Non-communicable chronic diseases and timely breast cancer screening among women of the Eastern Caribbean Health Outcomes Research Network (ECHORN) Cohort Study.

PURPOSE: The Caribbean population faces a growing burden of multiple non-communicable chronic diseases (NCDs). Breast cancer is the leading cause of cancer death for women in the Caribbean. Given the substantial burden of NCDs across the region, cancer prevention and control strategies may need to be specifically tailored for people with multiple co-morbidities. Preventive screening, such as timely mammography, is essential but may be either facilitated or hampered by chronic disease control. The main objective of this study is to examine the relationship between a chronic disease and timely breast cancer screening. METHODS: We conducted a cross-sectional data analysis using baseline data from the Eastern Caribbean Health Outcomes Research Network (ECHORN) Cohort Study-ECS. Our independent variables were presence of chronic diseases (hypertension or diabetes), defined as having been told by a clinical provider. Our dependent variable was timely screening mammography, as defined by receipt of mammography within the past 2 years. We examined bivariate and multivariate associations of covariates and timely screening mammography. RESULTS: In our sample (n = 841), 52% reported timely screening mammography. Among those with timely screening, 50.8% reported having hypertension, and 22.3% reported having diabetes. In our bivariate analyses, both diabetes and hypertension were associated with timely screening mammography. In partially adjusted models, we found that women with diabetes were significantly more likely to report timely screening mammography than women without diabetes. In our fully adjusted models, the association was no longer significant. Having a usual source of healthcare and a woman's island of residence were significantly associated with timely screening mammography (p < 0.05). CONCLUSIONS: We found that half of eligible women received timely screening mammography. Diabetes and hypertension, though common, are not associated with timely screening mammography. Usual source of care remains an important factor to timely breast cancer screening.

National Alcohol Survey of households in Trinidad and Tobago (NASHTT): Alcohol use in households.

BACKGROUND: To determine the patterns of alcohol use among households in Trinidad and Tobago (T&T) and to estimate the association between alcohol use and negative psychological, social, or physical events experienced by the household. METHODS: A convenience sample of 1837 households across T&T. We identified bivariate correlates of alcohol use, and heavy episodic drinking using chi-square and t-test analyses and used multivariable logistic regression to estimate adjusted associations between household alcohol use and experiences within the past 12 months adjusted for sociodemographic covariates. RESULTS: One thousand five hundred two households had complete data for all variables (82% response rate). Nearly two thirds (64%) of households included alcohol users; 57% of household that consumed alcohol also reported heavy episodic drinking. Households that reported alcohol consumption were significantly more likely to report illnesses within the households, relationship problems, and behavioral and antisocial problems with children. Among households where a member was employed, those who consumed alcohol were nearly twice as likely (OR = 1.98; 95% confidence interval (CI) 1.03, 3.82) to have a household member call in sick to work and 2.9 times as likely (OR = 2.9; CI 1.19, 7.04) to have a household member suffer work related problems compared with households who reported not consuming alcohol. CONCLUSIONS: Approximately two thirds of households in T&T reported using alcohol. These households were more likely to report psychological, physical, and social problems. These findings would support efforts to enforce current policies, laws, and regulations as well as new strategies to reduce the impact of harmful alcohol consumption on households in T&T.

Utility of the Tono-Pen in Measuring Intraocular Pressure in Trinidad: A Cross-sectional Study.

AIM: To determine the sensitivity and specificity of the Reichert™ Tono-Pen AVIA® when used by novice medical students in an ethnically diverse population in Trinidad. SUBJECTS AND METHOD: Participants were residents of Trinidad between the ages of 20 and 90 years attending the Ophthalmology Clinic at the Eric Williams Medical Sciences Complex (EWMSC). Intraocular pressure (IOP) was measured using the Goldmann applanation tonometer (the gold standard) for ophthalmology clinic patients as part of their routine care. Intraocular pressure measurements were then taken using the Tono-Pen. RESULTS: One hundred persons participated, consisting of Indo-Trinidadians (55%), Afro-Trinidadians (36%), Mixed (8%) and 1% of Caucasian descent. Fourteen per cent reported a diagnosis of glaucoma, with 70.6% of these being of African descent. One hundred and ninety-eight readings of IOP were taken. At a cut-off point of 21 mmHg, there were nine true positives, four false positives, seven false negatives and 178 true negatives. The sensitivity and specificity were found to be 56.3% (95% CI 33.2, 76.9) and 97.8% (95% CI 94.5, 99.1), respectively. The positive predictive value was calculated as 69.2% (95% CI 42.4, 87.3) while the negative predictive value was 96.2% (95% CI 92.4, 98.2). The prevalence of elevated IOP in this population was 8.1% (95% CI 4.8, 13.0). The likelihood ratio of a positive result was calculated to be 25.6 (95% CI 8.6, 73.9). CONCLUSION: The high specificity and negative predictive value suggests that the Tono-Pen can be used with minimal training, and can prove beneficial at the primary care level in the exclusion of increased IOP in an ethnically diverse high-risk Caribbean population.

Cervical Smears at Public Health Centres in Eastern Trinidad: Coverage and Follow-up, 2009-2010.

BACKGROUND: The objective was to examine the cervical screening programme at selected health centres in the Eastern Regional Health Authority (ERHA), Trinidad and Tobago, specifically regarding Pap smear coverage, frequency distribution of abnormal smears and the adequacy of follow-up of abnormal smears, according to the Caribbean Frameworks for Developing National Screening and Clinical Guidelines for Cervical Cancer Prevention and Control. METHODS: A retrospective analysis of secondary data from five health centres in the ERHA over the two-year period 2009-2010 was conducted. Data were entered into Microsoft Excel, cleaned and imported into SPSS (v 12) for analysis. Descriptive and Chi-squared analyses were carried out. RESULTS: The cumulative cervical screening coverage for the years 2009 and 2010 was 2600 Pap smears for a population of 28 811 women (9% coverage). The proportion of cervical smears done per age group ranged from 1.6% to 8.6% in 2009 and from 1.9% to 12.9% in 2010. The proportion of Pap smears for the target population, 25-49 years, stood at 11% in 2009 and 13.2% in 2010. The distribution of abnormal Pap smears (n = 155) was: atypical squamous cell of undetermined significance (ASCUS), 68.4%; low-grade squamous intra-epithelial lesion (LSIL), 14.2%; atypical squamous cells - high-grade squamous intra-epithelial lesion cannot be excluded (ASC-H), 4.5%; atypical glandular cells of undetermined significance (AGUS), 1.3% and invasive squamous cervical carcinoma, 0.6%. Human papillomavirus was detected in 7.7% of the study population. More than half of the women with abnormal smears did not follow-up on recommendations for further care and there was a significant loss to follow-up especially among the women who were referred for repeat Pap smear. The significant predictor to whether follow-up care occurred or not was age (p < 0.05). CONCLUSION: The cervical screening services in the ERHA in Trinidad did not provide adequate coverage to the target population or adequate follow-up care for women with abnormal smears in 2009 and 2010.

The prevalence of depression and its associated factors among elderly patients attending health centres in Trinidad

BACKGROUND: Depression is the most common mood disorder in the elderly. Internationally, most studies have found the prevalence of depression in the elderly population to range from appoximately 13% to 18%. In 2010 it is estimated that persons over 60 years of age made up 10% of the population of Trinidad and Tobago. The ageing population faces many complex issues such as chronic illness, disability, loneliness, isolation and adverse socio-economic circumstances that may contribute to depression. Locally, no studies have been done that investigate the depression specifically in the elderly. This study aims to establish preliminary data on this topic for the elderly population of Trinidad. METHODS This was a cross sectional descriptive study of patients over age 60, attending four health centres in Trinidad (Arima, St. Joseph, Freeport and Couva). Convenience sampling was used and participants completed a demographic questionaire and the Zung self rating depression scale. Data was analyzed using SPSS for Windows version 10.0 and the Chi-square test was used to determine statistically significant associations. RESULTS: There were 348 participants consisting of 200 females (57.4%) and 148 males (42.6%). Those 60-79 years made up 90.8%, while the remaining 9.1% were 80 years or older. Indo-Trinidadians made up 60.1%, Afro-Trinidadians 31.2% and mixed or others made up 8.7%. The prevalence of depression in this elderly population was found to be 17.2%. Depression was found to be associated with level of education (p=0.016). No association was found between gender (p=0.470), marital status (p=0.066), ethnicity (p=0.742)....... CONCLUSION: The prevalence of depression found in this population (17.2%), its association with level of education is comparable to that found in other elderly population internationally. Depression is intertwined with social and economic well being and self-perceived health and is an important consideration when caring for the elderly in Trinidad.

Reforming primary medical care in our Caribbean communities, part 1: continuity of care and the healing interpersonal relationship. A position paper of the Caribbean College of Family Physicians

This brief paper highlights the demographic transition to CNCD, the poor success of our present model of care for CNCD and advocates for a re-focusing of our community medical services to provide through regional policy a focus on improved interpersonal continuity of care.

What proportion of hypertensive diabetics at Macoya Health Centre are achieving the JNC VII recommended blood target 130/80 mmHg?

INTRODUCTION :Despite widespread dissemination of guidelines advocating tight control, many patients with diabetes continue to have uncontrolled hypertension. We set out to determine what percentage of diabetics are achieving the target blood pressure of <130/80 at The Macoya Health Centre. METHOD: The standard criteria for this audit was adopted from the American Diabetes Association with some modifications according to the most updated evidence- based clinical guideline. JNCVII. From the period July 22nd to August 26th, 2010, all patients, records in the chronic disease clinic were examined. Inclusion criteria included: Diabetic patients with hypertension included in the nurses' diabetic register, patients' records without target organ damage must show that their blood pressure was recorded at least two different occasion before the drug therapy was commenced and patients' records show that the assessments for control of blood pressure were done within 3 consultations after diagnosis with hypertension. RESULTS: of the 342 records examined, 209 were found to be both diabetic and hypertensive. 199 were eventually selected for data analysis with 10 rejected since they did not fulfill the inclusion criteria. the average age of patients was 62.7 years. the were 87 female patients and 112 male patients. A total of 75 (37.7%) of all diabetics achieved this ideal control of 130/80mmHg. this made up 44 (39%) males and 31 (35.6%) females. Discussion: The NHS Diabetics Audit for 2007-2008 showed that only 30% of the people who had their blood pressure checked during the audit period achieved the desired target blood pressure. Standards of Hypertension care for diabetics patients at the Macoya Health Centre are definitely not optimal although they are as good as those reported by other audits. However with implementation of audit recommendations and greater awareness of physicians this can improve .....

Applying the Stages of Change model to Type 2 diabetes care in Trinidad: a randomised trial.

OBJECTIVE: To improve glycaemic control among Type 2 diabetics using patient-physician consultations guided by the Stages of Change (SOC) model. DESIGN AND METHODS: A randomised trial was conducted. After ensuring concealment of allocation, Type 2 diabetics were randomly assigned to receive the intervention or the control. The intervention consisted of identifying each patient's Stage of Change for managing their diabetes by diet, exercise and medications, and applying personalised, stage-specific care during the patient-physician consultations based on the SOC model. Patients in the control group received routine care. The variables of interest were effect on glycaemic control (measured by the difference in HbA1c levels) and patients' readiness to change (measured by identifying patients' SOC for managing their diabetes by diet, exercise and medications). RESULTS: Participants were primarily over age 50, male and Indo-Trinidadian. Most had received only a primary school education and over 65% had a monthly income of $320 USD/month or less. Sixty-one Type 2 diabetics participated in each arm. Three patients were lost to follow-up in the intervention arm. After 48 weeks, there was an overall increase in HbA1c of 0.52% (SE 0.17) and 1.09% (SE 0.18) for both the intervention and control groups respectively. There was a relative reduction in HbA1c of 0.57% (95% CI 0.07, 1.07) with the intervention group compared to the control (p = 0.025). For exercise and diet there was an overall tendency for participants in the intervention arm to move to a more favourable SOC, but little change was noted with regards medication use. CONCLUSIONS: The result suggests a tendency to a worsening of glycaemic control in this population despite adopting more favourable SOC for diet and exercise. We hypothesized that harsh social conditions prevailing at the time of the study overrode the clinical intervention.

Depression among adolescents, aged 13-19 years, attending secondary schools in Trinidad: prevalence and associated factors.

OBJECTIVE: To determine the prevalence of depression and psychosocial factors associated with depression in secondary school students in Trinidad METHODS: This was a cross-sectional study of a stratified random sample of public secondary schools utilizing a modified pre-tested self-administered Beck Depression Inventory (BDI) to detect depression in students aged 13-19 years in Trinidad. RESULTS: In this study, 1290 students participated, a response rate of 79.6%; 43% were aged 13-15 years; 53.6% were Indo-Trinidadians; 82.5% were attending co-educational schools and 70.6% lived with both parents. The prevalence of depression was 25.3% +/- 2.37%. Chi-square analysis revealed statistically significant associations between depression and the categories of age, gender, living arrangements and school type. Similar findings were observed for respondents who admitted to cigarette and alcohol use or to being afraid of or being injured by their parent (p < 0.05). Logistic regression indicated that females were 1.7 times as likely to be depressed when compared with males; respondents not living with both parents were 1.5 times as likely to be depressed as those who were. Respondents reporting that they were afraid of parents or of being injured by parents were three times as likely to be depressed as respondents who had not had those experiences. CONCLUSIONS: One out of every four secondary school students in Trinidad was found to have significant depression. There were strong associations between depression and age, gender, school type and family structure. This study identifies that many adolescents experience violence in the home and those who did were more likely to be depressed.

The intimate partner abuse screening test (IPAST): validation in a family practice population in Trinidad

INTRODUCTION: Intimate Partner Abuse (IPA) is defined as physical, sexual, economic or psychological abuse to an individual perpertrated by a current or former partner (1). In primary care settings, the prevalence of IPA ranges from 15 per cent - 66 percent with an average approaching 50 per cent for lifetime experiences of abuse. Additionally, WHO studies, from 40 population-based studies done in 24 countires in four continents, found that 25 per cent to 50 per cent of women were victims of assult perpetrated by a male partner. It is important to note that the literature contains several terms when discussing this issue. These include domestic violence (DV), intimate partner abuse and intimate partner violence. DV is taken to refer to the wider violence occurring in the home between family members or persons living in the same home...

Depression and its associated factors among patients attending chronic disease clinics in southwest Trinidad / La depresión y sus factores asociados entre los pacientes que asisten a las clínicas de enfermedades crónicas en el suroeste de Trinidad

This study determined the prevalence of depression and associated factors, among patients attending chronic disease clinics in Southwest Trinidad. This was a cross-sectional survey using a sample of consecutive patients at four large clinics. To determine the presence of depression, an interviewer-applied modified Zung Scale was validated The modified Zung scale, at the cut-off index of 60, has a sensitivity of 60and a specificity of 94. Seven hundred and thirty-four completed questionnaires were received, a response rate of 76. The patients were primarily Indo-Trinidadian (70), over 50 years (76.4) and female (72.3). The prevalence of depression was 28.3. There were statistically significant differences in the level of depression by age, gender, educational level achieved and occupation (p < 0.05). There were also statistically significant differences in the level of depression by the number of presenting complaints, the number of chronic diseases, the presence of arthritis, the presence of diabetes mellitus with another chronic disease and the presence of ischaemic heart disease (p < 0.05). No significant differences were found with respect to ethnicity (p = 0.97) or the presence of diabetes mellitus by itself (p = 0.34). Results of logistic regression indicate that the independent predictors of depression (p < 0.05) were the level of education achieved, those with higher levels of education had less depression; the number of presenting complaints, those with more presenting complaints were more likely to be depressed and the presence of arthritis and female gender. It is imperative that policy be developed to address the mental health problems of patients attending these chronic disease clinics.

Este estudio determinó la prevalencia de la depresión y los factores asociados con ella, entre los pacientes que asisten a las clínicas en el suroeste de Trinidad. El mismo consistió en una encuesta transversal que utiliza una muestra de pacientes consecutivos en cuatro clínicas grandes. A fin de determinar la presencia de la depresión, validamos una escala de depresión de Zung modificada y aplicada por un entrevistador. La escala de Zung modificada, a un índice límite de 60, tiene una sensibilidad de 60% y una especificidad de 94%. Se recibieron setecientos treinta y cuatro cuestionarios respondidos, lo que equivale a una tasa de respuesta de 76%. Los pacientes fueron fundamentalmente indotrinitenses (70%), mayores de 50 años (76.4%) y mujeres (72.3%). La prevalencia de la depresión fue 28.3%. Hubo diferencias estadísticas significativas en el nivel de depresión por edad, sexo, nivel educacional alcanzado, y ocupación (p < 0.05). Hubo también diferencias estadísticamente significativas en el nivel de depresión por el número de quejas que se presentaban, el número de enfermedades crónicas, la presencia de artritis, la presencia de diabetes mellitus junto con otras enfermedades crónicas, y la presencia de cardiopatías isquémicas (p < 0.05). No se hallaron diferencias significativas en relación con la etnicidad (p = 0.97) o la presencia de diabetes mellitus por sí sola (p = 0.34). Los resultados de la regresión logística indican que los predictores independientes de la depresión (p < 0.05) fueron: el nivel educacional alcanzado, poseyendo aquellos con niveles de educación más altos, menos depresión; el número de quejas, presentándose en aquellos con más quejas, una mayor probabilidad de sentirse deprimidos; la presencia de artritis y género femenino. Es imprescindible desarrollar una política encaminada a abordar los problemas de salud mental de los pacientes que asisten a estas clínicas de enfermedades crónicas.

Critical incidents contributing to the initiation of substance use and abuse among women attending drug rehabilitation centres in Trinidad and Tobago.

The aim of this study was to determine the critical incidents that contribute to the initiation of substance use and abuse among women in Trinidad and Tobago. Twenty women were randomly selected from 46 women currently attending 43 drug rehabilitation centres, Narcotics Anonymous and Alcoholics Anonymous groups in Trinidad and Tobago. In-depth semi-structured interviews using the critical incident technique were conducted. Interviews were recorded, transcribed and analyzed. Concepts, categories and themes were determined by team study and group discussion. The critical incidents that influenced women to initiate the use and abuse of substances fell into eight major themes: factors intrinsic to the individual woman, family factors, social and environmental factors, life stresses, relationship issues, abuse, peer pressure and substance use and abuse as a coping mechanism. The results imply that the factors contributing to the initiation of substance use and abuse among women in Trinidad and Tobago are many and complex. As such any attempt to address this issue requires a broad-based approach. Such an approach should address family use of such substances, societal acceptance of them, availability, the self-esteem of the individual woman and her ability to cope with peer and internal stresses.

Critical incidents contributing to the initiation of substance use and abuse among women attending drug rehabilitation centres in Trinidad and Tobago / Incidentes críticos que contribuyen a la iniciación en el uso y abuso de sustancias entre mujeres que asisten a los centros de rehabilitación de droga en Trinidad y Tobago

The aim of this study was to determine the critical incidents that contribute to the initiation of substance use and abuse among women in Trinidad and Tobago. Twenty women were randomly selected from 46 women currently attending 43 drug rehabilitation centres, Narcotics Anonymous and Alcoholics Anonymous groups in Trinidad and Tobago. In-depth semi-structured interviews using the critical incident technique were conducted. Interviews were recorded, transcribed and analyzed. Concepts, categories and themes were determined by team study and group discussion. The critical incidents that influenced women to initiate the use and abuse of substances fell into eight major themes: factors intrinsic to the individual woman, family factors, social and environmental factors, life stresses, relationship issues, abuse, peer pressure and substance use and abuse as a coping mechanism. The results imply that the factors contributing to the initiation of substance use and abuse among women in Trinidad and Tobago are many and complex. As such any attempt to address this issue requires a broad-based approach. Such an approach should address family use of such substances, societal acceptance of them, availability, the self-esteem of the individual woman and her ability to cope with peer and internal stresses

El objetivo de este estudio era determinar los incidentes críticos que contribuyen a la iniciación en el uso yabuso de substancias entre las mujeres en Trinidad y Tobago. Se seleccionaron veinte mujeres al azar, de46 mujeres que asistían a 43 centros de rehabilitación de drogas, grupos de Alcohólicos Anónimos, y Narcóticos Anónimos en Trinidad y Tobago. Se realizaron entrevistas profundas semi- structuradas usando la técnica de incidentes críticos. Las entrevistas fueron grabadas, transcriptas, y analizadas. Los conceptos, categorías y temas fueron determinados mediante estudio en equipo y discusión en grupos. Los incidentes críticos que influyeron en que las mujeres se iniciaran en el uso y abuso de substancias comprendían ocho temas principales: factores intrínsecos a la mujer como individuo, factores familiares, factores sociales y medioambientales, estreses cotidianos, problemas en las relaciones, abusos, influencia de los amigos y malas compañías, y el uso y abuso de sustancias como mecanismo para hacer frente al estrés. Los resultados implican que los factores que contribuyen a la iniciación del uso y abuso de sustancias entre las mujeres de Trinidad y Tobago son muchos y complejos. Siendo así, cualquier intento por abordar este problema requiere un enfoque amplio. Tal enfoque debe abordar el uso de substancias por parte de la familia, la aceptación social de las substancias, la disponibilidad, la autoestima de la mujer como individuo y su capacidad para hacer frente tanto a su estrés interno como al que proviene de la presión que ejercen amigos y malas compañías.

Depression and its associated factors among patients attending chronic disease clinics in southwest Trinidad.

This study determined the prevalence of depression and associated factors, among patients attending chronic disease clinics in Southwest Trinidad. This was a cross-sectional survey using a sample of consecutive patients at four large clinics. To determine the presence of depression, an interviewer-applied modified Zung Scale was validated The modified Zung scale, at the cut-off index of 60, has a sensitivity of 60% and a specificity of 94%. Seven hundred and thirty-four completed questionnaires were received, a response rate of 76%. The patients were primarily Indo-Trinidadian (70%), over 50 years (76.4%) and female (72.3%). The prevalence of depression was 28.3%. There were statistically significant differences in the level of depression by age, gender, educational level achieved and occupation (p < 0.05). There were also statistically significant differences in the level of depression by the number of presenting complaints, the number of chronic diseases, the presence of arthritis, the presence of diabetes mellitus with another chronic disease and the presence of ischaemic heart disease (p < 0.05). No significant differences were found with respect to ethnicity (p = 0.97) or the presence of diabetes mellitus by itself (p = 0.34). Results of logistic regression indicate that the independent predictors of depression (p < 0.05) were the level of education achieved, those with higher levels of education had less depression; the number of presenting complaints, those with more presenting complaints were more likely to be depressed and the presence of arthritis and female gender. It is imperative that policy be developed to address the mental health problems of patients attending these chronic disease clinics.