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1.  Prevalence of oral pain and barriers to use of emergency oral care facilities among adult Tanzanians 
BMC Oral Health  2008;8:28.
Background
Oral pain has been the major cause of the attendances in the dental clinics in Tanzania. Some patients postpone seeing the dentist for as long as two to five days. This study determines the prevalence of oral pain and barriers to use of emergency oral care in Tanzania.
Methods
Questionnaire data were collected from 1,759 adult respondents aged 18 years and above. The study area covered six urban and eight rural study clusters, which had been selected using the WHO Pathfinder methodology. Chi-square tests and logistic regression analyses were performed to identify associations.
Results
Forty two percent of the respondents had utilized the oral health care facilities sometimes in their lifetime. About 59% of the respondents revealed that they had suffered from oral pain and/or discomfort within the twelve months that preceded the study, but only 26.5% of these had sought treatment from oral health care facilities. The reasons for not seeking emergency care were: lack of money to pay for treatment (27.9%); self medication (17.6%); respondents thinking that pain would disappear with time (15.7%); and lack of money to pay for transport to the dental clinic (15.0%). Older adults were more likely to report that they had experienced oral pain during the last 12 months than the younger adults (OR = 1.57, CI 1.07–1.57, P < 0.001). Respondents from rural areas were more likely report dental clinics far from home (OR = 5.31, CI = 2.09–13.54, P < 0.001); self medication at home (OR = 3.65, CI = 2.25–5.94, P < 0.001); and being treated by traditional healer (OR = 5.31, CI = 2.25–12.49, P < 0.001) as reasons for not seeking emergency care from the oral health care facilities than their counterparts from urban areas.
Conclusion
Oral pain and discomfort were prevalent among adult Tanzanians. Only a quarter of those who experienced oral pain or discomfort sought emergency oral care from oral health care facilities. Self medication was used as an alternative to using oral care facilities mainly by rural residents. Establishing oral care facilities in rural areas is recommended.
doi:10.1186/1472-6831-8-28
PMCID: PMC2564914  PMID: 18822180
2.  Oral health in a First Nations and a non-Aboriginal population in Manitoba 
International Journal of Circumpolar Health  2012;71:10.3402/ijch.v71i0.17394.
Objectives
To analyze the prevalence of poor oral health and selected determinants in First Nations (FN) and Caucasian samples in Manitoba, Canada.
Study design
Cross-sectional survey, nested in a cohort study.
Methods
FN and Caucasian participants completed a questionnaire on socio-demographic variables, oral health symptoms, and oral health-related behaviours as part of a broader cohort study comparing these ethnic groups for different chronic immune mediated diseases.
Results
Caucasians reported higher levels of employment, education, and urban dwelling than FNs (p<0.001). FNs reported smoking more, and having poorer oral health-related behaviours than Caucasians (p<0.001). After adjustment for age and sex, FN reported having more oral health symptoms than Caucasians (odds ratio (OR): 2.71; 95% confidence interval (CI): 1.73, 4.52), but the association was reduced and not statistically significant after adjustment for other socio-demographic variables (OR=1.34; 95% CI: 0.58, 3.10). Oral health symptoms were associated with current smoking among FN (adjusted OR=2.67, 95% CI: 1.05, 6.78). Oral hygiene behaviours were significantly related to smoking status, rural living and education for both groups.
Conclusions
Oral health-related behaviours and smoking were found to be significant factors explaining poor oral health, which were lower for the FNs cohort than the Caucasian sample. However oral health and related behaviours were less related to their ethnicity than to socio-demographic factors, suggesting that policies to change behaviour will not result in lasting reductions in oral health differences between these groups in Manitoba.
doi:10.3402/ijch.v71i0.17394
PMCID: PMC3417699  PMID: 22456040
oral health; oral health-related behaviours; smoking; First Nations; social determinants
3.  Dental pain, oral impacts and perceived need for dental treatment in Tanzanian school students: a cross-sectional study 
Background
Dental caries, dental pain and reported oral problems influence people's oral quality of life and thus their perceived need for dental care. So far there is scant information as to the psychosocial impacts of dental diseases and the perceived treatment need in child populations of sub-Saharan Africa.
Objectives
Focusing on primary school students in Kilwa, Tanzania, a district deprived of dental services and with low fluoride concentration in drinking water, this study aimed to assess the prevalence of dental pain and oral impacts on daily performances (OIDP), and to describe the distribution of OIDP by socio-demographics, dental caries, dental pain and reported oral problems. The relationship of perceived need estimates with OIDP was also investigated.
Methods
A cross-sectional study was conducted in 2008. A total of 1745 students (mean age 13.8 yr, sd = 1.67) completed an extensive personal interview and under-went clinical examination. The impacts on daily performances were assessed using a Kiswahili version of the Child-OIDP instrument and caries experience was recorded using WHO (1997) criteria.
Results
A total of 36.2% (41.3% urban and 31.4% rural, p < 0.001) reported at least one OIDP. The prevalence of dental caries was 17.4%, dental pain 36.4%, oral problems 54.1% and perceived need for dental treatment 46.8% in urban students. Corresponding estimates in rural students were 20.8%, 24.4%, 43.3% and 43.8%. Adjusted OR for reporting oral impacts if having dental pain ranged from 2.5 (95% CI 1.8–3.6) (problem smiling) to 4.7 (95% CI 3.4–6.5) (problem sleeping),- if having oral problems, from 1.9 (95% CI 1.3–2.6) (problem sleeping) to 3.8 (95% CI 2.7–5.2) (problem eating) and if having dental caries from 1.5 (95% CI 1.1–2.0) (problem eating) to 2.2 (95% CI 1.5–2.9) (problem sleeping). Students who perceived need for dental care were less likely to be females (OR = 0.8, 95% CI 0.6–0.9) and more likely to have impacts on eating (OR = 1.9, 95% CI 1.4–2.7) and tooth cleaning (OR = 1.6, 95% CI 1.6–2.5).
Conclusion
Substantial proportions of students suffered from untreated dental caries, oral impacts on daily performances and perceived need for dental care. Dental pain and reported oral problems varied systematically with OIDP across the eight impacts considered. Eating and tooth cleaning problems discriminated between subjects who perceived need for dental treatment and those who did not.
doi:10.1186/1477-7525-7-73
PMCID: PMC2726126  PMID: 19643004
4.  Multicenter case-control study of the risk factors for ulcerative colitis in China 
AIM: To evaluate potential risk factors in the development of ulcerative colitis (UC) in China.
METHODS: A total of 1308 patients with UC and 1308 age-matched and sex-matched controls were prospectively studied in China. The UC cases were collected from 17 hospitals in China from April 2007 to April 2010. Uniform questionnaires were designed to investigate risk factors including smoking, appendectomy, stress, socio-economic conditions, nonsteroidal anti-inflammatory drugs (NSAIDs), oral contraceptives, diet, breastfeeding, infections and family sanitary conditions. Group comparisons by each factor were done using simple logistic regression analysis. Conditional logistic regression was used for multivariate analysis.
RESULTS: By univariate analysis, the variables predictive of UC included feeling stress, light and heavy alcoholic drinking, spicy food, sugar consumption and infectious diarrhea, while heavy tea intake and tap water consumption were protective against UC. On multivariate analysis, the protective factor for UC was tap water consumption [odds ratios (OR) = 0.424, 95%CI: 0.302-0.594, P < 0.001]; while the potential risk factors for UC were heavy sugar consumption (OR = 1.632, 95%CI: 1.156-2.305, P < 0.001), spicy food (light intake: OR = 3.329, 95%CI: 2.282-4.857, P < 0.001; heavy intake: OR = 3.979, 95%CI: 2.700-5.863, P < 0.001), and often feeling stress (OR = 1.981, 95%CI: 1.447-2.711, P < 0.001). Other factors, such as smoking habit, appendectomy, breastfeeding, a history of measles, rural or urban residence, education, oral contraceptives, and NSAID use have not been found to have a significant association with the development of UC in the present study.
CONCLUSION: Our study showed tap water consumption was a protective factor for UC, while spicy food, heavy sugar consumption and often feeling stress were risk factors for UC in this Chinese population.
doi:10.3748/wjg.v19.i11.1827
PMCID: PMC3607760  PMID: 23555172
Ulcerative colitis; Risk factors; Case-control study
5.  Mouthwash Use in General Population: Results from Adult Dental Health Survey in Grampian, Scotland 
ABSTRACT
Objectives
The purpose of this study was to determine the pattern of mouthwash use and to investigate the associated factors in general population.
Material and Methods
An Adult Dental Health Survey was conducted on 3,022 residents of Grampian region of Scotland (adjusted participation rate 58.2%). Participants received a questionnaire consisting of questions on oral health and behavioural factors.
Results
The majority of participants (38.1%) have never used mouthwash, 17.5% used mouthwash less than once a month, 19.4% used mouthwash once every few days and 25.1% used mouthwash daily.
Prevalence of use decreased with age (P < 0.001). Woman were more likely to use mouthwash than men (P = 0.004). Mouthwash use decreased with decrease in the level of deprivation (P < 0.001). Never-smokers were less likely to use mouthwash (40.3%) compared to smokers (53.1%) or those who stopped smoking (46.5%) (P < 0.001). Mouthwash was used by smaller proportion of people drinking alcohol on daily basis (36.6%), than by abstainers (42.2%) (P = 0.012).
There was a positive relationship between flossing or brushing pattern and mouthwash use (P < 0.001). There was statistically significant relationship between mouthwash use and reasons for the last dental visit (P = 0.009).
When compared to healthy individuals, mouthwash was used by higher proportion of people reporting that they had gum disease (P = 0.001), ulcers (P = 0.001), oral infections or swelling (P = 0.002) or other problems (P = 0.025).
Conclusions
Mouthwash use in general population is associated with socio-demographic, health and behavioural factors.
doi: 10.5037/jomr.2010.1402
PMCID: PMC3886070  PMID: 24421979
mouthwashes; oral hygiene; dental plaque; epidemiology; dental health survey; population groups.
6.  A cohort study comparing cardiovascular risk factors in rural Māori, urban Māori and non-Māori communities in New Zealand 
BMJ Open  2012;2(3):e000799.
Objectives
To understand health disparities in cardiovascular disease (CVD) in the indigenous Māori of New Zealand, diagnosed and undiagnosed CVD risk factors were compared in rural Māori in an area remote from health services with urban Māori and non-Māori in a city well served with health services.
Design
Prospective cohort study.
Setting
Hauora Manawa is a cohort study of diagnosed and previously undiagnosed CVD, diabetes and risk factors, based on random selection from electoral rolls of the rural Wairoa District and Christchurch City, New Zealand.
Participants
Screening clinics were attended by 252 rural Māori, 243 urban Māori and 256 urban non-Māori, aged 20–64 years.
Main outcome measures
The study documented personal and family medical history, blood pressure, anthropometrics, fasting lipids, insulin, glucose, HbA1c and urate to identify risk factors in common and those that differ among the three communities.
Results
Mean age (SD) was 45.7 (11.5) versus 42.6 (11.2) versus 43.6 (11.5) years in rural Māori, urban Māori and non-Māori, respectively. Age-adjusted rates of diagnosed cardiac disease were not significantly different across the cohorts (7.5% vs 5.8% vs 2.8%, p=0.073). However, rural Māori had significantly higher levels of type-2 diabetes (10.7% vs 3.7% vs 2.4%, p<0.001), diagnosed hypertension (25.0% vs 14.9% vs 10.7%, p<0.001), treated dyslipidaemia (15.7% vs 7.1% vs 2.8%, p<0.001), current smoking (42.8% vs 30.5% vs 15.2%, p<0.001) and age-adjusted body mass index (30.7 (7.3) vs 29.1 (6.4) vs 26.1 (4.5) kg/m2, p<0.001). Similarly high rates of previously undocumented elevated blood pressure (22.2% vs 23.5% vs 17.6%, p=0.235) and high cholesterol (42.1% vs 54.3% vs 42.2%, p=0.008) were observed across all cohorts.
Conclusions
Supporting integrated rural healthcare to provide screening and management of CVD risk factors would reduce health disparities in this indigenous population.
Article summary
Article focus
The indigenous Māori of New Zealand have high rates of CVD mortality and morbidity. Current data on the key risk factors underlying this ethnic disparity mostly come from national surveys relying on self-reported diagnoses or have been collected in New Zealand's largest urban centre, Auckland City.
This is the first study to screen CVD and associated risk factors concurrently between rural Māori residing in an area remote from health services (Wairoa District), urban Māori in a city well served with secondary and tertiary health services (Christchurch City) and an urban non-Māori cohort.
Key messages
We found that rural Māori had higher levels of obesity, smoking, hypertension, dyslipidaemia, diabetes mellitus type 2 and hyperuriaemia than either urban Māori or non-Māori. Thus, national health surveys and data collected in large urban centres may significantly underestimate the burden of CVD risk carried by rural Māori.
Public health initiatives to reduce rates of smoking among rural Māori, along with enhanced implementation of CVD screening in primary care and more intensive clinical management of hypertension, dyslipidaemia and hypeuricaemia would help reduce cardiovascular health disparities in the New Zealand indigenous population.
Strengths and limitations of this study
This study was able to determine current levels of both diagnosed and undiagnosed risk factors within these communities by conducting CVD screening clinics in sectors of the community that are often hard to reach. The findings of this study are limited by the relatively small cohort sizes and lack of a rural non-Māori comparator cohort.
doi:10.1136/bmjopen-2011-000799
PMCID: PMC3378934  PMID: 22685219
7.  Oral health behavior patterns among Tanzanian university students: a repeat cross-sectional survey 
BMC Oral Health  2001;1:2.
Purpose
This study examines oral health behavioral trends and the development of sociodemographic differences in oral health behaviors among Tanzanian students between 1999 and 2000.
Methods
The population targeted was students attending the Muhimbili University College of Health Sciences (MUCHS) at the University of Dar es Salaam (UDSM), Dar es Salaam, Tanzania. Cross-sectional surveys were conducted and a total of 635 and 981 students, respectively, completed questionnaires in 1999 and 2001.
Results
Cross-tabulation analyses revealed that in 1999, the rates of abstinence from tobacco use, and of soft drink consumption, regular dental checkups, and intake of chocolate/candy were 84%, 51%, 48%, and 12%, respectively, among students of urban origin and 83%, 29%, 37%, and 5% among their rural counterparts. The corresponding rates in 2001 were 87%, 56%, 50%, and 9% among urban students and 84%, 44%, 38%, and 4% among rural ones. Multiple logistic regression analyses controlling for sex, age, place of origin, educational level, year of survey, and their interaction terms revealed a significant increase in the rate of soft drink consumption, implementation of oral hygiene measures, and abstinence from tobacco use between 1999 and 2001. Social inequalities observed in 1999, with urban students being more likely than their rural counterparts to take soft drinks and go for regular dental checkups, had leveled off by 2001.
Conclusion
This study provides initial evidence of oral health behavioral trends, that may be utilized in the planning of preventive programs among university students in Tanzania.
doi:10.1186/1472-6831-1-2
PMCID: PMC64501  PMID: 11782294
8.  Dental caries prevalence, oral health knowledge and practice among indigenous Chepang school children of Nepal 
BMC Oral Health  2013;13:20.
Background
Chepang communities are one of the most deprived ethnic communities in Nepal. According to the National Pathfinder Survey, dental caries is a highly prevalent childhood disease in Nepal. There is no data concerning the prevalence of caries along with knowledge, attitude and oral hygiene practices among Chepang schoolchildren. The objectives of this study were to 1) record the prevalence of dental caries 2) report experience of dental pain 3) evaluate knowledge, attitude and preventive practices on oral health of primary Chepang schoolchildren.
Method
A cross sectional epidemiological study was conducted in 5 government Primary schools of remote Chandibhanjyang Village Development Committee (VDC) in Chitwan district. Ethical approval was taken from the Institutional Review Board within the Research Department of the Institute of Medicine (IOM) Tribhuvan University. Consent was obtained from parents for conducting clinical examination and administrating questionnaire. Permission was taken from the school principal in all schools. Data was collected using a pretested questionnaire on 131 schoolchildren aged 8-16-year- olds attending Grade 3–5. Clinical examination was conducted on 361 school children aged 5–16 –year-olds attending grade 1–5. Criteria set by the World Health Organization (1997) was used for caries diagnosis. The questionnaires, originally constructed in English and translated into Nepali were administered to the schoolchildren by the researchers. SPSS 11software was used for data analysis.
Results
Caries prevalence for 5–6 –year-old was above the goals recommended by WHO and Federation of Dentistry international (FDI) of less than 50% caries free children. Caries prevalence in 5-6-year-olds was 52% and 12-13-year-olds was 41%. The mean dmft/DMFT score of 5–6 –year-olds and 12 -13-year -olds was 1.59, 0.31 and 0.52, 0.84 respectively. The DMFT scores increased with age and the d/D component constituted almost the entire dmft/DMFT index. About 31% of 8-16-year-olds school children who participated in the survey reported having suffered from oral pain. Further, the need for treatment of decayed teeth was reported at 100%. About 76% children perceived teeth as an important component of general health and 75% reported it was required to eat. A total 93% children never visited a dentist or a health care service. Out of 56% children reporting cleaning their teeth daily, only 24% reported brushing their teeth twice daily. About 86% of the children reported using toothbrush and toothpaste to clean their teeth. Although 61% children reported to have received oral health education, 82% children did not know about fluoride and its benefit on dental health. About 50% children reported bacteria as the main cause of tooth decay and 23% as not brushing teeth for gingivitis. Frequency of sugar exposure was low; 75% of children reported eating sugar rich food once daily.
Conclusions
Caries prevalence of 5–6 –year- old Chepang school children is above the recommended target set by FDI/WHO. The study reported 31% schoolchildren aged 8-16-year old suffered oral pain and decayed component constituted almost the entire dmft/DMFT index. The brushing habit was reportedly low with only 24% of the children brushing twice daily. A nationwide scientifically proven, cost effective school based interventions is needed for prevention and control of caries in schoolchildren in Nepal.
doi:10.1186/1472-6831-13-20
PMCID: PMC3655880  PMID: 23672487
Dental caries; School children; Oral hygiene
9.  Rates of influenza vaccination in older adults and factors associated with vaccine use: A secondary analysis of the Canadian Study of Health and Aging 
BMC Public Health  2004;4:36.
Background
Influenza vaccination has been shown to reduce morbidity and mortality in the older adult population. In Canada, vaccination rates remain suboptimal. We identified factors predictive of influenza vaccination, in order to determine which segments of the older adult population might be targeted to increase coverage in influenza vaccination programs.
Methods
The Canadian Study of Health and Aging (CSHA) is a population-based national cohort study of 10263 older adults (≥ 65) conducted in 1991. We used data from the 5007 community-dwelling participants in the CSHA without dementia for whom self-reported influenza vaccination status is known.
Results
Of 5007 respondents, 2763 (55.2%) reported having received an influenza vaccination within the previous 2 years. The largest predictive factors for flu vaccination included: being married (57.4 vs. 52.6%, p = 0.0007), having attained a higher education (11.0 vs. 10.3 years, p < 0.0001), smoking (57.1% vs. 52.9%, p = 0.0032), more alcohol use (57.9% of those who drank more vs. 53.2% of those who drank less, p = 0.001), poorer self-rated health (54.1% of those with good self-rated health vs. 60.6% of those with poor self-rated health, p = 0.0006), regular exercise (56.8% vs. 52.0%, p = 0.001), and urban living (55.8% vs. 51.0%, p = 0.03).
While many other differences were statistically significant, most were small (e.g. mean age 75.1 vs. 74.6 years for immunized vs. unimmunized older adults, p = 0.006, higher Modified Mini Mental Status Examination score (89.9 vs. 89.1, p < 0.0001), higher comorbidity (2.7 vs. 2.3 comorbidities, p < 0.0001).
Residents of Ontario were more likely (64.6%) to report vaccination (p < 0.0001), while those living in Quebec were less likely to do so (48.2%, p < 0.0001). Factors retaining significance in a multivariate analysis included older age, higher education, married status, drinking alcohol, smoking, engaging in regular exercise, and having higher comorbidity.
Conclusions
The vaccination rate in this sample, in whom influenza vaccination is indicated, was low (55.2%). Even in a publicly administered health care setting, influenza vaccination did not reach an important proportion of the elderly population. Whether these differences reflect patient preference or access remains to be determined.
doi:10.1186/1471-2458-4-36
PMCID: PMC514709  PMID: 15306030
10.  Determinants of preventive oral health behaviour among senior dental students in Nigeria 
BMC Oral Health  2013;13:28.
Background
To study the association between oral health behaviour of senior dental students in Nigeria and their gender, age, knowledge of preventive care, and attitudes towards preventive dentistry.
Methods
Questionnaires were administered to 179 senior dental students in the six dental schools in Nigeria. The questionnaire obtained information on age, gender, oral self-care, knowledge of preventive dental care and attitudes towards preventive dentistry. Attending a dental clinic for check-up by a dentist or a classmate within the last year was defined as preventive care use. Students who performed oral self-care and attended dental clinic for check-ups were noted to have complied with recommended oral self-care. Chi-square test and binary logistic regression models were used for statistical analyses.
Results
More male respondents agreed that the use of fluoride toothpaste was more important than the tooth brushing technique for caries prevention (P < 0.001). While the use of dental floss was very low (7.3%), more females were more likely to report using dental floss (p=0.03). Older students were also more likely to comply with recommended oral self-care (p<0.001). In binary regression models, respondents who were younger (p=0.04) and those with higher knowledge of preventive dental care (p=0.008) were more likely to consume sugary snacks less than once a day.
Conclusion
Gender differences in the awareness of the superiority of using fluoridated toothpaste over brushing in caries prevention; and in the use of dental floss were observed. While older students were more likely to comply with recommended oral self-care measures, younger students with good knowledge of preventive dental care were more likely to consume sugary snacks less than once a day.
doi:10.1186/1472-6831-13-28
PMCID: PMC3700852  PMID: 23777298
Nigeria; Dental; Students; Knowledge; Behaviour; Prevention
11.  Injectable and Oral Contraceptive Use and Cancers of the Breast, Cervix, Ovary, and Endometrium in Black South African Women: Case–Control Study 
PLoS Medicine  2012;9(3):e1001182.
A case-control study conducted in South Africa provides new estimates of the risk of specific cancers of the female reproductive system associated with use of injectable and oral contraceptives.
Background
Oral contraceptives are known to influence the risk of cancers of the female reproductive system. Evidence regarding the relationship between injectable contraceptives and these cancers is limited, especially in black South Africans, among whom injectable contraceptives are used more commonly than oral contraceptives.
Methods and Findings
We analysed data from a South African hospital-based case–control study of black females aged 18–79 y, comparing self-reported contraceptive use in patients with breast (n = 1,664), cervical (n = 2,182), ovarian (n = 182), and endometrial (n = 182) cancer, with self-reported contraceptive use in 1,492 control patients diagnosed with cancers with no known relationship to hormonal contraceptive use. We adjusted for potential confounding factors, including age, calendar year of diagnosis, education, smoking, alcohol, parity/age at first birth, and number of sexual partners. Among controls, 26% had used injectable and 20% had used oral contraceptives. For current and more recent users versus never users of oral or injectable contraceptives, the odds ratios (ORs) for breast cancer were significantly increased in users of oral and/or injectable contraceptives (OR 1.66, 95% CI 1.28–2.16, p<0.001) and separately among those exclusively using oral (1.57, 1.03–2.40, p = 0.04) and exclusively using injectable (OR 1.83, 1.31–2.55, p<0.001) contraceptives; corresponding ORs for cervical cancer were 1.38 (1.08–1.77, p = 0.01), 1.01 (0.66–1.56, p = 0.96), and 1.58 (1.16–2.15, p = 0.004). There was no significant increase in breast or cervical cancer risk among women ceasing hormonal contraceptive use ≥10 y previously (p = 0.3 and p = 0.9, respectively). For durations of use ≥5 y versus never use, the ORs of ovarian cancer were 0.60 (0.36–0.99, p = 0.04) for oral and/or injectable contraceptive use and 0.07 (0.01–0.49, p = 0.008) for injectable use exclusively; corresponding ORs for endometrial cancer were 0.44 (0.22–0.86, p = 0.02) and 0.36 (0.11–1.26, p = 0.1).
Conclusions
In this study, use of oral and of injectable hormonal contraceptives was associated with a transiently increased risk of breast and cervical cancer and, for long durations of use, with a reduced risk of ovarian and endometrial cancer. The observed effects of injectable and of oral contraceptives on cancer risk in this study did not appear to differ substantially.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Hormonal contraceptives are among the most commonly used medications. Globally, more than 210 million women currently use either hormonal contraceptive pills or injectable contraceptives. Contraceptive pills usually contain manmade versions of the female sex hormones estrogen and progesterone (the combined oral contraceptive, or “pill”); most injectable hormonal contraceptives contain only manmade progesterone preparations. Hormonal contraceptives, which prevent pregnancy by disrupting the cyclical changes in estrogen and progesterone levels that prepare the body for pregnancy, have revolutionized birth control since they first became available in the early 1960s. However, it is now known that taking the pill also influences women's risk of developing cancers of the female reproductive system. Current and recent users have an increased risk of developing breast and cervical cancer (the cervix is the structure that connects the womb to the vagina) compared to never users, although this increased risk quickly disappears when women stop taking the pill. By contrast, women who have used the pill have a reduced risk of developing ovarian cancer and cancer of the womb (endometrial cancer) compared to never users that increases with the duration of pill use and persists for many years after use ceases. These effects on reproductive system cancers are thought to occur because these cancers depend on naturally occurring sex hormones for their development and growth.
Why Was This Study Done?
Although the evidence that the pill influences the risk of developing cancers of the female reproductive system is extensive, much less is known about how injectable hormonal contraceptives affect cancer risk. In this hospital-based case–control study (a study that compares the characteristics of people with and without a specific condition), the researchers investigate the relationship between the use of oral and injectable hormonal contraceptives and cancers of the breast, cervix, ovary, and endometrium among black South African women. Injectable contraceptives have been used for longer in South Africa than elsewhere and are used more commonly than oral contraceptives among black South African women.
What Did the Researchers Do and Find?
As part of the Johannesburg Cancer Case Control Study, which recruits black patients attending Johannesburg public referral hospitals for cancer treatment, the researchers compared hormonal contraceptive use in women with breast, cervical, ovarian, or endometrial cancer with contraceptive use in women diagnosed with other cancers such as lung, colon, and rectal cancers, which are not known to be influenced by hormonal contraceptives. Among the controls, a quarter had used injectable contraceptives and a fifth had used oral contraceptives. After adjusting for other factors that might influence cancer risk such as age, smoking, and number of sexual partners, the odds ratio (OR) of breast cancer among current and recent users of oral and/or injectable contraceptives compared to never users was 1.66. That is, the risk of developing breast cancer among current and recent users of hormonal contraceptives was 1.66 times that among never users. For women using oral contraceptives exclusively or injectable contraceptives exclusively, the ORs of breast cancer were 1.57 and 1.83, respectively. There were also increases in cervical cancer risk among current and recent users of hormonal contraceptives compared to never users, but no significant increase in breast or cervical cancer risk among women who had ceased hormonal contraceptive use more than ten years previously. Finally, the use of hormonal contraceptives for more than five years reduced the risk of both ovarian and endometrial cancer.
What Do These Findings Mean?
These findings indicate that, among black women in South Africa, the use of oral or injectable hormonal contraceptives is associated with a transiently increased risk of breast and cervical cancer, and that extended use of these contraceptives is associated with a reduced risk of ovarian and endometrial cancer. Moreover, they suggest that the effects of oral versus injectable contraceptives on cancer risk do not differ substantially, although for endometrial and ovarian cancer the small number of cases exposed to injectable contraceptives limits the accuracy of the risk estimates. Other limitations of this study include the possibility that the findings may be affected by uncontrolled confounding. That is, women who used hormonal contraceptives may have shared other unidentified characteristics that affected their cancer risk. Nevertheless, these findings provide new information about the effects of oral and injectable hormonal contraceptives on cancer risk that should help women make informed decisions about their choice of contraceptive method.
Additional Information
Please access these web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001182.
The US National Cancer Institute provides information on breast cancer (including personal stories from breast cancer survivors), cervical cancer, ovarian cancer, and endometrial cancer for patients and health professionals, and a fact sheet on oral contraceptives and cancer risk (in English and Spanish)
Cancer Research UK also provides information on breast cancer, cervical cancer, ovarian cancer, and endometrial cancer and information about the birth control pill and cancer risk
Eyes on the Prize, an online support group for women who have had cancers of the female reproductive system, has personal stories; further personal stories about breast, cervical, and ovarian cancer are provided by the charity Healthtalkonline
doi:10.1371/journal.pmed.1001182
PMCID: PMC3295825  PMID: 22412354
12.  Combined Impact of Health Behaviours and Mortality in Men and Women: The EPIC-Norfolk Prospective Population Study 
PLoS Medicine  2008;5(1):e12.
Background
There is overwhelming evidence that behavioural factors influence health, but their combined impact on the general population is less well documented. We aimed to quantify the potential combined impact of four health behaviours on mortality in men and women living in the general community.
Methods and Findings
We examined the prospective relationship between lifestyle and mortality in a prospective population study of 20,244 men and women aged 45–79 y with no known cardiovascular disease or cancer at baseline survey in 1993–1997, living in the general community in the United Kingdom, and followed up to 2006. Participants scored one point for each health behaviour: current non-smoking, not physically inactive, moderate alcohol intake (1–14 units a week) and plasma vitamin C >50 mmol/l indicating fruit and vegetable intake of at least five servings a day, for a total score ranging from zero to four. After an average 11 y follow-up, the age-, sex-, body mass–, and social class–adjusted relative risks (95% confidence intervals) for all-cause mortality(1,987 deaths) for men and women who had three, two, one, and zero compared to four health behaviours were respectively, 1.39 (1.21–1.60), 1.95 (1.70–-2.25), 2.52 (2.13–3.00), and 4.04 (2.95–5.54) p < 0.001 trend. The relationships were consistent in subgroups stratified by sex, age, body mass index, and social class, and after excluding deaths within 2 y. The trends were strongest for cardiovascular causes. The mortality risk for those with four compared to zero health behaviours was equivalent to being 14 y younger in chronological age.
Conclusions
Four health behaviours combined predict a 4-fold difference in total mortality in men and women, with an estimated impact equivalent to 14 y in chronological age.
From a large prospective population study, Kay-Tee Khaw and colleagues estimate the combined impact of four behaviors--not smoking, not being physically inactive, moderate alcohol intake, and at least five vegetable servings a day--amounts to 14 additional years of life.
Editors' Summary
Background.
Every day, or so it seems, new research shows that some aspect of lifestyle—physical activity, diet, alcohol consumption, and so on—affects health and longevity. For the person in the street, all this information is confusing. What is a healthy diet, for example? Although there are some common themes such as the benefit of eating plenty of fruit and vegetables, the details often differ between studies. And exactly how much physical activity is needed to improve health? Is a gentle daily walk sufficient or simply a stepping stone to doing enough exercise to make a real difference? The situation with alcohol consumption is equally confusing. Small amounts of alcohol apparently improve health but large amounts are harmful. As a result, it can be hard for public-health officials to find effective ways to encourage the behavioral changes that the scientific evidence suggests might influence the health of populations.
Why Was This Study Done?
There is another factor that is hindering official attempts to provide healthy lifestyle advice to the public. Although there is overwhelming evidence that individual behavioral factors influence health, there is very little information about their combined impact. If the combination of several small differences in lifestyle could be shown to have a marked effect on the health of populations, it might be easier to persuade people to make behavioral changes to improve their health, particularly if those changes were simple and relatively easy to achieve. In this study, which forms part of the European Prospective Investigation into Cancer and Nutrition (EPIC), the researchers have examined the relationship between lifestyle and the risk of dying using a health behavior score based on four simply defined behaviors—smoking, physical activity, alcohol drinking, and fruit and vegetable intake.
What Did the Researchers Do and Find?
Between 1993 and 1997, about 20,000 men and women aged 45–79 living in Norfolk UK, none of whom had cancer or cardiovascular disease (heart or circulation problems), completed a health and lifestyle questionnaire, had a health examination, and had their blood vitamin C level measured as part of the EPIC-Norfolk study. A health behavior score of between 0 and 4 was calculated for each participant by giving one point for each of the following healthy behaviors: current non-smoking, not physically inactive (physical inactivity was defined as having a sedentary job and doing no recreational exercise), moderate alcohol intake (1–14 units a week; a unit of alcohol is half a pint of beer, a glass of wine, or a shot of spirit), and a blood vitamin C level consistent with a fruit and vegetable intake of at least five servings a day. Deaths among the participants were then recorded until 2006. After allowing for other factors that might have affected their likelihood of dying (for example, age), people with a health behavior score of 0 were four times as likely to have died (in particular, from cardiovascular disease) than those with a score of 4. People with a score of 2 were twice as likely to have died.
What Do These Findings Mean?
These findings indicate that the combination of four simply defined health behaviors predicts a 4-fold difference in the risk of dying over an average period of 11 years for middle-aged and older people. They also show that the risk of death (particularly from cardiovascular disease) decreases as the number of positive health behaviors increase. Finally, they can be used to calculate that a person with a health score of 0 has the same risk of dying as a person with a health score of 4 who is 14 years older. These findings need to be confirmed in other populations and extended to an analysis of how these combined health behaviors affect the quality of life as well as the risk of death. Nevertheless, they strongly suggest that modest and achievable lifestyle changes could have a marked effect on the health of populations. Armed with this information, public-health officials should now be in a better position to encourage behavior changes likely to improve the health of middle-aged and older people.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0050012.
The MedlinePlus encyclopedia contains a page on healthy living (in English and Spanish)
The MedlinePlus page on seniors' health contains links to many sites dealing with healthy lifestyles and longevity (in English and Spanish)
The European Prospective Investigation into Cancer and Nutrition (EPIC) study is investigating the relationship between nutrition and lifestyle and the development of cancer and other chronic diseases; information about the EPIC-Norfolk study is also available
The US Centers for Disease Control and Prevention provides information on healthy aging for older adults, including information on health-related behaviors (in English and Spanish)
The UK charity Age Concerns provides a fact sheet about staying healthy in later life
The London Health Observatory, which provides information for policy makers and practitioners about improving health and health care, has a section on how lifestyle and behavior affect health
doi:10.1371/journal.pmed.0050012
PMCID: PMC2174962  PMID: 18184033
13.  Health Behaviours, Socioeconomic Status, and Mortality: Further Analyses of the British Whitehall II and the French GAZEL Prospective Cohorts 
PLoS Medicine  2011;8(2):e1000419.
Further analysis of data from two prospective cohorts reveals differences in the extent to which health behaviors attenuate associations between socioeconomic position and mortality outcomes.
Background
Differences in morbidity and mortality between socioeconomic groups constitute one of the most consistent findings of epidemiologic research. However, research on social inequalities in health has yet to provide a comprehensive understanding of the mechanisms underlying this association. In recent analysis, we showed health behaviours, assessed longitudinally over the follow-up, to explain a major proportion of the association of socioeconomic status (SES) with mortality in the British Whitehall II study. However, whether health behaviours are equally important mediators of the SES-mortality association in different cultural settings remains unknown. In the present paper, we examine this issue in Whitehall II and another prospective European cohort, the French GAZEL study.
Methods and Findings
We included 9,771 participants from the Whitehall II study and 17,760 from the GAZEL study. Over the follow-up (mean 19.5 y in Whitehall II and 16.5 y in GAZEL), health behaviours (smoking, alcohol consumption, diet, and physical activity), were assessed longitudinally. Occupation (in the main analysis), education, and income (supplementary analysis) were the markers of SES. The socioeconomic gradient in smoking was greater (p<0.001) in Whitehall II (odds ratio [OR]  = 3.68, 95% confidence interval [CI] 3.11–4.36) than in GAZEL (OR  = 1.33, 95% CI 1.18–1.49); this was also true for unhealthy diet (OR  = 7.42, 95% CI 5.19–10.60 in Whitehall II and OR  = 1.31, 95% CI 1.15–1.49 in GAZEL, p<0.001). Socioeconomic differences in mortality were similar in the two cohorts, a hazard ratio of 1.62 (95% CI 1.28–2.05) in Whitehall II and 1.94 in GAZEL (95% CI 1.58–2.39) for lowest versus highest occupational position. Health behaviours attenuated the association of SES with mortality by 75% (95% CI 44%–149%) in Whitehall II but only by 19% (95% CI 13%–29%) in GAZEL. Analysis using education and income yielded similar results.
Conclusions
Health behaviours were strong predictors of mortality in both cohorts but their association with SES was remarkably different. Thus, health behaviours are likely to be major contributors of socioeconomic differences in health only in contexts with a marked social characterisation of health behaviours.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
The influence of the socioeconomic environment on the health of individuals and populations is well known, giving rise to the so-called social determinants of health. The social determinants of health are the conditions in which people are born, grow, live, work, and age, including the health system. These circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels, which are themselves influenced by policy choices. The social determinants of health are mostly responsible for health inequities—the unfair and avoidable differences in health status seen within and between countries. In addition, health-damaging behaviors are often strongly socially patterned. For example, material constraints, lack of knowledge, and limited opportunities to follow health promoting messages often act as barriers that prevent those from lower socioeconomic groups to adopt a healthy lifestyle. Yet the extent to which health behaviors explain social inequalities in health remains unclear and can range from 12% to 72% according to some studies.
Why Was This Study Done?
In a recently published paper using data from the British Whitehall II cohort, the researchers showed that longitudinal assessment of health behaviors accounted for socioeconomic differences in mortality better than a single baseline assessment as used in most previous studies. (The Whitehall II study started in 1985 to examine the socioeconomic gradient in health among 10,308 London-based civil servants [6,895 men and 3,413 women] aged 35–55).
However, it is not clear whether health behaviors are equally important mediators of the socioeconomic-health association in different cultural settings. In this study, the researchers examine this issue by comparing their recent findings of the Whitehall II study with another European cohort, the French GAZEL study. (The GAZEL study started in 1989 among employees of the French national gas and electricity company totaling 20,625 employees [15,011 men and 5,614 women], aged 35–50.) The Whitehall II study and the GAZEL study have comparable designs in the way both assess socioeconomic status, health behaviors, and mortality and have a similar age range and follow-up period.
What Did the Researchers Do and Find?
The researchers included 9,771 participants from the Whitehall II study and 17,760 from the GAZEL study—mean follow up for Whitehall II was 19.5 years and for GAZEL was 16.5 years. The researchers used occupation as the main marker of socioeconomic status, and education and income as supplementary markers of socioeconomic status. Apart from a few exceptions, the researchers analyzed each cohort separately and used statistical techniques to calculate: the mortality rates per 1000 person-years for each socioeconomic group; the age- and sex-adjusted prevalence rates of smoking, heavy alcohol consumption, unhealthy diet, and physical inactivity, at the first and the last follow-up of the study for each socioeconomic group; and the differences in health behaviors prevalence between lowest and highest occupational position. Then the researchers used a statistical model to deduce the contribution of all health behaviors.
The researchers found that the socioeconomic gradient in smoking, unhealthy diet, and physical inactivity was greater in Whitehall II than in GAZEL. Socioeconomic differences in mortality were similar in the two cohorts, a hazard ratio of 1.62 in Whitehall II and 1.94 in GAZEL for lowest versus highest occupational position. Health behaviors weakened the association between socioeconomic status and mortality by 75% in Whitehall II but only by 19% in GAZEL. The supplementary analysis the researchers conducted using education and income as socioeconomic markers gave similar results.
What Do These Findings Mean?
These results suggest that the social patterning of unhealthy behaviors differs between countries. Although in both cohorts socioeconomic status and health behaviors were strong predictors of mortality, major differences in the social patterning of unhealthy behaviors in the two cohorts meant that the causal chains leading from socioeconomic status to health behaviors to mortality were different. Therefore it may be that health behaviors are likely to only be major contributors of socioeconomic differences in health in contexts with a marked social characterization of those behaviors. In order to identify the common and unique determinants of social inequalities in health in different populations, there needs to be further comparative research on the relative importance of different pathways linking socioeconomic status to health.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000419.
WHO provides information on social determinants of health
University College London provides information on the Whitehall study
The GAZEL study is available in an online open access format
doi:10.1371/journal.pmed.1000419
PMCID: PMC3043001  PMID: 21364974
14.  The Effectiveness of Community Action in Reducing Risky Alcohol Consumption and Harm: A Cluster Randomised Controlled Trial 
PLoS Medicine  2014;11(3):e1001617.
In a cluster randomized controlled trial, Anthony Shakeshaft and colleagues measure the effectiveness of a multi-component community-based intervention for reducing alcohol-related harm.
Background
The World Health Organization, governments, and communities agree that community action is likely to reduce risky alcohol consumption and harm. Despite this agreement, there is little rigorous evidence that community action is effective: of the six randomised trials of community action published to date, all were US-based and focused on young people (rather than the whole community), and their outcomes were limited to self-report or alcohol purchase attempts. The objective of this study was to conduct the first non-US randomised controlled trial (RCT) of community action to quantify the effectiveness of this approach in reducing risky alcohol consumption and harms measured using both self-report and routinely collected data.
Methods and Findings
We conducted a cluster RCT comprising 20 communities in Australia that had populations of 5,000–20,000, were at least 100 km from an urban centre (population ≥ 100,000), and were not involved in another community alcohol project. Communities were pair-matched, and one member of each pair was randomly allocated to the experimental group. Thirteen interventions were implemented in the experimental communities from 2005 to 2009: community engagement; general practitioner training in alcohol screening and brief intervention (SBI); feedback to key stakeholders; media campaign; workplace policies/practices training; school-based intervention; general practitioner feedback on their prescribing of alcohol medications; community pharmacy-based SBI; web-based SBI; Aboriginal Community Controlled Health Services support for SBI; Good Sports program for sports clubs; identifying and targeting high-risk weekends; and hospital emergency department–based SBI. Primary outcomes based on routinely collected data were alcohol-related crime, traffic crashes, and hospital inpatient admissions. Routinely collected data for the entire study period (2001–2009) were obtained in 2010. Secondary outcomes based on pre- and post-intervention surveys (n = 2,977 and 2,255, respectively) were the following: long-term risky drinking, short-term high-risk drinking, short-term risky drinking, weekly consumption, hazardous/harmful alcohol use, and experience of alcohol harm. At the 5% level of statistical significance, there was insufficient evidence to conclude that the interventions were effective in the experimental, relative to control, communities for alcohol-related crime, traffic crashes, and hospital inpatient admissions, and for rates of risky alcohol consumption and hazardous/harmful alcohol use. Although respondents in the experimental communities reported statistically significantly lower average weekly consumption (1.90 fewer standard drinks per week, 95% CI = −3.37 to −0.43, p = 0.01) and less alcohol-related verbal abuse (odds ratio = 0.58, 95% CI = 0.35 to 0.96, p = 0.04) post-intervention, the low survey response rates (40% and 24% for the pre- and post-intervention surveys, respectively) require conservative interpretation. The main limitations of this study are as follows: (1) that the study may have been under-powered to detect differences in routinely collected data outcomes as statistically significant, and (2) the low survey response rates.
Conclusions
This RCT provides little evidence that community action significantly reduces risky alcohol consumption and alcohol-related harms, other than potential reductions in self-reported average weekly consumption and experience of alcohol-related verbal abuse. Complementary legislative action may be required to more effectively reduce alcohol harms.
Trial registration
Australian New Zealand Clinical Trials Registry ACTRN12607000123448
Please see later in the article for the Editors' Summary
Editors' Summary
Background
People have consumed alcoholic beverages throughout history, but alcohol use is now an increasing global public health problem. According to the World Health Organization's 2010 Global Burden of Disease Study, alcohol use is the fifth leading risk factor (after high blood pressure and smoking) for disease and is responsible for 3.9% of the global disease burden. Alcohol use contributes to heart disease, liver disease, depression, some cancers, and many other health conditions. Alcohol also affects the well-being and health of people around those who drink, through alcohol-related crimes and road traffic crashes. The impact of alcohol use on disease and injury depends on the amount of alcohol consumed and the pattern of drinking. Most guidelines define long-term risky drinking as more than four drinks per day on average for men or more than two drinks per day for women (a “drink” is, roughly speaking, a can of beer or a small glass of wine), and short-term risky drinking (also called binge drinking) as seven or more drinks on a single occasion for men or five or more drinks on a single occasion for women. However, recent changes to the Australian guidelines acknowledge that a lower level of alcohol consumption is considered risky (with lifetime risky drinking defined as more than two drinks a day and binge drinking defined as more than four drinks on one occasion).
Why Was This Study Done?
In 2010, the World Health Assembly endorsed a global strategy to reduce the harmful use of alcohol. This strategy emphasizes the importance of community action–a process in which a community defines its own needs and determines the actions that are required to meet these needs. Although community action is highly acceptable to community members, few studies have looked at the effectiveness of community action in reducing risky alcohol consumption and alcohol-related harm. Here, the researchers undertake a cluster randomized controlled trial (the Alcohol Action in Rural Communities [AARC] project) to quantify the effectiveness of community action in reducing risky alcohol consumption and harms in rural communities in Australia. A cluster randomized trial compares outcomes in clusters of people (here, communities) who receive alternative interventions assigned through the play of chance.
What Did the Researchers Do and Find?
The researchers pair-matched 20 rural Australian communities according to the proportion of their population that was Aboriginal (rates of alcohol-related harm are disproportionately higher among Aboriginal individuals than among non-Aboriginal individuals in Australia; they are also higher among young people and males, but the proportions of these two groups across communities was comparable). They randomly assigned one member of each pair to the experimental group and implemented 13 interventions in these communities by negotiating with key individuals in each community to define and implement each intervention. Examples of interventions included general practitioner training in screening for alcohol use disorders and in implementing a brief intervention, and a school-based interactive session designed to reduce alcohol harm among young people. The researchers quantified the effectiveness of the interventions using routinely collected data on alcohol-related crime and road traffic crashes, and on hospital inpatient admissions for alcohol dependence or abuse (which were expected to increase in the experimental group if the intervention was effective because of more people seeking or being referred for treatment). They also examined drinking habits and experiences of alcohol-related harm, such as verbal abuse, among community members using pre- and post-intervention surveys. After implementation of the interventions, the rates of alcohol-related crime, road traffic crashes, and hospital admissions, and of risky and hazardous/harmful alcohol consumption (measured using a validated tool called the Alcohol Use Disorders Identification Test) were not statistically significantly different in the experimental and control communities (a difference in outcomes that is not statistically significantly different can occur by chance). However, the reported average weekly consumption of alcohol was 20% lower in the experimental communities after the intervention than in the control communities (equivalent to 1.9 fewer standard drinks per week per respondent) and there was less alcohol-related verbal abuse post-intervention in the experimental communities than in the control communities.
What Do These Findings Mean?
These findings provide little evidence that community action reduced risky alcohol consumption and alcohol-related harms in rural Australian communities. Although there was some evidence of significant reductions in self-reported weekly alcohol consumption and in experiences of alcohol-related verbal abuse, these findings must be interpreted cautiously because they are based on surveys with very low response rates. A larger or differently designed study might provide statistically significant evidence for the effectiveness of community action in reducing risky alcohol consumption. However, given their findings, the researchers suggest that legislative approaches that are beyond the control of individual communities, such as alcohol taxation and restrictions on alcohol availability, may be required to effectively reduce alcohol harms. In other words, community action alone may not be the most effective way to reduce alcohol-related harm.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001617.
The World Health Organization provides detailed information about alcohol; its fact sheet on alcohol includes information about the global strategy to reduce the harmful use of alcohol; the Global Information System on Alcohol and Health provides further information about alcohol, including information on control policies around the world
The US National Institute on Alcohol Abuse and Alcoholism has information about alcohol and its effects on health
The US Centers for Disease Control and Prevention has a website on alcohol and public health that includes information on the health risks of excessive drinking
The UK National Health Service Choices website provides detailed information about drinking and alcohol, including information on the risks of drinking too much, tools for calculating alcohol consumption, and personal stories about alcohol use problems
MedlinePlus provides links to many other resources on alcohol
More information about the Alcohol Action in Rural Communities project is available
doi:10.1371/journal.pmed.1001617
PMCID: PMC3949675  PMID: 24618831
15.  Nutritional profile of Indian vegetarian diets – the Indian Migration Study (IMS) 
Nutrition Journal  2014;13:55.
Background
The cardiovascular and other health benefits and potential harms of protein and micronutrient deficiency of vegetarian diets continue to be debated.
Methods
Study participants included urban migrants, their rural siblings and urban residents (n = 6555, mean age - 40.9 yrs) of the Indian Migration Study from Lucknow, Nagpur, Hyderabad and Bangalore. Information on diet (validated interviewer-administered semi-quantitative food frequency questionnaire), tobacco, alcohol, physical activity, medical histories, as well as blood pressure, fasting blood and anthropometric measurements were collected. Nutrient databases were used to calculate nutrient content of regional recipes. Vegetarians ate no eggs, fish, poultry and meat. Using multivariate linear regression with robust standard error model, we compared the macro- and micro-nutrient profile of vegetarian and non-vegetarian diets.
Results
Vegetarians, (32.8% of the population), consumed greater amounts of legumes, vegetables, roots and tubers, dairy and sugar, while non-vegetarians had a greater intake of cereals, fruits, spices, salt (p < 0.01), fats and oils. Vegetarians had a higher socioeconomic status, and were less likely to smoke, drink alcohol (p < 0.0001) and engage in less physical activity (p = 0.04). On multivariate analysis, vegetarians consumed more carbohydrates (β = 7.0 g/day (95% CI: 9.9 to 4.0), p < 0.0001), vitamin C (β = 8.7 mg/day (95% CI: 4.3 to13.0), p < 0.0001) and folate (β = 8.0 mcg/day (95% CI: 3.3 to 12.7), p = 0.001) and lower levels of fat (β = −1.6 g/day (95% CI: −0.62 to −2.7), p = 0.002), protein (β = −6.4 g/day (95% CI: −5.8 to −7.0), p < 0.0001), vitamin B12 (β = −1.4 mcg/day (95% CI: −1.2 to −1.5), p < 0.0001) and zinc (β = −0.6 mg/day (95% CI: −0.4 to −0.7), p < 0.0001).
Conclusion
Overall, Indian vegetarian diets were found to be adequate to sustain nutritional demands according to recommended dietary allowances with less fat. Lower vitamin B12 bio-availability remains a concern and requires exploration of acceptable dietary sources for vegetarians.
doi:10.1186/1475-2891-13-55
PMCID: PMC4055802  PMID: 24899080
India; Diet; Nutrition; Vegetarian; Vitamin B12
16.  Immigrant-native differences in caries-related knowledge, attitude, and oral health behaviors: a cross-sectional study in Taiwan 
BMC Oral Health  2014;14:3.
Background
With the growing number of transnational marriages in Taiwan, oral health disparities have become a public health issue. This study assessed immigrant-native differences in oral health behaviors of urban mothers and their children.
Methods
We used the baseline data of an oral health promotion program to examine the immigrant-native differences in caries-related knowledge, attitude, and oral health behaviors. A cross-sectional study was conducted to collect data from mothers in urban area, Taiwan. A total of 150 immigrant and 440 native mothers completed the self-report questionnaires. Logistic regression models analyzed the racial differences in oral health behaviors.
Results
Approximately 37% of immigrant mothers used dental floss, 25% used fluoride toothpaste, and only 13.5% of them regularly visited a dentist. Less that 40% of immigrant mothers brush their children’s teeth before aged one year, 45% replaced child’s toothbrush within 3 months, and only half of the mothers regularly took their child to the dentist. Immigrant mothers had lower level of caries-related knowledge and attitudes than native mothers (p < .001). Compared to native group, the immigrant mothers were less likely to use of dental floss ([Adjusted odds ratio (aOR) =0.35], fluoride toothpaste (aOR = 0.29), visit a dentist in the past 2 years (aOR = 0.26), and take their children to regular dental check-up (aOR = 0.38); whereas, they were more likely to not consume sweeten beverages (aOR = 3.13).
Conclusions
The level of caries-related knowledge, attitudes and oral health behaviors were found lower in immigrant mothers than native ones. The findings suggested cross-cultural caries prevention programs aimed at reducing immigrant-native disparities in child oral health care must be developed for these immigrant minorities.
doi:10.1186/1472-6831-14-3
PMCID: PMC3898042  PMID: 24423385
Attitudes; Behavior; Dental caries; Immigrants; Health care
17.  Mobile and Portable Dental Services Catering to the Basic Oral Health Needs of the Underserved Population in Developing Countries: A Proposed Model 
India is the second most populous country in the world with an extensive rural population (68.8%). Children less than 18 years constitute about 40% of the population. Approximately, 23.5% of the urban population resides in urban slums. The extensive rural population, school children and the urban slum dwellers are denied of even the basic dental services though there is continuous advancement in the field of dentistry. The dentist to population ratio has dramatically improved in the last one to two decades with no significant improvement in the oral health status of the general population. The various studies have revealed an increasing trend in oral diseases in the recent times especially among this underserved population. Alternate strategies have to be thought about rather than the traditional oral health-care delivery through private dentists on fee for service basis. Mobile and portable dental services are a viable option to take the sophisticated oral health services to the doorsteps of the underserved population. The databases were searched for publications from 1900 to the present (2013) using terms such as Mobile dental services, Portable dental services and Mobile and portable dental services with key articles obtained primarily from MEDLINE. This paper reviews the published and unpublished literature from different sources on the various mobile dental service programs successfully implemented in some developed and developing countries. Though the mobile and portable systems have some practical difficulties like financial considerations, they still seem to be the only way to reach every section of the community in the absence of national oral health policy and organized school dental health programs in India. The material for the present review was obtained mainly by searching the biomedical databases for primary research material using the search engine with key words such as mobile and/or portable dental services in developed and developing countries (adding each of these terms in a sequential order). Based on the review of the programs successfully implemented in developed countries, we propose a model to cater to the basic oral health needs of an extensive underserved population in India that may be pilot tested. The increasing dental manpower can best be utilized for the promotion of oral health through mobile and portable dental services. The professional dental organizations should have a strong motive to translate this into reality.
doi:10.4103/2141-9248.133364
PMCID: PMC4071723  PMID: 24971198
Dental manpower; Developing countries; Mobile and portable dental services; Oral health; School dental programs
18.  Sexual Behavior and Reproductive Health Among HIV-Infected Patients in Urban and Rural South Africa 
Journal of acquired immune deficiency syndromes (1999)  2008;47(4):10.1097/QAI.0b013e3181648de8.
Background
With the rollout of antiretroviral therapy in South Africa and its potential to prolong the lives of HIV-infected individuals, understanding the sexual behavior of HIV-positive people is essential to curbing secondary HIV transmission.
Methods
We surveyed 3819 HIV-positive patients during their first visit to an urban wellness clinic and a rural wellness clinic.
Results
Urban residents were more likely than rural residents to have current regular sex partners (75.1% vs. 46.0%; χ2 odds ratio [OR] = 3.531; P < 0.001), to have any current sexual partners (75.3% vs. 51.2%; χ2 OR = 2.908; P < 0.001), and to report consistent condom use with regular partners (78.4% vs. 48.3%; χ2 OR = 3.886; P < 0.001) and with casual partners (68.6% vs. 48.3%; χ2 OR = 2.337; P < 0.001). In multivariate analysis, independent predictors of consistent condom use with regular partners included across gender, urban residence, and higher education levels; for women, disclosure and younger age; and for men only, no history of alcohol consumption. Male and female participants with a casual sexual partner were less likely to use a condom consistently with regular partners. Additionally, urban residence and a CD4 count greater than 200 cells/mm3 as well as (for women only) a higher household income and a history of alcohol consumption were predictors of having a regular sexual partner.
Conclusions
HIV prevention programs in South Africa that emphasize the importance of condom use and disclosure and are tailored to the needs of their attending populations are critical given the potential for HIV-infected individuals to resume risky sexual behavior with improving health.
doi:10.1097/QAI.0b013e3181648de8
PMCID: PMC3811008  PMID: 18209685
condom use; HIV prevention; positive prevention; sexual behavior; South Africa; urban-rural
19.  Urban-rural inequities in knowledge, attitudes and practices regarding tuberculosis in two districts of Pakistan's Punjab province 
Objective
The aim of this study was to explore inequities in knowledge, attitudes and practices regarding tuberculosis (TB) among the urban and rural populations.
Design
A cross-sectional study was conducted in two districts of Pakistan's Punjab province. The 1080 subjects aged 20 years and above, including 432 urban and 648 rural respondents, were randomly selected using multistage cluster sampling and interviewed after taking verbal informed consent. Logistic regression was used to calculate the crude odds ratio (OR) with 95% confidence interval (CI) for the urban area. The differences in knowledge, attitudes, practices and information sources between the urban and rural respondents were highlighted using Pearson chi-square test and Fisher's exact test.
Results
The study revealed poor knowledge regarding TB. The deficit was greater in the rural areas in all aspects. The knowledge regarding symptoms (OR 2.03, 95% CI 1.59-2.61), transmission (OR 1.93, 95% CI 1.44-2.59), prevention (OR 2.24, 95% CI 1.70-2.96), duration of standard treatment (OR 1.88, 95% 1.41-2.49) and DOTS (OR 1.84, 95% CI 1.43-2.38) was significantly higher in the urban areas (all P < 0.001). Although a majority of the subjects (urban 83.8%, rural 81.2%) were aware of the correct treatment for TB, less than half (urban 48.1%, rural 49.2%) were aware of the availability of the diagnostic facility and treatment free of cost. The practice of seeking treatment at a health facility (P = 0.030; OR 2.01, 95% CI 1.06-3.82), as soon as they realized that they had TB symptoms (P < 0.001; OR 1.72, 95% CI 1.26-2.35), was significantly higher in the urban areas. People in the urban areas were more likely to feel ashamed and embarrassed being a TB patient (P < 0.001; OR 2.03, 95% CI 1.50-2.76); however, they seem to be supportive in case their family member suffered from TB (P = 0.005; OR 1.53, 95% CI 1.13-2.06). Nearly half of the respondents, irrespective of the area of residence, believed that the community rejects the TB patient (urban 49.8%, rural 46.4%). Television (urban 80.1%, rural 68.1%) and health workers (urban 30.6%, rural 41.4%) were the main sources for people to acquire the TB related information.
Conclusion
Respondents' knowledge regarding TB was deficient in all aspects, particularly in the rural areas. Intended health seeking behavior was better in the urban areas. Television and health workers were the main sources for TB related information in both the urban as well as the rural areas. Therefore, the area of residence should be considered in tailoring communication strategies and designing future interventions for TB prevention and control.
doi:10.1186/1475-9276-10-8
PMCID: PMC3045313  PMID: 21294873
20.  Associations between Active Travel to Work and Overweight, Hypertension, and Diabetes in India: A Cross-Sectional Study 
PLoS Medicine  2013;10(6):e1001459.
Using data from the Indian Migration Study, Christopher Millett and colleagues examine the associations between active travel to work and overweight, hypertension, and diabetes.
Please see later in the article for the Editors' Summary
Background
Increasing active travel (walking, bicycling, and public transport) is promoted as a key strategy to increase physical activity and reduce the growing burden of noncommunicable diseases (NCDs) globally. Little is known about patterns of active travel or associated cardiovascular health benefits in low- and middle-income countries. This study examines mode and duration of travel to work in rural and urban India and associations between active travel and overweight, hypertension, and diabetes.
Methods and Findings
Cross-sectional study of 3,902 participants (1,366 rural, 2,536 urban) in the Indian Migration Study. Associations between mode and duration of active travel and cardiovascular risk factors were assessed using random-effect logistic regression models adjusting for age, sex, caste, standard of living, occupation, factory location, leisure time physical activity, daily fat intake, smoking status, and alcohol use. Rural dwellers were significantly more likely to bicycle (68.3% versus 15.9%; p<0.001) to work than urban dwellers. The prevalence of overweight or obesity was 50.0%, 37.6%, 24.2%, 24.9%; hypertension was 17.7%, 11.8%, 6.5%, 9.8%; and diabetes was 10.8%, 7.4%, 3.8%, 7.3% in participants who travelled to work by private transport, public transport, bicycling, and walking, respectively. In the adjusted analysis, those walking (adjusted risk ratio [ARR] 0.72; 95% CI 0.58–0.88) or bicycling to work (ARR 0.66; 95% CI 0.55–0.77) were significantly less likely to be overweight or obese than those travelling by private transport. Those bicycling to work were significantly less likely to have hypertension (ARR 0.51; 95% CI 0.36–0.71) or diabetes (ARR 0.65; 95% CI 0.44–0.95). There was evidence of a dose-response relationship between duration of bicycling to work and being overweight, having hypertension or diabetes. The main limitation of the study is the cross-sectional design, which limits causal inference for the associations found.
Conclusions
Walking and bicycling to work was associated with reduced cardiovascular risk in the Indian population. Efforts to increase active travel in urban areas and halt declines in rural areas should be integral to strategies to maintain healthy weight and prevent NCDs in India.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Noncommunicable diseases (NCDs) and obesity (excessive body fat) are major threats to global health. Every year, more than 36 million people (including 29 million in LMICs) die from NCDs—nearly two-thirds of the world's annual deaths. Cardiovascular diseases (conditions that affect the heart and the circulation), diabetes, cancer, and respiratory diseases are responsible for most NCD-related deaths. Obesity is a risk factor for all these NCDs and the global prevalence of obesity (the proportion of the world's population that is obese) has nearly doubled since 1980. In 2008, 35% of adults were overweight and 11% were obese. One reason for the growing burden of both obesity and NCDs is increasing physical inactivity. Regular physical activity helps to maintain a healthy body weight and to prevent or delay the onset of NCDs. For an adult, 30 minutes of moderate physical activity—walking briskly or cycling, for example—five times a week is sufficient to promote and maintain health. But the daily lives of people in both developed and developing countries are becoming increasingly sedentary and, nowadays, at least 60% of the world's population does not do even this modest amount of exercise.
Why Was This Study Done?
Strategies to increase physical activity levels often promote active travel (walking, cycling, and using public transport). The positive impact of active travel on physical activity levels and cardiovascular health is well established in high-income countries, but little is known about the patterns of active travel or the health benefits associated with active travel in poorer countries. In this cross-sectional study (an investigation that measures population characteristics at a single time point), the researchers examine the mode and duration of travel to work in rural and urban India and associations between active travel and overweight/obesity, hypertension (high blood pressure, a risk factor for cardiovascular disease), and diabetes. In India, a lower middle-income country, the prevalence of overweight and NCDs is projected to increase rapidly over the next two decades. Moreover, rapid unplanned urbanization and a large increase in registered motor vehicles has resulted in inadequate development of the public transport infrastructure and hazardous conditions for walking and cycling in most Indian towns and cities.
What Did the Researchers Do and Find?
For their study, researchers analyzed physical activity and health data collected from participants in the Indian Migration Study, which examined the association between migration from rural to urban areas and obesity and diabetes risk. People living in rural areas were more likely to cycle to work than people living in towns and cities (68.3% versus 15.9%). Among people who travelled to work by private transport, public transport, walking, and cycling, the prevalence of overweight or obesity was 50.0%, 37.6%, 24.9%, and 24.2%, respectively. Similar patterns were seen for the prevalence of hypertension and diabetes. After adjustment for factors that affect the risk of obesity, hypertension, and diabetes (for example, daily fat intake and leisure time physical activity), people walking or cycling to work were less likely to be overweight or obese than those travelling by public transport, and those cycling to walk were less likely to have hypertension or diabetes. Finally, people with long cycle rides to work had a lower risk of being overweight or having hypertension or diabetes than people with short cycle rides.
What Do These Findings Mean?
These findings suggest that, as in high-income settings, walking and cycling to work are associated with a reduced risk of cardiovascular disease in India. Because this was a cross-sectional study, these findings do not prove that active travel reduces the risk of cardiovascular disease—people who cycle to work may share other unknown characteristics that are actually responsible for their reduced risk of cardiovascular disease. Moreover, this study did not consider non-cardiovascular outcomes associated with active travel that might affect health such as increased exposure to air pollution. Nevertheless, these findings suggest that programs designed to maintain healthy weight and prevent NCDs in India should endeavor to increase active travel in urban areas and to halt declines in rural areas by, for example, increasing investment in public transport and improving the safety and convenience of walking and cycling routes in urban areas.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001459.
This study is further discussed in a PLOS Medicine Perspective by Kavi Bhalla
The US Centers for Disease Control and Prevention provides information on all aspects of healthy living, on chronic diseases and health promotion, on overweight and obesity and on non-communicable diseases around the world; its Physical Activity for Everyone web pages include guidelines, instructional videos and personal success stories (some information in English and Spanish)
The World Health Organization provides information about physical activity and health, about obesity, and about non-communicable diseases (in several languages); its 2010 Global Recommendations on Physical Activity for Health are available in several languages; its Global Noncommunicable Disease Network (NCDnet) aims to help low- and middle- income countries reduce NCD-related illnesses and death through implementation of the 20082013 Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases (also available in French); Face to face with chronic diseases is a selection of personal stories from around the world about dealing with NCDs
The American Heart Association provides information on many important risk factors for non-communicable diseases and provides tips for becoming more active
Information about the Indian Migration Study is available
doi:10.1371/journal.pmed.1001459
PMCID: PMC3679004  PMID: 23776412
21.  Socio-demographic and behavioural correlates of oral hygiene status and oral health related quality of life, the Limpopo - Arusha school health project (LASH): A cross-sectional study 
BMC Pediatrics  2010;10:87.
Background
Promoting oral health of adolescents is important for improvement of oral health globally. This study used baseline-data from LASH-project targeting secondary students to; 1) assess frequency of poor oral hygiene status and oral impacts on daily performances, OIDP, by socio-demographic and behavioural characteristics, 2) examine whether socio-economic and behavioural correlates of oral hygiene status and OIDP differed by gender and 3) examine whether socio-demographic disparity in oral health was explained by oral health-related behaviours.
Methods
Cross-sectional study was conducted in 2009 using one-stage cluster sampling design. Total of 2412 students (mean age 15.2 yr) completed self-administered questionnaires, whereas 1077 (mean age 14.9 yr) underwent dental-examination. Bivariate analyses were conducted using cross-tabulations and chi-square statistics. Multiple variable analyses were conducted using stepwise standardized logistic regression (SLR) with odds ratios and 95% Confidence intervals (CI).
Results
44.8% presented with fair to poor OHIS and 48.2% reported any OIDP. Older students, those from low socio-economic status families, had parents who couldn't afford dental care and had low educational-level reported oral impacts, poor oral hygiene, irregular toothbrushing, less dental attendance and fewer intakes of sugar-sweetened drinks more frequently than their counterparts. Stepwise logistic regression revealed that reporting any OIDP was independently associated with; older age-groups, parents do not afford dental care, smoking experience, no dental visits and fewer intakes of sugar-sweetened soft drinks. Behavioural factors accounted partly for association between low family SES and OIDP. Low family SES, no dental attendance and smoking experience were most important in males. Low family SES and fewer intakes of sugar-sweetened soft drinks were the most important correlates in females.
Socio-behavioural factors associated with higher odds ratios for poor OHIS were; older age, belonging to the poorest household category and having parents who did not afford dental care across both genders.
Conclusion
Disparities in oral hygiene status and OIDP existed in relation to age, affording dental care, smoking and intake of sugar sweetened soft drinks. Gender differences should be considered in intervention studies, and modifiable behaviours have some relevance in reducing social disparity in oral health.
doi:10.1186/1471-2431-10-87
PMCID: PMC3001697  PMID: 21118499
22.  Prevalence of Dental Caries in a Nigerian Rural Community: A Preliminary Local Survey 
Background:
Dental caries is the most prevalent oral disease of childhood; however, not much attention has been given to studies on this among the rural Nigerian children.
Objectives:
The aim of this study is to assess the prevalence and risk factors associated with dental caries in secondary school children residing in the rural communities of Awgu North Local Government Area, Enugu.
Methods:
Stratified random sampling technique was used to select 301 students who were 1 1-16years of age. Trained interviewers administered semi-structured questionnaires. Two calibrated examiners examined the participants. Diagnosis of caries was based on the guidelines laid down by the World Health Organization. Oral health education component was incorporated and toothpaste tubes were given out to all participants as an incentive. Analysis of data was done using EPI-INFO version 3.3.2 and PEPI version 11.0.
Results:
One hundred males (33.2%) and 201 females (66.8%) were studied, 35.5% had dental caries. Mean DMFT was 0.85 ± 1.50. Girls had significantly higher Decayed Missing and Filled Teeth (DMFT) than boys at ages 12 and 16 years (P = 0.027 and P<0.0001 respectively). Students who used fluoridated toothpaste were found to have less caries. Boys who cleaned their teeth with chewing sticks had more caries than boys who used toothbrush and paste. Decayed component accounted for 53(49.5%) of the dental caries while only (3) 2.8% of the caries were filled.
Conclusion:
The prevalence of caries is low in this study, but still higher than prevalence rates reported in urban areas of Enugu States. The findings of this study could serve as a guide for planning rural community oriented oral health promotion programmes.
PMCID: PMC3507107  PMID: 23209974
Prevalence; Caries; Rural; Nigeria
23.  Health status and quality of life among older adults in rural Tanzania 
Global Health Action  2010;3:10.3402/gha.v3i0.2142.
Background
Increasingly, human populations throughout the world are living longer and this trend is developing in sub-Saharan Africa. In developing African countries such as Tanzania, this demographic phenomenon is taking place against a background of poverty and poor health conditions. There has been limited research on how this process of ageing impacts upon the health of older people within such low-income settings.
Objective
The objective of this study is to describe the impacts of ageing on the health status, quality of life and well-being of older people in a rural population of Tanzania.
Design
A short version of the WHO Survey on Adult Health and Global Ageing questionnaire was used to collect information on the health status, quality of life and well-being of older adults living in Ifakara Health and Demographic Surveillance System, Tanzania, during early 2007. Questionnaires were administered through this framework to 8,206 people aged 50 and over.
Results
Among people aged 50 and over, having good quality of life and health status was significantly associated with being male, married and not being among the oldest old. Functional ability assessment was associated with age, with people reporting more difficulty in performing routine activities as age increased, particularly among women. Reports of good quality of life and well-being decreased with increasing age. Women were significantly more likely to report poor quality of life (odds ratio 1.31; p<0.001, 95% CI 1.15–1.50).
Conclusions
Older people within this rural Tanzanian setting reported that the ageing process had significant impacts on their health status, quality of life and physical ability. Poor quality of life and well-being, and poor health status in older people were significantly associated with marital status, sex, age and level of education. The process of ageing in this setting is challenging and raises public health concerns.
doi:10.3402/gha.v3i0.2142
PMCID: PMC2958089  PMID: 20975983
health status; quality of life; older people; ageing; Health and Demographic Surveillance System; INDEPTH WHO-SAGE
24.  Oral cancer screening and dental care use among women from Ohio Appalachia 
Rural and remote health  2012;12:2184.
Introduction
Residents of Appalachia may benefit from oral cancer screening given the region’s higher oral and pharyngeal cancer mortality rates. The current study examined the oral cancer screening behaviors and recent dental care (since dentists perform most screening examinations) of women from Ohio Appalachia.
Methods
Women from Ohio Appalachia were surveyed for the Community Awareness Resources Education (CARE) study, which was completed in 2006. A secondary aim of the CARE baseline survey was to examine oral cancer screening and dental care use among women from this region. Outcomes included whether women (n=477; cooperation rate = 71%) had ever had an oral cancer screening examination and when their most recent dental visit had occurred. Various demographic characteristics, health behaviors and psychosocial factors were examined as potential correlates. Analyses used multivariate logistic regression.
Results
Most women identified tobacco-related products as risk factors for oral cancer, but 43% of women did not know an early sign of oral cancer. Only 15% of women reported ever having had an oral cancer screening examination, with approximately 80% of these women indicating that a dentist had performed their most recent examination. Women were less likely to have reported a previous examination if they were from urban areas (OR=0.33, 95% CI: 0.13–0.85) or perceived a lower locus of health control (OR=0.94, 95% CI: 0.89–0.98). Women were more likely to have reported a previous examination if they had had a dental visit within the last year (OR=2.24, 95% CI: 1.03–4.88). Only 65% of women, however, indicated a dental visit within the last year. Women were more likely to have reported a recent dental visit if they were of a high socioeconomic status (OR=2.83, 95% CI: 1.58–5.06), had private health insurance (OR=2.20, 95% CI: 1.21–3.97) or had consumed alcohol in the last month (OR=2.03, 95% CI: 1.20–3.42).
Conclusion
Oral cancer screening was not common among women from Ohio Appalachia, with many missed opportunities having occurred at dental visits. Education programs targeting dentists and other healthcare providers (given dental providers are lacking in some areas of Ohio Appalachia) about opportunistic oral cancer screening may help to improve screening in Appalachia. These programs should include information about populations at high risk for oral cancer (eg smokers) and how screening may be especially beneficial for them. Future research is needed to examine the acceptability of such education programs to healthcare providers in the Appalachian region and to explore why screening was less common among women living in urban areas of Ohio Appalachia.
PMCID: PMC3838993  PMID: 23240899
Appalachia; oral cancer; screening; USA
25.  Healthcare-seeking behavior, treatment delays and its determinants among pulmonary tuberculosis patients in rural Nigeria: a cross-sectional study 
Background
Nigeria ranks fourth among 22 high tuberculosis (TB) burden countries. Although it reached 99% DOTS coverage in 2008, current case detection rate is 40%. Little is known about delays before the start of TB therapy and health-seeking behaviour of TB patients in rural resource-limited settings. We aimed to: 1) assess healthcare-seeking behaviour and delay in treatment of pulmonary TB patients, 2) identify the determinants of the delay in treatment of pulmonary TB.
Methods
We conducted a cross-sectional study of adult new pulmonary TB patients notified to the National Tuberculosis Control Programme (NTP) by three rural (two mission/one public) hospitals. Data on health-seeking and delays were collected using a standardised questionnaire. We defined patient delay as the interval (weeks) between the onset of cough and the first visit to any health provider, and health system delay as the time interval (weeks) between patient's first attendance to any health provider, and the onset of treatment. Total delay is the sum of both delays. Multiple linear regression models using nine exposure variables were built to identify determinants of delays.
Results
Of 450 patients (median age 30 years) enrolled, most were males (55%), subsistent farmers (49%), rural residents (78%); and 39% had no formal education. About 84% of patients reported first consulting a non-NTP provider. For such patients, the first facilities visited after onset of symptoms were drug shops (79%), traditional healers (10%), and private hospitals (10%). The median total delay was 11 (IQR 9–16) weeks, patient delay 8 (IQR 8–12) and health system (HS) delay 3 (IQR 1–4) weeks. Factors associated with increased patient delay were older age (P <0.001) longer walking distance to a public facility (<0.001), and urban residence (P <0.001). Male gender (P = 0.001) and an initial visit to a non-NTP provider (P = 0.025) were independent determinants of prolonged HS delay. Those associated with longer total delay were older age (P <0.001), male gender (P = 0.045), and urban residence (P<0.001).
Conclusion
Overall, TB treatment delays were high; and needs to be reduced in Nigeria. This may be achieved through improved access to care, further education of patients, engagement of informal care providers, and strengthening of existing public-private partnerships in TB control.
doi:10.1186/1472-6963-13-25
PMCID: PMC3560225  PMID: 23327613
Tuberculosis; Health-seeking delays; Private sector; Public sector; Rural; Low-resource setting

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