Special report

Healthy aging and care of the older adult with chronic

disease: a qualitative needs assessment in 14 eastern
and southern Caribbean islands
Nancy VanDevanter,1Madeline Naegle,1 Nasreen Nazia,1 Avion Bamodu,2 and Eileen Sullivan Marx1

Suggested citation VanDevanter N, Naegle M, Nazia N, Bamodu A, Sullivan Marx E. Health aging and care of the older adult with chronic dis-
ease: a qualitative needs assessment in 14 eastern and southern Caribbean islands. Rev Panam Salud Publica. 2023;47:e40.
https://doi.org/10.26633/RPSP.2023.40

ABSTRACT The objectives of this qualitative needs assessment were to assess perceived needs of health and social services
professionals in the Caribbean Region to enhance services supporting healthy aging and care of older adults and
to assess perceived facilitators and barriers to increasing capacity to serve their aging populations. The assess-
ment, informed by the Consolidated Framework for Implementation Science, was conducted in 14 islands in the
eastern and southern Caribbean. The results demonstrated need for education of professionals and the general
population about the prevention and treatment of non-communicable diseases (NCDs), assessment and services
for individuals with dementia, Alzheimer’s disease, depression, and harmful alcohol use, all of which pose signif-
icant challenges for older adults. Education of health and social services professionals, families, and the public
on the risk factors for NCDs and common mental and physical health problems is critical. Barriers to implementa-
tion of educational programs include lack of community awareness and resources within the islands. The needs
assessment findings are foundational to planning educational interventions. These will be developed by local
health providers with the collaboration and support of external resources including those of the Pan American
Health Organization/World Health Organization Collaborating Centre in Gerontological Nursing Education.

Keywords Aging; population dynamics; needs assessment; West Indies; Caribbean Region.

Global aging has undergone dramatic changes since the 2002 and premature death (3). Those diseases in order of prevalence
Madrid International Plan of Action adopted at the Second are heart disease (13%-25%), neoplasms (8%-25), diabetes (4%-
World Assembly on Ageing (1). Its three priority action areas 21%) and cardiovascular disease (1%-13%) (4). The 2010 UN
become more imperative with the rise in the percent of persons resolution making NCDs a global priority urged initiatives to
65+ from 7-9% of the world’s population, expected to reach 16% decrease risks like tobacco use, physical inactivity, the harmful
of the global population by 2050. In the Region of the Americas, use of alcohol and unhealthy diets (4). This needs assessment
adults 65+ make up 11 % of the population and life expectancy addresses these and three of the four action areas for the Decade
is around 81 years; by 2035 in the Caribbean, older persons will of Healthy Aging: combating ageism, integrated (prevention to
be 22% of the population (2). As this number increases, healthy end of life) care and long-term care. In 2019, a UN report on
aging is further compromised by pandemics such as COVID-19 aging from the Caribbean further noted the need reported by
and the prevalence of non-communicable diseases (NCDs). The several island states for more efforts to improve the quality and
Caribbean has the highest rates of death attributable to NCDs in monitoring of public and private health care services and resi-
the Americas, diseases that increase the likelihood of disability dential homes for older persons and to insure access and receipt

1
Rory Myers College of Nursing, New York University, New York, United States
2
Caribbean Public Health Agency (CARPHA), Port of Spain, Trinidad and
of America. * Nancy VanDevanter, [email protected]. Tobago

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Special report VanDevanter et al. • Healthy aging of the older adult with chronic disease

of care to older adults, especially ethnic, religious, and sexual norms, interests, and affiliations), and 5) Process (the process by
minorities (5). The global workforce shortage of those educated which the intervention is implemented). There are 39 constructs
in healthy aging and geriatric care is of great concern. As in associated with specific domains. The domains and constructs
North America, there are few specialized health professionals represent a synthesis of a range of theories about dissemination,
(physicians, nurses, social workers, psychologists) working innovation, and implementation.
with older adults in the Latin American and Caribbean (LAC) CFIR has proved to be a valuable tool to guide study design,
region. Noting the failure of U.S. federal efforts to expand the data collection and analysis. The framework has been used to
ranks of health professionals specializing in elder care, Ful- guide studies of interventions for weight control, tobacco cessa-
mer et al. (6) in a U.S. National Academy of Medicine special tion, alcohol cessation, asthma, nutrition, and dementia. In this
report, emphasized the importance of educating all health study, we utilized CFIR to guide the development of the inter-
care providers in healthy aging and elder care. They stress the view guide and the analysis to explore the perceived facilitators
importance of technology not only to increase the depth and and barriers to implementation of programs to address healthy
accessibility of training but also in health care delivery. The aging and care of the older adult with chronic disease.
2019 UN report describes continuing education programs for
professionals and paraprofessionals in many island states, but Data collection
most agency personnel note that these are infrequent and not
widespread. This needs assessment explores the limitations of Potential participants were identified by public health and
both fiscal and human resources which are well documented in social services leadership in the Region. Individual and small
the literature. group interviews were conducted by two experienced qualita-
The objectives of this needs assessment were to assess per- tive investigators who have previously provided training on
ceived needs of health and social services professionals in the healthy aging and care of older adults with chronic disease in
Caribbean Region to enhance services supporting healthy aging the region. Both individual and small group interviews were
and care of older adults and to assess perceived facilitators and conducted by one or both researchers who took detailed notes
barriers to increasing capacity to serve their aging populations. throughout the interviews. Interviews were conducted by tele-
phone or Zoom depending on local communication systems.
METHODS
Data analysis
Sample
Detailed interview notes were transcribed by a third member
The needs assessment was conducted in islands of the east- of the study team. Transcribed notes were read independently
ern and southern Caribbean Region in the fall and winter of by two investigators to identify emerging themes. A code book
2020-2021. was then developed that included the study aims: To identify
personnel, resources, educational readiness, program imple-
Design mentation barriers and facilitators to providing services in
support of healthy aging and care of older adults. These profes-
A qualitative cross-sectional needs assessment was conducted sionals identified by the health and social services leadership
for islands within the Organization of Eastern Caribbean States of the islands in the region were contacted by investigators by
(OECS), including Antigua and Barbuda, Commonwealth of an email asking them if they would be willing to participate.
Dominica, Grenada, St. Kitts and Nevis, St. Lucia, St. Vincent After three emails those who responded affirmatively (90%)
and the Grenadines and the British Virgin Islands, as well as were contacted by phone or Zoom call depending on their
the southern Caribbean islands of Trinidad and Tobago, and preference, technology access and willingness to participate.
Jamaica. Interview notes were transcribed by one of the investigators
(NN) and kept in a locked file with access limited to only the
Theoretical framework investigators. The study was reviewed by the NYU Office of
Human Research Compliance, a part of the NYU Institutional
The Consolidated Framework for Implementation Research Review Board, and as a qualitative needs assessment with
(CFIR) provided the theoretical framework for this study. For health and social services professionals did not meet the United
more than a decade CFIR has been used in multiple health care States Federal definition of human subject’s research as defined
and social service settings to guide implementation of new prac- by 45 CFR Part 46, 102; thus the study did not undergo formal
tices (7-15). The CFIR is an overarching typology for identifying IRB review.
barriers and facilitators influencing successful implementation
of a program or intervention. The CFIR is comprised of five RESULTS AND DISCUSSION
domains: 1) Intervention Characteristics (Characteristics of
the intervention that may influence success: If interventions Age trajectory for the region populations
are not adapted to the setting they will likely be resisted by
the community), 2) Outer Setting (the economic, political, and All islands reported a significant growth in the older adult
social context within which an organization resides that may population due to some advances in treatment and prevention.
influence success), 3) Inner Setting (internal structural, politi- Current life expectancy is 75.42 years (5). Many respondents
cal, and cultural contexts through which the implementation reported increases in life expectancy over the last several
process will proceed), 4) Characteristics of Individuals (cul- decades due to improvement in diagnosis and treatment of
tural, organizational, professional, and individual mindsets, NCDs. Most expressed the belief that treatment was improving

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VanDevanter et al. • Healthy aging of the older adult with chronic disease Special report

but that there is a need for greater emphasis on prevention • Planning for retirement from early career and employment
through healthy lifestyle interventions. This should begin in • Training for medical caregivers and family members on
the early middle years and include improved accessibility to signs of cognitive disorders
comprehensive support services for individuals and families • Capacity building to disseminate information and conduct
with chronic diseases. training are further compromised by a) lack of access to tech-
nology, and b) lack of education on use of technology for
Health priorities for the older adult population learning purposes. The learning lags and slow shift to greater
technology use on many islands have impaired health edu-
Physical health. All needs assessment participants iden- cation initiatives especially for the elderly and many of the
tified improved prevention and treatment of NCDs as high caregivers in both care homes and clinical settings.
priorities. The most common health issues/diseases identified • Aging education. At the present time, most island govern-
were obesity, diabetes (diabetic retinopathy, amputation due to ing structures lack units dedicated to Aging in the Health
diabetes), hypertension, and heart disease. Cancer and kidney Ministry. The result is few formal advocates for older adults
disease are less common but very costly. In addition, osteopo- and few persons in government agencies to champion their
rosis and auto-immune diseases often require resources that are causes. The interviewees see a great need for expanded anal-
scarce. The development of most of NCDs can be attributed to ysis of these situations, and organizational units that are more
lifestyle and diet. Participants suggested that there is a need for team based, organized and inclusive of all stakeholders.
well-developed educational materials and in-person courses as
well as webinars to educate older adults, health and social ser- Internal resources
vice professionals, caregivers of older adults, and the general
public. Several participants also noted tobacco use as more of Along with the gaps in services for the older adult population,
an issue for older, versus younger adults making it a lifetime participants also identified some local community and regional
habit more difficult to quit. resources that have been implemented for healthy aging and
Mental health. Dementia, Alzheimer’s disease, depression, care of the older adult. In 2007, the Heads of Government of
and harmful alcohol use were all identified by all participants as the Caribbean Community (CARICOM) made a collaborative
challenges for older adults. Cultural beliefs and stigma inhibit declaration calling for action to address NCDs in the region.
reporting and correct assessment of their prevalence. Social iso- CARICOM members and other Caribbean islands issued a call
lation of older adults was identified as a significant contributor to action throughout the region to highlight the critical impor-
to mental health challenges like depression, substance use and tance of addressing NCDs.
isolation across the region. There is a critical need to educate Individual islands have implemented some programs that
health professionals, families and the general public about com- provide a framework or models for further development in the
mon mental health problems in older adults. Many older adults region. Activities of individual island states alone or in collab-
live alone and even when social services are available, it is only oration with other islands are highlighted below as exemplars,
for a limited number of hours in a day. In situations where chil- although this is not a complete listing of all healthy aging
dren have emigrated, older adults must rely on social services programs.
and friends. The island nation of St. Lucia is home to the OECS and a
leader in this region for aging and other health related issues.
Educational and program needs St. Lucia is among the islands with the largest populations.
They work closely with University of the West Indies where
Overall, the need for community resources and central- there is a Conference on Aging, and they lead some of the
ized information for resources is evident. The need for more initiatives in OECS. There are a growing number of policies
educational programs targeting health and mental health pro- and programs on aging populations. Psycho-social wellbeing
fessionals as well as family and community care providers was and mental health are important for this population. Because
strongly articulated by all participants; these should address of St. Lucia’s role in the OECS they have strong connections
prevention, diagnosis, and treatment of NCDs and mental throughout the region and the ability to identify and col-
health issues. Information on the WHO/PAHO Healthy Carib- laborate with other island members extensive experience in
bean initiative was cited by respondents. The need for the gerontology and in the PAHO/WHO ICOPE training on care
recognition of cognitive changes and differentiating among of the older adult.
types of cognitive disorders were consistently cited. All health British Virgin Islands are a group of four main islands with
professionals should screen for mental health diagnoses in a total population of about 30 000. One participant in the needs
standardized ways. Several participants noted that many assessment noted “While there are significant problems finan-
health and social services providers do not receive education cially and health wise for older adults, the elderly are beloved
on healthy aging and care of the older adult in their basic edu- in our society and will be taken care of.”
cational preparation. In addition, pay is very low for caregivers St. Kitts reported the development of some social programs
of older adults with disabilities, dementia, and mobility issues. for older adults. One is an active social enrichment program, and
Many participants also identified a need for public education another is a formal program for home based older adults. These
about normal changes associated with the life course. Par- programs are staffed by community health workers who have
ticipants articulated the need for educational programs for had training from Department of Social Services (DSS). Other
caregivers of older adults to help them cope with the challenges resources for older adults in St. Kitts are “Golden age clubs” and
identified in the Needs Assessment. Proposed educational pro- the Ministry of Health (MOH) provides education on health
grams included: promotion through social media, courses, materials. Nevis has

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Special report VanDevanter et al. • Healthy aging of the older adult with chronic disease

TABLE 1. External resources identified to meet educational needs

Resource Scope
NYU Meyers Hartford Institute for Geriatric Nursing (HIGN) Website and online learning resources on health and aging and common geriatric conditions. An extensive
menu of on-line learning programs at two levels 1) community-based adults and their care givers 2) health
care professionals
NYU Meyers graduate and undergraduate geriatric faculty Faculty conduct research and serve as consultants on long term care, primary care and chronic illness in
experts older adults.
PAHO/WHO Nursing and Midwifery Collaborating Centers The goals of these networks include regional and international consultation by experts in nursing and other
(CCs); Global Network of Nursing and Midwifery CCs Other disciples. Research colloquia and regional meetings are held in the PAHO region and provide opportunities for
WHO Aging CCs information sharing and knowledge dissemination.
John A. Hartford Foundation located in New York City Investment in training and innovative care models to improve the quality-of-care delivery to older adults.

a program with community health workers (CHWs) for older CFIR barriers and facilitators to implementation of
adults trained by University of the West Indies (UWI), although services for the aging population
few providers have advanced training in aging or geriatric care.
These community health workers can see older adults at home Primary barriers identified by participants are lack of inter-
three days per week. The program has 15 field offices around nal resources for education and programs and low community
the island. Caregivers know how to lift persons from the bed, awareness of the aging of the population. Internal facilitators
how to feed, change up-pampers etc. These CHWs have skills to education interventions are commitment to and respect for
to care for older adults “though we do try to encourage family older adults as well as external educational resources including
members to play a major role in the care.” PAHO, Meyers Hartford Institute for Geriatric Nursing, and
The island of Dominica has several support groups for John Hartford Foundation.
families with older adults with dementia. The dementia pro- The CFIR provided a valuable framework for assessing the
gram “Yes we care” is currently active, though the scope of the environment for introducing education programs regarding
program is unclear. There is also an organization “Dementia is healthy aging and the care of older adults with chronic disease.
friends.” A new program has just been started that focuses on It also confirmed the assessment from the literature regarding
getting young people to volunteer but they are struggling with the extent of the needs for such a program (13-15).
funding. The scope of its activities is unclear. There is a Domin- External resources required to address the needs of the grow-
ican Counsel on Aging. ing aging population were also identified and are shown in
Though there are no day programs for people with dementia Table 1.
there are several care homes for these patients. There are few This study demonstrated the deep concern that health and
public care homes but a growing number of private homes. social service providers in the islands have for this vulnera-
Trinidad and Tobago are two islands that have somewhat ble and growing population. As a qualitative study, however,
different political structures; the combined population is about it is subject to some important limitations. Sample size is
1.3 million. Because of size, programs there have been more limited, subjects may be biased, the group agreeing to par-
fully developed. The government has put in place a program ticipate may not represent the viewpoint of the larger group,
that provides assistance for individuals with chronic disease. and the researchers may also be biased. To address these lim-
It serves the older adult population as well as younger persons itations, we included a large group of geographically diverse
with chronic diseases. A number of senior health and social ser- islands. Those recruited had the option of not participating;
vice leaders have successfully advocated to make aging a focus however, 90% did agree. In addition, the findings were very
for the government and health departments. consistent across islands despite the differences in popula-
In Jamaica, an agency provides training for caregivers as does tions. To address investigator bias, two investigators read the
as the Ministry of Health. Though Jamaica is further along in verbatim transcribed notes and achieved 89% consistency in
the development of programs to address issues of healthy aging coding of data.
and care of the older adult, there is a need for more interdisci- In conclusion, this needs assessment identified significant
plinary collaboration and education about the natural process educational needs of health and human services providers in the
of aging. The introduction of the Healthy Caribbean program Caribbean islands regarding healthy aging and care of the older
has not been followed with sufficient education for the pub- adult with chronic diseases, in particular for NCDs, depression,
lic or health professionals. The University of the West Indies dementia and substance use. Many participants highlighted the
Aging Program is mentioned by many islands as a resource for need for an increase in health promotion activities and educa-
healthy aging and care of older adults. tional programs for this population of older adults and for the
The education of individuals, families and care givers could community in general.
be delivered by local nurses if they receive formal geriatric The assessment also identified barriers and facilitators to
education through one of the resources above and/or local implementation of educational programs to enhance care of
education provided through the CARICOM, OECS, UWI aging the older adult for healthy aging and care of those with chronic
program and other local geriatric education programs. Next disease. Participants identified a lack of knowledge about nor-
steps include developing an approach to providing educational mal changes in community dwelling older adults that occur
programs for health and human services providers in collabo- over the life course. The need to understand the treatment and
ration with the Caribbean leaders. clinical management of common conditions/illnesses in older

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VanDevanter et al. • Healthy aging of the older adult with chronic disease Special report

adults in the community and care settings was evident. In June Author contributions. NV and MN conceptualized the study,
2021, WHO convened the first conference focused on island developed the proposal and interview instrument, and con-
health. Outcomes noted that all islands face challenges with ducted the interviews with the participants. NN developed
lack of health infrastructure, logistical difficulties obtaining verbatim transcripts of detailed interview notes. MN and NV
supplies (equipment, medications, etc.), and the ability to train conducted the data analysis and drafted the paper. SM and AB
and retain physicians, nurses, and other health professionals. reviewed and commented on paper drafts of the findings and
These problems are mirrored in the testimony of needs assess- made suggestions for revision.
ment participants.
NYU Meyers College of Nursing will work with NYU Meyers Conflict of interest. None declared.
Hartford Institute for Geriatric Nursing and the other identified
external resources and with each of the participating islands to Disclaimer. Authors hold sole responsibility for the views
support achieving the goals identified by PAHO and WHO for expressed in the manuscript, which may not necessarily reflect
the Decade of Healthy Aging, by developing and implementing the opinion or policy of the Revista Panamericana de Salud
learning tools for health and social services organizations, as Pública / Pan American Journal of Public Health and/or those
well as tools for community education. of the Pan American Health Organization.

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Special report VanDevanter et al. • Healthy aging of the older adult with chronic disease

Envejecimiento saludable y atención de las personas mayores con

enfermedades crónicas: evaluación cualitativa de las necesidades en 14 islas
del Caribe oriental y meridional
Resumen Los objetivos de esta evaluación cualitativa de las necesidades fueron evaluar las necesidades que perciben
los profesionales de la salud y de los servicios sociales en el Caribe a fin de mejorar los servicios de apoyo al
envejecimiento saludable y el cuidado de las personas mayores, así como evaluar los factores percibidos como
facilitadores y como obstáculos para mejorar su capacidad de atender a la población que está envejeciendo.
La evaluación, basada en el marco consolidado para la ciencia de la implementación, se realizó en 14
islas del Caribe oriental y meridional. Los resultados mostraron la necesidad de capacitar a los profesionales y
educar a la población en general acerca de la prevención y el tratamiento de las enfermedades no transmisi-
bles (ENT), la evaluación y los servicios para las personas con demencia, alzhéimer, depresión y problemas
de consumo nocivo de alcohol, todos los cuales plantean importantes desafíos para las personas mayores.
Es imprescindible capacitar a los profesionales de la salud y de los servicios sociales, así como educar a las
familias y al público en general sobre los factores de riesgo de las ENT y los problemas de salud mental y
física más habituales. Entre los obstáculos a la aplicación de los programas educativos se encuentran la falta
de concientización de la comunidad y la falta de recursos en las islas. Los resultados de la evaluación de las
necesidades son fundamentales para planificar las intervenciones educativas, que serán formuladas por los
prestadores de atención de salud locales con la colaboración y el apoyo de recursos externos, incluidos los
del Centro Colaborador de la Organización Panamericana de la Salud/Organización Mundial de la Salud en
Educación en Enfermería Gerontológica.

Palabras clave Envejecimiento; dinámica poblacional; evaluación de necesidades; Indias Occidentales, Región del Caribe.

Envelhecimento saudável e atenção à pessoa idosa com doença crônica:

avaliação qualitativa das necessidades em 14 ilhas do Caribe oriental e
meridional
RESUMO Os objetivos desta avaliação qualitativa das necessidades foram avaliar as necessidades percebidas do
pessoal da saúde e dos serviços de assistência social na região do Caribe, visando a melhorar os serviços
de apoio ao envelhecimento saudável e de atenção às pessoas idosas e determinar os facilitadores e as
barreiras percebidos, com vistas a melhorar a capacidade de prestar assistência às populações idosas.
Esta avaliação foi realizada com base na Consolidated Framework for Implementation Science em 14 ilhas
do Caribe oriental e meridional. Os resultados obtidos demonstraram que é necessário prover conhecimento
aos profissionais e à população geral sobre a prevenção e o tratamento de doenças não transmissíveis, e
a avaliação de pessoas com demência, doença de Alzheimer, depressão e uso prejudicial de álcool e os
respectivos serviços, visto que são enormes desafios enfrentados pelas pessoas idosas. É fundamental que
o pessoal da saúde e dos serviços sociais, os familiares e o público em geral conheçam os fatores de risco
para doenças não transmissíveis e os problemas comuns de saúde mental e física que afligem a população
idosa. A falta de sensibilização da comunidade e a escassez de recursos são barreiras à implementação
de programas educacionais. As conclusões desta avaliação servem de base para o planejamento de inter-
venções educacionais a serem desenvolvidas localmente pelo pessoal da saúde, com a colaboração e o
apoio de entidades internacionais, como o Centro Colaborador da Organização Pan-Americana da Saúde/
Organização Mundial da Saúde para Educação em Enfermagem Gerontológica.

Palavras-chave Envelhecimento; dinâmica populacional; determinação de necessidades de cuidados de saúde; Índias

Ocidentais; Região do Caribe.

6 Rev Panam Salud Publica 47, 2023 | www.paho.org/journal | https://doi.org/10.26633/RPSP.2023.40