sample of X-rays in chronological order that were done on referral from primary care physicians in 1992 by the Queen Elizabeth Hospital's X-ray Department. Of the 691 X-rays evaluated at the Queen Elizabeth Hospital, 90.5 percent were of 6 types ( chest - 21.9 percent, lower extremity - 18.5 percent, upper extremity - 14.6 percent, contrast - 13.9 percent, spine - 11.1 percent, and head 10.9 percent). For all types of X-rays females were X-rayed more than males (overall 52.2 percent vs 40.1 percent, with no data on 3.8 percent). Forty-two percent (42.8 percent) of X-rays were abnormal, with X-rays of the spine most likely to be abnormal (66.2 percent) and mammogram (9.4 percent) least likely. No seasonal pattern of X-ray use was detected. Public sector referrals were responsible for 78.9 percent of X-rays and the private sector for 21.1 percent. These two sectors of primary care showed similarities in the frequencies of X-ray requests, by gender and result. For private sector referrals, 56.8 percent of patients were over 50 years of age compared to 26.2 percent for public sector referrals. Twenty percent (19.9 percent) of chest X-rays were requested to screen the patient, with 93.3 percent of these being normal, while of the 80.1 percent requested for other reasons 52.1 percent were normal. Most mammograms (62.5 percent) were requested on women under 50 years of age. For barium meals, 58.6 percent were done on patients over 50 years of age, and these showed a greater percentage of abnormal results than those done on patients under 50 years of age. This study provides a foundation on which further investigations of family physicians' use of radiology services can be based (AU)

Confidentiality in Caribbean health care - abstract

The AIDS epidemic has brought into sharp focus the ancient ethic of confidentiality of medical information. This report is part of a larger study commissioned by the Caribbean Community Secretariat on ethical and legal issues pertaining to the HIV/AIDS epidemic. Twenty-one persons in leadership posts were interviewed; these included Chief Medical Officers of 9 Ministries of Health, holders of top positions in 9 Non-governmental Organisations, including UWI's Faculties of Medical Sciences and Law, trade unions, professional organisations and 3 top Barbadian Civil Servants. The number of years' service by the respondents was 9.38 (SD 6.32). They were unanimous in their view that breaches of confidentiality by health care workers warranted disciplinary action by the relevant professional council, although 4 (19.0 percent) suggested more lenient approaches in certain cases. Despite this, 15 (71.4 percent) said that medical records should be complete and accurate, with all confidential information recorded, and that records should be more professionally managed. Sixteen respondents (76.2 percent) said that third parties, including insurance companies, immigration departments, CMOs' offices, etc., would be guilty of an offence in law if a patient's confidential matters were leaked by them. Most respondents thought that the duty to warn the spouse of an HIV-infected patient of the risk of infection was a very difficult issue. Eleven (52.4 percent) said the doctor should, if necessary, break a patient's confidentiality and warn his/her spose. In small Caribbean societies confidentiality is very important. If people feel that their private affairs will be divulged, they will stay away from health care workers, compromising their care and threatening public safety. It is recommended that the issue of confidentiality be given more attention in CME and in medical practice in the Caribbean (AU)

Is preventive medicine a component of the primary care service for diabetes in Barbados? - abstract

Diabetes mellitus is a chronic illness that requires continued medical care and education to prevent acute complications and to reduce the risk of long-term complications. Diabetics should receive care and treatment from a health team with interest and expertise in the management of diabetes. This study aimed to evaluate the quality of care offered to diabetics in three different clinic settings in Barbados. The case notes of 690 diabetic patients attending private practitioner offices, polyclinic general clinics and polyclinic diabetic clinics, were identified during a six-week index period, and a questionnaire was completed for each patient. Although the average number of visits annually was similar in each of the three settings (5-6 visits/year), private practitioners had the lowest percentage of patients (30.7 percent) with poor glycaemic control (defined here as a fasting blood sugar >/=8 mmol/l, or any other blood sugar >/=10 mmol/l. Overall, the glycaemic control was poor in 44.9 percent of patients. Screening for potential long-term complications such as cardiovascular complications, foot problems, eye problems and kidney problems was recorded as being done in a minority of patients, while the concomitant menace of poorly controlled hypertension, which is known to accelerate the progression of diabetic complications, was present in a significant number of patients. While recognising the limitations of the technique of case note review, these results indicate a need for clear concise guidelines for diabetic primary care, with emphasis on prevention and early detection (AU)

A knowledge, attitude and practice, survey among adult Barbadians: attitudes, and practices in relation to condom use - abstract

A survey of knowledge, attitudes and practices in relation to AIDS was conducted on a 0.4 percent sample of adult Barbadians, obtained from the country's electoral register. Interviews were conducted by trained social science service students in the respondents' homes. The demography of the sample in relation to race and gender are representative of the population. However, the age group 25-44 years, is under-represented compared with the estimated adult population. Respondents were aware of the correct modes of transmission of HIV; 79.6 percent of them perceived that their lifestyle would prevent them from acquiring HIV infection, and 9 percent said it would not. Myths are present, however; for example, 40.9 percent of respondents thought that by practising vaginal sex only they could avoid transmission of HIV, and 59.7 percent thought that lesbians were at high risk for getting HIV. Although 68.7 percent of respondents agreed that condoms provided good protection against the transmission of HIV, 14.5 percent disagreed. The 18-24 year-old group, both men and women, were significantly more in agreement about the protection that condoms afforded. There was no significant difference between men and women in the 11 percent of respondents who said that they always used condoms. However, there were significantly more women who said they never used condoms at all and more men than women who said they used them sometimes. Both men and women, 15.4 percent of those responding, agreed that some women refused to have sex without condoms, and that men responded postively when asked to do so. However, a quarter of the men said that some women requested that condoms be not used; this paralleled the quarter of women who said they did not use condoms because it reduced their pleasure. In that regard, 42.9 percent of men said they did not use condoms because they reduced their pleasure in sex. It is of interest that 60 percent of the women responding did not agree that condoms were a man's responsibility only (AU)

Continuing medical education in the Caribbean - abstract

The rapid changes in medical knowledge involve both the adoption of new facts and ideas and the discarding of once well-established ones. It is quite impossible to work in the field over a 5 - 10 year period without some form of Continuing Medical Education (CME). In the Caribbean, this need is more acute as many physicians work in relative isolation. Further reinforcing this need is the situation where many physicians, even with postgraduate training, work in general areas of health care. Efforts at CME in Barbados have achieved only limited results, specifically with the few faithful "familiar faces" updating their knowledge, skills and participation. The continuing education of a majority of the thousands of doctors produced by our Faculty since 1954 remains uncertain. It is not unreasonable that Caribbean doctors will be asked to demonstrate their "qualification" in CME, particularly as our developing societies grow in sophistication. It is essential that the medical profession itself deals with this problem and that it is not left to be dealt with by administrative, legal or political authorities (AU)

Ethical issues in Caribbean medical practice

In the Caribbean today, issues and perspectives of Medical thics are presently influenced by a profession that shows only moderate awareness and interest on one hand, and a society still discovering its entitlements and rights, on the other. In the past, society has changed its perspective of ethical issues quite dramatically. There is evidence that this is occuring in the Caribbean. The medical professionals involved in health care delivery, must shake off their lethargy in dealing with ethics, and through education, awareness and application, maintain the dignity of the profession, and restore the rights of the patient

Ethical issues in Caribbean medical practice

In the Caribbean today, issues and perspectives of Medical thics are presently influenced by a profession that shows only moderate awareness and interest on one hand, and a society still discovering its entitlements and rights, on the other. In the past, society has changed its perspective of ethical issues quite dramatically. There is evidence that this is occuring in the Caribbean. The medical professionals involved in health care delivery, must shake off their lethargy in dealing with ethics, and through education, awareness and application, maintain the dignity of the profession, and restore the rights of the patient

A Knowledge, attitude and practices survey among adult Barbadians: reduction in sexual activity - abstract

A survey of knowledge, attitudes and practices in relation to AIDS and sexual matters was conducted on a 0.4 per cent sample of adult Barbadians obtained from the country's electoral register. Ninety-two point nine per cent knew that HIV was a sexually transmitted disease, but 33.8 per cent thought that the virus could be passed in saliva. Ninety-six per cent of respondents considered promiscuity, including male homosexuality, as high risk for getting AIDS, but this extended to female homosexuals where 59.7 per cent of the respondents felt that such women were also at high risk. In regard to sexual practices, respondents reported that they had reduced the number of their sexual partners in the past year, when compared to 5 years before - for male respondents, 70.6 per cent said they had had either one or no sexual partners in the past year, compared to 48.3 per cent of 5 years before. The results demonstrate that myths and stigmatisation counter sound knowledge of HIV transmission to some extent, and self-reported reduced number of partners in the past year suggests a favourable response to sex education and AIDS/HIV educational efforts (AU)

Understanding obesity in the Caribbean

There is a high prevalence of obesity in the Caribbean and evidence in Barbados that this is increasing and occurring in teenagers. There are important concepts and beliefs underlying this problem, the foremost of which is inaccurate perception of body image. The beliefs that overweight women are more attractive to men, that obesity is associated with good health and wealth and that it must be accepted as normal because it "runs in families" must all be dealt with before a change in lifestyle can occur. Long-term diet and exercise changes will correct obesity, but family traditions and market forces make this more difficult to accomplish. (AU)

Hypertension, diabetes, and obesity in Barbados: findings from a recent population-based survey

A stratified random sample of 464 persons aged 40 ato 79 years, drawn from enumeration registers in the Bridgetown area of Barbados, participated in this survey. The prevalence of hypertension (defined as systolic blood pressure of at least 160mm Hg, diastolic blood pressure of at least 95 mm Hg, or use of antihypertensive medication) was 47 percent and 43 percent for women and men, respectively. Diabetes was present in 17 percent of all subjects (18 percent of women and 15 percent of men). Of the 209 hypertensive subjects, 82 percent were aware of their blood pressure status. The proportion of previously diagnosed hypertensive subjects on medication was 72 percent for men and 68 percent for women. Fifty-three percent of men and 42 percent of women were overweight (body mass indices [weight in kilograms divided by height in meters squared] between 25 and 30. However, 30 percent of women and 10 percent of men were obese (body mass indices over 30), supporting the growing recognition of the marked gender disparity in obesity among persons of African origin in the Caribbean. Body mass index was positively associated with hypertension (OR=1.33; 95 percent CI: 1.1-1.6). Obese persons experienced a 2.6 times greater risk of hypertension compared to those with body mass indices below 25. Similar statistically significant associations were observed between diabetes and body mass index: Or comparing body mass index over 30 with body mass index under 25 was 2.5 (95 percent CI: 1.3-5.1) for all subjects, 1.0 (0.3-4.1) for men only, and 5.2 (1.9-14) for women only. Preventing obesity in this population could reduce the incidence of hypertension and diabetes by approximately 30 percent and 33 percent among men and women, respectively. (Au)