Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697647581574.pdf (Bahamas)
83340_00i-xxiv 3/31/05 8:33 PM Page i Bahamas Living Conditions Survey 2001 Department of Statistics 2004 Nassau, The Bahamas 83340_00i-xxiv 3/31/05 8:33 PM Page ii © 2004 Department of Statistics Clarence Bain Building Thompson Boulevard Nassau, The Bahamas All rights reserved Produced by the Department of Statistics Cover photos (clockwise from left): The Bahamas Tourist Office—Curious faces (Hope Town, Abaco), Typical picket-fenced house (Harbour Island, Eleuthera), Fernandez Bay (Cat Island), Androsia, a type of batik, hung out to dry (Andros); Ministry of Education—Students at lunch vendor, H.O.
Nash Junior High School (Nassau, New Providence).
Map: Design Unit, Inter-American Development Bank, Washington, D.C., USA Printing and cover design: Automated Graphics Systems, Inc., White Plains, Maryland, USA ISBN: 976-95136-0-1 83340_00i-xxiv 3/31/05 8:33 PM Page xix Abbreviations and Acronyms BGCSE The Bahamas General Certificate of BLCS BMI CHP COB CPI FAO Secondary Education Bahamas Living Conditions Survey Body Mass Index Child Health Passport College of The Bahamas Consumer Price Index Food and Agriculture Organization of the United Nations Female Headed Household General Certificate of Education Gross Domestic Product FHH GCE GDP GOBH Government of the Commonwealth of HAZ HQI LAC The Bahamas Height for Age Housing Quality Index Latin America and the Caribbean Key Numerical Codes Geographical Regions 1 New Providence and Grand Bahama 2 Abaco, Andros, and Eleuthera 3 Exuma and Long Island 4 Other Family Islands xix | Liquefied Petroleum Gas LPG MHH Male Headed Household MOE Ministry of Education MOF Ministry of Finance MOH Ministry of Health NHNS National Health and Nutrition Survey NSLP PG SES SLC SPG THE UNDP United Nations Development Programme WAZ Weight for Age WHO World Health Organization WHZ Weight for Height National School Lunch Programme Poverty Gap Socioeconomic Status School Leaving Certificate Squared Poverty Gap Total Health Expenditure Consumption Quintiles 1 lowest (poorest) 2 next to lowest (or poorest) 3 middle 4 next to highest (or wealthiest) 5 highest
 (wealthiest) Expenditure Ranges (per capita) $0.00–3,967.99 $3,968.00–5,947.99 $5,948.00–8,523.99 $8,524.00–13,446.99 $13,447.00–infinity Notes to the Tables Throughout the chapter tables, the abbreviation N equals number of observations.
Unless otherwise indicated, the num- bers in the body of the tables represent percentages of N. xix 83340_061-086 3/31/05 9:20 PM Page 61 CHAPTER 4 Health Status: Socioeconomic Analysis Camille S. Deleveaux, Arneta D. Clarke, Sandra C. Adderley-Coleby, Adelma L. Penn, and Melissa Underwood T he health of any country’s population is affected by the socioeconomic status (SES) of its citizens.
The Bahamas Living Conditions Survey (BLCS) provided an opportu- nity to evaluate the causal link between SES and health in the Bahamian context.

In addition, the Survey provided a baseline for selected health in- dicators, while allowing for a comparison with the findings of earlier investigations.
It examined the following health-related areas: self-reported health status; child health; nutritional status of children, adolescents, and adults; female-repro- ductive health; health-services use and expendi- ture; and health-insurance coverage.

SELF-REPORTED HEALTH STATUS Whilst self-reporting reveals much about a pop- ulation’s health, it is subject to biases that lead to underreporting; thus, a population’s true health status may be clouded by survey respondents’ perception and level of well-being.
If feasible, health measures that use physical evaluations are preferable and more accurate.

Ideally, both mea- sures can be used to enhance understanding of a population’s health status.

Inferences drawn from findings based on self-reporting should be considered in light of these limitations.

BLCS respondents were asked to report on several aspects of their health status: recent ill- ness, injury or accident, and disability.
They were also asked whether they had previously been diagnosed with chronic diabetes and hyper- tension.

Approximately 1 in 10 respondents (13.4%) reported having had an illness or injury during the four-week period preceding the sur- vey (Table 4-1); of these, slightly more than half (53.6%) subsequently visited a health practi- tioner to treat their condition.
The majority of those who did not seek treatment either found it unnecessary (57%) or chose to self-medicate at home (41%).1 The average length of illness was eight days.

1 With initial symptoms of illness, self-medication is a com- mon tendency in The Bahamas, where over-the-counter drugs are readily available and “bush” medicine is com- monly practiced.
61 83340_061-086 3/31/05 9:20 PM Page 62 62 | BAHAMAS LIVING CONDITIONS SURVEY 2001 TABLE 4-1 Ill Residents Who Sought Care (%), by Population Characteristic Population characteristic Gender Male Female Age group (years) 0–4 5–14 15–19 20–34 35–54 55–64 65 and older Region 1 2 3 4 Quintile Total Ill residents (%) 11.8 14.9 23.1 12.2 7.6 11.0 13.4 12.6 20.3 13.4 15.1 10.6 9.2 10.7 10.5 14.9 15.0 15.7 13.4 N 3,152 3,262 625 1,394 503 1,435 1,623 389 446 3,413 1,775 621 605 1,560 1,325 1,247 1,173 1,024 6,414 Ill residents who sought care (%) 49.2 56.8 69.4 51.8 39.1 43.7 52.8 41.6 66.2 53.0 56.4 61.6 56.4 49.5 63.1 51.7 52.0 49.9 53.6 N 382 465 142 172 33 152 217 47 84 457 267 67 56 161 147 178 189 164 847 In terms of gender, fewer males (11.8%) than females (14.9%) reported an illness.
Vulnerable or immuno- compromised groups—children under 5 years (23.1%) and adults 65 years and older (20.3%)—were more likely to report an illness during the reference period.

Reporting of illness was also higher amongst persons from the better- off households; for example, 15.7% of those from the wealthiest quintile (of per-capita consumption expendi- ture) reported being ill, compared to only 10.8% from the poorest quintile.
Higher reporting of illness amongst better-off households is consistent with similar surveys conducted around the world, and is often viewed as repre- sentative of reporting bias rather than poorer health status.

Geographically, more residents (15.1%) of the Family Islands of Region 2 (Abaco, Andros, and Eleuthera)— where about 10% of Bahamians live—reported an illness than persons residing in the other three regions (Table 4-1).
Disabilities and Injuries The Survey sought to determine the prevalence of both physical and mental disabilities in the population (Table 4-2).

Approximately 6% of the sample population re- ported having a physical or mental disability.

Of those who had a disability, 68.5% of reported disabilities were related to sight, hearing, or speech; 18.2% to limbs; and 13.3% to mental disabilities.

Males and females were equally likely (6%) to report having a disability.
Regardless of the type of physical or mental disability, it generally increased with age.

For ex- ample, whilst only 3.7% of children under 5 years of age had a disability, 17.6% of the elderly were disabled—a nearly fivefold increase.

Mental disabilities were also more common amongst the elderly (2.3%) (Figure 4-1).
These findings support conclusions drawn from institu- tional data, which show that aging is associated with 83340_061-086 3/31/05 9:20 PM Page 63 TABLE 4-2 Proportion of Respondents with a Disability or Injury in Past 12 Months FIGURE 4-1 Prevalence of Disability, by Type and Age Group HEALTH STATUS: SOCIOECONOMIC ANALYSIS 63 | Population characteristic Physical or mental disability (%) Injury (%) N Gender Male Female Age group (years) 0–4 5–14 15–19 20–34 35–54 55–64 65 and older Region 1 2 3 4 Quintile Total disability, which further affects quality of life and may be linked to poverty.
That residents in quintile 4 had the highest proportion of disability (8.5%) requires further investigation.

Lowest reporting of disabilities was found in quintiles 3 (3.3%) and 5 (4.6%).

Lack of a systematic pattern suggests that living standards bear little relationship to incidence of dis- ability in the population or that the effect is heavily out- weighed by other factors, such as age.
Residents of Region 3 (Exuma and Long Island) had the greatest proportion (9.5%) of persons with disabilities overall—both physical (7%) and mental (2.5%)—whilst the lowest proportion was found in Region 2 (Abaco, An- dros, and Eleuthera) (4.0%), where the elderly population comprises about 7%.
Respondents were asked whether they had experienced any injury due to an accident at their workplace, gunshot, t n e c r e P 16 14 12 10 8 6 4 2 0 8.9 15.2 2.3 3.7 4.0 3.1 5.2 4.5 0.0 < 5 0.1 5–14 0.7 0.5 0.8 0.8 15–19 20–34 35–54 55–64 65+ Age Group (Years) Physical Mental stabbing, or other external cause during the past 12 months (Table 4-2).

Approximately 4% of the popula- tion—4.7% of males and 4.1% of females—reported an injury over the reference period.
Most incidents occurred at work or school (63%) (Figure 4-2).

The proportion of reported injuries was highest amongst the elderly (5.9%), who are more likely to experience falls, and amongst work- ing-age individuals in age groups 20–34 years (5.7%) and 35–54 years (5.1%).
FIGURE 4-2 Distribution of Injuries, by Type (%) Occupational/ School 63% Motor Vehicle Accident 12% Gunshot/Stab 10% Other 15% (n = 246) 83340_061-086 3/31/05 9:20 PM Page 64 64 | BAHAMAS LIVING CONDITIONS SURVEY 2001 The highest and lowest occurrences of injuries were found in quintiles 4 (6.7%) and 3 (2.1%), respectively.
In terms of region of residence, Bahamians on the most de- veloped islands of New Providence and Grand Bahama (Region 1), as well as Exuma and Long Island (Region 3), had the most injuries.

Diabetes and Hypertension To estimate the prevalence of diabetes and hypertension, BLCS respondents were asked whether they had a history of those conditions or whether a doctor or nurse had ever told them they had these chronic diseases.
Notably, it is well documented that reported history of diabetes and hy- pertension is significantly lower than what actually occurs in a population.

As Table 4-3 shows, prevalence of diabetes was 3.3%, with knowledge of the condition more prevalent amongst females (3.8%) than males (2.7%), a significant difference, proven by chi-square testing (p 0.000).
Amongst males, prevalence increased from nearly 1% for those 20–34 years of age to about 17% for those 55–64 years old, and remained at the same level amongst elderly men 65 years and older.

Amongst females, preva- lence increased from less than 1% (0.1%) for girls un- der 20 years old, peaking at 19.1% for women 55–64 years old, and then declining to 15.7% amongst elderly women.
National Health and Nutrition Survey (NHNS) (1988–1989) respondents were asked: “Has a doctor ever told you that you have diabetes?” Answers showed that prevalence of self-reported diabetes was 3.3% in the 15- to-64 age group, and 14% in the elderly group.

Corre- sponding BLCS rates were 3.8% and 16.4%, respectively.
Higher rates may have resulted from changing lifestyle TABLE 4-3 Self-reported Diabetes and Hypertension and Proportion Treated Diabetes Hypertension Population characteristic Self-reported diagnosis (%) Gender Male Female Age group (years) 0–4 5–14 15–19 20–34 35–54 55–64 65 and over Region 1 2 3 4 Quintile Total 2.7 3.8 0.0 0.1 0.0 1.3 4.4 18.2 16.4 3.0 5.1 5.3 5.0 2.2 3.1 3.9 3.1 4.2 3.3 Received treatment (%) 88.6 90.1 0.0 100.0 0.0 78.3 83.2 95.5 95.1 90.0 87.8 88.4 87.3 95.7 92.7 86.1 96.3 81.8 89.5 N 3,152 3,262 625 1,394 503 1,435 1,623 389 446 3,413 1,775 621 605 1,560 1,325 1,247 1,173 1,024 6,414 N 94 160 0 1 0 18 83 74 78 101 89 33 31 48 61 48 46 48 254 Self-reported diagnosis (%) 6.1 12.3 0.3 0.2 0.1 3.8 15.8 36.0 44.0 8.3 15.1 14.0 13.3 6.4 7.3 9.8 9.9 13.1 9.3 Received treatment (%) 85.2 92.4 11.1 47.6 0.0 78.3 88.5 90.8 99.5 90.2 89.4 94.4 86.8 95.8 92.4 89.8 91.6 84.6 90.1 N 3,252 3,262 625 1,394 503 1,435 1,623 389 446 3,413 1,775 621 605 1,560 1,325 1,247 1,173 1,024 6,414 N 242 479 2 2 1 69 295 158 194 289 263 88 81 137 129 148 142 155 721 83340_061-086 3/31/05 9:20 PM Page 65 practices and increased obesity—a risk factor for diabetes—in addition to a growing elderly population.
In the BLCS, prevalence of diabetes based on reported history increased as levels of consumption rose between the first (2.3%) and third (3.9%) quintiles, but fluctuated thereafter; a statistical association was not found between the proportion of persons with diabetes and quintile levels.

These results may reflect differences in obesity levels across consumption groups.
The highest prevalence of diabetes (about 5%) was found in the Family Islands (Regions 2, 3, and 4), as com- pared to 3% in the urban areas of Region 1 (New Provi- dence and Grand Bahama).

One contributing factor may have been the elevated levels of obesity amongst adults in these regions, as first reported in the NHNS and observed in the present BLCS.
In addition, low consumption of complex carbohydrates—including fresh fruits and veg- etables, root crops, and legumes—persists.2 Nearly 1 out every 10 persons (9.3%) had a self- reported history of hypertension, with rates for females about twice that of males (12.3% versus 6.2%).

Like dia- betes, reported hypertension increased with age, from about 4% in adults aged 20–34 years, to 44% in the el- derly.
The proportion of females with a history of hyper- tension increased from less than 1% (0.2%) in girls under 20 years old to 50.9% in elderly women; that is, 1 out of every 2 women 65 years or older had a reported history of hypertension.

Self-reported hypertension amongst males ranged from less than 1% in boys under 20 years old to about 34.5% in elderly men.
NHNS blood-pressure measurements showed that prevalence of hypertension amongst adults aged 15–64 years was 13%,3 compared to BLCS self-reported results of 11% for the same age group.

In addition, the NHNS classified 37.9% of those 65 years or older as hypertensive by blood-pressure measurement, compared to 53.1% who reported hypertension.

In the BLCS, 44% of the el- derly reported a history of hypertension.
In the NHNS, self-reporting was determined by responses to a question similar to that asked in the BLCS: “Did a doctor ever tell you that you had hypertension?” 2 This problem is evidenced in the most recent Food and Agriculture Organization (FAO) data on food availability data, as well as in NHNS observations.

3 NHNS classification for hypertension was systolic 160 and/or dias- tolic 95.
HEALTH STATUS: SOCIOECONOMIC ANALYSIS 65 | Analysis by quintiles of consumption groups showed the proportion of self-reported hypertension to increase by quintile, rising from 6.4% in the lowest, to 13.1% in the highest.

This may reflect a tendency of better-off individ- uals to seek health care, thus having a greater opportunity for diagnosis.
The highest prevalence of hypertension by reported history was 15.1%, found in Region 2 (Abaco, Andros, and Eleuthera), whilst the lowest was 8.4%, found in Re- gion 1 (New Providence and Grand Bahama).

About 9 out of every 10 persons with a history of dia- betes or hypertension subsequently received treatment, and a greater proportion of these persons was 55 years or older.

Those most likely to seek treatment lived on islands with greater access to health care (New Providence and Grand Bahama) (90.5%).
A greater percentage from Re- gion 3 (Exuma and Long Island) was treated for hyperten- sion (94.4%).

Whilst the proportion of treated persons was high, the extent of compliance with prescribed medications to con- trol the conditions is not known.
Consequently, in addi- tion to the need to reduce the percentage of untreated per- sons, particularly adults 54 years and younger, an aggressive approach is needed to create awareness of the signs and symptoms of diabetes and related complications to improve compliance.

These findings on diabetes and hypertension ade- quately reflect the current reality in the population.
Both diseases present a public-health problem of alarming pro- portion, which, if ignored, could result in a deficit of hu- man capital and reduced quality of life.

CHILD HEALTH In terms of childhood illness, BLCS results showed that, in children ages 5 years and younger, respiratory illness is a major concern.
During the four weeks prior to the Sur- vey, amongst children in this age group, coughs, colds, and runny noses were the most common illnesses (41.6%), followed by diarrhoea (6.6%) and asthma (2.4%).

A greater percentage of girls than boys was re- ported as having each illness; however, no significant sta- tistical association was found by gender (Table 4-4).
Incidence of diarrhoea amongst children five years of age and younger was 7.8%; only 3 out of every 10 (28.6%) who suffered with the condition were given oral rehydra- tion therapy, the course of treatment recommended by the 83340_061-086 3/31/05 9:20 PM Page 66 66 | BAHAMAS LIVING CONDITIONS SURVEY 2001 TABLE 4-4 Proportion of Children Five Years and Younger with Common Illnesses in Past Four Weeks Cough, cold, or runny nose 42.1 44.7 46.9 46.4 36.8 43.8 41.6 41.0 34.8 41.4 45.1 45.1 39.5 47.9 41.6 Population characteristic Gender Male Female Age group (years) 0–1 2–3 4–5 Region 1 2 3 4 Quintile Total Asthma Diarrhoea N World Health Organization (WHO).
Most of the chil- dren affected were in the lowest consumption quintile.

Re- gion 4 (Other Family Islands) had the highest incidence (16.5%), whilst Region 3 (Exuma and Long Island) had the lowest (2.2%).

As part of the Expanded Program on Immunization (EPI), children in The Bahamas are immunized against Diphtheria, Pertussis, and Tetanus (DPT), Poliomyelitis (Polio), Haemophilus Influenza Type B (HIB) and Hep- atitis B (Hep B) within the first year of life; and Measles, Mumps, and Rubella (MMR) at age 1.
DPT and HIB boosters are given at 15 months, whilst Paediatric Diph- theria Tetanus (Paed DT), Polio, and MMR boosters are given at ages 4–5 years.

In accordance with the national immunization sched- ule, coverage levels for infants and children ages 0–71 months who had received the required three doses of vac- cines on schedule were: DPT (88.8%); Polio (87.2%); HIB (71.9%); and Hep B (32.1%).4 Coverage amongst children 12–71 months who received their first dose of MMR on schedule was 69.1% (Figure 4-3).
Amongst infants 6–11 months, the coverage level was 74% for DPT, Polio, and HIB; and, amongst children 12–23 months, MMR coverage was 74%.

Less than 3% of the children surveyed were not immu- nized against DPT and Polio.

Higher proportions were not immunized for HIB (12.6%), Hep B (48%), and MMR (7.7%) (Figure 4-4).
Immunization coverage (for DPT, Polio, and HIB) was generally higher amongst children from progressively better-off households, but sample sizes were smaller in the upper two quintiles (Table 4-5).

Amongst the four regions, Exuma and Long Island had the highest reported coverage levels for DPT (93%) and Polio (97.5%).
Both Exuma and Long Island and Other Family Islands had the highest coverage for MMR (76%), whilst New Providence and Grand Bahama had the high- est for HIB (74.9%) and Hep B (35.7%) (Table 4-5).

The immunization or vaccination card, used to verify a child’s immunization status, is a requirement for school enrolment.
The Child Health Passport (CHP), currently used in place of the original immunization card, was 4 The Hep B vaccine, as part of the pentavalent vaccine, was introduced to the public sector in July 2001, which explains its low coverage level at the time of the BLCS.
FIGURE 4-3 Vaccination Coverage Amongst Children 0–71 Months, by Vaccine t n e c r e P 100 80 60 40 20 0 88.8 87.2 71.9 69.1 32.1 DPT3 Polio Hep B MMR HIB Vaccine 83340_061-086 3/31/05 9:20 PM Page 67 FIGURE 4-4 Children 0–71 Months Not Vaccinated or Behind Schedule t n e c r e P 60 50 40 30 20 10 0 47.7 8.2 8.4 1.6 1.5 2.7 1.7 DPT Polio 12.6 12.2 3.3 HIB Vaccine 15.3 5 19.9 7.7 3.3 Hep B MMR Not Vaccinated Behind Schedule Not Known* *While most of these children were vaccinated, a card was not pro- duced to verify dosage.
HEALTH STATUS: SOCIOECONOMIC ANALYSIS 67 | presented for about 88% of children who participated in the BLCS.

Nurse enumerators then reviewed the card and determined coverage levels.

The CHP may have presented some limitations during data collection, as it was not designed to capture new vaccines added to the national immunization schedule.
In evaluating the immunization status of infants and children 0–5 years, coverage levels reported for children under 1 year were slightly lower than national figures (Table 4-6A).

However, through defaulter tracing and im- munization outreach, coverage levels usually increased by age 2, as reflected in Survey findings.

Potential factors contributing to low coverage levels included small or non- representative sample sizes for children under 2 years.
In addition, CHPs may not have been up to date; moreover, children may not have been due their third dose at the TABLE 4-5 Immunization Coverage Amongst Children 0–71 Months Population characteristic DPT (%) N Polio (%) N HIB (%) N Hep B (%) N MMR1 (%) N Gender Male Female Age (months) 0–5 6–11 12–23 24–71 Region 1 2 3 4 Quintile Total n.a.
n.a.

73.62 69.6 62.6 75.5 76.5 66.1 71.8 67.5 71.5 71.4 69.1 259 248 n.a.

n.a.

90 2 284 144 37 42 161 109 109 84 44 507 1 Children ages 12–71 months.

2 MMR age groups differed for older children: 24–47 mo.

coverage 93.0% (n 196); 48–71 mo.

coverage 44.4% (n 221).

n.a.

 not applicable.


83340_061-086 3/31/05 9:20 PM Page 68 68 | BAHAMAS LIVING CONDITIONS SURVEY 2001 TABLE 4-6A National Immunization Coverage Levels, 1997–2000 coverage was reported at 99% for DPT; 92% for Polio and HIB; and 94% for MMR (Tables 4-6A and B).

Coverage level NUTRITIONAL STATUS OF CHILDREN Vaccine type 1997 1998 1999 2000 DPT Polio HIB Hep B MMR 87 86 n.a n.a 94 89 88 n.a n.a 92 84 84 77 n.a 87 99 92 92 n.a.

94 n.a.

 not applicable.


time of the Survey because of defaulting.

Additional con- tributing factors were the recent introduction of HIB and Hep B into the national immunization schedule.5 National figures for the 1997–2000 period show that, amongst vaccine-preventable diseases, there were no re- ported cases of DPT, whooping cough, polio, tetanus neonatorum, or mumps.

In 1997 and 1998, respectively, one case of measles and four cases of congenital rubella were reported.
Since introduction of the HIB vaccination in 1999, the number of reported cases declined from six that year to none in 2000.

In 2000, national vaccination 5 HIB was introduced into the schedule in 1999, and Hep B was in- cluded in 2001; however, at the time the BLCS was conducted, the third dose of Hep B was not administered routinely to infants under age 1 by all private doctors.
TABLE 4-6B Vaccine-preventable Cases Reported, 1997–2000 Disease 1997 1998 1999 2000 Diphtheria Whooping cough Poliomyelitis Tetanus neonatorum Measles Mumps Congenital rubella syndrome Rubella (German measles) Hep B HIB The nutritional status of children 2–10 years was assessed, using the anthropometric measurements of weight and height compared with WHO reference standards (Z- scores).
The three indices examined were Weight for Age (WAZ), Height for Age (HAZ), and Weight for Height (WHZ).

WAZ compares a child’s weight with the WHO reference standard weight for a child of the same age.

WAZ is the easiest indicator to measure, and therefore the most common measure of nutritional well-being.

HAZ compares a child’s height with the WHO refer- ence standard height for a child of the same age.
In chil- dren older than 3 years, HAZ is a proxy for the cumulative environmental conditions—past influences—of the pe- riod of earlier growth, principal amongst which is the ef- fect of poor nutrition (a clear indicator of stunted growth).

In children younger than 3 years, HAZ is a proxy for past and current influences on nutritional status, as well as fu- ture growth failure and resulting associated risk; it is also a stronger predictor of mortality in children of this age.
WHZ compares a child’s weight with the WHO reference standard weight for a child of the same height.

It is used to assess wasting, is the most sensitive measure of the three used, and is a proxy for current nutritional status.

Across a population, it is generally expected that 2.3% of children will be undernourished (Z-score of 2.00), whilst 2.3% will be overnourished (Z-score of 2.00).
Prevalence of Undernutrition As shown in Table 4-7, 11% of Bahamian children had low HAZ, whilst 6% had low WHZ.

The indicators stunt- ing (low HAZ) and wasting (low WHZ) were at least three times greater than what is normally expected, with Region 1 indicating the highest prevalence.

These levels suggest the population may have pockets of endemic undernutri- tion.

This extreme situation is difficult to assess in this type of survey and requires surveillance and clinic-based data.
The proportion of children with low weight for age (WAZ) (3.3%) was within normal levels (Table 4-7).

Stunting is slightly more prevalent amongst boys (11%) than girls (10% ), and both percentages are unacceptably high.
Using the other two indicators—WHZ and WAZ— percentages were significantly lower, with 8% of boys and 83340_061-086 3/31/05 9:20 PM Page 69 HEALTH STATUS: SOCIOECONOMIC ANALYSIS 69 | TABLE 4-7 Low and High Z-scores for Children 2–10 Years of Age* Population characteristic 2.0 2.0 2.0 2.0 2.0 2.0 HAZ-score (%) WAZ-score (%) WHZ-score (%) Gender Male Female Region 1 2 3 4 Quintile Total N 492 332 437 212 87 88 273 181 175 130 65 824 * Low Z-scores 2.0; high Z-scores 2.0.
4% of girls having low WHZ; 4% of boys had low WAZ, whilst the percentage of girls with low WAZ (2%) was in keeping with the expected proportion (Table 4-7).

The highest rate of stunting was found amongst the youngest population, with proportions declining as chil- dren grew older.

The HAZ-score indicated that 15% of children 2–4 years of age were at significant risk of stunt- ing; that proportion was more than halved (7%) in chil- dren 7–10 years of age.
These results show a reverse of the pattern usually found in populations with a certain level of food deprivation; they may suggest an error in either data collection or measurement or reflect a current or emerging economic situation that is acutely depressed.

In any event, these results warrant further investigation by the social agencies of the various ministries and the local, national, and international institutions involved.
The overall trend of low WHZ-scores (wasting), which reflect current nutritional status, showed that the potential for undernourishment increased as children grew older.

This was evident in the increase from 4% in children 2–4 years to 8% in children 7–10 years, a proportion triple that of what is expected by global standards.

This pattern deviates from what is typically found in other surveys.
In the BLCS, the higher prevalence of wasting amongst older children reflects similar results from two previous surveys, and may indicate that, within households, the nutritional status of younger children is a priority.

Both WHZ- and HAZ-scores showed the highest prevalence of undernutrition on the urbanized islands of Region 1 (New Providence and Grand Bahama) and the lowest on the less developed Family Islands of Region 4 (Other Family Islands).
In both developing and developed countries, this pattern suggests that, for individual house- holds, the economic and social safety net (e.g., land for farming or extended family) is less secure in urban areas during periods of economic stress.

Prevalence of Overweight Children The WHZ-score, the indicator used to determine under- weight children, was also used to assess the extent of overweight children.
Overall, 14% of the total sample of 2–10 year-olds was overweight, indicating the emergence of chronic overnutrition.

As Table 4-7 shows, the pro- portion of children considered clinically obese was six times more than what was expected.

The likelihood that these children will become overweight adults has daunt- ing consequences for the long-term public health of the country.
83340_061-086 3/31/05 9:20 PM Page 70 70 | BAHAMAS LIVING CONDITIONS SURVEY 2001 As observed in the wider population, more girls than boys (16% versus 13%) were overweight; amongst all chil- dren, weight increased with age.

Of those in age group 2–4 years, 11% registered above normal weight, compared to the 2.3% referenced as normal; the prevalence of excessive weight for height further increased to 16% amongst chil- dren 7–10 years.

Overall, 14% of children 2–10 years were overweight and 6% underweight.
Both scenarios underscore the need to identify environmental risk factors—household food insecurity and poor nutritional practices—in this subgroup to determine the causal relation (which is be- yond the scope of this study).

According to WHO stan- dards, only 5% of a sample should be outside normal ranges.

For the most part, WHZ increased with higher per- capita, household-consumption expenditure.
Regions 2 (Abaco, Andros, and Eleuthera) and 4 (Other Family Is- lands) had the lowest prevalence of overweight children (10.4% and 13.3%, respectively), whilst Region 3 (Exuma and Long Island) reported the highest, with 20%.

NUTRITIONAL STATUS OF ADOLESCENTS Adolescence, a period characterized by rapid physical growth and social adjustment, makes the adolescent child susceptible to environmental factors, particularly those re- lated to food and nutrition.
Amidst the concern of sexual maturation and the milieu of social development and ad- justment problems is the disorder of obesity, which is common in adolescents generally.

The Body Mass Index (BMI) is a simple and reliable index of weight for height commonly used to classify underweight, overweight, and obesity; the BMI provides useful, crude data on the afore- mentioned measurements within the population.
The BMI for age and gender was determined for ado- lescents 11–20 years of age, using reference standards from the Centers for Disease Control.

BMI categories used were: underweight (5th percentile); normal weight; at risk of overweight (85th percentile); and overweight (95th per- centile).
As shown in Table 4-8, of all youth measured, 59% were reported to have normal weight, 14% were at risk of becoming overweight, and approximately 9% were TABLE 4-8 Body Mass Indices for Adolescents, Ages 11–20 Years Population characteristic Underweight Normal BMI (%) At risk for overweight Overweight Total N Mean BMI Gender Male Female Age group (years) 11–15 16–20 Region 1 2 3 4 Quintile Total 83340_061-086 3/31/05 9:20 PM Page 71 overweight for their age.
Notably, 18% of these adoles- cents were underweight at the time of the Survey.

Age group and gender trends revealed more overweight females than males, specifically amongst those 16–20 years (13%).

Young people living on more urbanized islands were more likely to have normal weight than those resid- ing in less developed regions.
With regard to the relationship between BMI and so- cioeconomic status, more children and teenagers who were underweight for their age and gender were from higher-consumption households (quintiles 4 and 5), which contradicts results found in similar surveys.

How- ever, this finding could reflect concern for physical ap- pearance, a common phenomenon in populations of wealth and affluence.

More boys than girls were classified as underweight.
Overall, the highest prevalence of underweight youth was observed in the less developed islands of Region 4 (Other Family Islands) (Table 4-8).

NUTRITIONAL STATUS OF ADULTS Evidence is convincing that mortality rates increase as ex- cessive weight increases, as measured by the BMI.

More- over, as the BMI increases, the proportion of people with one or more co-morbid conditions also increases.
In this regard, assessing the nutritional status of the adult popula- tion is particularly important to understanding its relationship to disease and death, health effects, and the human development index.

The nutritional status of adults 21–60 years of age was assessed based on weights and heights taken during the BLCS.

General BMI rankings are:6 normal weight for height, underweight for height, and overweight for height.

The latter is further subdivided into three classes of obe- sity.
WHO-accepted cutoffs for BMI are: 18.5 (under- weight), 18.5–24.9 (normal), 25–29.9 (pre-obesity or overweight), 30–34.9 (obesity class I), 35–39.9 (obesity class II), and 40 (obesity class III).

As Table 4-9 indicates, the mean BMI was 28 for adults; 34.4% of adults were overweight, a further 30.9% 6 BMI, the international standard for determining weight range, is cal- culated by weight in kilograms (kg), divided by height in meters (m) squared (kg/m2).
HEALTH STATUS: SOCIOECONOMIC ANALYSIS 71 | were obese, and about 2% were underweight.

When the figures were combined, the percentage of overweight or obese adults was 65%, approximately two-thirds of this population.

The 1988–1989 NHNS showed that, in adults 15–64 years of age, this prevalence was 49%.

It can reasonably be concluded that The Bahamas, like many other high-income countries, is experiencing an obesity epidemic.
Within the adult population, females had a significantly higher prevalence of obesity (37%) than did males (24%) (Table 4-9).

Female obesity was highest in Region 4 (Other Family Islands), the most un- derdeveloped area; there, overweight (35%) and obese (49%) females comprised 84% of the Region’s female population, a grave revelation (Tables 4-10 and 4-11).

As shown in Table 4-10, the youngest group of males was the healthiest group in terms of weight.
On average, one out of every two men 21–30 years of age (49.5%) was of normal weight.

About 62% of men were too heavy for their height, whilst 69% of women had a BMI of 25 or more (Table 4-11).

These results clearly show that a high proportion of Bahamian adults is at risk for developing one or more co-morbidities of the chronic, non-commu- nicable diseases.

Amongst all persons, the combination of being over- weight and obese increased with age.
Obesity was most notable in the age groups between 31–50 years (about 35%), as well as in the 51–60 age group (33%), whilst young adults in the 21–30 age group were predominantly the healthiest in terms of weight (Table 4-9).

As an indirect measure of socioeconomic status, obe- sity is more common amongst middle-aged women in low-income countries.
In high-income countries, it is more prevalent amongst middle-aged people, as well as younger adults and children, and tends to be associ- ated with lower socioeconomic status.

The highest preva- lence of overweight persons was found in quintile 5 (38%) and decreased steadily in lower-consumption households.
With regard to obesity, however, the wealth- iest households had the smallest proportion of obese persons (27%), whilst quintile 2 had the highest (35%), an expected result for high-income populations (Table 4-9).

Overall, the highest prevalence of overweight and obese persons was found in Region 3 (Exuma and Long Island).
Gender differences, noted in Table 4-10, show that those two islands have the highest percentage of obese men 83340_061-086 3/31/05 9:20 PM Page 72 TABLE 4-9 Body Mass Indices for All Persons, Ages 21–60 Years BMI (%) Population characteristic Underweight (18.5) Normal weight (18.5–24.9) Overweight (25.0–29.9) Obese (30) Total N Mean BMI Age group (years) 21–30 31–40 41–50 51–60 Region 1 2 3 4 Quintile Total TABLE 4-10 Body Mass Indices of Males, Ages 21–60 Years BMI (%) Population characteristic Underweight (18.5) Normal Overweight (18.5–24.9) Obese (25.0–29.9) Total (30) N Mean BMI Age group (years) 21–30 31–40 41–50 51–60 Region 1 2 3 4 Quintile Total 100.0
83340_061-086 3/31/05 9:20 PM Page 73 HEALTH STATUS: SOCIOECONOMIC ANALYSIS 73 | TABLE 4-11 Body Mass Indices of Females, Ages 21–60 Years BMI (%) Population characteristic Underweight (18.5) Normal (18.5–24.9) Overweight (25.0–29.9) Obese (30) Total N Mean BMI Age group (years) 21–30 31–40 41–50 51–60 Region 1 2 3 4 Quintile Total 2.6 1.7 0.8 0.0 1.6
3 4 Quintile Total (28%).
The greatest proportion of obese women was found on Other Family Islands (Region 4), where 47% had a BMI of 30 or more (Table 4-11).

Overall, New Providence and Grand Bahama had the lowest prevalence of obesity amongst island regions (Table 4-9).

It follows that overweight persons and obesity present a significant public-health problem, especially in the less developed Family Islands (Region 4) and poorest segments of the population.
BREASTFEEDING Results on breastfeeding show that approximately 74% of all children 24 months and younger had been breastfed (Table 4-12).7 More boys (79%) than girls (69.6%) had been breastfed.

The lowest prevalence of recorded breast- feeding was for infants 7–12 months (69.1%), which was 7 Children’s ages were classified as 0–6 months, 7–12 months, and 13–24 months.

lower than that for children 13–24 months (74.6%).


This unexpected finding may be a factor of memory and the ac- curacy of recall by mothers of older children.

As expected, the highest prevalence of breastfeeding (76%) was amongst children 0–6 months of age.

The highest prevalence of breastfeeding (94%) was found in the median quintile, whilst the lowest was found in quintile 4 (63%).
Mothers residing in the more devel- oped islands of Region 1 (New Providence and Grand Ba- hama) and 2 (Abaco, Andros, and Eleuthera) were most likely to breastfeed their infants.

Amongst those house- holds, approximately 74% of children were breastfed.

These results show that breastfeeding is more prevalent in urban areas than rural ones, which is not typically found.

However, this result can be attributed to the National Breastfeeding Campaign.
Initiated eight years prior to the BLCS, the Campaign has influenced Regions 1 and 2 more than 3 and 4 because of the way in which resources have been concentrated.
According to lactation management research, the opti- mal length of time recommended for exclusive breastfeed- 83340_061-086 3/31/05 9:20 PM Page 74 74 | BAHAMAS LIVING CONDITIONS SURVEY 2001 TABLE 4-12 Breastfeeding Incidence and Median Months of Exclusive Breastfeeding* Population characteristic % breastfed Gender Male Female Age (months) 0–6 7–12 13–24 Mother’s education completed Secondary school College/university Region 1 2 3 4 Quintile Total 79.0 69.6 76.3 69.1 74.6 70.2 82.2 74.2 72.6 57.3 62.6 68.3 70.7 93.6 62.5 72.5 73.7 N 86 115 50 51 100 150 28 126 49 7 18 62 50 41 29 19 201 Median months of exclusive breastfeeding 2 2 1 1 3 2 3 2 3 3 3 2 2 2 1 3 2 N 57 68 35 31 59 91 20 81 29 4 10 32 30 33 19 11 125 * Note: Breastfeeding sample was for children 24 months or younger; exclusive breastfeeding was for those 6 months or younger.
ing is six months.

This is important to prevent incidence of diarrhoeal diseases, which can increase infant morbidity and mortality.

A pertinent indicator of the benefits of breastfeeding is the duration of exclusive breastfeeding.8 Infants 6 months of age and younger were exclusively breastfed for a median of 2 months.

For the purpose of comparison with the NHNS of 1988–1989, the level of breastfeeding of children 12 months of age and younger was assessed.
BLCS results showed that 7% of children were exclusively breastfed for 4 months, compared to 2% of children in the NHNS, a marked improvement in prevalence rate for exclusive breastfeeding.

8 The term exclusive breastfeeding is defined as an infant being solely breastfed or fed expressed breast milk via the spoon-and-cup method; and given no bottle (even if it contains expressed breast milk), water, formula, or baby food.
With regard to exclusive breastfeeding by region, Re- gion 1 mothers exclusively breastfed their babies for an av- erage of 2 months.

Sample sizes for the other regions were too small to make comparisons.

FEMALE REPRODUCTIVE HEALTH Approximately 61.9% of females 10–49 years of age reported being pregnant at least once, with a propor- tional range from 6% in adolescent girls 10–19 years of age to 91.8% in women 40–49 years.
The average number of reported pregnancies increased from less than one for girls 10–19 years to three for women 40–49 years.

In each age group, those least able to afford it became pregnant, as the highest proportion of women who were ever pregnant was found in the lowest quintile.
Amongst 83340_061-086 3/31/05 9:20 PM Page 75 HEALTH STATUS: SOCIOECONOMIC ANALYSIS 75 | TABLE 4-13 Percentage of Females, 10–49 Years of Age, Who Have Ever Been Pregnant Population characteristic Education Primary or lower 1–3 grades of higher secondary 4–5 grades of higher secondary Higher secondary or technical/vocational Jr. college, community college, or college/univ.

Region 1 2 3 4 Quintile Total 10–19 yrs.

20–29 yrs.

30–39 yrs.

40–49 yrs.
% 5.1 1.6 5.0 19.3 0.0 5.6 8.4 8.2 4.9 9.2 8.8 3.5 5.2 0.0 6.0 N 85 153 113 84 % 100 76.7 79.9 73.8 N 10 19 54 240 % 95.4 95.7 93.2 87.1 N 27 32 53 231 % N 62 26 32 143 188 83 42 30 55 65 71 75 78 344 age groups, a greater proportion residing in Family Is- lands reported pregnancies (Table 4-13).
About 67% of all females had had at least one gynae- cological examination.

Amongst women 20–49 years of age, more than 80% across all quintile levels had been examined.

Level of contraceptive use to avoid pregnancy was 5.6% for girls 10–19 years of age, 57% for women 30–39 years, declining to 33% for women 40 years and older (some of whom may have no longer needed contraception because of hysterectomies or menopause).
Women who had had at least one live birth were more likely to use con- traceptive methods than those who had had no deliveries.

The birth control pill was the most popular contra- ceptive method used amongst all females (47%), fol- lowed by female sterilization (19.7%), which was used primarily by older women.
Other methods included in- jectables (16.1%), condoms (9.1%), and other modern FIGURE 4-5 Common Contraceptive Methods Women Used, by Age and Type t n e c r e P 80 60 40 20 0 69.9 58.3 51.4 43.4 20.6 22.1 22.7 14.6 27.5 4.0 0 10-19 10.4 3.5 7.6 10.8 5.7 20–29 30–39 40–49 Age Group Pill Injectable Sterilization Condom 83340_061-086 3/31/05 9:20 PM Page 76 76 | BAHAMAS LIVING CONDITIONS SURVEY 2001 methods (6.5%) (Figure 4-5).

This pattern was compara- ble by quintile.


HEALTH-SERVICES USE AND EXPENDITURE The Government attempts to make health-care services available to all residents of the Bahamas by subsidizing costs for certain population groups, and deferring or waiv- ing costs in cases of demonstrated lack of ability to pay.
Because of this policy, infants, children under 19 years (students only), civil servants, pregnant women, the phys- ically disabled, the elderly (pensioners), and holders of the social-services medical card are exempt from facility fees, including medicines.

Over the past five years, health services accounted for about 15% of the national budget.
In fiscal year (FY) 2001–2002, about 69% of the health budget was appor- tioned to the delivery of health care, with institutions re- ceiving the majority of the share.

Given the Government’s mandate to ensure the availability of accessible and afford- able health care for all persons living in The Bahamas, the BLCS sought to determine whether inequities existed in the level of facility use.
Outpatient Visits In the four-week period immediately preceding the Sur- vey, approximately 1 in 10 persons (12.9%) visited a health practitioner for outpatient care.

More females (15.3%) than males (10.4%) made visits.

This finding is not surprising, as pregnant females are more likely to re- port illness and visit health facilities.

The very young (18.7%) and the elderly (24.6%) represented the highest proportion of visits (Table 4-14).
The percentage of persons seeking outpatient care rose with consumption levels, from 8% in the lowest quintile to about 20% in the highest (Table 4-14).
TABLE 4-14 Outpatients (during Past Four Weeks) and Inpatients (during Past 12 Months) Population characteristic Outpatient visits Total Average length of stay Inpatient admissions Gender Male Female Age group (years) 0–4 5–14 15–19 20–34 35–54 55–64 65 Region 1 2 3 4 Quintile Total N 3,152 3,262 625 1,394 503 1,435 1,623 389 446 3,413 1,725 621 605 1,560 1,325 1,247 1,173 1,024 6,414 83340_061-086 3/31/05 9:20 PM Page 77 HEALTH STATUS: SOCIOECONOMIC ANALYSIS 77 | TABLE 4-15 Outpatient Visits to Health Facilities in Past Four Weeks, by Facility and Sector Public Private Characteristic Total Hospital Clinic Total Hospital Clinic Professional Foreign medical N Gender Males Females Age group 0–4 5–14 15–19 20–34 35–54 55–64 65 Region 1 2 3 4 Quintile Total 30.3
Table 4-15 shows that as consumption quintiles in- creased, visits to public health facilities decreased while those to private practitioners increased.
About 62% was made to public-health facilities, 36.2% to private practi- tioners, and 2.3% to health facilities abroad.

On most islands outside of New Providence and Grand Bahama (Region 1), health care is largely limited to Government clinics.

The data shows greater usage on Family Islands (Regions 2, 3, and 4), where 70–87% of medical visits were made to public-health facilities, especially clinics.
Residents in Region 1 used public-health facilities the least and made the highest proportion of visits to private practitioners (47.9%).

This finding is predictable, given that most private-health facilities are found on New Prov- idence and Grand Bahama.

Despite comparatively lim- ited availability of private-health facilities on the Family Islands, about 10–27% of those residents chose private facilities for outpatient care, either locally or on other is- lands.
The proportion of outpatient visits to foreign med- ical facilities was modest in most areas.

Medicine As Table 4-16A illustrates, respondents who were outpa- tients tended to buy their medicine from both public and private facilities,9 although they spent more at the latter over the reference period (past four weeks).
When expen- diture at public- and private-health facilities was com- bined, results showed that, on average, about $4 was spent on medicine, with females spending more than males ($4.61 versus $3.91).

9 Expenditure on medicine is at an individual level, inclusive of those who did not pay, including Government-subsidized groups.
83340_061-086 3/31/05 9:20 PM Page 78 78 | BAHAMAS LIVING CONDITIONS SURVEY 2001 TABLE 4-16A Average Expenditure on Outpatient and Inpatient Care Outpatient ($) Population characteristic Public Private Foreign Public Medicine private Both Inpatient (all sectors) (B$) Gender Male Female Age group (years) 0–4 5–14 15–19 20–34 35–54 55–64 65 or older Region 1 2 3 4 Quintile Gini coefficient Total N 3,061 3,175 611 1,350 489 1,403 1,573 380 431 3,306 1,721 616 594 1,553 1,316 1,220 1,144 1,004 6,236 6,236 In terms of age group, adults aged 55–64 years incurred the highest average cost for medicine ($13.78), most of which was spent at private facilities.
Persons under 35 years had the lowest cost (less than $3.00).

Low expenditure amongst infants and children reflect, in part, the Government’s policy to subsidize their health-care costs in the public sector.

Average spending increased by quintile when expendi- tures at public and private facilities were combined.

On average, individuals in the highest quintile paid 13 times more for medicines to treat various health conditions ($11.39) than those in the lowest quintile ($0.86).
This may be related to the tendency of better-off persons to buy medicines at private, rather than public, facilities.

Medicinal expenditure ranged from about $3.00 to $6.00 in the island regions, with residents of Region 2 (Abaco, Andros and Eleuthera) paying the most for medicines ($5.52), as compared to persons in the remaining Family Islands of Regions 3 and 4, who spent about $3.00.
Expenditure As Table 4-16A shows, the average expenditure for out- patient care (during the four-week period preceding the survey) at public, private, and foreign facilities was $1.43, $9.06, and $0.57, respectively.

Expenses were averaged for all costs associated with outpatient visits—excluding medicines, transportation, and insurance-reimbursed costs.

Per-capita spending on overall outpatient care was 83340_061-086 3/31/05 9:20 PM Page 79 $11.07, averaging $12.78 for females and $9.26 for males.
On average, males spent more on outpatient care at public health facilities and overseas, whilst females spent more at local private facilities.

The average health-care cost at public facilities was $2.14 for males and $0.77 for fe- males.

At private facilities, average expenditure was $6.30 for males and $11.67 for females.

Amongst those who sought outpatient care in the pub- lic sector, expenditures decreased with age amongst adults in the 35 years and older age groups.
Average expenses de- creased from $3.58 (for adults aged 35–54 years) to $1.33 (those 65 years or older).

For children and young adults, the average cost of public-health care was less than $1.00.

For private costs, average expenses increased from $2.92 for children aged 5–14 years to $11.19 for adults aged HEALTH STATUS: SOCIOECONOMIC ANALYSIS 79 | 35–54 years.

Overall, the highest average, private-care cost was found amongst the elderly ($25.84), whilst the lowest was amongst children 5–14 years.
Amongst residents who traveled abroad for outpatient care, the elderly incurred the highest average cost ($4.43).

Across all sectors, health expenditure increased as quintiles rose.

Results using the Gini coefficient to mea- sure inequality showed statistical differences by con- sumption quintile (the measure was greater than 0.95 in each sector).

Mean expenditure on public-health care, by region, was about $2 or less.
Residents of Region 1 (New Provi- dence and Grand Bahama), where most private health- care facilities are found, had the highest private health-care expenditure ($9.54).
Persons living in Region 4 (Other Family Islands), who had to travel longer distances for TABLE 4-16B Average Annual Health Expenditure and Percentage Distribution, by Expenditure Type Population characteristic Average annual expenditure (B$) Public Private Foreign Medicine Total Inpatient (all sectors) Distribution (%) Outpatient Gender Male Female Age Group (years) 0–4 5–14 15–19 20–34 35–54 55–64 65 or older Region 1 2 3 4 Quintile Total N 3,156 3,269 626 1,396 503 1,436 1,625 391 448 3,367 1,745 620 599 1,560 1,325 1,248 1,177 1,021 6,425 83340_061-086 3/31/05 9:20 PM Page 80 80 | BAHAMAS LIVING CONDITIONS SURVEY 2001 hospital services, had the highest average expenditure for outpatient care abroad ($7.44).
Table 4-16B shows that the share of Total Health Ex- penditure (THE) increased between the lowest and middle consumption quintiles (78.8% and 90.4%, respectively) and fluctuated in the highest ones.

Share of public-sector expenditure decreased as consumption levels increased (from 11% in the lowest consumption quintile to about 5% in the upper quintiles).

This finding corresponds with the earlier observation that visits to the public-health sec- tor decrease with increased levels of well-being.
Conversely, the share of private-sector (and foreign facility) expenditure increased as consumption levels rose (from 7.9% in the lowest quintile to 34.2% in the highest); this represented a fourfold increase, indicating that, with higher levels of af- fluence, a greater portion of THE is spent on private care.

The expenditure share on medicines was highest amongst persons in the lowest consumption quintile and decreased between the middle and highest quintiles.
Inpatient Admissions and Expenditure During the 12 months preceding the BLCS, 5.5% of all respondents were admitted to a health facility for inpatient care: 4% at public facilities and 1.5% at local private or foreign ones.

In all facilities combined, female admissions were nearly twice as high as that of males (7.1% compared to 3.8%).

Adults 65 years and older (11.5%), followed by those 20–34 years (7.7%), were more likely than other groups to be admitted for medical care (Table 4-15).
The difference between consumption quintiles was only 3% (4–7%) and only 1% (5–6%) across the island regions.

Average Length of Stay Whilst some Government-owned clinics have accommoda- tions for overnight medical stay, most persons requiring ex- tended medical care are retained in a hospital.

As shown in Table 4-14, the average length of stay in health-care institu- tions over the reference period (last 12 months) was 7 nights.
Even though fewer males than females were admit- ted to health-care facilities, they were retained longer (9 ver- sus 7 nights).

The reasons may be that males are more likely to suffer from externally caused, acute illnesses and be diag- nosed at a more advanced stage of illness.

The elderly and children 5–14 years had the longest average periods of stay (16 nights and 13 nights, respectively), whilst children un- der 5 years were retained for the shortest period of time (4 nights).
Generally, as quintiles increased, the average number of nights spent in a health facility decreased.

Whilst respon- dents in the lower two quintiles spent an average of about 8 nights, this decreased to about 6 nights in the higher quintiles.
Whilst it is possible that persons in a lower so- cioeconomic level may have more severe illness, resulting from deprivation of certain services, it is also possible that these results may reflect who is paying the bills (i.e., Gov- ernment, persons paying out of pocket, or a third party).

On average, respondents from the more remote islands of Region 4 (Other Family Islands) had the longest stay (11 nights), followed by those from Region 2 (Abaco, Andros, and Eleuthera) (9 nights).
In Regions 1 and 3, respondents were retained for an average of about 7 nights.

This finding may reflect the need for more diagnostic ser- vices for persons referred to hospitals in New Providence or Grand Bahama from the other islands, or simply that only the more serious cases are referred.
Expenditure Table 4-16A, which summarizes the average expenditure amongst those admitted to a health facility over the 12-month period prior to the Survey, shows expenditure, which covered all payments associated with inpatient vis- its (including medicines), but excluded transportation, room and board, and insurance-reimbursed costs.

Combined per-capita expenditure for inpatient care (public, private, and foreign) was $28.41.
Average expen- diture on inpatient health care was lower amongst males than females ($23.00 versus $33.56).

By age group, the el- derly incurred the highest average cost ($49.15), whilst children 5–14 years had the lowest ($12.52).

Average cost increased with age between the 5–14 and 35–54 age groups.
Expenses for adults 55–64 were lower ($41.27) but rose again for those 65 and older.10 Average expenditure on health care over the past 12 months increased steadily by quintile, from $5.47 at the lowest quintile to $72.04 at the highest—roughly a thirteen-fold increase.

This finding most likely reflects the preference for private services as socioeconomic status (SES) increases.
However, as shown in Table 4-16B, the share of THE on inpatient care (including medicine) dif- 10 These results are interesting, considering that the Government heav- ily subsidizes care to the elderly.

83340_061-086 3/31/05 9:20 PM Page 81 fered by quintile.

It was highest in the lowest quintile (21.2%), which was about twice that of the middle and highest quintiles.
This latter finding clearly indicates the SES/health cycle: How poor health can negatively affect SES and how poverty can lead to poor health.

Amongst island regions, average expenditure was high- est on Family Islands, where average cost ranged between $40 and $49 for inpatient care.

It was lowest for Region 1 residents, who spent an average of $25.89 (Table 4-16A).
Whilst expenditure rose by quintile, the share of THE on outpatient care was lowest amongst children and the el- derly, both subsidized by Government.

The poor allocated the greatest proportion of their THE share to inpatient care.

Medicines comprised the greatest share of THE.

Overall, the average annual expenditure on health care per person was $309.20 ($252.40 amongst males and $363.20 amongst females).

Generally, expenses increased with age (with the exception of adults 55 to 64 years).
By consumption quintile, persons in the lowest quintile spent an average of $25.50 annually, compared to $747.80 for those in the highest quintile.

Regional comparisons showed that Region 3 (Exuma and Long Island) had the lowest annual cost ($164.20), whilst Region 4 (Other Family Islands) had the highest ($249.60) (Table 4-16B).

HEALTH INSURANCE COVERAGE The principal avenues by which health care is financed are: • Government.

Approximately 15% of the nation’s budget is allocated to health (MOF 2004).
• Private health insurance.

About $102 million was spent in 2001.

• User fees at both public and private facilities.

Total out-of-pocket expenditure was $309 per capita over the last 12 months.

• Social health insurance.

Through the National Insurance Board (industrial injury component).

• External sources.

Such sources are limited because of the country’s economic profile (MOH 2004, p. 77).
Survey results revealed that 51.4% of respondents re- ported having some form of health insurance, leaving oth- ers to cover health-care expenses out of pocket or with Gov- ernment assistance.
In terms of gender, coverage levels did not differ significantly between males (50.7%) and females HEALTH STATUS: SOCIOECONOMIC ANALYSIS 81 | TABLE 4-17 Population characteristic Gender Male Female Age group (years) 0–4 5–14 15–19 20–34 35–54 55–64 65 Region 1 2 3 4 Quintile Total Proportion of Respondents with Medical and Dental Coverage Medical (%) Dental (%) N (52.2%).
The age groups with the least coverage were those most likely to seek care: the elderly (34.7%) and children under 5 years (42.8%).

Both groups are more vulnerable to illness than others, and additionally, the cost of insurance for the elderly is prohibitive.

Coverage for employable per- sons (ages 20–64) ranged from 50%–59%.

Individuals from better-off households (higher con- sumption quintiles) had higher levels of coverage.
For ex- ample, only 20.1% of those in the poorest quintile had coverage, compared to 76% in the wealthiest quintile.

In addition to differences in level of insurance coverage, scope of coverage differed.

Higher-income persons were more likely to have comprehensive health-insurance packages, whilst lower-income persons, who purchased lower-priced premiums, faced higher deductibles (MOH 2003).
83340_061-086 3/31/05 9:20 PM Page 82 82 | BAHAMAS LIVING CONDITIONS SURVEY 2001 FIGURE 4-6 Medical Insurance Payers TABLE 4-18 Average Medical Insurance Payments 50 40 t n e c r e P 30 20 10 0 Self Family Employer 1 39.2 44.6 15.2 2 44.6 42.1 13.5 4 37.5 40.8 23.4 3 38.0 46.0 19.7 Quintile 5 39.8 33.6 31.6 Results also showed that family members were the pri- mary sources of obtaining both medical (40.8%) and den- tal (44.2%) insurance coverage.
However, as consumption quintiles increased, the level of coverage by employers in- creased, whilst coverage by family members decreased (Figure 4-6).

Residents of the most developed islands of New Provi- dence and Grand Bahama (Region 1) had the highest cov- erage level (54%), whilst residents of Exuma and Long Island (Region 3) had the lowest (30.8%).
Further analysis revealed that a much greater propor- tion of respondents had medical (50%), as opposed to dental (5%), insurance, possibly because of the lower pri- ority given to oral health care and the more affordable, out-of-pocket cost of dental care.

Males and females had comparable levels of medical ( 50%) and dental (5%) cov- erage.

On a monthly basis, respondents paid an average of nearly three times as much for medical insurance ($61.1) as for dental coverage ($21.20).
Table 4-18 provides de- tails on medical insurance payments (dental-insurance payments are excluded because of small sample sizes in most subgroups).

Predictably, payments increased with levels of consumption.
Residents of Region 2 (Abaco, Andros, and Eleuthera) had the highest average cost for Population characteristic Medical insurance ($) N Gender Male Female Age group 0–4 5–14 15–19 20–34 35–54 55–64 65 and older Region 1 2 3 4 Quintile Total medical insurance ($74), whilst the Family Islands of Region 3 (Exuma and Long Island) had the lowest ($57).
Total outpatient expenditure on visits to health facili- ties (over the past four weeks) was estimated at about $2 million amongst persons with private insurance and about $1 million amongst those without coverage.

Total inpa- tient expenditure was higher, at about $6 million amongst those insured and $3 million for the uninsured (MOH 2003).
This finding raises the question: Do those with - insurance make more use of the service or are pricing and billing differences based on whether an individual has coverage?

CONCLUSIONS AND POLICY RECOMMENDATIONS The Survey findings described above reveal the need for comprehensive, intersectoral interventions to improve the 83340_061-086 3/31/05 9:20 PM Page 83 overall health status of Bahamians of all ages.

Various ini- tiatives are recommended for consideration at the policy or program level.
Some of the more critical ones are sum- marized below.

Self-reported Health Status Accidents and Workplace Injuries The proportion of injuries due to violence and preventable accidents is of increasing concern to health-care practi- tioners and the general public.

(About 20% of reported ac- cidents and workplace injuries resulted from gunshots or stabbing and motor vehicle accidents.)
As reflected in both national morbidity and mortality statistics, such injuries affect productivity levels and result in temporary or per- manent disability, or even death.

Given that the leading causes of mortality are external, it is important to under- stand and prevent the occurrence of such events through evidence-based interventions.

In the BLCS, most injuries reported occurred at the workplace or school.
This highlights the need to strengthen and implement national occupational health- safety initiatives that are intersectoral—including labour, education, and other social agencies.

Appropriate linkages must be forged to ensure that safety measures are in place in the workplace and school environments.
Chronic Non-Communicable Disease With regard to chronic non-communicable diseases—the chief contributors to morbidity and mortality in the pop- ulation—The Bahamas has characteristics similar to those of industrialized countries.

Its profile of hypertension and diabetes, particularly the greater prevalence of the latter in the Family Islands, is of concern, and efforts to control these diseases must be strengthened.
A related factor may be food availability,11 which, ac- cording to FAO data, has increased in recent years.

For ex- ample, the WHO-recommended, daily-caloric availability per capita is 2,250 for a population the size of the Ba- hamas.

In 2001, 2,777 total calories were available in the population, compared with 2,500 in 1999 and 2,498 in 1992.
Another contributing factor is the shift in quality of dietary intake toward increasingly higher percentages of 11 In The Bahamas, food availability is a proxy for consumption, as no portion of imported foods is exported, but is consumed by the popula- tion and its visitors.

HEALTH STATUS: SOCIOECONOMIC ANALYSIS 83 | refined carbohydrates and high-fat foods.
Combined with a sedentary lifestyle, this factor exacerbates the problem of obesity—a risk factor for diabetes, hypertension, and other chronic diseases.

These realities require a comprehensive response in- volving all levels of Bahamian society—national, commu- nity, and individual—so that people will be empowered to take greater responsibility for their health.

To this end, the following recommendations are proposed: • Adoption of the National Food and Nutrition Pol- icy.
This Policy defines the direction of such initia- tives as national dietary guidelines, food standards, regulatory measures, education, promotion of best nutrition practices, and institutional strengthening for the prevention of obesity and chronic non-com- municable diseases.

• Increased health education and promotion and com- munity awareness-raising of associated risk factors.

• Targeted research on the relationship between non- communicable diseases and socioeconomic status and region of residence.
Child Health Immunization The current instrument used to record vaccinations is inadequate, and should be revised to address such limita- tions as the inclusion of new vaccines.

Moreover, an im- munization database should be established to capture vac- cination information on each child.

This would allow for detection of defaulters and early follow-up, and would improve coverage rates.
Respiratory Illness In view of the high incidence of upper-respiratory ill- nesses, compared to that of asthma and diarrhoea (Table 4-4), it is recommended that further research be con- ducted to determine contributing factors so that preven- tive measures can be taken.
Nutrition Children: Ages 2–10 Years Although prevalence of undernutrition in this age group is low by World Health Classification standards (less than 20%), the low HAZ-score in this Survey for children 2–4 years of age (15%) is cause for concern.

This is especially true for children 3 years and younger, as this measurement 83340_061-086 3/31/05 9:20 PM Page 84 84 | BAHAMAS LIVING CONDITIONS SURVEY 2001 is a most sensitive predictor of mortality in this age group.
Further investigation should be conducted to determine the extent to which this problem exists so that appropriate intervention strategies may be implemented, if and where necessary, to prevent exacerbating the problem.

Although wasting is not a significant public-health problem, targeted health- and social-sector programs are needed for children 7–10 years of age (the group with the highest prevalence rate).
The health sector should monitor this group closely to ensure intervention response and con- trol of the condition.

Survey results indicate that, for this age group, be- ing overweight is a nutritional problem of sufficient public-health magnitude to warrant immediate action to abate a future crisis.

Response to the current situation must be multifaceted and multisectoral.

Prevention should be the primary focus of targeted interventions.
Adolescents: Ages 11–20 Years As with younger children, prevention, containment, and reduction are a top priority.

Survey results showed that children living in households with overweight adults were four times more likely to be overweight, or at risk of be- coming overweight than those not living with overweight adults.

This shows that obesity is a familial problem re- lated to household consumption patterns, as well as ge- netic traits.
Thus, it is recommended that: • Prevention programs be family-oriented.

• Targeted programs meet the needs and expectations of adolescents.

In addition, underweight adolescents (18%) should be followed closely, and contributing environmental factors should be identified as an early warning of household food insecurity (espe- cially in the urban areas, taking note of the implica- tion of nationality).
Adults: Ages 21–60 Years Every avenue must be explored to empower adults to take better care of their health.

This includes making healthy food choices, increasing physical exercise and limiting lifestyle practices that negatively affect health and well-being.

Adults 21–60 years of age comprise the majority of human capital in the Bahamian workforce.

This group is critical to the country’s economic and social development, underscoring the need for it to main- tain good health.
The prevention approach to the over- weight and obesity issue is needed amongst younger adults to delay the onset of chronic non-communicable diseases.

It is recommended that: • Partnerships and linkages be forged with all segments of society to enable a synergistic effect and minimize the burden in terms of human and financial capital expenditure, as proposed in the National Food and Nutrition Policy.
• Gender-specific programs and components on chronic non-communicable disease be strengthened and integrated into all other health programs.

Na- tionwide health education and promotion strategies must continue to be developed to empower individ- uals to take greater responsibility for their health care.
Breastfeeding Populations with a high prevalence of breastfeeding are characterized by reduced incidence of childhood disease, particularly diarrhoea and upper-respiratory infections; subsequently, such a reduction lowers morbidity and mor- tality rates of children under 2 years.

Since inception of the National Breastfeeding Campaign more than a decade ago, incidences of childhood diseases, including gastroen- teritis, have been significantly reduced and, by extension, infant mortality rates have declined.
The Campaign has also succeeded in increasing breastfeeding prevalence amongst lactating women, particularly in Regions 1 and 2, where Campaign efforts were more concentrated.

The same effect on breastfeeding was not observed in Regions 3 and 4.

These factors indicate the need to target health- promotion efforts evenly across all regions.
Additionally, there is a need for the Government to approve the Na- tional Breastfeeding Policy, (currently in draft form), which will mobilize all necessary resources to create a baby-friendly environment.

Female Reproductive Health Based on the Survey results, it is recommended that pro- motion of health education be increased throughout The Bahamas to raise awareness of the importance of family planning.
Health Services Use, Expenditure, and Insurance Survey results showed that, as wealth increased, a shift oc- curred in the use of health-care facilities.

With increasing 83340_061-086-R1 4/7/05 10:28 PM Page 85 consumption levels, the proportion of visits to public- health facilities decreased, whilst those to private facilities increased, indicating that private providers were the pre- ferred choice.
Clearly, public-health care is affordable; however, users tend to choose other alternatives as their socioeconomic capacity—and thus their health-care options—increases.

Given the rising costs of private coverage and many persons not being able to afford private coverage, the Blue Ribbon Commission was formed to investigate the feasi- bility of forming a national health insurance system to ensure equity of access to all.
The Commission recom- mended that a compulsory social health insurance be in- troduced as the principal method of financing health care for The Bahamas (MOH 2004, p. ix).

REFERENCES HEALTH STATUS: SOCIOECONOMIC ANALYSIS 85 | MOH.

2003.

“Blue Ribbon Commission on National Insur- ance.” 2003 Private Health Insurance Company Sur- vey.

Nassau: Commonwealth of The Bahamas, Min- istry of Health.

Unpublished data.

_______.

2004.

Report of the Blue Ribbon Commission.


Nassau: Commonwealth of The Bahamas, Ministry of Health.

FOR FURTHER READING MOH.

2000.

Commonwealth of The Bahamas National Health Services Strategic Plan, 2000–2004.

Nassau: Com- monwealth of The Bahamas, Ministry of Health.

_______.

2002.

Annual Report of the Chief Medical Officer.

Nas- sau: Commonwealth of The Bahamas, Ministry of Health.

MOF.

2004.

Draft Estimates of Revenue and Expenditure (Recur- rent and Capital).
Nassau: Commonwealth of The Ba- hamas, Ministry of Finance.

PAHO.

2002.

Health in the Americas, 2002 edition.

2 vols.

Washington, D.C.: Pan American Health Organiza- tion.

Also available in Spanish.