Health status of the elderly in the Marigot Health District, Dominica

The health status and the prevalence of hypertension, diabetes mellitus, glaucoma and visual disorders of 123 elderly people (56 men, 67 women) in the Marigot Health District, Dominica, were assessed by means of four questionnaires: collection of data from their medical records; physical examination, measurement of blood pressure, visual acuity and intra-ocular pressure (IOP); and testing for glucosuria. The overall health status was good, but 20 percent were dependent on care. 74 percent were independent in the activities in daily life, with only moderate limitations in activities. The health status decreased considerably in those over 75 years of age. There were slight perceived differences in health status between men and women. About 40 percent of the study population were known to be hypertensive, and another 13 percent had an elevated blood pressure on examination. Diabetes mellitus was present in 15 percent. 20 percent had a visual acuity of 0.1 or below, and 10 percent had an elevated IOP. During the study, a considerable number of new cases of hypertension, diabetes mellitus and elevated IOP were diagnosed. 50 percent of the study population who were on medication used this more than as prescribed. This study indicates a high prevalence of the secondary complications of hypertension, diabetes mellitus, cataract, glaucoma and osteo-arthritis that cause disability and dependency in the elderly population. Education, diagnosis at an early stage and appropriate treatment of these disorders may prevent or delay their development. We suggest the development of a programme oriented approach of primary health care for the elderly to support this.(AU)

Sickle cell disease in primary health care in Dominica: a study in the Marigot Health District

Increased understanding of sickle cell disease (SCD) and improved management strategies of the disease in recent decades have been shown to reduce morbidity and mortality. For this, neonatal screening and specialized sickle cell clinics are prerequisites. In Dominica, there is one out-patient clinic for SCD patients at the Princess Margaret Hospital, but there is no neonatal screening for SCD. Based on available data, 10 of the approximately 2000 babies in Dominica are estimated to have homozygous SCD at birth each year. In the Marigot Health District where 200 births take place annually, the expected incidence is 1. The present study aimed to assess the known prevalence of SCD and its co-morbidity in the Marigot Health District, as well as the utilization of the available health care services by patients with SCD. In one year, 17 episodes of SCD were registered at the district clinics in patients aged 1 to 43 years. It appeared that not all SCD patients were known, especially in the youngest age group, where mortality is highest. Most encounters were prompted by acute complications of the disease. Registered co-morbidity was especially related to pregnancy and chronic leg ulcers. Follow-up at the sickle cell clinic appeared to be poor. For adequate care of SCD patients, implementation of a neonatal screening programme for SCD appears to be essential, together with a protocol for its follow-up and management. Such a protocol should optimize cooperation between primary and secondary levels of care in the management of SCD.(AU)

Gastro-enteritis in Dominica: from major cause of morbidity and mortality to minor primary care condition

Gastro-enteritis continues to be a major health problem in the developing world, especially in children. We studied morbidity and mortality rates of gastro-enteritis in the past 50 years in Dominica. All cases of gastro-enteritis registered during one year at the different levels of the primary health care services in the Marigot Health district were analysed. In a total district population of 8,554, 296 cases of gastro-enteritis (incidence 3,460/100,000) presented to the Casualty Department of the Marigot District Hospital and the district health centres. Of these, 143 were referred to the District Medical Officer. A total of 44 cases were admitted to the Marigot district hospital for short term observation and oral rehydration therapy. Only one child needed to be referred to the secondary level of care at the Princess Margaret Hospital. From being a major cause of morbidity and mortality, as well as a major reason for admission to hospital wards in the past 50 years, gastro-enteritis has become a minor condition which is generally treated at primary levels of health care. In addition to increased affluence and socio-economic conditions, this enormous improvement is attributed to the introduction of oral rehydration therapy and the development of easily accessible primary health care services.(AU)

Hypertension, diabetes and concurrent morbidity in primary health care in Marigot Health District, Dominica

This is one of a series of studies on the primary health care services in the Marigot Health District, Dominica, West Indies. The clinic records of all patients known to have hypertension or diabetes during the one-year period October 1991 - September 1992 were analyzed. The use of the International Classification of Primary Care facilitated the analysis both of episodes of disease and the prevalence of concurrent episodes. There were 514 patients with diabetes and/or hypertension, 409 episodes of hypertension and 197 of diabetes. One-quarter of the hypertensive patients were also diabetic and about one-half of the diabetics were hypertensive. From previous population-based studies, only 50 percent of the hypertensives and 80 percent of the diabetics were registered at the district clinics. Most of the care of these patients was at the primary care level. The most frequent concurrent episodes were 'disorders of stomach functions' osteoarthritis of knee, 'no disease' and obesity. The prevalence of episodes of conditions known to occur in the presence of hypertension and diabetes was, in descending order: obesity, heart failure (n=30), cataract (24), stroke (22), hypoglycaemia (16),'adverse effects of medical agents' (13), ischaemic heart disease (8), 'other disorders of urinary system' (6), acute myocardial infarction and angina pectoris (1 each). This study shows that health care for hypertension and diabetes largely takes place at primary care leve. The results confirm the previously reported low prevalence of coronary artery disease in Afro-Caribbeans with hypertension and diabetes. (AU)

District nurses in Dominica - abstract

The aims of this study was to assess the work and workload of the district nurses, and to study other aspects relatd to the profession of a district nurse. The study was conducted from June to October 1995. All encounters of three district nurses were registered during periods of four weeks, using the Internatonal Classification of Primary Care. Information on other aspects of district nursing was collected by observation and the use of a questionnaire. In the study period, 411 clients were attended to in 495 encounters. Check-ups for hypertension, diabetes, pregnancy and immunizations were among the most common reasons for encounter. Together they constitute 40 percent of all reasons for encounter. "No disease" was the most frequent diagnosis, followed by hypertension, diabetes, pregnancy, fever and skin conditions. Partial medical examinations were conducted at almost all encounters. The ranking of the treatment given was medication, education and dressing. Prevention was the most frequent activity. The district nurses effectively dealt with 80 percent of all contacts; only 20 percent of patients were referred to the district medical officer. There were several factors that negatively affected nurses' motivation. On average, the nurses worked 43 hours a week. The long walking to do household visits and being on call were considered to be the most demanding aspects. In addition to being a nurse, each has her family and other obligations. Finally, career mobility is limited. Postgraduate training with diversified certification and upgrading of wages could contribute to a continued high motivation and job satisfaction. (AU)

District medical officers encounters in the Marigot Health District, Dominica

As part of a series of studies on Primary Health Care Services in the Marigot Health District, the encounters of District Medical Officers (DMOs) and the Family Nurse Practitioners (FNPs) were studied during the one-year period October 1991 - September 1992. For this purpose, the International Classification of Primary Care (ICPC) was used. During the study period 3 518 patients (40 percent of the district's population) were seen at 7 267 encounters with 11 835 RFE'S leading to 10 914 diagnoses. There were 7 176 episodes, 1 302 originating from the period before the study and 5 874 new episodes. More women than men attended the clinics and the youngest and the oldest age groups were seen more frequently than the other age-groups. Of all encounters, 60 percent were at regular clinics, whereas 40 percent were emergency after hours encounters at the Casualty of the Marigot Hospital. The most frequent episodes of chronic conditions were hypertension (5 percent of all episodes), diabetes mellitus (3 percent) and osteoarthrosis (1 percent). Most acute conditions were due to accidents (5 percent) and infectious conditions of skin (4 percent), respiratory (6 percent) and digestive system (2 percent). "No disease" accounted for 3 percent of the episodes; in general, the results of this study are similar to previous studies conducted on primary care in Barbados and Saba. Most of the differences between the studies can be attributed to differences in the structure of the health care delivery systems, with the exception of gastritis (4 percent) and helminthiasis (2 percent) which are health problems commonly seen at the DMO clinics in Dominica (AU)

Health status of the elderly in Marigot health district, Dominica

Between July and October 1994 the health status and the incidences of hypertension, diabetes mellitus and glaucoma were assessed in 123 elderly in the Marigot Health District. Functional health status was assessed by means of four questionnaires: the Barthel Activities in Daily Life (ADL)-index , The Frenchay Activity Index (FAI), the Dartmouth COOP Functional Health Assessment Charts/WONCA and the RAND 36-item Health Survey. Data were collected from the medical records, bloodpressure, visual acuity and intraocular pressure (IOP) were measured and urine tested for glucosuria. Most elderly (74 percent) were independent with no more than moderate limitations in activities. In the elderly over 75 years of age, the health status decreases considerably. There was no significant difference in health status between men and women. Almost 20 percent of the study population had an elevated diastolic bloodpressure. Diabetes mellitus was present in 15 percent. The mean visual acuity was 0.45 (SD 0.27), and 10 percent had an elevated IOP. During the study, a considerable number of new patients with hypertension, diabetes mellitus and elevated IOP were diagnosed. Fifty per cent of the population who were prescribed medication, used this in another way than prescribed. A previous study showed that secondary complications of hypertension, diabetes, cataract, glaucoma and osteo-arthritis were the most common causes for the elderly to become 'shut-in'. The results of this study indicate that at least some of these causes of disability and dependency are preventable by special programmes on health care for the elderly, emphasizing education and the diagnosis and treatment of these conditions (AU)

Analysis of referrals from the Marigot primary health care district to secondary care in Dominica - abstract

As part of a series on the Primary Health Care Services in the Marigot Health District, referrals from the district to secondary care were analyzed for patterns of morbidity and actual utilization of the services offered. From 1st October, 1991 to 30th September, 1992, 560 referrals were registered. Of these, 260 were directly admitted to the wards of the central Princess Margaret Hospital (PMH), 68 were referred to the Casualty Department of the PMH and 232 to specialist outpatient clinics. Surgical cases, especially fractures and acute abdomen, are the most common reason for referral to the wards. Simple fractures are seen and treated at the Casualty Department. Reasons for referral to the outpatient departments are also mainly surgical, especialy phimosis, hernias and thyroid lumps. Few referral notes arrived back in the district. Half of the records of patients referred to the outpatient departments could not be traced. Twenty-two patients were known not to have kept their appointment, and it is most likely that a substantial number of the remainder did not keep theirs either. Other patients discontinued their visits on their own initiative. Some patients may discontinue follow-up because they misjudge the seriousness of their condition and may develop subsequent secondary complications of their condition because of this. Further expansion of the district outreach programme with outpatient clinics in the district may improve quality of compliance and care, especially for the elderly population, and improce communication between primary and secondary care (AU)

Health status of shut-ins in the Marigot Health District, Commonwealth of Dominica

In the Commonwealth of Dominica, the health and disability status of 108 people who, fo various reasons, are confined to their homes -- the so-called "shut-ins" -- were studied. Eighty per cent of them were over 65 years of age and 10 percent were children. Most shut-ins were independent in self-care but dependent in general activities. Their overall health was poor. Twenty-one suffered from diseases of the musculo-skeletal system c.q. osteoarthritis. 13 from blindness of various origins, 13 from neurological diseases, 13 from CVA, psychosis or dementia and 13 from different other diseases. One-third suffered from more than one disease. A special programme would be required to optimize the home-care for the shut-ins and to encourage them to become more active (AU)

Analysis of admissions to a district primary care hospital in Dominica - abstract

As part of a series of studies on the Primary Health Care Services in the Marigot Health District, the medical records of the Marigot Hospital, a 23-bed primary care hospital were analyzed for patterns of morbidity and specific qualities of a primary care hospital, using the International Classification of Primary Care. From 1st October, 1991 to 30th September, 1992, a total of 608 admissions was registered, spending a total of 3328 nights. Duration of admission ranged from 1 to 105 days, with a mean of 5.5 and a median of 2 days. The average daily bed occupancy rate was 9.1. Nearly all admissions were ad hoc, mostly through the casualty department. The most frequent diagnoses on admission were mainly medical: hypertension, diabetes mellitus, asthma, seizure disorders and infectious diseases of skin, gastro-intestinal tract and respiratory system. The elderly population was admitted mainly for diabetes mellitus, hypertension and cellulitis, and stayed relatively long, whereas admissions for febrile diseases, respiratory tract infections and gastroenteritis were of short duration. The main concurrent diagnoses were diabetes mellitus and hypertension. Surgical and gynaecological cases are generally directly referred to the central Princess Margaret Hospital. Eight terminally ill patients spent on average of 32 days in the hospital. It is concluded that (district) primary care hosptials have distinctive qualities; at relatively low cost adequate care for most common medical and paediatric conditions, terminal care and post-operative care and rehabilitation can be provided. Primary care hospitals could be used more efficiently with improving liaising between primary and secondary levels of care and a more detailed definition of the position of primary care hospitals within the health care services (AU)

Health status of shut-ins in the Marigot Health District, Dominica - abstract

The health status of 108 homebound people (shut-ins) in the Marigot Health District, Dominica, was evaluated by visiting, interviewing and examining them during the months of November 1991 to January 1992. Objective parameters were obtained by an interview about age, sex, marital status, diagnoses and caretaker of the shut-in. The health status and disability were measured by means of 4 questionnaires: The Barthel-ADL Index, The Frenchay Activities Index (FAI), the Dartmouth COOP Functional Health Assessment Charts/WONCA and the Duke Health Profile. An analysis and cross-tabulation of the 4 questionnaires and the objective parameters were done. The results show a considerable independence for the Activities of Daily Life (Barthel-SDL Index), but a very low level of general, physical, social and household activities (COOP and FAI). The most frequent diagnoses (causing their being `shut-in') were arthritis, blindness, neurological and mental disorders, stroke and psychiatric diseases. The caretaker was a family member, mostly a woman in approximately 90 per cent of cases. We concluded that most shut-ins are taken pretty good care of by their family as far as basic life-necessities, most are independent in self-care, but dependent in general activities while their overall health is poor (AU)

Utilization and morbidity patterns at a district casualty department in Dominica - abstract

The registers of the Casualty Department at the Marigot District Hospital, a 26-bed primary care facility, were analyzed for morbidity and utilization patterns, using the International Classification of Primary Care. From 1st October, 1991 to 30th September, 1992, a total of 9,504 encounters was recorded with a daily average attendance of 26 patients. A random 1 in 4 sample of records was analysed. Most patients came from Marigot village. The bulk of encounters (40.3 per cent) was for skin conditions. Of these, a third required only routine wound care. Other major reasons for encounter (REF) were abdominal pain, daily insulin treatment, musculoskeletal complaints, fever, cough and common cold and gastroenteritis. Circulatory, gynaecological and obstetrical conditions were relatively rare, the latter being attributed to the effective linkage of midwives with the obstetrical wards of the central referral hospital. Twenty to 25 per cent of all encounters were for strictly primary care activities such as routine wound care and administering of medication. A significant proportion of (19 per cent) was made up of children aged 0 - 4 years, mainly for cough and the common cold, gastroenteritis and skin conditions. A quarter of the patients seen were referred to the medical officer or family nurse practitioner, 4.3 per cent were admitted to the district hospital and 2.1 per cent referred to the central referral hospital (AU)

Indicators of long chain polyunsaturated fatty acid status of exclusively breastfed infants at delivery and after 20-22 days

The fatty acid composition of plasma cholesterol esters (CE), erythrocytes (RBC) and mature milk from seven lactating women and their exclusively breastfed newborns, living on Dominica, were studied. Blood samples were taken from umbilical cord and mother at birth. A sample of breastmilk was collected on day 20-22 postpartum, together with a blood sample from the baby. At birth, cord blood plasma CE and RBC total long chain polyunsaturated fatty acid (LC-PUFA) contents were higher, and linoleic (18:2c, omega 6) and alpha-linolenic (18:3c, omega 3) acid contents lower, than in corresponding maternal compartments. Cord blood RBC LC-PUFA omega 3 content was lower and LC-PUFA omega 6 content higher than in maternal RBC. After birth, feeding with human milk led to a drop in LC-PUFA content in the plasma CE fraction, whereas RBC LC-PUFA content remained virtually constant. Current understanding of the origin and relative affinity of fatty acids incorporated in plasma CE and RBC suggests that RBC LC-PUFA content is a more reliable parameter for LC-PUFA status than plasma CE LC-PUFA content. The RBC LC-PUFA data suggest therefore that at birth the newborn has a lower LC-PUFA omega 3 status than the mother, and that this does not change during three weeks of exclusive breastfeeding (AU)

Obstetrical condition and neonatal neurological outcome in Dominica, the Caribbean - a comparative study

Risk factors during pregnancy and delivery and neurological morbidity of newborns were assessed in a birth cohort in Dominica, the Caribbean. The data were compared with two reference groups, one from Grenada, the Caribbean, and the other from Groningen, the Netherlands. Despite variations in cultural and socio-economic situation, the similarities in obstetrical conditions, neonatal neurological morbidity and perinatal relationships between the three groups were more striking than the differences. The Dominican group showed a significantly higher rate of preterm births than the two other groups. Preterm birth was associated with a significant increase in neurological deviancy. In general motility and muscle tone were found to be lower in the Caribbean region than in the Netherlands (AU)

Long chain polyunsaturated fatty acid status of the exclusively breastfed infant in Dominica at delivery and after 20-22 days - abstract

The fatty compositions of plasma cholesterol esters (CE) and erythrocytes (RBC) from five lactating women and their exclusively breastfed newborns, living in Dominica, were studied. Blood samples were taken from the umbilical cord and mother at birth. A second blood sample of the newborn and a sample of breast milk were taken on day 20-22 postpartum. Fatty acids were determined by capillary gas chromatography. At birth, cord blood plasma CE and RBC long chain polyunsaturated fatty acids (LC-PUFA) contents were higher, and linoleic acid (18:2c, w6) contents lower, than in corresponding maternal compartments. Accretion of LC-PUFA by the foetus may be accomplished by a-fetoprotein , that has a high affinity for LC-PUFA and is taken up by a variety of foetal tissues in a receptor-mediated fashion. After birth breastfeeding leads to a drop of LC-PUFA content in the plasma CE fraction, whereas RBC LC-PUFA content remains constant. Is is conceivable that RBC LC-PUFA content is a more reliable parameter for LC-PUFA status than the plasma CE LC-PUFA (AU)

Obstetrical condition and neonatal neurological outcome in Dominica, the Caribbean: a comparative study - abstract

The risk factors during pregnancy and delivery and neurological morbidity of the newborn were assessed in a birth cohort in Dominica, West Indies. The data were compared with those from 2 reference groups from Grenada, West Indies and Groningen, the Netherlands. Despite variations in cultural and socio-economic factors among the 3 groups, the similarities in obstetrical status, neonatal neurological morbidity and perinatal relationships were more striking than the differences. The Dominican group showed a significantly higher rate of preterm births than the other 2 groups. Preterm birth was associated with a significant increase in neurological deviancy. In general, motility and muscle tone were found to be lower in West Indians than in Netherlands newborns (AU)