September: 2015

Chronic Non-Communicable Diseases:

Trinidad and Tobagos Burden of Health
NEW DIRECTIONS IN PUBLIC HEALTH POLICY AND PROMOTION: WHAT WORKS?
A HEALTH ISSUE PAPER

Ava Rampersad
UNIVERSITY OF ROEHAMPTON, LONDON - ONLINE | PROGRAMME: MASTERS OF PUBLIC HEALTH (MPH)

TRINIDAD AND TOBAGO:

Trinidad and Tobago was reclassified from a developing economy to a high income country in
2015 (World Bank, 2015). The country has a population of 1,328,019, a population density
measure of 261.43 (people per sq. km); the median age is 32.6 years and the classical
population pyramid is shifting to a bi-modal distribution with age cohorts 20 to 34 years and
45 to 55 years being dominant (CSO, 2011).
The Human Development Atlas (2012) reports that 22% of the total population has chronic
illnesses and the highest concentrations are in east and central Trinidad. Many health
problems occurring in adulthood are linked to health conditions in earlier life, the onset of an
aging population can mean longer life and poor health; compromised health amidst a dense
population is also linked to an increased likelihood of endemic outbreaks (WHO, 2011).
The state entity, the Ministry of Health, coordinates and oversees the countrys health system
and health care services are delivered by Regional Health Authorities (RHAs) which are
independent entities across different areas of the country (MOH, 2015). People can access
free health care at any of the 5 RHAs and health insurance is not required (PAHO, 2008). Any
planned health intervention should include the technical or networking capacity of the
Ministry of Health.
CHRONIC, NON-COMMUNICABLE DISEASES (CNCDS):
CNCDs are a collection of conditions that are not primarily caused by critical infections and
have an increased likelihood of lifetime health challenges demanding ongoing treatment and
care (US Department of Health and Human Services, [no date]). CNCDs were mistakenly
considered a developed nations concern, however almost 80% of deaths resulting from
chronic CNCDs are in low and middle income states and they are among the top causes of
death in many countries (Goldstein, 2011).
Over the last 20 years, ischaemic heart disease, diabetes and stroke are among the top 10
causes of death in Trinidad and Tobago (Institute for Health Metrics and Evaluation, 2010).
Furthermore, illness and death rates caused by chronic non-communicable diseases are
among the highest in the Caribbean and these rates are increasing over time, claiming 60% of
premature loss of life (Ministry of Health, 2012). Modifiable risk factors are leading the CNCD
epidemic (Baldwin and Amato, 2012). In fact among, 15 to 24 year-old males and females in
Trinidad and Tobago, daily habits include: 78% and 34% respectively are smoke and drink;
34% do not eat fruits and/or vegetables; there was a mean of 4.6 hours of daily sedentary
activities (Ministry of Health, 2012). The sample population also reported alarming rates of
hereditary conditions including: diabetes, high blood pressure, cholesterol, stroke and cancer.
CNCDs have not only been regarded as a danger to human well-being, but also to economic
growth and development (Bloom et al, 2011). CNCDs are progressively affecting younger
people resulting in earlier starts to health costs whilst the loss of productivity and strain on
the labour force are noted during working ages. CNCDs is also placing a massive and mounting
strain on the health system (UNDP, 2013). In 2001 the direct cost of diabetes in Trinidad and
Tobago was USD 484 million (5.21% GDP); expenditure on hypertension was USD $259 million
(2.79% GDP); in 2005, this expenditure on treatment and care of diabetes and hypertension
increased to USD $52.5 million and yet again folded to USD $111.7 million in 2008 and, in
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2009 there was another increase to USD $121.8 million [about USD $15 per capita] (PAHO,
[no date]).
SOCIAL DETERMINANT OF CNCDS:
The notion of social determinants of health is two-fold, firstly it denotes the social dynamics
that advance and discourage individual and population health and secondly, the social
processes underscoring the disproportionate delivery of these factors between segments
inhabiting imbalanced places in society (Graham, 2004 cited in Solar and Irwin, 2007).
In 2008, the Commission on Social Determinants of Health (CSDH) created a social
determinants framework, comprising of three fields that comprehensively underscores the
social determinants of CNCDs (UNDP, 2013).
According to UNDP (2013), the first field called health inequity pertains to the obvious health
discrimination existing in health outcomes coupled with the social and economic effects of ill
health. This field is dependent on the social stratification and intermediate determinants
also called the second field. The CSDH states that the second field is the interaction or
association with transitional influences such as socio-economic, psycho-social influences and
behavioural and genetic features that define health, is cultured by social stratification, builds
disparity and vulnerability and is premised on social position. Social position is moulded by
structural determinants and is known as the third field. The third field encompasses public
policies, economic policies which are determined by and are created by society.
Using the CSDH framework, it can be purported that there is evidence in the Human
Development Atlas (2012) to suggest health inequity exists in socio-economic status,
geographic location, education levels and poor nutrition. Findings from 2 of 15 municipal
areas (Diego Martin and Mayaro/Rio Claro) show: in Diego Martin there is a 20% prevalence
rate of chronic illnesses, household per capita income of US $7176.3 and 72% received
secondary and higher education and 52% where practicing poor nutrition (not consuming
iodised salt). However, in the Mayaro/Rio Claro there is an escalating 26% chronic illness
prevalence, household per capita income is US $4594, 53% of the residents received
secondary and higher education and 69% were practicing poor nutrition (not consuming
iodised salt).
Furthermore, social stratification and structural determinant inequities are ever increasing as
Trinidad and Tobago is experiencing a spurt in population and economic development which
contributes to evolving demographics, swift urbanisation and mounting demands for more
urbane consumer tastes (UNDP, 2006). These second and third domain inequities have
fostered the intensified growth in the fast-food industry (Cadiz, 2011) and is perhaps an
influencing factor of the worsening intake of fruits and vegetables alongside a change from
manual labour to more labour-saving technology service sector another influencer of
increased physical inactivity (Ministry of Health, 2012).
CHRONIC DISEASE ASSISTANCE PROGRAMME (CDAP):
Recognising the extensive burden of CNCDs, the Ministry of Health of Trinidad and Tobago
has established a few initiatives and the main current initiative is the Chronic Disease
Assistance Programme (CDAP). Through partnerships with public and private pharmacies, at
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no cost to the patient, CDAP facilitates the expansion of the distribution network for
prescription drugs and medical supplies for certain health conditions including: diabetes,
heart diseases, glaucoma, hypertension and high cholesterol (Ministry of Health, 2012).
In a review of the CDAP program conducted by the University of the West Indies, the
programs potential and the need for improvements are clear. The review found 1 in 7 persons
in accessed CDAP (i.e. approximately 43% coverage of those in need), there was an overall
reduction in CNCD deaths and increased cancer and diabetes mortality rates. However, the
same review showed that 42% of participating pharmacies had severe stock replenishment
issues, 78% of participating pharmacies waited more than 4 weeks for payment of claims and
as such was not inclined to continue with the program and 33% were not satisfied with the
quality of drugs since they were generic drugs and changed often (Theodore and Metivier,
2013).
THE ROLE OF HEALTH PROMOTION:
Population-wide efforts to prevent CNCDs present the likelihood to reduce the impact of any
health burden, but it does not provide an effective response to the need to strengthen and
build capacity and skill-sets of people to lead healthier lives (WHO, 2011). A high health
impact is likely to occur if a population-wide approach is complemented by health promotion
at an individual level, targeting 2 groups of individuals: those who already have CNCDs or
those who are at high risk for developing a condition.
The World Health Organisation purports that there is need for a process oriented approach
to empower people to intensify control over the determinants of health and thus improve
their health (Davies and Macdowall, 2006). Concerted efforts to promote health and health
seeking behaviours through behaviour change focusing on the individual is likely in the
application of models that guide the development of strategies that foster self-protective
action, lessen behaviours that intensify health risk, and enable effective adaptation to and
managing illness (National Academy of Sciences, 2001). With these objectives in mind two
key health promotion models come to mind: the PRECEDE framework and the
transtheoretical model.
PRECEDE FRAMEWORK AND TRANSTHEORETICAL MODEL:
PRECEDE is an acronym meaning predisposing (reason for change), reinforcing (continuous
rewards/incentives for behaviour) and enabling (realisation of motivating factors) constructs
in educational diagnosis and evaluation (Green at al, 1980 cited in Brindis et al, 2005). It is a
methodical planning process that seeks to empower participants with awareness, motivation,
skill-sets and community participation in an effort to promote behaviours, policies and
regulations with a positive health outcome (Brindis et al, 2005).
The transtheoretical model on the other hand, represents a continuum of steps where
beneficiaries progress towards healthier actions this includes activities, processes that
propel the recipient from one stage to another (National Academy of Sciences, 2001).
According to Brindis et al (2005) the model comprises of 5 core stages: the first stage is
unawareness, the individual has not recognised their health risk (pre-contemplation); the
second stage the person recognises their risk and starts self-assessments (contemplation);
the third and fourth stages the person decides to take positive action (preparation) and
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initiates change (action) followed by the fifth stage which is repeating the healthy behaviour
until it becomes normal behaviour (maintenance).
The PRECEDE framework recognises health as an integral part of the creation of an improved
quality of life that is not limited to physical wellbeing, it allows for a participatory approach
and is influenced by community attitudes (Raingruber, 2015). It involves assessing social,
epidemiological, behavioural, environmental, educational, and ecological factors that inform
the development of an intervention (Doughty, [no date]). Complementing this heuristic
approach is an effort to action change, but to do so is both intricate and difficult hence the
consideration of the transtheoretical model. This approach calls for unique action(s)
depending on the respective stage. People who do not display the behaviours ascribed to a
specific stage may stay at that stage for a while or revert to the previous stage but, by
determining an individuals current stage and their preparedness to change appropriate
interventions can be engaged (Brindis et al, 2005). The univariate application of a theory does
not necessarily provide a holistic fit, successful health impact often calls for the appropriate
application of more than one theoretical assumption the following illustration is a
consideration for the application of the PRECEDE and transtheoretical models:

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Figure 1:
Illustration of implementation of CNCD health promotion intervention using PRECEDE and
Transtheoretical Approaches

TRANSTHEORETICAL
MODEL

STAGES or
CONSTRUCTS

Pre-disposing
Factors
Pre Build
contemplation
knowledge and
awareness
Contemplation

Shift attitudes
Preparation
to promote
Action
healthier
behaviours
Maintenance
Shift
perceptions
about health
and health
products and
services

PRECEDE FRAMEWORK
Enabling Factors
Reinforcing Factors

Resource
development
and allocation
Improve access
to products and
services
Capacity
development

Create social
support to
promote
normalising
healthier
behaviours
Create social
norms that
normalise key
health
behaviours
Motivate health
outcomes

Intervention Activity
Focus:

Intervention Activity
Focus:

Intervention Activity
Focus:

Mass media
campaigns
(traditional and social
media)
Peer education
Buy in from key
stakeholders e.g.
schools, parent
support groups

Public-Private
partnerships
Social Franchising
Peer education
Training and
development for
service delivery

Community
consultations
Peer education
Mass media
campaigns
Buy in from key
stakeholders e.g.
schools, parent
support groups,
Ministries of Health
and Education

The increased positive health impact of an NCD health promotion intervention should include
impact evaluation assessments that analyse the changes in the different factors which will
determine the possibility of achieving goal-healthier behaviours and guide the development
of outcome evaluations. Participatory approaches to planning that drive individual and
community-level involvement are instrumental to an effective intervention design (Best et al,
2003; Glanz, Rimer and Lewis, 2002; Green and Kreuter, 1999 cited in Raingruber, 2015).

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