Abstracts: evidence to Inform a multi-disciplinary response to the pandemic

The document highlights some of the ongoing research being conducted by the staff at The UWI St. Augustine campus. The collection of abstracts provides viewers and participants with some insight into the multidisciplinary work being conducted across the various Faculties of Social Sciences and Science and Technology. This event aims to contribute an evidence-informed approach to addressing the COVID-19 pandemic in Trinidad and Tobago and the Caribbean.

COVID-19: Social Displacement and Glucocorticoid Resistance

This study aims to evaluate the effect or lack thereof, of glucocorticoids on Black, Asian, and Minority ethnic groups (BAME) when compared to white populations in the setting of COVID-19 treatment

Is obesity a significant impacting factor of asthma control?

OBJECTIVE: To measure the control of bronchial asthma, quality of life, trigger factors and co-morbidities in patients of different weight classes. SUBJECTS AND METHODS: This cross-sectional study involved 365 adult asthmatics from outpatient clinics at four major health facilities in Trinidad. Data were obtained from patient interviews, asthma control test (ACT) and the Mini Asthma Quality of Life Questionnaire (Mini AQLQ). Weight and height measurements were taken to determine body mass index (BMI), waist circumference and waist/hip ratio. Data obtained were analysed to determine associations between obesity and asthma control, associated co-morbidities, risk factors and impaired quality of life. RESULTS: A significant number of participants was females(81%), aged 60+ years (37%), Indo-Trinidadians (62%),obese (41%) and uncontrolled asthmatics (72%). Chisquared analysis revealed significant association between obesity and asthma control status (5.810; df = 1; p =0.016). Receiver operating characteristic analysis revealed BMI (AUC = 0.648) as the strongest predictor of asthma control among all obesity parameters. Logistic regression showed that higher BMI (OR = 1.05; p = 0.008) or general obesity (OR = 2.37; p = 0.003) were significantly associated with the increased odds of having uncontrolled asthma. Major trigger factors and co-morbidities were similar among obese and non-obese asthmatics. Sub analysis of obese asthmatics showed that the following were significantly associated with poor asthma control: sleep apnoea (OR = 0.45, p = 0.006), allergic rhinitis (OR= 0.562, p = 0.031) and stress (OR = 0.480, p = 0.027). CONCLUSION: Obesity negatively affects asthma control and the quality of life of asthmatics. Further studies are needed to confirm these findings and to evaluate the role of weight reduction in asthma control.

Changes in drug therapy and disease control in a subset of diabetic patients at public primary healthcare facilities in Trinidad

OBJECTIVE: To determine changes in drug treatment over a five-year period in a subset of diabetic patients who were either uncontrolled on monotherapy or required polypharmacy with or without insulin. These changes were assessed in their ability to be able to achieve glycaemic control.SUBJECTS AND METHOD: A cross-sectional survey was conducted between June and August 2015 at 24 primary healthcare facilities across Trinidad. Demographic details, drug use, blood glucose readings and self-reported adherence to drug therapy, dietary restrictions and exercise were collected. Additionally, patients’ files were reviewed for drug changes and blood glucose readings over the previous five-year period.RESULTS: A total of 236 patients were enrolled and 49% had random blood glucose greater than 180 mg/dL (uncontrolled). Most patients (91%) were prescribed metformin or gliclazide (67.5%) either singly or in combination; 92 patients (39%) were prescribed insulin. Over the five-year period, monotherapy declined from 26.9% to 8.4%; conversely, polypharmacy increased from 68.2% to 82.4%. Additionally, doses of all antidiabetic drugs increased. However, despite these changes, only modest decreases in random blood glucose were observed, ranging from 18 mg/dL to 43 mg/dL for the various drug combinations. On average, none of these combinations produced blood glucose levels below 180 mg/dL to achieve glycaemic control. CONCLUSION: Over the five-year period, there was a shift from monotherapy to polypharmacy, with increasing doses of individual drugs and further addition of insulin. Despitethese therapeutic changes, accompanied by moderate decreases in random blood glucose, they were insufficient to achieve glycaemic control in a significant number of patients.

Incidence of mesothelioma in Trinidad and Tobago during the period 2009–2014 and the demographic, aetiologic and pathological characteristics of each case

OBJECTIVE: To determine the incidence of mesothelioma between 2009 and 2014 and the aetiologic, pathologic and demographic characteristics of each case, and its comparisonto the incidence of mesothelioma in the years prior, to determine any changing trends and common features of mesothelioma within Trinidad and Tobago. SUBJECTS AND METHODS: This study is a retrospective case series study that utilized existing patient records from the Cancer Registry, Death Registry and Chest Unit of the Eric Williams Medical Sciences Complex, Death Registry of San Fernando General Hospital, Death Registry of Port-of-Spain General Hospital, Death Registry of Sangre Grande Hospital and the records of pathologists, private physicians and private hospitals. The data were submitted for analysis using the Statistical Programme for Social Sciences (SPSS). RESULTS: Results from this study show that the incidence of mesothelioma between 1995 and 2007 was 0.891 per million per annum and between 2009 and 2014, it was 1.004 per million per annum. Between 1995 and 2007, mesothelioma was far more common in patients of African descent, was most commonly localized to the pleura, was more common in males and most common in the 45–54-year age group. Between 2009 and 2014, it was more common in females and was evenly distributed amongst all age groups. CONCLUSION: The incidence of mesothelioma in 2009–2014 of 1.004 per million per annum is higher than the incidence in 1995–2007 of 0.891 per million per annum. Demographic information about mesothelioma showed a higher number of cases in African descents, higher numberof female cases in 2009–2014 and a remarkably low survival time after diagnosis

Association between obesity and lung function among teenagers in Trinidad

OBJECTIVE: To examine association between obesity and lung function among teenagers in Trinidad. SUBJECTS AND METHODS: This study is part of an ongoing five-year cohort study in which five schools in the St.George East educational district of Trinidad were selected and students entering form one were followed up to form three (2012 to 2015). A questionnaire was completed on previous pulmonary disorders, eating and exercise habits along with demographic data. Data were available on 584 male students and 502 female students for three years. Descriptive analyses were performed according to year. General linear model analyses were performed to determine relationship of lung function variable ratio (forcedexpiratory volume in 1st second/forced vital capacity[FEV1/FVC]) to independent variables. RESULTS: Analysis of variance, according to year, showed that among the male students, FEV1, FVC, forced expiratory flow (FEF), peak expiratory flow rate (PEFR)in L/min, waist circumference, diastolic and systolic blood pressure, age and FEV1/FVC (%) were significant,whereas moderate exercise, FEV1, FVC, FEF, PEFR, age and FEV1/FVC (%) were significant in female students. The mean (year of study) PEFR in males were 285 (1), 302(2) and 384 (3). The mean (year of study) PEFR in females were 273 (1), 278 (2) and 338 (3). General linear model analysis showed PEFR to be a common significant factor for FEV1/FVC in both male and female students. In addition to PEFR, age, body mass index (BMI)-for-age-Zscore, ethnicity and interaction of religion and ethnicity were also significant among females. CONCLUSION: Based on results, BMI-for-age-Z-score issignificantly associated with FEV1/FVC in female students, but not in male students.

Analysis of intervention and counselling for at-risk youth to reduce crime, violence and improve outcomesfor the individual, the schools and the family

OBJECTIVES: In this study, we examined how counselling of students and their parents can change youth misbehavior and reduce school violence and crime. Our primary objective was to derive empirical data on successful counselling therapies for at-risk secondary school students within Trinidad and Tobago. SUBJECTS AND METHODS: Participants included 145 secondary school students from selected secondary schools in one school district in Trinidad and Tobago. Of these, 49(17.3%) participants were referred by the school principals as suspended or at risk of being suspended. Participants had to complete a 12-week counselling programme consisting of individual, group and parent guidance sessions. RESULTS: After controlling for demographic characteristics, results indicate that a 12-week counselling intervention and participation in multi-modal therapeutic counseling sessions was statistically significant in changing at-risk youth negative mood states and student misbehaviour and school violence. CONCLUSION: The results of this study show that the socioeconomic environmental factors present in high-risk communities contribute to hopelessness and depression which manifest themselves in physical and mental health problems. In our study, more than 50% of school youth involved in school crime and violence are afflicted with health problems. These health problems include maladies such as depression, emotional, verbal, or physical abuse, unresolved grief and loss. Research is needed to determine the potential causal nature of the relationships between mental health problems (ie hopelessness, depression) on youth violence and crime and its potential effects on health and well-being.

Prevalence of overweight and obesity and intentions of healthcare workers of the public community clinics on New Providence, The Bahamas

OBJECTIVE: To determine prevalence of overweight and obesity and weight control intentions of health care workers (HCWs) of the public community clinics on New Providence, The Bahamas. SUBJECTS AND METHOD: Using a cross-sectional study design, 163 HCWs of eight clinics were surveyed. Participants completed a questionnaire indicating weight control intentions and had weight, height and abdominal circumferences measured. Data were analysed using IBMSPSS, v 21. RESULTS: Of 163 participants, 92.0% (150) were females. Overall, mean (± SD) age was 44 (± 11.10) years. Healthcare workers were grouped into three main categories: physicians 8.0% (13), nurses 41.1% (67) and other HCWs 50.9% (83). The majority (68.5%; 111) of the participants had high-risk abdominal circumferences. Combined prevalence of overweight and obesity was 81.6% (133); 26.4% (43) were overweight and 55.2% (90)obese. Of the males, 23.1% (3) were overweight and 69.2% (9) obese. Of females, 26.7% (40) were overweight and 54.0% (81) obese. More than half (55.8%; 91) of HCWs misperceived their body mass index (BMI); 85.3%(139) of HCWs had weight concerns, 48.2% (67) were in a planning phase of change, another 48.2% (67) were in an action phase and a small percentage, 3.6% (5), were not ready to make any changes. Most (90.7%; 147) participants expressed a greater willingness to participate in a workplace healthy lifestyle programme, mean wellness inclination score of 15.3 (± 3.78).CONCLUSIONS: Healthcare workers had high-risk abdominal circumferences. Prevalence of overweight and obesity was 81.6%. Many misperceived their BMI, were concerned about their BMI status and were inclined to make changes for a healthier weight.

Socio-economic health disparities in tobacco smoking among Afro-Caribbean adults: Findings from the Jamaica Health and Lifestyle Survey 2007–2008

OBJECTIVES: To evaluate whether education attainment oroccupation class was associated with the prevalence of tobacco smoking among Jamaican adults. SUBJECTS AND METHODS: This study was a secondary analysis of data collected from the Jamaica Health and Lifestyle Survey 2007–2008 (JHLS-II) and included participants who were 25–74 years old. Data on current tobacco smoking, highest educational attainment and usual occupation were collected using an interviewer-administered questionnaire. Poisson regression models were used to estimate sex-specific, age-adjusted prevalence and prevalence ratios (PR). RESULTS: Analyses included 2299 participants (696 men,1603 women) with mean age of 42.9 years. Prevalence of current smoking among men and women was 25.8% and 7.8%, respectively (p < 0.001). Age-adjusted prevalence of current smoking in men was highest in the primary education group (36.5%) and lowest in the post-secondary education group (10.2%), p (trend) = 0.003. Among women, prevalence was highest among those with junior secondary education (10.2%) and lowest among those with primary education (4.7%), p (trend) = 0.014. Using post secondary education as the reference category, age adjusted PR showed statistically significant two- to three fold higher prevalence of current smoking for all the lower education groups among men. Prevalence ratios for women were lower and not statistically significant. Disparity patterns for occupation were similar, with statistically significant higher age-adjusted prevalence among men in the lower occupational categories, but not among women. CONCLUSION: There are large socio-economic disparities in tobacco smoking among men, but less so among women in Jamaica. Interventions to reduce smoking should consider these socio-economic disparities.

The efficacy of premarin versus ketoconazole on prostate-specific antigen responses in castrate-resistant prostate cancer in Jamaica

OBJECTIVES: Premarin and ketoconazole are affordable secondary hormonal options available for castrate-resistant prostate cancer (CRPC) in Jamaica. The aim of this study was to compare the relative efficacy of both drugs to decrease prostate-specific antigen (PSA) in CRPC in a population of patients of predominantly African escent. SUBJECTS AND METHODS: This study retrospectively identified patients with CRPC that presented to the University Hospital of the West Indies (January 1, 2009-December 31, 2013) and patients from a private urology clinic (November 2, 2005-June 3, 2015). The primary endpoint was to identify the proportion of patients with a decline of ¡Ý 50% in PSA level after treatment. The relative efficacy was assessed by the time to progression (TTP), an increase in PSA of 25% above nadir with PSA progression defined by Prostate Cancer Clinical Trials Working Group2 criteria. RESULTS: Thirty-five patients diagnosed with CRPC were identified; 32 initially treated with premarin and three with ketoconazole. Nine of the patients initially on premarin were crossed over to the ketoconazole treatment roup, bringing to twelve the patients treated with ketoconazole. Decline in PSA of ¡Ý 50% was observed in 43.8% (14 of32) and 25% (3 of 12) of patients on premarin and ketoconazole, respectively. The median (95% CI) TTP for patients treated with premarin was 24.00 (19.28, 28.724)months and ketoconazole was 13.54 (1.66, 25.41) months with no statistically significant difference between the groups (p = 0.107; log rank test). CONCLUSION: The study did not identify differences in the relative efficacy between premarin and ketoconazole in treating patients with CRPC.

Analysing the HIV care cascade: a site-level examination of viral load suppression in Kingston, Jamaica

OBJECTIVE: To analyse the HIV care cascade at the site level at the University Hospital of the West Indies,Kingston, Jamaica. SUBJECTS AND METHODS: This was a retrospective analysis of the national HIV treatment database for all entries between the years 2010 and 2013 identifying the key stepsin the HIV care cascade with an increased focus on parameters influencing viral load suppression. Proportions by classic cascade denominator and new denominators were calculated. Equality of proportions, with corresponding p-values and confidence intervals, was used to assess cascade step differences. RESULTS: Total enrolment in the clinic increased over the period (from 1206 to 1472 patients), as did number of patients receiving antiretroviral therapy [ART] (from 879to 1199). Using the classic denominator approach, significant increases were seen for patients on ART (8.4%,95% CI 0.053, 0.127) and significant declines were seen in viral load samples collected (-5.1%, 95% CI -0.099,-0.001) and viral load results returned (-12.1%, 95% CI-0.164, -0.056). No significant changes were identified in patients engaged in care (p = 0.885) or viral load suppression(p = 0.124). New denominator analysis showed significant changes in patients on ART engaged in care,-9.4% (95% CI -0.116, -0.072), as well as viral load suppression for patients on ART, 7.9% (95% CI 0.009,0.148). CONCLUSIONS: Site-level data can increase the detail included in the HIV care cascade and avoid limitations of the classic cascade. Site-level analysis can provide greater insight into the factors affecting patient outcomes and furnish the required data

Depression among tertiary education students in a developing country

OBJECTIVE: To determine the prevalence of depression among students at The University of the West Indies, St Augustine campus over the period 2014–2015. SUBJECTS AND METHOD: A cross-sectional study utilizing convenience sampling was executed between January and May 2015. A self-administered questionnaire based on the Centre for Epidemiological Studies Depression Scale-Revised (CESD-R) was formulated by the addition of demographic and other variables and was distributed to a total of 1020 undergraduate students at The University of the West Indies, St Augustine. The acquired data were analysed using Statistical Package for Social Sciences (SPSS) for Windows 8. RESULTS: With a response rate of 95.2%, the study revealed the overall prevalence of depression to be 39.8%, with 39.3% of non-medical students and 40.2% of medical students being depressed (95%CI). The factors statistically associated with depression were religion (p = 0.013), smoking (p < 0.001), alcohol consumption (p < 0.001), illicit drug use (p = 0.008) and being previously treated for depression (p < 0.001). More than two-thirds (69.5%) of respondents thought that they could recognize the symptoms of personal depression; however, 53.5% of them misdiagnosed themselves as not being depressed (95%CI). A quarter (24.9%) of respondents believed there is a stigma attached to seeking help for depression while 37.8% of them were unaware of the available counseling resources (95%CI). CONCLUSION: The overall prevalence of depression at The University of the West Indies, St Augustine campus during the 2014–2015 period was found to be 39.8%. The factors associated with depression were alcohol consumption, illicit drug use, smoking, religion and a previous diagnosis of depression.

Smoke-free legislation in Barbados: Compliance among hospitality venues

OBJECTIVE: To evaluate the level of compliance with the smoke-free legislation among hospitality venues (bars and restaurants) in Barbados. SUBJECTS AND METHODS: A cross-sectional study was conducted among 67 venues using purposive sampling. Venues were recruited from two coastal areas patronized by tourists and one rural area patronized by Barbadians. Compliance status was determined using an observation checklist containing five indicators. Univariate analysis provided proportions with 95% confidence intervals (95%CI) using Epi Info 7. Fisher¡¯s exact test examined the association between location and compliance with p ¡Ü 0.05accepted as significant. RESULTS: Overall compliance status of venues was full compliance 6% (95% CI 1.7, 14.6), partial compliance 63% (95% CI 50.1, 74.2), non-compliance 31% (95% CI20.6, 43.8). Indicators showed that more than half (55%) of the venues displayed ¡® no smoking ¡¯ signage, 7% signage compliance, 40% smoking indoors and 36% having ashtrays/ashbins present. When viewed by location, more venues in the tourist area were non-compliant (57%; 95%CI 19.6, 49.6) compared to the non-tourist area (28%; 95%CI 12.1, 49.4), provided significantly more ashtrays/ashbins (p = 0.03752) and were plagued with challenges of active smoking nearly twice as many times as venues within the non-tourist area (50% vs 28%). CONCLUSIONS: Full compliance with the smoke-free legislation is very low in Barbados among hospitality venues. Training programmes targeting operators and night-time surveillance are critical to raising the level of conformity to the legislation.

Household food security, HIV knowledge and dietary patterns among Trinidadian adults: A cross-sectional study

OBJECTIVE: To determine the relationship between food consumption patterns and prevalence of food insecurity among Trinidadian adults. METHODS: A convenience sample of two hundred and twenty selected households participated in the study. Data were collected over a three-month period in the year 2015. A structured paper-based questionnaire was used to collect data on HIV knowledge, food consumption frequency, food security status and sexual risk behaviours. Principal component analysis was used to derive dietary patterns. Multiple logistic regression models were used to determine the association between household food security and HIV knowledge and dietary pattern scores. All models were adjusted for gender, age, ethnicity, employment status and educational status. RESULTS: Two dietary consumption patterns were identified, namely westernized and prudent patterns. Overall, household food insecurity was approximately 65%, with food insecurity with children being that of 41% and without children 63%. Average HIV knowledge was 61.48 ± 15.16% among participants. Higher HIV knowledge (OR = 0.84; p = 0.002) and prudent dietary factor scores (OR = 0.64; p < 0.001) were associated with a greater odds of being food secure. Conversely, higher westernized dietary factor scores (OR = 1.33; p = 0.008) were associated witha greater likelihood of being food insecure. CONCLUSION: Greater awareness to HIV and healthier dietary patterns were seen among individuals from food secure households while persons who had westernized lifestyles were more likely to be from food insecure households. A greater effort is needed by governmental and public health institutions to help reduce the burden of food insecurity in the Caribbean.

From past to present: 100 years of public health practice in Trinidad

OBJECTIVE: The aim of this study is to map the chronological achievements of public health, supported by the outlining and discussion of emerging themes.SUBJECTS AND METHODS: A retrospective analysis was doneof data from the published population and vital statistics reports of the Central Statistical Office for the period1953–2006, as well as all available published reports of the Ministry of Health. Data were also collected from the published reports of the Registrar General for the period 1944–52.RESULTS: The study chronologically showed the elimination of hookworm, smallpox, malaria, cholera, typhoid,yellow fever and the vaccine preventable diseases such asmeasles, mumps, rubella, poliomyelitis, diphtheria, tetanus and pertussis. In addition, for the first time, the mumpsepidemic of 2000–2003 was identified.CONCLUSION: While much has been achieved over the past 100 years, many challenges lie ahead. Hence a highly trained and skilled public health workforce is required to confront a changing healthcare landscape, epidemics and rising expectations to address key determinants of health.

Spirometry quality control: man versus machine

OBJECTIVE: To compare the efficacy of local quality control (QC) of BOLD (Burden of Obstructive Lung Disease) Trinidad and Tobago study with spirometer machine quality grades as well as with BOLD Pulmonary Function Reading Centre QC standards at Imperial College, London. METHODOLOGY: Quality of the randomly chosen two hundred spirometries was independently assessed by the local team based on the 2005 ATS/ERS spirometry standards. Central QC quality assessment results were blinded to the local team. However, the machine quality grades were readily available to both the central and local teams during interpretation. Local and machine QC performances were correlated with the central QC which was taken as the gold standard for this study. RESULTS: According to central QC, 17.5% of the spirometries were declared as unacceptable. The noted common errors were prolonged peak expiratory flow time(14.5%), submaximal blasts (11.5%), variable efforts (11%) and poor reproducibility (10%). Cronbach’s alpha assessment revealed an overall reliability of 0.82 and a correlation of 0.73 between central and local QC. The correlation between central and machine QC was poor(0.548). Local QC exhibited 89.1% sensitivity and 94.3% specificity relative to the central QC. Though the machine QC displayed a better sensitivity (97.6%), its specificity was significantly lower 45.7%). CONCLUSION: Local QC was effective when compared with the central QC and executed better performance than the machine’s QC. This expertise can now be utilized for the future spirometry based local research studies. Due to limitations in identifying various errors, machine QC should not solely be used as the determinant of acceptability.

Clinical audit of referrals for sexual abuse among females ages 13–19 years attending the Agape Family Medicine Clinic, Nassau, Bahamas, 2011–2015

OBJECTIVE: To evaluate the adequacy of the documentation of referrals for sexually abused females ages 13–19 years directed to the Agape Family Medicine Clinic for interim management. SUBJECTS AND METHODS: An approved review was performed on 123 referral forms regarding sexually abused females 13–19 years old who attended Agape’s Sexual Assault Follow-up and Evaluation (SAFE) clinic, Nassau, Bahamas. The exercise focussed on documentation adequacy based on a scoring system developed by the researchers: > 50% was assessed to be adequate, and recording disposition, date of incident and sexually transmitted infection (STI) screening was considered vital for adequacy. A current version of Statistical Package for the Social Sciences (IBM SPSS, v 21) generated descriptive and inferential statistics. RESULTS: Participants’ median age was 14 (IQR: 13, 15) years old. Of 63.4% (n = 78) with documented nationality, 88.5% (n = 69) were Bahamian and 11.5% (n = 9) Haitian. Documentation status did not differ statistically significantly by nationality. Regarding documentation, 74% (n =91) recorded school, 59.3% (n = 73) recorded knowing the assailant and 17.9% (n = 22) indicated not knowing. Approximately two-thirds (65.9%; n = 81) indicated penetration type; 18.7% recorded disposition, 29.8% (n =36) incident date and 60.2% STI screening; 7.3% (n = 9) documented all three and 22.8% (n = 28) two. Among public health clinics (PHCs), 45.3% (n = 29) did not indicate any of the three vital variables versus 7.8% (n = 4) for Accident and Emergency (A&E) referrals. Mean percent documentation for vital variables was 49.3 (± 3.6)%for A&E versus 30.5 (± 4.0)% for PHCs (p = 0.001). CONCLUSION: The deficient documentation status of referral forms demands the need for reform. Complete, consistent documentation is required.

Neurophobia and its implications: evidence from a Caribbean medical school.

BACKGROUND: Neurology is regarded as a difficult component of the medical curriculum. This has been so marked that the term neurophobia and its effects are being investigated. Given the impact of neurological disorders worldwide, neurophobia has the potential to affect the diagnosis and management of such cases. METHODS: A cross-sectional survey was done among clinical fourth and fifth year students at the Faculty of Medical Sciences, University of the West Indies, St. Augustine, Trinidad & Tobago. A survey tool successfully used in other schools was adapted to assess perceived level of difficulty, knowledge and interest in various medical sub-specialties including, neurology, cardiology, psychiatry, geriatrics, endocrinology, respiratory medicine, gastroenterology and pediatrics. Questions asked included: "What is your current level of interest in the following medical specialties?"; "What is your current level of knowledge in the given medical specialties?"; "Do you think the subject is easy or difficult?" and "Why do you think neurology is difficult?" Students were required to answer using a Likert scale and results were tabulated into mean scores and standard errors. RESULTS: The response rate was 65 per cent (167/255). Neurology was identified as the subject which students found most difficult (score 3.89 +/- 0.068) and had least knowledge of (2.32 +/- 0.075). These scores were significantly different from those observed for the other disciplines (p < 0.001). The need to know basic neuroscience was identified as the biggest contributor to the difficulty associated with neurology (3.89 +/- 0.072) followed closely by the complex clinical examination associated with neurology (3.69 +/- 0.072). Greater clinical and practical exposure, more time being spent on the subject, and improved teaching skills of lecturers were put forward as suggestions for improving the teaching of neurology...