Vol.5, No.11B, 35-42 (2013) Health
http://dx.doi.org/10.4236/health.2013.511A2006
Availability and accessibility of diabetes clinics on
Trinidad: An analysis using proximity tools in a GIS
environment
Patricia Boda
Department of Geosciences, Middle Tennessee State University, Murfreesboro, USA;
Received 16 August 2013; revised 25 September 2013; accepted 8 October 2013
Copyright © 2013 Patricia Boda. This is an open access article distributed under the Creative Commons Attribution License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Non-communicable diseases (NCDs), account
for a growing number of deaths worldwide. The
English-speaking Caribbean has the highest per
capita burden of NCDs in the region of the
Americas [1]. This p aper presents an overview of
availability and accessibility based on clinic
hours and physician fulltime equivalents (FTE)
on the island of Trinidad devoted to diabetes
and wound care. The project integrates a Geo-
graphic Information System (GIS) with epidemi-
ologic and bio-statistical data to provide a nec-
essary spatial analysis not otherwise possible. It
examines the island’s ability to effectively de-
liver treatment to re siden ts with diabetes by pro-
viding a geographic perspective to data pub-
lished on the internet by the Trinidad-Tobago
Ministry of Health and the Central Statistical Of-
fice. Results indicate a significant regional vari-
ability in both numbers of physicians and office
hours devoted to diabe tes treatment.
Keyw ords: Access; Health Care; Caribbean;
Trinidad; Diabetes
1. INTRODUCTION
Non-communicable diseases (NCDs) are now the
leading causes of deaths worldwide. In fact, heart dis-
ease, cancer, chronic respiratory diseases and diabetes
account for 63% of all deaths [2]. Although the percep-
tion is that NCDs primarily affect wealthy nations, nearly
80% of NCD deaths occur in low- and middle-income
countries [1,2]. The English-speaking Caribbean has the
highest per capita burden of chronic non-communicable
diseases (CNCDs) in the region of the Americas [1].
Cardiovascular disease, cancer, diabetes, and chronic res-
piratory disease account for 71% of all deaths in Latin
America and the Caribbean in 2008 and that rate is ex-
pected to rise to 81% by 2030 [2]. For the most part,
these countries have passed through the demographic and
epidemiological transition which has resulted in rapidly
aging populations who are more prone to chronic illness.
Research concerning health in the Caribbean is some-
what limited as it is often linked with Latin America
[3-5]. A portion of the work that has been produced on
NCDs in the Caribbean has called for increased aware-
ness and prioritization of combatting the epidemic rise of
NCDs in the region [6,7] and strategies to be incorporated
into public policy [8 ]. A fair vo lume of research has been
based on surveys of self-reported prevalence of non-
communicable or chronic diseases [9-12]. These studies
examined indicators affecting negative health status such
as rural residence, age, gender and level of education,
and have been conducted in various countries. A key
factor affecting health status is the ability for a patient to
visit a health care facility. The more often a patient re-
ceives an examinatio n, the better health is believe d to be.
However, in many Caribbean countries, it has been do-
cumented that patients are often dissatisfied with treat-
ment and are less likely to see a provider to manage their
chronic illness [13]. In these studies, patients reported
excessive wait times and too little time with providers.
The particular interest to this study is work regarding
diabetes in the Caribbean, specifically research con-
ducted on diabetes in Trinidad. Although much research
is focused on epidemiological, diagnostic or treatment
procedures [14-17], there are four primary areas of addi-
tional relevant research: 1) prevalence, 2) socioeconomic
factors, 3) economic impacts, and 4) efficacy of treat-
ments, in particular, treatment of foot wounds. Attempts
to define the prevalence of diabetes on Trinidad and To-
bago have produced interesting results. Early research of
diabetes in Trinidad included a study by Ariyanayagam-
Baksh in 1995, which reported that during a six-month

P. Boda / Health 5 (2013) 35-42
36
period at Port of Spain General Hospital, 1447 patients
with diabetes accounted for 1722 admissions. This ac-
counted for 13.6% of hospital admissions and 23% of
hospital bed occupancy in 1995, demonstrating the large
burden of illness carries in Trinidad and Tobago [18]. In
1997, Guilliford found similar nu mbers of admission due
to diabetes during another six-month period [19]. How-
ever, neither of these studies included data on the number
of new cases nor repeated patients since the Ministry of
Health did not report that information.
More recent attempts to determine prevalence rates of
diabetes on Trinidad produced varied results. Chadee et
al. determined self-reported prevalence of diabetes in
2008-2009 to be 19.5% [12] while Nicholls stated the
rate was closer to 11% in 2010 [20] and WHO reported
the figure to be approximately 14% in 2011 [1]. Regard-
less of the exact number, diabetes is now the second
leading cause of death and the leading cause of blindness
in Trinidad and Tobago [20]. Recently released epide-
miological information on diabetes in Trinidad and To-
bago reveals that 1 in 4 hospital admissions is attributed
to diabetes. There were 1000 new cases diagnosed in
persons aged 20 years or older in 2007. Trinidad and
Tobago had the highest per capita rate of diabetes in the
Western Hemisphere and ranked 5th in the world in that
category [20].
Socioeconomic studies have documented the differ-
ences between the two dominant ethnic groups and be-
tween wealthy and lower income groups in the country.
Ariyanayagam-Baksh reported that hospital admission rates
were 33% higher in the Indian origin population and
47% lower in those of mixed ethnicity than those of Af-
rican ancestry, suggesting ethnic associations exist [18].
These differences are significant since approximately
45% of the population is of Indian ancestry and 45% is
of African ancestry. Guilliford’s study concluded that
prevalence and morbidity from diabetes were signifi-
cantly greater in groups with lower socioeconomic status
and lower educational achievement [19]. This is signifi-
cant because although Trinidad and Tobago is consid-
ered as a high income country by the World Bank, much
of the population is of relatively lower income.
The economic consequence of diabetes has an enor-
mous impact on Trinidad-Tobago as well. Ariyanaya-
gam-Baksh estimated that the annual cost of admissions
with diabetes was conservatively estimated at TT$ 10.66
million in 1995 [18]. More recently, the cost has been
estimated at $49,335,000 (TT$296,010,000) as reported
by Nicholls. However, Nicholls pointed out that the
$49,335,000 likely represented only direct costs. If indi-
rect costs, such as loss of earnings due to illness or pre-
mature death, disability payments, time lost from work,
and so forth, are factored in, the economic debacle as-
sumes even graver proportions with more negative im-
pacts on GDP [20].
Effective treatment options are important aspects to
manage chronic illness and several studies have been
conducted on various elements of diabetes treatment in
Trinidad and Tobago. Popularity and value of traditional
medicines were examined by Mahabir and Guilliford
1997 [21], and more recently by Motilal and Maharaj in
2012, both reported inconclusive results [22]. While
some patients experienced improvement with some treat-
ments, others did not. With few exceptions, little attention
has been paid to the importance of patient self-manage-
ment strategies. Self-management practices of monitor-
ing chronic illnesses are very effective in reducing the
economic burden and reducing hospital loads [23,24].
Because one serious and common complication of dia-
betes is foot wound which often results in amputation,
availability of effective wound treatments and foot clin-
ics are important areas of concern [25,26].
While there have been many important publications on
diabetes in Trinidad, little if any atten tion has been given
to the network of hospitals and providers available to
treat the thousands of persons with diabetes in Trinidad
and Tobago. A geographic or spatial approach is an es-
sential component when attempting to redu ce the number
or treat populations with diabetes. Such an analysis of
access to services has been conspicuously absent from
published research. This study attempts to fill this void
by examining the level of available diabetes care based
on established health districts and amount of clinic hours
devoted to the treatment of diabetes. It presents an over-
view of facility services on the island of Trinidad. Data
were entered into ArcMap. Distances and populations to
provider ratios were calculated. The process revealed that
there were significant deficits in access to ser vices locally,
regionally among the four health districts, and nationally.
2. DATA SOURCES AND METHODS
Community shapefiles with 2000 populations, streets
and community boundaries were provided by The Uni-
versity of the West Indies, St. Augustine. Community
files for Tobago were not included and therefore Tobago
is not represented in this study.
Data on public clinic locations, street name and com-
munity as well as diabetes specific clinic hours were ac-
cessed from the Ministry of Health (MOH) website. The
Ministry also included a schedule of clinic times devoted
to particular conditions such as pre-natal, ante-natal,
chronic disease, diabetes and wound care. However,
clinic schedules only included “morning session” or “af-
ternoon session” without a specific listing of times.
Therefore it was assumed the morning session was 4
hours and the af ternoon was 4 hours in length.
Each clinic schedule was examined and clinic times
devoted specifically to “wound care” and “diabetes

P. Boda / Health 5 (2013) 35-42 37
clinic” were calculated according to the following stan-
dards:
If morning hours stated only wound care or diabetes
clinic the entire 4 hour morning clinic was entered into
the calculations for diabetes clinics;
If morning schedule indicated wound care or diabetes
clinic but also displayed other clinics such as pre-natal,
ante-natal, primary care, or any other clinic, the time
devoted to diabetes and wound care was divided propor-
tionally am ong the number of other clinic ho urs.
Clinic hours devoted to wound and diabetes care were
calculated by clinic, by district and n ationally.
Clinic locations, hours of diabetes treatment and com-
munity data were entered into ArcMAp 10 .0 for analysis
and were manually placed on the community maps ac-
cording to the following method:
The community was located on the community shape-
file map using “select by attribute” for the community
name. Street names for the clinics were located by the
same method, and the clinics were laced on the correct
street, in the correct community by placing the clinic in
the middle of the street.
Hours of diabetes and wound care clinics were added
and divided by 40 hours to produce a full time equivalent
(FTE) for the provider. It was not stated if the clinic ser-
vices were provided by a physician or another trained
professional such as nurse, so the assumption was made
that care was provided by a single physician.
Proximity was determined by applying buffers and
Theissen Polygons.
Six clinics were not entered because no street name
was provided, no community name was provided, or
there was no schedule of hours provided.
3. AVAILABILITY AND ACCESSIBILITY
TO DIABETES CLINICS
In order to effectively reduce the burden of diabetes in
Trinidad, there must be a threefold approach that includes
surveillance, prevention, and intervention. Surveillance
consists of monitoring exposures (risk factors), monitor-
ing outcomes. Prevention includes addressing exposures
(risk factors) and enlisting education. Intervention and
treatment examines levels of availability by assessing
health system capacity and o access to services.
Access can be difficult to define as it is a multi-di-
mensional concept that evaluates the ability of a popula-
tion to use medical services [27]. Penchansky and Tho-
mas identified five dimensions that identify specific bar-
riers: availability, accessibility, accommodation, afforda-
bility, and acceptability. Availability defines numbers of
providers such as physicians, dentists, nurses and other
health care workers in relation to the demand for their
services. It also includes numbers of hospital beds and
services that facilities provide. Accessibility generally
describes geographic accessibility and identifies the geo-
graphic barriers to receiving such services such as dis-
tance, transportation, and travel time to the facility. Ac-
commodation refers to the degree that services meet the
needs of patients and include hours of service, waiting
times, appointments and scheduling. Affordability dis-
cusses the cost of services an d acceptability describes how
the provider interacts with the pa tient on a personal leve l.
Acceptability includes potential barriers such as gender,
ethnicity, language and sexual orientation but also en-
compasses patient satisfaction [28]. Each dimension can
obstruct access by creating barriers that limit utilization of
services. This study utilizes the Penchansky and Thomas
definitions of “availability” and “accessibility”.
3.1. Provider Availability by Health District
Define Availability defines numbers of providers in re-
lation to the demand for their services and includes num-
bers of services that facilities provide. The map of Trini-
dad in Figure 1, displays community populations by
health district. It also reveals that clinics are located
fairly unevenly on the island and clinics with higher
numbers of hours devoted to diabetes care are shown
with larger circles. Several clinics had zero hours sched-
uled.
In this study, assessment of the number of providers
was based on scheduled hours devoted to diabetes care or
wound care. Clinic hours devoted to diabetes and wound
care ranged from zero to twelve hours per week at the
Cumuto Clinic This was the only clinic with twelve
hours scheduled per week. The clinic is located in the
Eastern Health District and is identified in Figure 1 by
the yellow cross.
Calculations of the Full Time Equivalents (FTE) for
the providers reveal significant differences among the
four health districts. Of the 14 clinics in Northwest Dis-
trict only 3 clinics reported to have diabetes/wound care
hours scheduled. The 3 clinics had a total of 13 hours per
week scheduled. Two clinics had 4 hours per week and 1
clinic had 5 hours. The 13 hours per week calculates to
be 0.325 FTE. In the North Central district 8 of the 10
clinics had diabetes care scheduled. Hours ranged from 2
to 8 hours per week and totaled 50 hours per week re-
sulting in an FTE of 1.25. The Eastern district has 16
clinics, 11 of which scheduled hours for diabetes care.
Hours ranged from 3 to 12, totaling 65 hours per week
and an FTE of 1.625. The Southwest district has the
highest number of clinics and the highest FTE. Only on e
of the 25 clinics in this district did not have scheduled
hours for diabetes or wound care. Hours scheduled
ranged from 2 to 8 and totaled 114 hours per week which
is 2.85 FTE. The total clinic-based FTE for diabetes or
wound care on Trinidad therefore is 6.05.
Assessment of the demand for services of clinic and

P. Boda / Health 5 (2013) 35-42
38
Figure 1. Clinic locations and number of hours devoted to diabetes care.
wound care scheduled hours was estimated by assuming
approximately 15.25% of the population in each district
has diabetes. That number represents the midpoint be-
tween the high estimate of 19.5% [12] and the lowest of
11% mentioned earlier [20]. With that assumption, there
are approximately 76,2 50 people in the southwest district
with diabetes, 15,487 in th e eastern district, 30,736 in the
north central, and 62,208 in the northwest. Using the
15.25% figure to estimate demand for diabetes services,
there are a total of 185,681 persons on the island who
have diabetes.
Population to provider ratios were estimated by calcu-
lating the estimated population with diabetes to FTE of
physician clinic hours devoted to diabetes or wound care
by district. Those ratios are 26,754:1 in the Southwest
district, 9530:1 in the Eastern district, 128,991:1 in the
North Central, and 191,409:1 in the Northwest. There are
a total of 184,681 people with diabetes to 6.05 FTE
clinic hours per week results in an island ratio of
30,525:1 (Table 1).
The highest population to diabetes provider ratio is in
the North Central district. This is somewhat misleading
however because there is a la rge, private medical facility,
Eric Williams Medical Complex, located in the district.
This analysis only includes public facilities. The Eastern
district has the lowest ratio due to the large FTE at the
Cumuto Clinic and the lower popu lation.
3.2. Geographic Accessibility
Accessibility describes geographic accessibility and
identifies the geographic barriers to receiving services
such as distance, transportation, and travel time to the
facility. As Figure 1 reveals, clinics are located th rough-
out the island but are unevenly distributed. There is more
clustering of facilities on the eastern or leeward side of
the island where higher populations are, and more
sparsely located in the south eastern quarter of the island.
For the most part, it appears that the clinics are located
near populations. Howev er, when clinics with zero hours
scheduled for diabetes care are eliminated as shown in
Figure 2, there are several communities of the island
lacking a clinic, several of which contain fairly substan-
ial populations. t

P. Boda / Health 5 (2013) 35-42 39
Figure 2. Clinics with diabetes care and 5 mile surrounding area.
Table 1. Estimated population to provider ratios (P:P) of health
districts. Based on estimated persons with diabetes and FTE of
diabetes clinics.
Southwest Eastern North
Central Northwest Trinidad Total
Population
2000 500,000 101,551 201,549 414,452 1,217,552
Diabetes
clinic FTE 2.85 1.625 1.25 0.325 6.05
Diabetes
Population 76,250 15,487 30,736 62,208 1854,681
Diabetes P:P 26,754:1 9,530:1 128,991:1 191,409: 1 30,525:1
Figure 2 also displays clinic locations with a 5 mile
buffer around each clinic. While most of the island is in-
cluded within the 5 mile zone, there are areas in the
northern, central and eastern areas of the island that are
not.
In addition, many of the areas within the 5 mile zone
are a substantial distance from primary roads which are
shown in red (Figure 2). These areas experience exces-
sive drive times. Driving speed in Tr in idad varies greatly.
The central portion of the country is mountainous, creat-
ing both physical barriers to access as well as time.
Changes in elevation and sharp turns on the roadways
often reduce driving speed to 25 - 30 mile per hour or
less. For example, Figure 2 displays a community on the
edge of the 5 mile buffer from the clinic in Indian Walk.
Both the clinic at Indian Walk and the community are
symbolized with the green dots. By add ing the lengths of
each of the street segments, the actual driving distance
on the primary road of Naparama Mayaro was calculated
at more than 10 miles. It is likely that the driving time

P. Boda / Health 5 (2013) 35-42
40
would be in excess of 20 minutes on a primary road. As
indicated in Figure 2, there is a conspicuous lack of pri-
mary roads in central Trinidad.
Another method to determine accessibility is to exam-
ine the numbers of people served by a particular facility
who drive excessive distances for health care. Assuming
populations visit the provider nearest to them, a useful
tool to measure FTE burden is to create “catchment” ar-
eas. That is, areas and the populations most likely to go
to a certain facility for care. Theissen polygons create
catchment areas where each clinic, in this case, is the
center of the polygon. All points within that polygon are
nearest to that clinic, and all other clinics therefore are
further away. Figure 3 shows the Theissen polygon
catchment areas for each clinic.
Ideally the polygons should show a somewhat equal
burden on the diabetes clinic providers. That is, a higher
FTE should, in theory at least, have a larger catchment
area in terms of square miles and in terms of the popula-
tion which it serves in order to level the burden. This is
not what is shown in Figure 3 however. Adding the seg-
ments of the primary road leading to the Rio Claro clin ic,
symbolized by the green dot, from the eastern edge of the
island is more than 25 miles and would require nearly 45
minutes driving time.
Likewise, there are also inconsistencies in the number
of persons served by the clinics. Although the polygons
do not line up with the co mmunity boundaries, estimates
of populations within the catchment polygons were es-
tablished. Adding the population of the Rio Claro poly-
gon and the Cumuto Clinic, it is clear the heavier burd en
is on Rio Claro with a population of 19,393 co mpared to
Cumuto’s population of 10,920.
Cumuto Clinic, which has the largest FTE of 0.3, has a
Figure 3. Diabetes clinics shown with catchment areas.

P. Boda / Health 5 (2013) 35-42 41
significantly smaller area than Rio Claro, for example,
which has an FTE of 0.1. The Rio Claro catchment area
diabetes population is estimated at 4405 with an FTE of
0.1. The population to provider ratio is 44,050:1.
According to the Bureau of Primary Health Care, the
U.S. agency that determined which areas of the country
are Health professional Shortage Areas or Medically
Underserved, the acceptable ratio for populations to pro-
vider is 3500 persons for each provider and the accept-
able driving time is 30 minutes [29].
4. CONCLUSIONS
This study presented a geographic overview of avail-
ability and accessibility to diabetes health services
through public clinics. Trinidad faces a substantial chal-
lenge to reduce and treat the populations who have dia-
betes due to the small island size with limited resources.
The four challenges represented in previous studies 1)
high prevalence, 2) mixed socioeconomic factors, 3)
substantial economic impacts, and 4) delivery of treat-
ment, in particular, treatment of foot wounds, are great
concerns today. The Ministry of Health has made strides
to address the problem of treating existing cases. It is
also attempting to reduce the number of new cases
through educational programs targeted at youth [30].
However this assessment of the current status of avail-
ability of diabetes care on the islands reveals several
concerns that need to be addressed.
The populations of the Southwest and North Central
regions face enormous population to diabetes provider
with ratios of more than 26,000:1 and 128,000:1 respec-
tively. This results in a significant barrier to availability
due to excessive wait times, limited time with the physi-
cian and ultimately little incentive to visit the provider.
Availability of providers is essential to effectively man-
age diabetes.
The Eastern district has the lowest ratio due to the
large FTE at the Cumuto Clinic and the lower population.
It does however comprise the largest geographical area
and distance becomes a barrier to geographic access as a
result. Although there are several clinics in the district
that schedule diabetes clinic hours, populations in the
eastern district face substantial driving times to reach
these clinics.
In addition, many populations in the central regions of
the island face challenges of availability of providers and
also geographic accessibility due to the mountainous
terrain, lack of primary roads, and lack of clinics.
In summary, there is a significant lack of availability
and accessibility to diabetes services in the public clinic
system of Trinidad. Relocation of financial and personnel
resources to areas severely underserved is desperately
needed.
5. LIMITATIONS
Since the island of Tobago was not included in the
shapefiles, this study represented only availability and
accessibility on the island of Trinidad.
This analysis only includes public facilities with data
published on the Ministry of Health website. Data were
last updated in 2012. It is possible that more up-to-date
information exists but has not yet been made available.
The Ministry has been criticized by some people for the
information that is made available is inaccurate and/or
incomplete [20]. However when visiting the facilities in
person to verify web data, I did not find that to be the
case.
6. FUNDING ACKNOWLEDGE MENTS
Special acknowledge is due to the Faculty Research and Creativity
Committee and the Geosciences Department at Middle Tennessee State
University. This project would not have been possible without this
substantial financial support received from the Middle Tennessee State
University committee and the Department.
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