Perceptions and attitudes towards child sexual abuse in Trinidad and Tobago: The case for a gendered approach to management

Objective: The sociocultural context for sexual violence in the Caribbean includes several interconnected factors including gender inequity. The centrality of social norms based on patriarchal ideologies, and gender inequity however continues to be under-recognized and so not addressed in social or health programming or policy. Design and Methodology: As part of a larger action research project conducted in Trinidad and Tobago, service providers from multiple sectors involved in management of victims and potential victims of child sexual abuse (CSA) were surveyed. Data were collected from a purposive sample of 68 service providers from social, health and legal sectors on their understanding of and attitude to CSA; gender sensitivity towards CSA and its victims, and their perceptions of the contextual factors that impact the service provided. Results: Personal attitudes to CSA reflected societal myths; stigmatization; and gender ideologies, norms and stereotypes which impacted both the identification and assessment of victims of sexual abuse, and the related service provision. Service providers also identified legislation that perpetuated gender inequity and compromised the safety of victims of CSA. The majority of service providers received no gender sensitization despite the dominant effect of gender biases on perception and acceptance, and therefore management of CSA. Conclusion: These findings have significant implications for the service delivered to victims of CSA and support the need for a gendered approach to its management.

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.

Viewpoint: Why do we need a point-of-care CD4 test for low-income countries?

In this paper, we discuss the reasons why we urgently need a point-of-care (POC) CD4 test, elaborate the problems we have experienced with the current technology which hampers CD4-count coverage and highlight the ideal characteristics of a universal CD4 POC test. It is high-time that CD4 technology is simplified and adapted for wider use in low-income countries to change the current paradigm of restricted access once and for all.

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.

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.

HIV seroprevalence and risk factors in female substance abusers seeking rehabilitation in Trinidad and Tobago.

Crack cocaine use, especially among females, is associated with risky sexual behaviour. Data from 122 female substance abusers admitted to a rehabilitation centre in Trinidad and Tobago between 1996 and 2002 were retrospectively reviewed to determine Human Immunodeficiency Virus (HIV) seroprevalence and other associated risk factors. HIV seroprevalence was 19.7%, eight times higher than in the general population. Factors significantly associated with HIV infection were use of crack cocaine, low educational attainment and diagnosis of a sexually transmitted infection. Other factors associated with risky sexual behaviour were common--use of cocaine in combination with alcohol (65.6%), psychiatric illness (28.7%) and a history of sexual abuse (83%). Female substance abusers, especially female crack addicts are at high risk of acquiring and transmitting HIV. Rehabilitation programmes should include HIV prevention interventions which specifically target all risk factors including trauma counselling, skills development and screening for sexually transmitted infections.

Substance abuse among first admissions to the psychiatric unit of a general hospital in Trinidad.

Admissions for first episode of psychiatric illness provide information on service utilization which can be used to improve service delivery. The present study reviews the use of in-patient general psychiatric services in southern Trinidad using data from first admissions in one year, specifically to determine service utilization by substance-abusing patients. Case files of all admissions to the psychiatric unit of the San Fernando General Hospital in one year were reviewed and analyzed for demographic data, substance abuse, diagnosis and associated features of the admission. Significant rates of substance abuse were found among first admissions. Of 123 new patients, 43.1% were diagnosed with a substance abuse disorder, 56.6% of whom had a comorbid psychiatric disorder. Patients with substance abuse problems tended to be young males. The substance most commonly abused was alcohol (26.8%) and alcohol abusers were more likely to be of East Indian descent. Management within this mental health catchment area needs to address identification, early intervention and prevention of substance abuse among psychiatric patients. It is proposed that both hospital and community-based substance abuse interventions should be employed in the management of acute psychiatric patients.

HIV seroprevalence and risk factors in female substance abusers seeking rehabilitation in Trinidad and Tobago

Crack cocaine use, especially among females, is associated with risky sexual behaviour. Data from 122 female substance abusers admitted to a rehabilitation centre in Trinidad and Tobago between 1996 and 2002 were retrospectively reviewed to determine Human Immunodeficiency Virus (HIV) seroprevalence and other associated risk factors. HIV seroprevalence was 19.7, eight times higher than in the general population. Factors significantly associated with HIV infection were use of crack cocaine, low educational attainment and diagnosis of a sexually transmitted infection. Other factors associated with risky sexual behaviour were common--use of cocaine in combination with alcohol (65.6), psychiatric illness (28.7) and a history of sexual abuse (83). Female substance abusers, especially female crack addicts are at high risk of acquiring and transmitting HIV. Rehabilitation programmes should include HIV prevention interventions which specifically target all risk factors including trauma counselling, skills development and screening for sexually transmitted infections

Substance abuse among first admissions to the psychiatric unit of a general hospital in Trinidad

Admissions for first episode of psychiatric illness provide information on service utilization which can be used to improve service delivery. The present study reviews the use of in-patient general psychiatric services in southern Trinidad using data from first admissions in one year, specifically to determine service utilization by substance-abusing patients. Case files of all admissions to the psychiatric unit of the San Fernando General Hospital in one year were reviewed and analyzed for demographic data, substance abuse, diagnosis and associated features of the admission. Significant rates of substance abuse were found among first admissions. Of 123 new patients, 43.1 were diagnosed with a substance abuse disorder, 56.6 of whom had a comorbid psychiatric disorder. Patients with substance abuse problems tended to be young males. The substance most commonly abused was alcohol (26.8) and alcohol abusers were more likely to be of East Indian descent. Management within this mental health catchment area needs to address identification, early intervention and prevention of substance abuse among psychiatric patients. It is proposed that both hospital and community-based substance abuse interventions should be employed in the management of acute psychiatric patients

Multilocus analysis of extracellular putative virulence proteins made by group A Streptococcus: population genetics, human serologic response, and gene transcription.

Species of pathogenic microbes are composed of an array of evolutionarily distinct chromosomal genotypes characterized by diversity in gene content and sequence (allelic variation). The occurrence of substantial genetic diversity has hindered progress in developing a comprehensive understanding of the molecular basis of virulence and new therapeutics such as vaccines. To provide new information that bears on these issues, 11 genes encoding extracellular proteins in the human bacterial pathogen group A Streptococcus identified by analysis of four genomes were studied. Eight of the 11 genes encode proteins with a LPXTG(L) motif that covalently links Gram-positive virulence factors to the bacterial cell surface. Sequence analysis of the 11 genes in 37 geographically and phylogenetically diverse group A Streptococcus strains cultured from patients with different infection types found that recent horizontal gene transfer has contributed substantially to chromosomal diversity. Regions of the inferred proteins likely to interact with the host were identified by molecular population genetic analysis, and Western immunoblot analysis with sera from infected patients confirmed that they were antigenic. Real-time reverse transcriptase-PCR (TaqMan) assays found that transcription of six of the 11 genes was substantially up-regulated in the stationary phase. In addition, transcription of many genes was influenced by the covR and mga trans-acting gene regulatory loci. Multilocus investigation of putative virulence genes by the integrated approach described herein provides an important strategy to aid microbial pathogenesis research and rapidly identify new targets for therapeutics research.

Progression of dreams of crack cocaine abusers as a predictor of treatment outcome: a preliminary report.

This study tested the hypotheses that a) the dream content of crack cocaine abusers in Trinidad and Tobago changes during abstinence, and b) the change in dream content can be used to predict treatment outcome. The sample comprised 46 consecutive patients who completed a 3-month residential treatment program and were followed up after 6 months. Dreams and associated emotions were recorded during the first month of inpatient treatment and at 6 months follow-up. Forty-one (89.1%) patients reported drug dreams during the first month, mainly of using the drug. Twenty-eight (60.9%) had drug dreams at 6 months follow-up, mainly of using or refusing the drug. There was an abstinence rate of 56.5% at 6 months. A better treatment outcome was associated with having drug dreams at 6 months follow-up (p < .05) and dreams of refusing the drug (p < .05). Findings support the need to further explore the progression of dreams during treatment as a predictive tool.

Pseudodementia in a twenty-one-year-old with bipolar disorder and vitamin B12 and folate deficiency

A twenty-one-year-old female known to suffer from bipolar type I disorder developed features of a pseudodementia. Following prompt initial response to treatment with antidepressants, there was an early recurrence of cognitive impairment. Blood investigations confirmed a macrocytic anaemia and vitamin B12 and folate deficiencies. There was dramatic resolution of cognitive impairment after vitamin replacement. This suggested the occurrence of a reversible nutritional dementia and reinforced the need to rule out secondary organic causes of psychiatric symptoms even in patients previously diagnosed with a primary psychiatric disorder.

Identification and characterization of the scl gene encoding a group A Streptococcus extracellular protein virulence factor with similarity to human collagen.

Group A Streptococcus (GAS) expresses cell surface proteins that mediate important biological functions such as resistance to phagocytosis, adherence to plasma and extracellular matrix proteins, and degradation of host proteins. An open reading frame encoding a protein of 348 amino acid residues was identified by analysis of the genome sequence available for a serotype M1 strain. The protein has an LPATGE sequence located near the carboxy terminus that matches the consensus sequence (LPXTGX) present in many gram-positive cell wall-anchored molecules. Importantly, the central region of this protein contains 50 contiguous Gly-X-X triplet amino acid motifs characteristic of the structure of human collagen. The structural gene (designated scl for streptococcal collagen-like) was present in all 50 GAS isolates tested, which together express 21 different M protein types and represent the breadth of genomic diversity in the species. DNA sequence analysis of the gene in these 50 isolates found that the number of contiguous Gly-X-X motifs ranged from 14 in serotype M6 isolates to 62 in a serotype M41 organism. M1 and M18 organisms had the identical allele, which indicates very recent horizontal gene transfer. The gene was transcribed abundantly in the logarithmic but not stationary phase of growth, a result consistent with the occurrence of a DNA sequence with substantial homology with a consensus Mga binding site immediately upstream of the scl open reading frame. Two isogenic mutant M1 strains created by nonpolar mutagenesis of the scl structural gene were not attenuated for mouse virulence as assessed by intraperitoneal inoculation. In contrast, the isogenic mutant derivative made from the M1 strain representative of the subclone most frequently causing human infections was significantly less virulent when inoculated subcutaneously into mice. In addition, both isogenic mutant strains had significantly reduced adherence to human A549 epithelial cells grown in culture. These studies identify a new extracellular GAS virulence factor that is widely distributed in the species and participates in adherence to host cells and soft tissue pathology.

Cytokine regulation of CD44 expression on rat intestinal epithelial cells.

CD44 comprises a family of type I transmembrane glycoproteins that is expressed on a wide range of cells including those of epithelial, lymphoid and myeloid lineage. Although expression of CD44 in the small intestine is typically localised in the crypts of Lieberkuhn, we have reported the expression of CD44 on mature, intestinal villus epithelial cells during the development of small bowel allograft rejection. The mechanisms underlying CD44 up-regulation are unknown, although it may be influenced by localised cytokine production. This study used flow cytometry to assess the effects of recombinant IFN-gamma and TNF-alpha on CD44 expression and hyaluronan binding by the rat small intestinal epithelial cell lines, RIE and IEC 6. IFN-gamma upregulated CD44 expression on RIE (155% of unstimulated control) and IEC 6 (209% of unstimulated control) cells, whereas TNF-alpha had no effect. IFN-gamma had no qualitative effect on CD44, as binding of the ubiquitously expressed extracellular matrix polysaccharide hyaluronan was unchanged. RIE and IEC 6 cells expressed the 82 kDa and 130 kDa major isoforms of CD44, however cytokine stimulation did not affect the expression of these, nor did stimulation induce the expression of other variants. In summary, these findings demonstrate that CD44 expression by intestinal epithelial cells can be regulated by cytokines, yet their ability to bind hyaluronan and the isoform of the expressed CD44 remains unaltered. It appears that localised inflammatory conditions and cytokine production may modify epithelial cell expression of CD44, however the physiological role for such a response has yet to be elucidated.

Parallel evolution of virulence in pathogenic Escherichia coli.

The mechanisms underlying the evolution and emergence of new bacterial pathogens are not well understood. To elucidate the evolution of pathogenic Escherichia coli strains, here we sequenced seven housekeeping genes to build a phylogenetic tree and trace the history of the acquisition of virulence genes. Compatibility analysis indicates that more than 70% of the informative sites agree with a single phylogeny, suggesting that recombination has not completely obscured the remnants of ancestral chromosomes. On the basis of the rate of synonymous substitution for E. coli and Salmonella enterica (4.7 x 10(-9) per site per year), the radiation of clones began about 9 million years ago and the highly virulent pathogen responsible for epidemics of food poisoning, E. coli O157:H7, separated from a common ancestor of E. coli K-12 as long as 4.5 million years ago. Phylogenetic analysis reveals that old lineages of E. coli have acquired the same virulence factors in parallel, including a pathogenicity island involved in intestinal adhesion, a plasmid-borne haemolysin, and phage-encoded Shiga toxins. Such parallel evolution indicates that natural selection has favoured an ordered acquisition of genes and the progressive build-up of molecular mechanisms that increase virulence.

The control of T cell responses by dendritic cell subsets.

Dendritic cells are known as the most efficient antigen-presenting cell type to activate naïve T cells; however, they are able to do more than just efficiently present antigen to T cells. They are key modulators of the immune response that can influence Th cell differentiation by preferentially inducing Th type 1 or 2 cell responses, and the differential polarisation of CD4(+) T cells appears to be mediated by discrete dendritic cell subsets.

Pseudodementia in a twenty-one-year-old with bipolar disorder and vitamin B12 and folate deficiency.

A twenty-one-year-old female known to suffer from bipolar type I disorder developed features of a pseudodementia. Following prompt initial response to treatment with antidepressants, there was an early recurrence of cognitive impairment. Blood investigations confirmed a macrocytic anaemia and vitamin B12 and folate deficiencies. There was dramatic resolution of cognitive impairment after vitamin replacement. This suggested the occurrence of a reversible nutritional dementia and reinforced the need to rule out secondary organic causes of psychiatric symptoms even in patients previously diagnosed with a primary psychiatric disorder.

Drug use, sexual behaviour and HIV risk of the homeless in Port-of-Spain, Trinidad.

Data were collected from 88 homeless persons in Port-of-Spain, Trinidad to assess HIV risk. 68% of the sample were engaging in unprotected sex with multiple partners, 25% were exchanging sex for money, and 29.5% were regularly smoking crack cocaine. Many had two or more of these behaviours that put them at high risk of HIV infection. Females were significantly more likely to be sex traders, to engage in bisexual behaviour and to have a history of psychiatric illness. The relationship between psychiatric illness and HIV risk behaviours among homeless female persons is explored. Educational interventions are suggested to reduce the public health risks in this population.

Molecular detection and identification of intimin alleles in pathogenic Escherichia coli by multiplex PCR.

A multiplex PCR was designed to detect the eae gene and simultaneously identify specific alleles in pathogenic Escherichia coli. The method was tested on 87 strains representing the diarrheagenic E. coli clones. The results show that the PCR assay accurately detects eae and resolves alleles encoding the alpha, beta, and gamma intimin variants.