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1.  Knowledge, attitudes, practices, and barriers reported by patients receiving diabetes and hypertension primary health care in Barbados: a focus group study 
BMC Family Practice  2011;12:135.
Background
Deficiencies in the quality of diabetes and hypertension primary care and outcomes have been documented in Barbados. This study aimed to explore the knowledge, attitudes and practices, and the barriers faced by people with diabetes and hypertension in Barbados that might contribute to these deficiencies.
Methods
Five structured focus groups were conducted for randomly selected people with diabetes and hypertension.
Results
Twenty-one patients (5 diabetic, 5 hypertensive, and 11 with both diseases) with a mean age of 59 years attended 5 focus group sessions.
Patient factors that affected care included the difficulty in maintaining behaviour change. Practitioner factors included not considering the "whole person" and patient expectations, and not showing enough respect for patients. Health care system factors revolved around the amount of time spent accessing care because of long waiting times in public sector clinics and pharmacies. Society related barriers included the high cost and limited availability of appropriate food, the availability of exercise facilities, stigma of disease and difficulty taking time off work.
Attendees were not familiar with guidelines for diabetes and hypertension management, but welcomed a patient version detailing a place to record results, the frequency of tests, and blood pressure and blood glucose targets. Appropriate education from practitioners during consultations, while waiting in clinic, through support and education groups, and for the general public through the schools, mass media and billboards were recommended.
Conclusions
Primary care providers should take a more patient centred approach to the care of those with diabetes and hypertension. The care system should provide better service by reducing waiting times. Patient self-management could be encouraged by a patient version of care guidelines and greater educational efforts.
doi:10.1186/1471-2296-12-135
PMCID: PMC3282655  PMID: 22136415
2.  Are primary care practitioners in Barbados following diabetes guidelines? - a chart audit with comparison between public and private care sectors 
BMC Research Notes  2011;4:199.
Background
Over 19% of the population ≥ 40 years of age in Barbados are diabetic. The quality of diabetes primary care is uncertain.
Findings
Charts of diabetic and hypertensive patients were randomly sampled at all public and 20 private sector primary care clinics. Charts of all diabetic patients ≥ 40 years of age were then selected. Processes of care, and quality targets for blood pressure (BP), fasting blood glucose (FBG) and glycosylated haemoglobin (HbA1c) were documented.
252 charts of diabetic patients (125 public and 127 private) were audited. Patients had the following characteristics: mean age 64 years, female gender 61%, mean duration of diagnosis 9 years, and hypertension diagnosed 78%. Patients had an average of 4.7 clinic visits per year, 66% were prescribed metformin, 68% a sulphonylurea, 25% a statin, 21% insulin, 15% aspirin and 12% a glucosidase inhibitor. Public patients compared to private patients were more likely to be female (77% vs. 46%, p < 0.01); have a longer duration of diagnosis (11.4 vs. 6.6 years, p < 0.01), have more clinic visits per year (5.2 vs. 4.3, p < 0.01), and to be using insulin (28 vs. 15% p = 0.01). Over a 2 year period, the proportion of charts with the following recorded at least once was: BP 98%, weight 80%, FBG 76%, total cholesterol 72%, urine tested for albumin 66%, serum creatinine 62%, dietary advice 61%, exercise advice 49%, lipid profile 48%, foot examination 41%, HbA1c 33%, dietician referral 23%, retinal examination 18%, tobacco use 17%, body mass index 0%, and waist circumference 0%. Public patients were more likely to have recorded: weight (92% vs. 68%, p = < 0.01); tests for total cholesterol (78% vs. 65%, p = 0.02), albuminuria (72% vs. 59%, p = 0.03), serum creatinine (79% vs. 44%, p < 0.01), and foot examination (50% vs. 32%, p = < 0.01); dietician referral (37% vs. 8%, p < 0.01), and tobacco use (26% vs. 8%, p < 0.01). For those tested, the most recent BP was < 140/90 for 43%, HBA1c was < 7% for 28%, and FBG was < 6.7 mmol/L for 27%.
Conclusions
Interventions such as body mass assessment, lifestyle advice, screening for retinopathy, monitoring blood glucose control, and achieving BP and glycaemic targets need improvement.
doi:10.1186/1756-0500-4-199
PMCID: PMC3155833  PMID: 21676257
3.  Diabetes and hypertension guidelines and the primary health care practitioner in Barbados: knowledge, attitudes, practices and barriers-a focus group study 
BMC Family Practice  2010;11:96.
Background
Audits have shown numerous deficiencies in the quality of hypertension and diabetes primary care in Barbados, despite distribution of regional guidelines. This study aimed to evaluate the knowledge, attitudes and practices, and the barriers faced by primary care practitioners in Barbados concerning the recommendations of available diabetes and hypertension guidelines.
Methods
Focus groups using a moderator's manual were conducted at all 8 public sector polyclinics, and 5 sessions were held for private practitioners.
Results
Polyclinic sessions were attended by 63 persons (17 physicians, 34 nurses, 3 dieticians, 3 podiatrists, 5 pharmacists, and 1 other), and private sector sessions by 20 persons (12 physicians, 1 nurse, 3 dieticians, 2 podiatrists and 2 pharmacists).
Practitioners generally thought they gave a good quality of care. Commonwealth Caribbean Medical Research Council 1995 diabetes and 1998 hypertension guidelines, and the Ministry of Health 2001 diabetes protocol had been seen by 38%, 32% and 78% respectively of polyclinic practitioners, 67%, 83%, and 33% of private physicians, and 25%, 0% and 38% of non-physician private practitioners. Current guidelines were considered by some to be outdated, unavailable, difficult to remember and lacking in advice to tackle barriers. Practitioners thought that guidelines should be circulated widely, promoted with repeated educational sessions, and kept short. Patient oriented versions of the guidelines were welcomed.
Patient factors causing barriers to ideal outcome included denial and fear of stigma; financial resources to access an appropriate diet, exercise and monitoring equipment; confusion over medication regimens, not valuing free medication, belief in alternative medicines, and being unable to change habits. System barriers included lack of access to blood investigations, clinic equipment and medication; the lack of human resources in polyclinics; and an uncoordinated team approach. Patients faced cultural barriers with regards to meals, exercise, appropriate body size, footwear, medication taking, and taking responsibility for one's health; and difficulty getting time off work to attend clinic.
Conclusions
Guidelines need to be promoted repeatedly, and implemented with strategies to overcome barriers. Their development and implementation must be guided by input from all providers on the primary health care team.
doi:10.1186/1471-2296-11-96
PMCID: PMC3014884  PMID: 21129180
4.  Are primary care practitioners in Barbados following hypertension guidelines? - a chart audit 
BMC Research Notes  2010;3:316.
Background
About 55% of the population 40 to 80 years of age in Barbados is hypertensive. The quality of hypertension primary care compared to available practice guidelines is uncertain.
Findings
Charts of hypertensive and diabetic patients were randomly sampled at all public and 20 private sector primary care clinics. Charts of all hypertensive patients ≥ 40 years of age were then selected and processes of care and blood pressure (BP) maintenance < 140/90 documented.
343 charts of hypertensive patients (170 public, and 173 private) were audited. Patients had the following characteristics: mean age 64 years, female gender 63%, mean duration of diagnosis 9.1 years, and diabetes diagnosed 58%. Patients had an average of 4.7 clinic visits per year, 70% were prescribed a thiazide diuretic, 42% a calcium channel blocker, 40% an angiotensin receptor blocker, and 19% a beta blocker. Public patients compared to private patients were more likely to be female (73% vs. 52%, p < 0.01); have a longer duration of diagnosis (11.7 vs. 6.5 years, p < 0.01), and more clinic visits per year (5.0 vs. 4.5, p < 0.01). Over a 2 year period, the proportion of charts with the following recorded at least once was: BP 98%, weight 80%, total cholesterol 71%, urine tested for albumin 67%, serum creatinine 59%, dietary advice 55%, lipid profile 48%, exercise advice 45%, fasting blood glucose for non-diabetics 39%, dietician referral 21%, tobacco advice 17%, retinal examination 16%, body mass index 1%, and waist circumference 0%. Public patients were more likely to have recorded: weight (92% vs. 68%, p = < 0.01); tests for total cholesterol (77% vs. 67%, p = 0.04), albuminuria (77% vs. 58%, p = < 0.01), serum creatinine (75% vs. 43%, p < 0.01), and fasting blood glucose for non-diabetics (49% vs. 30%, p = 0.02); dietician referral (34% vs. 9%, p < 0.01), and tobacco advice (24% vs. 10%, p < 0.01). Most (92%) diastolic BP readings ended in 0 or 5 (72% ended in 0). At the last visit 36% of patients had a BP < 140/90 mmHg.
Conclusions
Improvements are needed in following guidelines for basic interventions such as body mass assessment, accurate BP measurement, use of thiazide diuretics and lifestyle advice. BP control is inadequate.
doi:10.1186/1756-0500-3-316
PMCID: PMC3006423  PMID: 21092153
5.  Feasibility of a Population Based Survey on HIV Prevalence in Barbados, and Population Preference for Sample Identification Method 
The Open AIDS Journal  2010;4:84-87.
Objective:
To predict response rate and validity of a population-based HIV prevalence survey in Barbados using oral fluid, and the method of sample identification preferred by participants.
Methods:
Persons age 18 to 35 randomly selected from the voters’ register to participate in a study of the prevalence of chlamydia and gonorrhoea (STI) were invited to answer a questionnaire.
Results:
Of 496 persons selected for the STI study, 88 did not participate, and a further 10 did not answer the questionnaire, leaving 398 respondents. 329 persons or 66% (60% men, 73% women, p = 0.003) of the original 496 persons said that they would be willing to take part in an HIV survey using oral fluid.
People indicating willingness to take part in an HIV survey did not differ significantly from non-respondents and those indicating unwillingness to participate by a number of demographic and STI risk factors including age, education level, partnership status, number of partners, condom use, drug use, and STI infection status.
For persons willing to participate in a HIV survey, confidential linked sample identification was acceptable to 99.0% (95% CI ± 1.0), and unlinked identification to 1.6% (95% CI ± 1.3).
Conclusion:
The HIV prevalence estimated by a linked survey would have a reasonable response rate and be valid, as likelihood of participation is not related to infection risk.
doi:10.2174/1874613601004010084
PMCID: PMC2864420  PMID: 20448809
HIV; saliva; population surveillance; prevalence; sample identification.
6.  Purchasing online journal access for a hospital medical library: how to identify value in commercially available products 
Background
Medical practice today requires evaluating large amounts of information which should be available at all times. This information is found most easily in a digital form. Some information has already been evaluated for validity (evidence based medicine sources) and some is in unevaluated form (paper and online journals). In order to improve access to digital information, the School of Clinical Medicine and Research at the University of the West Indies and Queen Elizabeth Hospital decided to enhance the library by offering online full text medical articles and evidence based medicine sources. The aim of this paper is to evaluate the relative value of online journal commercial products available for a small hospital and medical school library.
Methods
Three reference standards were chosen to represent the ideal list of core periodicals for a broad range of medical care: 2 Brandon/Hill selected lists of journals for the small medical library (BH and BH core) and the academic medical library core journal collection chosen for the Florida State University College of Medicine Medical Library. Six commercially available collections were compared to the reference standards and to the current paper journal subscription list as regards to number of journals matched and cost per journal matched. Ease of use and presence of secondary sources were also considered.
Results
The cost per journal matched ranged from US $ 3194 to $ 81. Because of their low subscription prices, the Biomedical Reference Collection and Proquest products were the most cost beneficial. However, they provided low coverage of the ideal lists (12 – 17% and 21–32% respectively) and contained significant embargoes on current editions, were not user friendly and contained no secondary sources. The Ovid Brandon/Hill Plus Collection overcame these difficulties but had a much higher cost-benefit range while providing higher coverage of the ideal lists (14–47%).
Conclusion
After considering costs, benefits, ease of use, embargoes, presence of secondary sources (ACP Journal Club, DARE), the Ovid Brandon/Hill Plus Collection was the best choice for our hospital considering our budget. However, the option to individually select our own journal list from Ovid and pay per journal has a certain appeal as well.
doi:10.1186/1742-5581-3-8
PMCID: PMC1533853  PMID: 16836760
7.  What is the quality of drug therapy clinical practice guidelines in Canada? 
Background
The Canadian Medical Association maintains a national online database of clinical practice guidelines developed, endorsed or reviewed by Canadian organizations within 5 years of the current date. This study was designed to identify and describe guidelines in the database that make recommendations related to the use of drug therapy, and to assess their quality using a standardized guideline appraisal instrument.
Methods
Drug therapy guidelines in the database were identified with the use of search terms and hand searching. Descriptive information about the developers, endorsement by other organizations, publication status, disease and drug focus was abstracted. Each guideline was independently assessed by 3 appraisers (a physician, a pharmacist and a methodologist) with the use of the Appraisal Instrument for Clinical Guidelines. Conditions were classified according to the tenth revision of the International Statistical Classification of Diseases and Related Health Problems.
Results
We identified 217 drug therapy guidelines produced or reviewed from 1994 to 1998. Guideline developers included national organizations (47.0%), paragovernment organizations (39.6%) and professional associations (30.9%); 31.3% of the guidelines were published, and 10.6% stated drug company sponsorship. The most common conditions addressed by the guidelines were infections and parasitic diseases (39.6%), neoplasms (11.5%) and diseases of the circulatory system (11.5%). Drugs most commonly cited were anti-infective agents (42.9%), antiviral agents (15.2%) and cardiovascular drugs (16.1%). Eleven organizations produced 176 (81.1%) of the guidelines. In all, 14.7% of the guidelines met half or more of the 20 items assessing rigour of guideline development on the appraisal instrument (mean quality score 30.0% [95% confidence interval (CI) 27.5%–32.6%]), 61.8% met half or more of the 12 items assessing guideline context and content (mean score 57.0% [95% CI 54.6%–59.3%]), and none met half or more of the 5 items assessing guideline application (mean score 5.6% [95% CI 4.7%–6.5%]). Overall, 64.6% of the guidelines were recommended with modification by at least 2 of the 3 appraisers, 9.2% were recommended without change, and 26.3% were not recommended. The quality of the guidelines assessed varied significantly by developer, publication status and drug company sponsorship. No substantial improvement in guideline quality was observed over the 5-year study period.
Interpretation
Developers of Canadian drug therapy guidelines are producing guidelines that are often perceived to be clinically useful to physicians and pharmacists, although the methods (or the description of the methods) by which they are developed need to be more rigorous and thorough.
PMCID: PMC81282  PMID: 11501454
8.  Proceedings of the 1994 Canadian Clinical Practice Guidelines Network Workshop 
A workshop on the Clinical Practice Guidelines (CPG) Network was held in Ottawa on Oct. 31 and Nov. 1, 1994. Five plenary sessions focused on CPGs and the roles of organizations, priority setting, dissemination and implementation, evaluation, and establishment of a network of individuals and organizations active in the CPG field. In general, the participants identified consumers as important stakeholders in CPG processes and agreed that there was a role for national coordination and information gathering, however, local and regional bodies have a role in CPG development, dissemination and implementation. Burden of illness and likeliness that the guidelines would affect the burden were key criteria for setting priorities. Eighteen high-priority topics were identified for CPG development and dissemination. Methods to enhance the effectiveness of dissemination and implementation were identified: improved funding, enhanced research and decreased duplication of effort. Barriers to CPG evaluation were lack of funding and inadequate data sources. Voluntary self-audit was the preferred evaluation method. The participants agreed on three important functions of the network: facilitation, cooperation and communication, operation of a central CPG information centre, and provision of expertise in CPG processes. They also agreed to the use of an existing organization as a secretariat for the network, with a voluntary, informal membership of all those interested.
PMCID: PMC1488167  PMID: 8529185
9.  Hepatitis B Infection in Canada 
Canadian Family Physician  1992;38:2656-2666.
A review of Canadian surveillance data for the past decade indicates that the incidence of reported hepatitis B cases has increased despite the availability of safe and effective vaccine. Sexual transmission (particularly heterosexual transmission) is the major route of virus spread in North America. Because of this fact, and because immunization of selected high-risk groups has failed to control disease, universal immunization is the strategy of choice
PMCID: PMC2145899  PMID: 21221353

Results 1-10 (10)