Madhuvanti M. Murphy

Use of complementary and alternative medicine among midlife Arab women living in Qatar.

The prevalence of use of complementary and alternative medicine (CAM) is widespread and is growing worldwide. This cross-sectional study in Qatar examined the use of CAM and its correlates among Arab women in their midlife years. Women aged 40-60 years (n = 814) were recruited at primary care centres in Qatar and completed a specially designed, pre-tested questionnaire. Overall, 38.2% of midlife women in Qatar had used CAM in the previous 12 months. Nutritional remedies and herbal remedies were the most commonly used CAM therapies, followed by physical methods. Qatari nationality and higher level of education were independently associated with CAM use. Menopause transition status was not independently associated with use of CAM. The prevalence of CAM use by women in Qatar was high, consistent with other reports worldwide. It is essential to educate and inform patients and health-care providers about the benefits and limitations associated with CAM.

Female gender is a social determinant of diabetes in the Caribbean: a systematic review and meta-analysis.

Background Diabetes (DM) is estimated to affect 10–15% of the adult population in the Caribbean. Preventive efforts require population wide measures to address its social determinants. We undertook a systematic review to determine current knowledge about the social distribution of diabetes, its risk factors and major complications in the Caribbean. This paper describes our findings on the distribution by gender. Methods We searched Medline, Embase and five databases through the Virtual Health Library, for Caribbean studies published between 2007 and 2013 that described the distribution by gender for: known risk factors for Type 2 DM, prevalence of DM, and DM control or complications. PRISMA guidance on reporting systematic reviews on health equity was followed. Only quantitative studies (n>50) were included; each was assessed for risk of bias. Meta-analyses were performed, where appropriate, on studies with a low or medium risk of bias, using random effects models. Results We found 50 articles from 27 studies, yielding 118 relationships between gender and the outcomes. Women were more likely to have DM, obesity, be less physically active but less likely to smoke. In meta-analyses of good quality population-based studies odds ratios for women vs. men for DM, obesity and smoking were: 1.65 (95% CI 1.43, 1.91), 3.10 (2.43, 3.94), and 0.24 (0.17, 0.34). Three studies found men more likely to have better glycaemic control but only one achieved statistical significance. Conclusion and Implications Female gender is a determinant of DM prevalence in the Caribbean. In the vast majority of world regions women are at a similar or lower risk of type 2 diabetes than men, even when obesity is higher in women. Caribbean female excess of diabetes may be due to a much greater excess of risk factors in women, especially obesity. These findings have major implications for preventive policies and research.

Trends in Longevity in the Americas: Disparities in Life Expectancy in Women and Men, 1965-2010

Objective We describe trends in life expectancy at birth (LE) and between-country LE disparities since 1965, in Latin America and the Caribbean. Methods & Findings LE trends since 1965 are described for three geographical sub-regions: the Caribbean, Central America, and South America. LE disparities are explored using a suite of absolute and relative disparity metrics, with measurement consensus providing confidence to observed differences. LE has increased throughout Latin America and the Caribbean. Compared to the Caribbean, LE has increased by an additional 6.6 years in Central America and 4.1 years in South America. Since 1965, average reductions in between-country LE disparities were 14% (absolute disparity) and 23% (relative disparity) in the Caribbean, 55% and 51% in Central America, 55% and 52% in South America. Conclusions LE in Latin America and the Caribbean is exceeding ‘minimum standard’ international targets, and is improving relative to the world region with the highest human longevity. The Caribbean, which had the highest LE and the lowest between-country LE disparities in Latin America and the Caribbean in 1965-70, had the lowest LE and the highest LE disparities by 2005-10. Caribbean Governments have championed a collaborative solution to the growing burden of non-communicable disease, with 15 territories signing on to the Declaration of Port of Spain, signalling regional commitment to a coordinated public-health response. The persistent LE inequity between Caribbean countries suggests that public health interventions should be tailored to individual countries to be most effective. Between- and within-country disparity monitoring for a range of health metrics should be a priority, first to guide country-level policy initiatives, then to contribute to the assessment of policy success.

Social determinants of breast cancer in the Caribbean: a systematic review

BackgroundBreast cancer is the leading cause of cancer deaths among women in the Caribbean and accounts for >1 million disability adjusted life years. Little is known about the social inequalities of this disease in the Caribbean. In support of the Rio Political Declaration on addressing health inequities, this article presents a systematic review of evidence on the distribution, by social determinants, of breast cancer risk factors, frequency, and adverse outcomes in Caribbean women.MethodsMEDLINE, EMBASE, SciELO, CINAHL, CUMED, LILACS, and IBECS were searched for observational studies reporting associations between social determinants and breast cancer risk factors, frequency, or outcomes. Based on the PROGRESS-plus checklist, we considered 8 social determinant groups for 14 breast cancer endpoints, which totalled to 189 possible ways (‘relationship groups’) to explore the role of social determinants on breast cancer. Studies with >50 participants conducted in Caribbean territories between 2004 and 2014 were eligible for inclusion. The review was conducted according to STROBE and PRISMA guidelines and results were planned as a narrative synthesis, with meta-analysis if possible.ResultsThirty-four articles were included from 5,190 screened citations. From these included studies, 75 inequality relationships were reported examining 30 distinct relationship groups, leaving 84% of relationship groups unexplored. Most inequality relationships were reported for risk factors, particularly alcohol and overweight/obesity which generally showed a positive relationship with indicators of lower socioeconomic position. Evidence for breast cancer frequency and outcomes was scarce. Unmarried women tended to have a higher likelihood of being diagnosed with breast cancer when compared to married women. While no association was observed between breast cancer frequency and ethnicity, mortality from breast cancer was shown to be slightly higher among Asian-Indian compared to African-descent populations in Trinidad (OR 1.2, 95% CI 1.1–1.4) and Guyana (OR 1.3, 95% CI 1.0–1.6).ConclusionStudy quantity, quality, and variability in outcomes and reporting limited the synthesis of evidence on the role of social determinants on breast cancer in the Caribbean. This report represents important current evidence on the region, and can guide future research priorities for better describing and understanding of Caribbean breast cancer inequalities.

Provider Workload and Multiple Morbidities in the Caribbean and South Africa

This chapter discusses the current state of healthcare, challenges and potential local and cross-national solutions related to multiple morbidity in low and middle income countries and vulnerable populations in high income countries, based on interdisciplinary research of provider workload in South Africa and the Caribbean. With a high chronic and noncommunicable disease (NCD) and HIV burden in both settings, it is not uncommon to find patients having this double burden of disease. Additionally, patient resiliency is exacerbated by the multiplication of both demands made by the interactions from treatment modalities and multiple service providers. The Cumulative Complexity Model (CCM) posits that as the burden of disease and resulting workload increase, the patient capacity to respond to it diminishes. In middle and high-income countries, a dedicated system of care for people living with HIV/AIDS was developed in parallel to existing systems of care for NCDs, which has been successful in increasing advocacy, political will, and healthcare worker empowerment. We explore the application of this model across settings, along with other potential solutions.

Increasing Implementation Fidelity for School-Based Drug Abuse Prevention: Effectiveness of Enhanced Training and Technical Assistance

Objective: A substantial barrier to translating prevention science into practice is the potential for low implementation fidelity when evidence-based interventions are delivered in real-world settings. This study tested the extent to which enhanced training and technical assistance can improve implementation fidelity of LifeSkills Training, an evidence-based drug abuse prevention program. Method: We recruited and randomly assigned middle schools (N = 34) to either a standard provider training condition or a fidelity-enhancement (FE) condition. Teachers in both conditions participated in a standard 1-day training session led by a certified trainer. Teachers in the FE condition received supplemental training and technical assistance (TA), which included planning workbooks, interactive DVD training tools, just-in-time e-mail reminders, and access to TA via the Internet and telephone. Trained coders rated videotapes of classroom teachers implementing curriculum sessions. An intent-to-treat analysis included all videotapes received, including sessions that were only partially implemented or videotaped. Results: Teachers in the FE condition covered significantly more curriculum points and objectives, taught longer sessions, and spent more time using facilitated group discussion and skills practice than teachers in the standard condition. Conclusions: Findings suggest that providing program providers with planning tools and telephone, e-mail and Internet-based TA can significantly enhance implementation fidelity.

RF22 HIV and type 2 diabetes (T2DM): a qualitative exploration of the burden of care experienced and perceived by persons living with the comorbidities

Background Research exploring the intersection of communicable and non-communicable diseases, as well as, the lived experiences of persons with multiple chronic morbidities, is limited. This study sought to explore how persons living with HIV (PLHIV) and Type 2 diabetes (T2DM) experience and manage the burden of treatment related to these comorbidities in the context health systems and culture in small island developing states. Methods Participants with a diagnosis of both HIV and T2DM for more than 2 years were purposively selected with the assistance of HIV treatment centres on the islands of Barbados and Trinidad & Tobago. Twenty individual, face-to-face semi-structured interviews (10 in each country) explored self-care, health care delivery, socioeconomic support and internal resilience. A total of 13 females and 7 males aged 39–65 years were interviewed. All interviews were audio-taped and transcribed verbatim. Data was analyzed using thematic analysis with constant comparison. ATLAS.ti(7) data management software used to manage the data analysis process. Results Aspects of T2DM self- care such as daily blood glucose monitoring and controlling diet were more onerous than perceived minimal HIV care actions of adhering to oral anti-retroviral therapy (‘you just take your medication and go’) and clinic visits. While HIV was experienced and perceived as having lower physical workload than T2DM, there was a higher psychological workload throughout the disease trajectory, particularly related to stigma and discrimination in health care settings and in general. T2DM’s lower psychological workload was perceived as due to the absence of stigma and discrimination attached to the disease, but adhering to multiple modalities to controll blood glucose increased the physical workload. The impact of having HIV on social determinants such as housing and employment, increased the psychological burden, and impacted on participants’ internal resilience. A preference for centralised integrated care (instead of de-centralisation to clinics throughout the health care delivery system), with a more holistic approach within health care settings on both islands was also identified by participants (i.e. having comorbidities such as diabetes also checked and treated at routine HIV clinic visits). Conclusion Integrated communicable and non-communicable care models which assess both physical and psychological workload should be considered in healthcare, especially since HIV treatment now follows a more chronic treatment pathway. In addition, addressing stigma and discrimination in the general population as well as in health care delivery settings, and their impact on health outcomes for PLHIV, is still an area for public health concern within the Caribbean.

Social determinants of depression and suicidal behaviour in the Caribbean: a systematic review

BackgroundDepressive disorder is the largest contributor to years lived with disability in the Caribbean, adding 948 per 100,000 in 2013. Depression is also a major risk factor for suicidal behaviour. Social inequalities influence the occurrence of depression, yet little is known about the social inequalities of this condition in the Caribbean. In support of the 2011 Rio Political Declaration on addressing health inequities, this article presents a systematic review of the role of social determinants on depression and its suicidal behaviours in the Caribbean.MethodsEight databases were searched for observational studies reporting associations between social determinants and depression frequency, severity, or outcomes. Based on the PROGRESS-plus checklist, we considered 9 social determinant groups (of 15 endpoints) for 6 depression endpoints, totalling 90 possible ways (‘relationship groups’) to explore the role of social determinants on depression. Studies with ≥50 participants conducted in Caribbean territories between 2004 and 2014 were eligible. The review was conducted according to STROBE and PRISMA guidelines. Results were planned as a narrative synthesis, with meta-analysis if possible.ResultsFrom 3951 citations, 55 articles from 45 studies were included. Most were classified as serious risk of bias. Fifty-seven relationship groups were reported by the 55 included articles, leaving 33 relationship groups (37%) without an evidence base. Most associations were reported for gender, age, residence, marital status, and education. Depression, its severity, and its outcomes were more common among females (except suicide which was more common among males), early and middle adolescents (among youth), and those with lower levels of education. Marriage emerged as both a risk and protective factor for depression score and prevalence, while several inequality relationships in Haiti were in contrast to typical trends.ConclusionThe risk of bias and few numbers of studies within relationship groups restricted the synthesis of Caribbean evidence on social inequalities of depression. Along with more research focusing on regional social inequalities, attempts at standardizing reporting guidelines for observational studies of inequality and studies examining depression is necessitated. This review offers as a benchmark to prioritize future research into the social determinants of depression frequency and outcomes in the Caribbean.