Trinidad and Tobago
- Overall Context
- Leading Health Challenges
- Health Situation and Trends
- Full Article
The Republic of Trinidad and Tobago is a twin-island state at the southern end of the Caribbean. Trinidad and Tobago’s landmass covers 5,127 km2. Since its independence from Great Britain in 1962, the country has evolved into a well-developed, multicultural society. Abundant reserves of natural gas and oil drive its economic wealth, making it a country with a relatively high gross domestic product (GDP) for the Caribbean and recognized by the World Bank as a higher-income economy ().
In 2011,the country’s population was 1,328,019 (). The population’s ethnic composition comprises 35.4% East Indians, 34.2% of African descent, 23.0% mixed races, and 8.4% of other ethnic groups (Asian, European, Middle Eastern); the male-to-female ratio is roughly 1:1 ().
Figure 1 shows the country’s population structure, by age and sex, for 1990 and 2015. Between 1990 and 2010, the population 60 years old and older increased an average of 4% annually, compared to an annual 2.5% decrease seen in the age group 5-19 years old and a 0.9% increase in the age group under 5 years old. Life expectancy at birth is 71 years. Trinidad and Tobago is experiencing a demographic shift involving a declining fertility rate (estimated at 1.78 in 2014), an aging population, a decrease in communicable diseases and an increase in noncommunicable diseases (NCDs), and the emergence of new vector-borne diseases. For the health sector, these epidemiological changes call for greater focus on primary health care.
Figure 1. Population structure, by age and sex, Trinidad and Tobago, 1990 and 2015
Trinidad and Tobago’s population increased 11.3% between 1990 and 2015. In 1990, the population structure had an expansive structure. By 2015, the pyramidal structure had shifted to ages older than 50 years, while the structure under that age became stationary with slower growth. These changes were due to to decreases in birth rate and mortality, especially in the last three decades.
Source: Pan American Health Organization, based on the United Nations Department of Economic and Social Affairs, Population Division. Revision 2015, New York, 2015.
The economy is predominantly industrial, with a heavy reliance on the energy sector, which has been transitioning from a reliance on oil to primarily a natural gas–based economy. In 2015, the gross national income (GNI) per capita was US$ 18,600 (). Health expenditure per capita was US$ 1,136.31 in 2014 (). The economy experienced a slowing in GDP growth after 2007, a weak recovery in 2012-2014, and a contraction in 2015 due to declining oil and gas prices (). Reliance on natural gas and limited economic diversification has led to several initiatives to revitalize other economic sectors such as manufacturing, tourism, agriculture, finance, and the creative industries (). Health expenditure accounted for 5.9% of the GDP, compared to the 43% that represented the share for the petroleum and petrochemical industry (). Approximately US$ 1.5 billion was spent on health care (US$ 1,156 per capita), of which 38% was spent by households and 54% by the government ().
In 2015, with the economy operating at full employment, the labor force participation rate was 60.6% and unemployment rates were down to 3.4% from a high of 5.9% in 2010 (). However, among the younger workers (15-24 years old), rates were higher (): youth unemployment averaged around 12.1% during 2010-2015, compared to 4.4% overall. Women also experienced relatively higher unemployment rates in 2010-2015 averaging 18.6% for 15-19-year-old and 11.8% for 20-24-year-old women, compared to 12.2% and 7.9% among males in the same age categories (). Rates for these age groups in 2015 were at 13.1% and 7.3%, respectively. High unemployment rates among younger populations may trigger unintended social problems such as harm to health outcomes, poverty, and crime and violence (). There are no current data for assessing the country’s poverty; however, in 2009 it was estimated that 18.9% of the population was living in poverty, a figure expected to drop by 2% in 2015 ().
Social Determinants of Health
Free education is available to all citizens; however, the 2011 census reports that as much as 38.7% of the population aged 15 years or older may have attended school or vocational training, but had either not completed the schooling or failed to receive a certification (). Primary level education was attained by 29.8% of the population, 43.5% had attained secondary and post-secondary, and 14.6%, had attained tertiary education (university and non-university) ().
The Health System
Trinidad and Tobago’s health system includes public and private sectors and nongovernmental organizations (NGOs); the public sector is dominant. All public sector health services are free, funded by the government and taxpayers.
The public health system operates along two tiers. At the first level is the Ministry of Health, which oversees the system, and is responsible for financing, regulation, and governance, and for setting any necessary policies and enacting legislation. The Ministry of Health’s work is set by the Strategic Plan for fiscal years 2012-2016, which states that the Ministry’s mission is “… to provide effective leadership for the health sector by focusing on evidence-based policy making; planning; monitoring; evaluation; collaboration and regulation” (). To that end, the Ministry operates under 12 core strategic priorities, seven of which are discussed in this review: chronic NCDs; communicable diseases; maternal and child health; mental health and wellness; human resource planning and development, the integration of information and communication technology in the health sector; and improved health sector management ().
At the next level, the health care delivery system is decentralized into five semiautonomous Regional Health Authorities (RHAs): four in Trinidad and one in Tobago. Health care services are delivered through a network of 96 health centers, nine district health facilities, and nine hospitals. Each RHA in Trinidad has at least one district health facility and a referral hospital. Approximately two-thirds of the health centers are located in Trinidad’s western half, where most of the population lives. The Ministry of Health continues to manage some vertical services and national programs, such as the Insect Vector Control Programme, the National Blood Transfusion Service, and the National Oncology Programme.
The private sector operates on a fee-for-service model, which is often expensive and beyond the reach of most low-income earners. Information on utilization and cost for clinical and ancillary services provided to the paying public is limited. The Ministry of Health runs an external patient program, whereby some services such as diagnostic scans; cataract, knee, and hip replacement surgery; and radiation oncology services are outsourced to private health care institutions.
The Ministry bolsters its work through partnerships with regional and international entities and NGOs. The development of policies and guidelines are further guided by the government being signatory to a number of international and subregional health-related conventions and agreements, for example: the UN Sustainable Development Goals (SDGs); the World Health Organization (WHO) Framework Convention on Tobacco Control; the UN Convention on the Rights of the Child; the UN International Convention on the Protection of the Rights of All Migrant Workers and Members of Their Families; the UN Declaration on Diabetes and Chronic Non-communicable Diseases (2011); and subregionally: the Caribbean Cooperation in Health IV (CCH IV); Port of Spain Declaration on chronic NCDs (2007); the WHO Health Agenda for the Americas 2008–2017; the Nassau Declaration; and the Pan Caribbean Partnership against HIV/AIDS (PANCAP).
Leading Health Challenges
Critical Health Problems
In 2016, up to the end of September, there were 243 confirmed chikungunya cases and 498 confirmed Zika cases, which included 294 pregnant women infected with the latter virus (). Measures were adopted to prevent, control, and reduce associated risk of emerging and reemerging diseases, including strengthening core public health capacities. Chikungunya and Zika virus were detected in Trinidad and Tobago in July 2014 and February 2016, respectively.
Based on information from the health care services and hospital data submitted to the Ministry of Health, tuberculosis (TB) deaths declined from 2.1 per 100,000 population in 2010 to 1.1 in 2015. This decrease notwithstanding, TB surveillance remains active. There were 218 notified cases and 196 new and relapsed cases (). The incidence of TB was 17 per 100,000 population (including HIV coinfection) and 2.9 for those with HIV coinfection (). Treatment and coverage was relatively high, at 87%, but multidrug- resistant TB was present and 16% of the new or relapsed cases were positive for HIV().
A nationwide approach is needed to combat TB and TB/HIV coinfection that takes into account how socioeconomic conditions (e.g., poverty, patient location, drug and alcohol addiction) affect treatment outcome and follow-up (). A TB treatment program has been put in place as a way to address the fact that about 15% of TB and TB/HIV coinfected patients do not comply with their treatment regimens. However, TB screening among the HIV-positive population is not standard and isoniazid preventive therapy is very limited.
Maternal and Infant Mortality
The country has yet to achieve its Millennium Development Goal (MDG) target of 14 maternal deaths per 100,000 live births (). In fact, the high rates of maternal and infant mortality in 2015¾46.9 and 10.4 per 100,000 live births, respectively¾has placed the improvement of maternal and child health high on the list of the Ministry of Health’s priorities ().
To that end, maternity services have been reviewed and, as a result, the government has agreed to form a Directorate for Women’s Health that can provide leadership and policy formulation aimed at reducing the maternal and perinatal mortality rates. Guidelines and protocols also have been developed, such as the Standard Operating Procedure Manual for Obstetrics and Midwifery Services, which became operational in June 2011, and the 2012 Standards for Neonatal Care. In 2015, a Maternal and Child Health Manual was also produced; it is based on the work of a multidisciplinary team, with technical collaboration from the University of the West Indies (UWI), the Caribbean Public Health Association (CARIPHA), Pan American Health Organization (PAHO), the UN Population Fund (UNFPA), and UNICEF.
Chronic NCDs are the leading causes of death in Trinidad and Tobago; as such, they are a national priority. On average, approximately 53% of hospital admissions between 2010 and 2015 had an NCD as a discharge diagnosis. Of these, injuries, cardiovascular diseases, and diseases of the digestive system were the most frequently reported conditions, as well as the most frequent causes of death.
The Ministry of Health has adopted an integrated, multi-sector, public/private, “whole of society” approach to cope with the prevention and management of NCDs. In 2014, various initiatives in this regard were launched, such as the “Healthy Me” childhood obesity prevention camp that fosters healthy lifestyles for children 7-13 years old; to date, it has benefited 160 children. Other efforts designed to address risk factors for NCDs include the“Fight the Fat” “Healthy Communities” initiative, which has benefited approximately 5,000 people; the Workplace Wellness Programme; and the “Annual Wellness Campaign” (“Health for All” initiative), a nationwide campaign that raises awareness about chronic diseases and their risk factors and has benefited some 11,000 persons (). The government will also be implementing an NCD surveillance project as part of a US$ 48.4 million loan from the Inter-American Development Bank (IDB). Trinidadians also benefit from a Chronic Disease Assistance Programme (CDAP) that provides free drugs and pharmaceutical items to combat 12 targeted diseases; these inputs are distributed through over 250 public and private pharmacies nationwide. Finally, the Extended Patient Programme (EPP) also manages the Medical Aid, Cardiac Care, and Dialysis Programme to facilitate the care of patients in the private system that cannot be accommodated in the public system.
Workforce shortages are problematic across all health personnel categories in Trinidad and Tobago. The Ministry of Health has drafted a 10-year human resource plan (2016-2025) that will ensure that the public health sector is both adequately and appropriately staffed for the optimal delivery of quality health care. Funding under the IDB-sponsored NCD surveillance project mentioned above will also contribute toward this recruitment and retention strategy.
To fill some of the shortages, the Ministry of Health recruits health care professionals from overseas. Since 2011, 446 health foreign professionals have been recruited: 228 Cuban nurses; 109 Cuban doctors; 17 Cuban pharmacists; 1 biomedical engineer; 35 nurses from Grenada; 74 nurses from Saint Vincent and the Grenadines; and 19 nurses from Saint Lucia. The Ministry has pursued various bilateral and multilateral agreements with such agencies and countries as the UN Volunteers (UNV) Programme, the Donation and Transplantation Institute (DTI) (Spain), Shriners Hospitals for Children (USA), the United Kingdom, and the People’s Republic of China. Negotiations are under way to finalize agreements with Colombia, Nigeria, Uganda, and the Philippines. As part of its effort to solve the health personnel shortages, the Ministry also pursues traditional recruitment methods, such as strengthening partnerships with academic and training institutions and granting study leave to employees.
There are several health-related, educational opportunities in-country: UWI (St. Augustine campus in Trinidad) offers medical (across various specialties), biomedical, nursing, and public health programs at all degree levels; the College of Science, Technology, and Applied Arts of Trinidad and Tobago (COSTAATT) offers nursing and health science technology degrees; and the University of Trinidad and Tobago (UTT) offers a degree program in biomedical engineering and a postgraduate degree in health administration. PAHO provides numerous online training opportunities for various health workers through its Virtual Campus for Public Health (VCPH).
The Ministry of Health worked with the former Ministry of Tertiary Education and Skills Training and the Schools of Nursing and Midwifery to graduate additional nurses, midwives, and nursing assistants. The two ministries have signed a memorandum of understanding with the nursing and midwifery schools to have students work as interns at RHA facilities to gain clinical experience; discussions regarding clinical experience and the expansion of postgraduate specializations are ongoing with UTT and UWI, respectively. The Ministry of Health and the RHAs offer scholarships in critical-need areas, with beneficiaries required to serve in the health care system upon completion of their study programs. Enforcement of this provision is weak, however, and leads to broken contracts, in part due to the sector’s inability to immediately absorb returning scholars. The 10-year Human Resources for Health (HRH) Strategic Plan addresses these and other areas.
Health Knowledge, Technology, and Information
Independent entities, such as academic institutions and NGOs, often are the ones undertaking health-related research in the country, with the Ministry of Health acting as a collaborating partner. Among studies undertaken under this modality were the 2015 National Eye Survey of Trinidad and Tobago (NESTT), which analyzed visual impairments in the country; the 2014 Burden of Obstructive Lung Disease (BOLD) initiative, which explored the prevalence of chronic obstructive pulmonary disease (COPD) and its risk factors; and the 2011 NCD risk factor (STEPS) survey (), which assessed the risk factors for chronic diseases. All health research requires ethical approval from the Ministry’s Ethics Committee or other relevant Ethics Committees. Research skills are developed through various collaborative efforts, such as the Trinidad and Tobago Health Sciences Initiative (TTHSI) (2007–2014) developed jointly with Johns Hopkins Medicine International; UWI, UTT; the Ministry of Health; the former Ministry of Science, Technology, and Tertiary Education; and other government ministries and local organizations, which aimed at improving the health care sector through academics and research ().
While there is no single repository for local research data, the Ministry of Health has a medical library service that provides e-resources for all staff and members of the public through InfoMed Plus, the first Caribbean e-Medical Portal offering access to thousands of medical e-journals.
The existing health information system (HIS) is predominantly manual and inefficient(). Cellma, an administrative electronic linked tool, is used by most RHAs to capture basic patient data. The RHAs submit quarterly reports to the Ministry, along with manually compiled treatment and care data. The slow modernization of the HIS has contributed to difficulties in accessing up-to-date information. The government is committed to implementing a nationwide electronic health information management system as part of the NCD surveillance project (); the first modules to be procured and implemented will be patient registration, electronic health records, and appointment and scheduling software.
The HIS also has progressed in other areas: the National Health Card System, for example, has been set up for cloud-based electronic management of the dispensing of select, free prescription medications for certain diseases such as cancer and HIV, and to allow access to multiple public health services. The Ministry of Health and the Ministry of Industry and Trade, the Port Health Department, and the MOH Chemistry, Food and Drugs Division worked to implement an electronic single window to issue clearance certificates for shipping and airline cargo, and for passengers.
The Environment and Human Security
The country is vulnerable to the direct and indirect effects of climate change on the population’s health.
Natural and Manmade Disasters
Trinidad and Tobago is at low risk for hurricanes, but is more vulnerable to earthquakes. The country is usually affected by the indirect impact of tropical waves in the form of heavy rainfall, flooding, and landslides. The country’s Office of Disaster Preparedness and Management (ODPM), which is responsible for disaster preparedness, response, prevention, and mitigation, in 2010 developed a comprehensive disaster management policy framework that sets forth the strategic direction for the government’s comprehensive approach for all hazards (). As a way to streamline climate services, the government is developing a National Framework for Climate Services within the National Disaster Risk Reduction Platform coordinated by ODPM; the Ministry of Health serves as a core member of the Climate Services Panel.
Based on data supplied by ODPM, there were 271 hazard events reported between 2010 and 2014, with more natural disaster occurrences than man-made disasters, and floods, landslides, fires, and damaging high winds dominating. As the public’s awareness of the ODPM’s role increased, data capture improved, with 582 hazards reported between January 2015 to March 2016 (). In 2015 alone, there were 14 earthquakes, ranging from 3.4 to 6.5 on the Richter scale, all of which directly or indirectly affected the population’s health and well-being. In 2010, the impact of countrywide flooding and landslides resulted in the loss of crops to over 2,000 farmers and compensation estimated at TT$ 13 million; a 2012 flood resulted in two reported deaths, two missing persons, and several injuries requiring hospitalization; and in December 2013, the largest oil spill in the history of Trinidad and Tobago harmed air quality, tourism, and the marine ecosystem.
Food Safety and Security
The consequences of climate change, coupled with shortages of arable land and agricultural labor, threaten the population’s food security and food safety. Under the aegis of several UN agencies, the Ministry of Health and the Ministry of Agriculture, Land, and Fisheries have been working together to ensure the safety and quality of Trinidad and Tobago’s food supply, while building capacity in addressing food safety, quality control, and quality assurance (). For example, in 2016, with support from the UN Development Assistance Framework (UNDAF), the Food and Agriculture Organization (FAO), and PAHO, a Food Safety Policy and Communications Project was launched to conduct a food safety situation analysis, develop a national food safety policy, and prepare a manual for risk-based food safety inspection. PAHO also partnered with the Ministry of Health and national senior public health inspectors to harmonize the requirements to register food handlers and food premises.
A multi-sector Food Advisory Committee is responsible for developing food-safety standards and regulations; this body advises the Minister of Health on food safety and quality matters and on trade issues. Medical officers and public health inspectors monitor all public facilities and ports of entry to detect and control risks to human health and enforce the public health laws. Food fraud has also become a national concern and a Joint Select Committee on food fraud was formed in May 2016.
Access to Clean Water and Sanitation
Data from Trinidad and Tobago’s Water and Sewerage Authority (WASA) shows that access to improved clean drinking water was 94% in 2015, and access to chlorinated water increased from 91% in 2011 to 99% in 2015. As many as 88% of households had direct access to piped water while 12% had to utilize indirect access (i.e., a standpipe in the yard or community). Nearly 70% of the population received water 24 hours a day 7 days a week in 2015, which represents a significant improvement in service when compared to 31% of the population receiving water on a 24/7 basis in 2011. Gaps in 24/7 water supply and reliance on indirect sources of water is an indication that storage of water is common. Most of the water supplied (more than 55%) in both Trinidad and Tobago is from reservoirs and springs, followed by groundwater (wells). Trinidad also derives some water (20%) from desalination. Access to improved sanitation facilities is available to 94% of the population. Trinidad and Tobago fully met MDG 7 standards for safe drinking water and moderately met standards for sanitation ().
Trinidad and Tobago has an aging population. According to the 2011 census, approximately 13% of the population was over age 60; that age cohort was estimated to be 14.2% in 2015 and projected to be 28.2% by 2050 (). Hypertension, diabetes, arthritis, Alzheimer’s disease, and heart disease are reported as some of the leading causes of hospitalization among the elderly. The expected growth of this population segment, with the accompanying increase in chronic diseases, will tax the health system, particularly primary care services. The government has put in place programs to improve the well-being of the elderly and the quality of care they receive. Aside from the CDAP, which has already benefitted 25,000 patients, the government gives out food-subsidy grants and provides homecare, free medical equipment, and home improvements; in addition, it operates a senior citizens bureau and a geriatric/adolescent partnership program. Furthermore, a National Policy on Aging was developed that targets priority areas for action such as health care and standards for facilities, social security, income security and employment, housing, and legislation ().
Health Situation and Trends
Health of Population Groups
Maternal and Reproductive Health
The maternal mortality rate, based on hospital utilization, was high in 2010, at 46 per 100,000 live births, and peaked at 64 in 2013 before decreasing to 46.9 in 2015 (Table 1). These fluctuations could be due to problems in reporting. Risk factors include complications from hypertension, diabetes, and premature labor, which is cause for concern due to declining fertility rates (); suboptimal staffing and late access to prenatal care are possible factors too. Between 2008 and 2012, the prevalence of contraceptive use among women was 42.5% (). During the same period, more than 95% of pregnant women received antenatal care at least once, had their deliveries in an institution, and received attention from a skilled attendant during delivery (). Of all the women attending their first antennal visit in the public health system, 16.3% in 2010 and 12.4% in 2015 were under the age of 20 years; in 2010, the adolescent fertility rate was 44.9 per 1,000 women aged 15-19 ().
Table 1. Maternal, under-5, and infant mortality rates,a Trinidad and Tobago, 2010 2015
|Maternal mortality rate||46||52||54||64||58||46.9|
|Under-5 mortality rate||14||15||12||13.2||14||15|
|Infant mortality rate||20||19||18||14||12||10.4|
a The Trinidad and Tobago Ministry of Health expresses these rates per 100,000 live births.
Source: Trinidad and Tobago, Ministry of Health, Statistics, Hospital Utilization Reports, World Health Data, 2016.
Through a network of 105 health facilities, the Ministry of Health’s Population Programme Unit provides free maternal, child, and adolescent health services that include administering pap smears and pregnancy tests. The Unit is the main provider of sexual and reproductive health services, focusing on fertility control services and mainly targeting women.
Child Health (Under 5 Years)
According to Ministry of Health information, mortality rates in children under 5 years old have increased over the period, from 12.0 deaths per 100,000 live births in 2012 to 15.0 in 2015, on par with pre-2012 rates and above the MDG target of 11.0 (Table 1). Common causes of death in this age group include congenital anomalies, prematurity, and birth asphyxia, followed by pneumonia, injuries, and neonatal sepsis. Infant mortality rates steadily decreased between 2010 and 2012, from 20.0 deaths per 100,000 live births to 10.4. To further reduce infant mortality rates, the country needs to sustain its high immunization coverage and further promote breastfeeding. A survey on breastfeeding practices conducted by the Ministry of Health and (CARIPHA) found that while 95.5% of mothers initiated breastfeeding, only 24.1% exclusively breastfed for three months and only 5.4% exclusively breastfed for six months. The survey highlighted insufficient antenatal preparation being given to mothers. The country has a national breastfeeding policy, and the Population Programme Unit, working through the Nutrition and Metabolism Programme, has “well baby” clinics at all hospitals and health centers. Milk and milk supplements are provided for needy children, with special emphasis on supporting HIV-positive mothers to prevent mother-to-child transmission (MTCT) of HIV.
Health of Schoolchildren and Adolescents (5–19 Years Old)
Among adolescents 10-19 years old, assault (homicide), intentional self-harm (suicide), and land transport accidents were the leading causes of death, with mortality rates of 24.5, 6.4, and 5.9 per 100,000, respectively; rates were much higher among males (). The Ministry of Health’s Health Education Unit conducted a survey in 2011 that found that 67% of secondary-school students perceived in-school violence to be very serious or serious, and approximately 36% reported that they were bullied at school. The 2011 Global School Health Survey (GSHS) found that 35.9% of students reported having been in a physical altercation one or more times during 2010, with boys being more likely to be involved than girls (44.6% vs. 27.2%). Injuries (one or more times in 2010) had been experienced by 41.1% of students (46.5% boys vs. 35.4% girls). Bullying, which is viewed as a public health problem, was reported to have occurred on one or more days during the month prior to the survey by every 3 in 20 students, and more frequently by boys (17.9%) than girls (13.0%).
The government committed TT$ 3 million in 2014 to support projects under the Youth Health Programme () that disseminated information across nine districts on healthy lifestyles and engaged the community in activities to expose students to information on HIV/AIDS prevention, substance abuse prevention, domestic violence and adolescent rights. An Adolescent Intervention Programme provides psychosocial support for post-secondary students to ease the stress of transitioning between schools. The government also provides financial assistance to children under 18 years of age who need critical surgery unavailable in the public or private health system; as of November 2016, this fund had provided assistance to 226 children for a total of TT$ 53.8 million.
Health of Adults (18–60 Years Old)
Assault and/or homicide was the leading cause of death among adults 18-44 years of age; among older adults (45-60 years old), the leading causes were ischemic heart disease and diabetes (Table 2). Self-harm was the second leading cause of death for those under 20 years old, transport accidents for those 20-34 years old, and HIV for those 35-44 years old. The population has high rates of NCDs, with hospital services discharging more than 50,000 cases related to NCDs each year.
Table 2. Number of deaths, rank, and ratea for the leading causes of death, by sex, Trinidad and Tobago, 2010
|Total deaths||Male deaths||Female deaths|
|Group||Rank||No.||Rate||Rank||No.||Rate||Rank||No.||Rate||Heart disease (Ischemic heart dis.)||1||1,523||114.68||1||877||133.43||2||646||96.3|
|Malignant neoplasm of prostate||5||258||39.25|
|Malignant neoplasm of breast||5||172||25.64|
a The Trinidad and Tobago Ministry of Health expresses these rates per 100,000 live births.
Source: Pan American Health Organization, Mortality Data.
Health of the Elderly (Over 60 Years Old)
It is estimated that 14.2% of the population was over 60 years old in 2015, up from 12.4% in 2010 (). The elderly population is characterized by NCDs, with the leading causes of mortality in 2006 being cardiovascular disease, malignant neoplasm, diabetes mellitus, and cerebrovascular disease (). More than half of the elderly are females, with a life expectancy of 73 years, compared to 67 years for their male counterparts, and 70 years for the general population (). Hypertensive disease, diabetes mellitus, and cerebrovascular disease raise the risk for dementia and cognitive impairment; diabetes alone nearly doubles the risk (). Loneliness, characterized as low levels of social interaction and stimulation, has been identified as an area of concern among elderly persons ().
Health of the Family
On average, there are three persons to a household in Trinidad and Tobago, with about one-third of households being headed by women (). The ratio of women- vs. men- headed households increased with age: in ages 60-79 years, the ratio was approximately 1:1, but after age 80 women-headed households increased.
Various efforts were undertaken in 2010-2014 to improve overall wellness and, in turn, benefit family health: for example, the “Healthy Spaces” initiative increases public awareness and education about healthy living and making healthy choices, the “Wellness Centre” initiative promotes physical activity, a social communication strategy tackles overall health, and the “Health Fair” initiative promotes a healthier lifestyle in schools. The Population Programme Unit now offers services beyond fertility control, delivering a comprehensive range of services for the benefit of the whole family, such as addressing social relationships, the psycho-physiological dynamics of aging, male health, sexually transmitted infections, and adolescent sexual and reproductive health. Finally, as part of the primary health focus, district health facilities have been set up to address community and family needs.
The five leading causes of death in 2010 were, in ranked order, ischemic heart disease, diabetes, cerebrovascular diseases, assault (homicide), and hypertensive diseases (Table 2)(). Most are chronic conditions, to which the government has assigned priority. Among males, the first four ranked as the leading causes of death, the same as for the general population. Among men, however, cancer of the prostate caused more deaths than hypertensive diseases; the heart disease rate also was much higher among males than for the general population. Assault/homicide, the fourth leading cause of death among men, was the leading cause of death among young males (20-44 years). For females, diabetes was the leading cause of death, followed by heart disease, cerebrovascular disease, hypertensive disease, and breast cancer. Diabetes and HIV were the main causes of death among young females (20–44 years). The five leading causes of death for the overall population and for males and females remained unchanged between 2006 and 2010.
Vector-borne diseases are a matter of concern, particularly the introduction of two new diseases—Zika and chikungunya viruses—carried primarily by the Aedes aegypti mosquito. Dengue fever is endemic, with multiple strains circulating and increasing numbers of reported cases between 2010 and 2014. Trinidad was declared malaria-free in 1965, but aggressive surveillance continues and imported cases are usually detected.
The Ministry of Health pursues a combination strategy that includes source reduction, use of insecticides, and public education to control the mosquito population, but there is an over-reliance on fogging to eliminate the vector, rather than using basic public health measures to clear potential breeding sites. More recently, broader eradication measures were put in place, including a “ChikV Campaign” that educated citizens about disease symptoms, preventive measures, and cleanup strategies.
The HIV/AIDS epidemic in Trinidad and Tobago has become generalized, with a prevalence of 1.5% over 2009-2012 and a slight increase, to 1.65%, in 2013 (Table 3)(). There were 1,053 reported cases of new HIV-positive infection in 2014, reflecting a decrease since 2010. Women accounted for 43% of the reported new HIV infections in 2014, compared to 47% in 2005. Young adults accounted for 12% of new cases in 2014, with the majority, 64%, occurring among 15–49-year-olds. The proportion of persons older than 50 years who were newly diagnosed with HIV infection increased from 12% in 2010 to 17% in 2014. A biobehavioral surveillance survey conducted among men (2010–2015) found that HIV prevalence among men who have sex with men was estimated at 27%, with 24% of them being unaware of their HIV status and 37% being older than 30 years (). HIV was the only communicable disease among the 10 leading causes of death in 2010, ranked seventh (). AIDS-related deaths declined by 70% between 2005 and 2014 and by 47% from 2010 to 2014 (). This decline is likely due to the provision of antiretroviral drugs at no cost to patients.
Table 3. Adult HIV prevalence rates, number of new HIV infections, AIDS cases, and number of AIDS deaths, Trinidad and Tobago, 2010-2014
|Adult HIV prevalence (estimate)||1.5%||1.5%||1.5%||1.65%||1.60%|
|Number of new HIV infections||1,154||1,077||1,284||964||1053|
Source: Trinidad and Tobago, Ministry of Health (2016) HIV and AIDS Coordinating Unit Global AIDS Programme Report, 2016.
The response to HIV/AIDS is guided by the multi-sectoral National Strategic Plan 2013–2018 (). Treatment and care is provided through seven adult and four pediatric locations. The country has achieved good progress in the prevention of MTCT of HIV, with rates now generally holding below 1% (). HIV testing is free and available at numerous testing sites and during major events like Carnival, World AIDS Day, and Regional Testing Day. Campaigns also target specific groups, such as the 2014 “Like Yuhself” Campaign, through which more than 2,400 adolescents were made aware of disease risk factors.
Since 2006, there have been no reported cases of vaccine-preventable diseases in Trinidad and Tobago (), likely attributable to high immunization coverage rates, typically over 90%. Free vaccines are provided for all citizens from birth through adulthood under the PAHO/WHO Expanded Program on Immunization. The immunization schedule targets children during the first 5 years of their lives, and immunizations are required prior to registration with the primary school system. Because of these measures, infectious diseases are not a significant cause of death among children. Private medical practitioners also provide vaccines for a fee.
Chronic Non-Communicable Diseases
The results of a 2011 STEPS survey among persons aged 15-64 years old found that the prevalence of having three or more risk factors for NCDs ranged from 47.6% to 54.3% among those aged 25-64 years old ().
Diabetes remained a matter of concern, with the disease’s prevalence fluctuating between 16.6% and 24.4% among 15-64-year-olds () (Table 4), a high rate that is driven by a diet of high carbohydrate intake and a predisposition for the disease associated with low levels of physical activity (). The prevalence of hypertension was also high, holding between 18.7% and 23.0% (25.4% among males and 16.4% among females)().
Table 4. Chronic diseases and risk factors among 15–64-year olds, by sex, Trinidad and Tobago, 2011
|All (%)||Male (%)||Female (%)|
|Current smoker (tobacco products)||21.1||33.5||9.6|
|Daily smoker (tobacco products)||18.0||29.1||7.7|
|Average age started smokinga||17a||17a||19a|
a Values measured in years.
Source: Noncommunicable Disease Prevalence and Risk Factor Survey (STEPS).
As Trinidad and Tobago advances toward a developed-country status, health problems seen in industrialized countries also increase¾the most worrisome one being obesity: the country is considered to have one of the highest levels of obesity in the Caribbean, at 30.0% (). The STEPS survey found a prevalence of obesity of 25.7% among 15-64-year-olds, with females having much higher rates (31.7%) than males (19.4%) () (Table 4). Up to 30.0% of the surveyed population was overweight. Among the youth, 29.7% of those aged 15-18 years were overweight and 13.1% were obese; among 19-24-year-olds, 37.9% were overweight and 10.8% were obese ().
The “Healthy Me” childhood obesity prevention camp was introduced in 2014 to support healthy lifestyles in children ages 7-13; it has benefited over 160 children to date. Other interventions in 2014 and 2015 include the development and implementation of nutritional and dietary guidelines for food sold at or served in schools, and the launching of the Childhood Obesity Prevention Policy.
Mental health services include a major psychiatric facility, St. Ann’s Hospital. Acute care is provided at other major hospitals and through community-based mental health services at local and district health centers. Although there is no comprehensive mental health data, the 2014 WHO Mental Health Atlas reported 5,826 cases of severe mental disorder (both outpatients and inpatients) and put the treatment prevalence at 433.4 per 100,000 population (). The leading mental health issues were schizophrenia, mood/affective disorders (e.g., depression), mental and behavioral disorders (e.g., suicide), and substance abuse. The Mental Health Atlas also reported that 77% of inpatients had been institutionalized for longer than 5 years, 16% for under one year, and 7% for one-to-five years (). Suicide had a mortality rate of 12.05 per 100,000 in 2010, 4.62 among women and 19.63 among men, making it one of the 10 leading causes of death for men (). In 2011, 16.8% of students aged 13-15 years in Trinidad, compared to 20.1% in Tobago, reported having seriously considered attempting suicide (); on both islands, more girls than boys had considered suicide and more girls than boys had attempted suicide.
The Ministry of Health has different primary health initiatives to address mental health. For example, there are two child guidance clinics located in Trinidad, and a child and adolescent center in Tobago cater to adolescents 10-19 years old; both serve referrals and walk-ins for mental health assessment and psychological testing. In 2012, the National Mental Health Educational Campaign and the Mental Health Awareness campaign were launched to improve citizens’ awareness of mental health issues. A Mental Health Policy also was implemented to provide awareness and educate on issues dealing with mental health in the workplace. Finally, a program to prevent and manage aggression and violence was put in place, and support groups were organized for attention-deficit/ hyperactivity disorder (ADHD), depression, anxiety, substance abuse, and for families and carers of those suffering from mental health issues. See Box 1 for details on the evolution of Tobago’s mental health services.
Box 1. A Culturally Appropriate, Client-centered Mental Health Care Model: The Tobago Experience
None of these changes would have been possible without the right number and mix of human resources, however. Up to the mid-1970s, mental health care on the island was provided by a visiting team from St. Ann’s Hospital in Trinidad (a psychiatrist, a couple of nurses, and an occasional mental Health Officer). Then, in 1995, with the opening of a 12-bed inpatient psychiatric ward at the former Tobago Regional Hospital, a full-time psychiatrist was first appointed in Tobago. But even in the early 2000s, Tobago’s mental health staffing was inadequate. A 2002 analysis of the island’s mental health services conducted by the Pan American Health Organization highlighted some drawbacks mental health services were driven by specialty care; could only be accessed at the hospital level; had personnel shortages, especially for services targeted for children and adolescents; and lacked physical facilities and transportation options. Over time, as Tobago continued to move toward the “integration of mental health services into community health care,” staffing significantly expanded, to include such posts as house officers, registrars, consultants, mental health officers, a psychologist, occupational therapists, a speech therapist, a psychiatric social worker, rehabilitation assistants, mental health nurses, nursing assistants, and ward attendants, including access to services of physical therapists.
A sound promotion strategy also was key to success. A multi-pronged approach included community awareness initiatives, mental health advocacy efforts with the police force and the judiciary, and training of primary care physicians on the early identification and treatment of mental illness. These efforts did much to “sell” the concept of integrated mental health services to the community and to stakeholders, and worked to de-stigmatize mental health patients and better understand traditional approaches (obeah) to mental health and illness.
Today, Tobago has its own acute care ward at the new Scarborough General Hospital (SGH), with satellite services in several health centers. Among the wide range of mental health services currently available in Tobago are acute psychiatric care at SGH; psychiatric assessment and treatment at the hospital, at the outpatient clinics housed at the Scarborough Health Centre and satellite community clinics in the various health centres; substance abuse clinic housed at the facilities of the former Tobago Regional Hospital, offering various interventions, counselling, and psychotherapy; a “Memory Clinic” serving the elderly; and a Child and Adolescent Centre providing care for children with mental and developmental disorders.
At the heart of this dynamic mental health model is the cadre of multi-disciplinary health professionals and support staff who are committed to deliver integrated and comprehensive mental health services to the population of Tobago.
- Bolastig, E (2010). Final Report: Participatory rapid appraisal of the Tobago Mental Health system and Proposed mental health care delivery model. Trinidad and Tobago: Pan American Health Organization/World Health Organization
- Hickling, F. W. (1988). Psychiatry in the Commonwealth Caribbean: A Brief Historical Overview. Bulletin of the Royal College of Psychiatrists, 12 (10), pp. 434 (available online at http://pb.rcpsych.org/cgi/reprint/12/10/434.pdf.)
- Ryan, J. (2002). Final Report: A Situational Analysis of Mental Health Services in Tobago. Trinidad and Tobago: Pan American Health Organization/World Health Organization
Accidents and Violence
For persons aged 55 years and under, land transportation accidents, assault (homicide), suicide, and accidental drowning were among the leading five causes of death in 2010. Data from the Police Service for 2010-2015 show that there were 1,040 persons killed due to 841 road traffic accidents, most of them male (81%) and most under 35 years of age (46.1%); one in four persons were aged 25-34 years, 20.1% were under 25 years, and 13% were 50 years old and older. From 2010 to 2015, there was an annual average of 406 murders, 642 woundings and shootings, and 732 sexual offences (rapes/incest), accounting for approximately 12% of all reported crimes. During 2010–2012, there were 5,909 reported cases of domestic violence, with 6.6% of the victims being under 19 years old, 29.2% being 20-29 years old, and 44.2% being 30-49 years old (). During this review period, injuries were the leading cause of discharges.
Acknowledging the seriousness of the trends in injury and violence in the country, the Ministry of Health completed a Situational Analysis on Injuries and Violence in 2010, reviewed an RHA’s Injury Surveillance System, continued to work to roll out such a system in the remaining RHAs, and finalized a multi-sectoral plan for the prevention of violence and injuries.
Risk and Protective Factors
Addiction treatment for alcohol and substance abuse is offered free of charge at various facilities throughout the country.
According to the 2011 STEPS survey, the overall prevalence of current drinkers was 40.4%, 50.6% among males and 30.9% among females (). Among current drinkers, the average number of standard drinks consumed on a drinking occasion was 4.1, with men drinking an average of five standard drinks, compared to three drinks consumed by women. Among current drinkers, 33.9% of males indulged in binge drinking on any day of the week preceding the survey (five or more drinks on a single occasion), compared to 16.8% of females binge drinking (four or more drinks).
The prevalence of smoking varied between the males and females. Approximately one in five persons were current smokers, with the prevalence being much greater among males (Table 4). Daily smoking among men started at age 17 (at 19 years for women), with an overall prevalence of 18% (). Among current smokers, the number of cigarettes smoked per day was much higher for men (12.2), compared to women (9.1). Smoking was most prevalent among youth and adults aged 25-34 years. Current smoking among men increased with age, but decreased among women (Table 4). The duration of smoking was also longer for males compared to females. Moreover, 17.8% of respondents reported that they had been exposed to tobacco smoke at home, and 16.7% reported that they had been exposed in the workplace ().
Trinidad and Tobago has ratified the Framework Convention on Tobacco Control, and during the 2010–2014 reporting period enacted tobacco-related legislation and regulations. The national 2010 Tobacco Control Act seeks to ban smoking in public places and significantly limits the marketing and sale of tobacco products, especially to children. The 2013 Tobacco Control Regulations set standards for the packaging and labeling of tobacco products. In addition, the Ministry of Health has established a Tobacco Unit to implement the Tobacco Control Act, ensuring that relevant structures are established to facilitate tobacco control measures. The Ministry is also working to integrate smoking cessation clinics into primary health care, and the North West Regional Health Authority has introduced a smoking cessation program.
The Government of Trinidad and Tobago, through its Policy Framework, has embarked upon a strategy for achieving universal health care. As part of that overarching goal, there are ongoing assessments to identify various health service gaps. As the country continues to strengthen its primary health care system, these gaps are expected to be significantly reduced.
Trinidad and Tobago has been making efforts towards the accreditation of all its health facilities, a process that will be done every three years. This accreditation, in turn, bolsters the primary health care system, which is the main driver for being able to offer the population efficient, equitable, and accessible health services. As part of this vision, the Ministry of Health also is pursuing strategies and interventions that focus on population health and the role of community, health promotion, and preventive care. Embracing this multi-sector, whole-of-government approach will be critical to address NCDs and gaps in human resources for health.
Over the next 5 to 10 years, the country will focus on lowering NCDs and tackling their risk factors. To this end, the Ministry of Health will work across sectors and with various partners to roll out the National Strategic Plan for the Prevention of Non Communicable Disease. Efforts will track along four key strategic objectives: multi-sectoral policies and partnerships for NCD prevention and control, understanding NCD risk and protective factors, the health system’s response to NCDs and their risk factors, and NCD surveillance and research. Adequate and effective human resources for health are critical to success. The 10-year HRH Plan must address current gaps, foresee future needs, and build in sustainability. Primary health care facilities also must be refurbished and modernized so they can offer access to comprehensive services and ensure that facilities are IT-ready for health information systems. Finally, the Ministry of Health must ensure that its management plan for the workforce will lead to a smooth transition.
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1. Some of these entities include the Caribbean Community (CARICOM) Secretariat, the Caribbean Public Health Agency (CARPHA), the Pan American Health Organization, various other United Nations (UN) agencies, the World Bank, the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), and the European Union, among others.
2. For additional information on this issue, please refer to the subsections on “Maternal and Reproductive Health” and Child Health” under the section “Health Situation and Trends.”
3. See the subsection on “Mortality” under the section “Health Situation and Trends.”
4. Trinidad & Tobago dollars (TT$ 1 = US$ 0.15).
5. MDG 7: reducing by half the number of people without access to safe drinking water and improved sanitation.
6. As defined by the United Nations (10% or more of a population over the age of 60 years).
7. Risk factors include daily smoking, inadequate daily servings of fruits and vegetables, low level of physical activity, overweight, and elevated blood pressure.