1. BACKGROUND TO THE SURVEY

Barbados is the most easterly island of the West Indies, situated 13º 4' north of the equator on latitude 59º 37' west. The island has an area of approximately 430 km², and is mostly of coral formation and flat, except for the central part, which rises to a height of 336 m. Average annual rainfall ranges from 760 mm in the coastal areas to 2 000 mm in the central parts of the island. Located within the hurricane belt, Barbados is cooled by the trade winds from the North Atlantic, and experiences little variation in temperature (ranging from 22º to 32º C).

An independent nation, Barbados is a member of the Commonwealth and of the Caribbean Community. It has a two-party democratic parliamentary system of government with a Senate of 21 members and a House of Assembly of 28. There is no local government system. The island is divided into 11 parishes, with Bridgetown being the capital and the only seaport. The postal, transport and telecommunication systems are excellent.

Demography and health: trends and indicators

The island has a high population density of 620 people per square kilometre, most of whom live in the southern, southeastern and southwestern sections. Two censuses (1990 and 2000) and other government reports provide the following information on recent demographic and health trends and indicators:

• Between 1990 and 2000, the population increased from 260 491 to 268 792, while the growth rate decreased from 0.5 to 0.2 percent.

• In 2000, women (51.9 percent of the total population) outnumbered men (48.1 percent).

• There were 83 026 households in 2000, a large proportion of which (44.5 percent) were headed by women.

• Barbadian households have the following amenities:

  - 96.5 percent have electricity and piped water;

  - liquid propane gas is the cooking fuel used by most households (78.5 percent);

  - 91 percent own household appliances such as refrigerators, stoves, televisions, and radios;

  - 82.5 percent are connected to the telephone line.

• The proportion of the population living in rural areas has fallen steadily, from 59.8 percent in 1980, to 55.3 percent in 1990, and 50.2 percent in 2000.

• The proportion engaged in agriculture has also fallen, from 10 percent in 1980 to 4.1 percent in 2000.

• In both 1990 and 2000, 22 percent of the population was under 15 years of age.

• In 1990, 11.6 percent, and in 2000, 12 percent of the population were aged 65 years or over.

• The birth rate stands at a little over 14 percent, and the mortality rate at slightly over 9 percent.

• Life expectancy at birth is 72 years for men and 77 years for women.

• Between 1997 and 2000, the infant mortality rate increased from 10.6 to 13.4 deaths per thousand live births.

• Among individuals aged 15 to 24 years, homicide, motor vehicle accidents, heart disease and HIV/AIDS are now the leading causes of death.

• Among adults, heart disease, cerebrovascular disease, diabetes, cancer, hypertension and HIV/AIDS are the leading causes of death.

• Health clinic data indicate that the conditions most commonly treated among adults aged 20 to 65 years are chronic non-communicable diseases (CNCDs), i.e. hypertension, diabetes, coronary heart disease and cancers.

• Morbidity rates from CNCDs are highest in the group aged 45 to 65 years.

The economy

In 2000, the Barbadian economy experienced its eighth consecutive year of growth. Real gross domestic product (GDP) grew by an estimated 3.6 percent in 2000, compared with 0.8 percent in 1993, which was the first year of growth following implementation of the Stabilization and Adjustment Programme in 1991-1992. This programme comprised measures to reduce expenditure, enhance revenue, rebuild reserves and resuscitate the productive sectors. Construction, tourism and sugar were the major sectors contributing to growth in the economy. In 2000, the unemployment rate stood at a record low of 9.3 percent, having fallen from 24.3 percent in 1993. The inflation rate was 2.5 percent: increases in oil prices led to increases in the costs of fuel, light, transportation, housing and food prices.

Despite improvements in the economy and reductions in unemployment, poverty continues to exist in Barbados: 9 percent of Barbadians are estimated to live below the United Nations Development Programme (UNDP) poverty line of B$5 503^[1] per household per annum. The Poverty Alleviation Bureau, established in 1998, is the administrative agency responsible for eradicating poverty in Barbados. The bureau also collaborates with and assists government and non-governmental agencies with the implementation of various programmes. It provides assistance to individuals in four categories:

• the low-paid, working poor;

• the unemployed;

• one-parent families;

• mentally and physically challenged persons and noncontributory pensioners.

Education

Barbados has a high literacy rate of approximately 95 percent. It has a well-developed educational system providing primary, secondary and tertiary education. Education is compulsory for all children aged between five and sixteen years, and is provided free at government institutions for all levels - primary, secondary and tertiary, as well as in vocational institutions. Students in selected primary schools are trained in computer skills as part of the Education Sector Enhancement Programme, which was introduced in 1998. There are special schools to cater for the needs of physically and mentally challenged children. A low-cost lunch (BS$0.10) is available to all children in all government and some private primary, composite and senior schools, as well as to selected students in secondary and special schools. The lunch aims to provide one-third of the school-aged child's daily nutrient requirement.

Agriculture and food supply

Barbados relies heavily on imports to meet its food needs. With an economy that is increasingly geared to tourism, local agriculture supplies less and less of the national food supply, as reflected by the decreased proportion of the population engaged in agriculture (from 10 to 4 percent between 1980 and 2000). Food imports have risen steadily over the past 20 years, as follows (all figures are inclusive of food cost, insurance and freight, and are averaged over the three year periods):

• 1981-1983: BS$576/year/person;

• 1991-1993: BS$731/year/person;

• 1999-2001: BS$1 244/year/person.

Table 1.1 provides data from Barbados' Food Balance Sheets (FBS) for the periods 1968-1970, 1978-1980, 1988-1990 and 1998-2000.^[2] As comparison, it also provides data for 1998-2000 from Jamaica, Trinidad and the United Kingdom. It is essential to note that data from FBS cannot be compared with data from food consumption surveys.^[3]

Table 1.1 Trends in food supplies, 1968-2000 (three-year averages)

Data include the total calorie and fat supply available for human consumption, expressed in terms of per capita per day, as well as the proportions of calories contributed by food groups to the total supply. The table indicates the following trends and comparisons:

• Both total energy supply and fat supply have increased steadily over the past 30 years, with the possible exception of a fall in 1998-2000. Barbados' energy supply now falls almost exactly midway between that of the United Kingdom and those of its Caribbean neighbours.

• The percentage of calories from fat has increased substantially over the period, again with a possible fall in the most recent figures. The Barbados figure is substantially higher than those of Jamaica and Trinidad, but still much lower than that of the United Kingdom.

• After 20 years of little variation, the percentage of calories from vegetable products seems to have risen in 1998-2000, but still falls far short of its equivalents in Jamaica and Trinidad.

• There has been little change in the calorie contribution of cereals, but the contribution of starchy roots and tubers has fallen sharply to less than half its 1968-1970 value.

• As in its Caribbean neighbours, the contribution of sugar and other sweeteners to total calorie supply is very high in Barbados, and shows no clear signs of decreasing.

• Pulses contribute little to total calorie supply, and their contribution seems to be falling. Trinidad has a higher contribution from pulses, which is likely to be a reflection of the ethnic mix of its population.

• Calories from vegetable oils have increased sharply to almost double their 1968-1970 figure, while calories from animal fats have fallen. This figure is now similar to those from the comparison countries.

• There seems to be an encouraging rise in the contribution of fruits and vegetables to the total calorie supply.

• Meat consumption is clearly an important feature of the Barbadian diet: in Barbados the contribution of meats, poultry and offal to the energy supply is much higher than it is in either of neighbours, and similar to that in the United Kingdom.

• In comparison with the United Kingdom, the contribution of milk and eggs is low in all three Caribbean countries.

In summary, it seems that Barbados' food supplies have altered substantially over the last 30 years, reflecting changing food consumption patterns. While still retaining features common to Jamaica and Trinidad, some aspects are closer to the food supply of an industrialized nation such as the United Kingdom. From a health and nutrition perspective, there are some worrying trends, however: increased fat calories and the continuing high contribution of sugar are the most important of these. On the positive side, supplies of fruit and vegetables may have improved, and meat consumption may be falling.^[4]

Health care

Comprehensive health care is available from both the public and private sectors. In the public sector, care is administered through the Ministry of Health and is free of charge to the entire population at the point of delivery, with the exception of technologically intensive services (such as MRI), which are offered free only to individuals who qualify under the Medical Aid Scheme. The present system offers preventive, rehabilitative and curative services through:

• the Queen Elizabeth Hospital, a 547-bed facility that offers 24-hour acute, secondary, tertiary and emergency care;

• one geriatric hospital and three district hospitals offering geriatric care;

• a mental health hospital;

• a half-way house for substance abusers;

• two rehabilitation institutions for the physically and mentally challenged;

• an AIDS hostel;

• a development centre for children and adolescents who are physically challenged;

• a nutrition centre.

Primary health care is also offered free to all Barbadians at the country's eight polyclinics and four satellite clinics, whose services include:

• maternal and child health care;

• family life development;

• dental care;

• eye care;

• community-based mental health care;

• nutrition advice and services;

• pharmaceutical services;

• environmental health services;

• programmes for the control and management of both communicable and non-communicable diseases;

• physiotherapy;

• chiropody;

• dermatology.

Public health nurses routinely visit schools to monitor the health of schoolchildren and provide BCG inoculations against tuberculosis. Adolescents from schools are invited to attend adolescent health clinics, which offer advice and guidance on relevant topics.

In addition to health services from the health system's hospitals and clinics, the government has allocated funds to the Alternative Care for the Elderly Programme, which purchases space in private nursing homes for the care of ambulant older people. An Inspection and Advisory Committee is responsible for licensing and monitoring the private nursing homes.

Health care is also available from the private sector, in which more than 100 general practitioners and consultants operate in individual and group practices. Private sector care is offered through one private hospital, homes for long-term care, and centres and individuals offering pharmaceutical, diagnostic, dental, psychiatric, nutrition and physical therapy services.

Nutrition services

The National Nutrition Centre (NNC) is the Ministry of Health department with responsibility for implementing programmes to improve the nutritional status of the population. Nutrition services were decentralized in 1980, and Community Nutrition Officers (CNOs) now operate through polyclinics, where the focus is on counselling on the prevention and management of obesity and CNCDs (diabetes, hypertension and coronary heart disease). CNOs also conduct counselling and education programmes at the health clinics and participate in a variety of community nutrition education programmes, such as those promoting backyard gardening, nutrition and food preparation.

NNC also advises the government on all issues related to food and nutrition, including providing recommendations based on the findings of local and national surveys. It implements, monitors and evaluates community-based nutrition education programmes, and conducts growth monitoring of young children as part of the Nutrition Surveillance Information System. Schoolchildren aged ten to fourteen years are targeted through the annual summer camp, which is conducted at different schools throughout the island. The aim is to educate children about good nutrition and healthy eating practices through theoretical and practical activities. There is also an annual Food, Nutrition and Health Day for adolescents, which aims to focus attention on World Food Day.

The centre offers advice on nutritional policies and hospital-based food services to the dietary departments of the geriatric and district hospitals and the St Andrew's Children Centre. Similar advice is available to other government institutions on request. NNC also provides training in nutrition to medical and paramedical personnel and child care workers.