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1.  Socio-economic factors explain differences in public health-related variables among women in Bangladesh: A cross-sectional study 
BMC Public Health  2008;8:254.
Background
Worldwide one billion people are living in slum communities and experts projected that this number would double by 2030. Slum populations, which are increasing at an alarming rate in Bangladesh mainly due to rural-urban migration, are often neglected and characterized by poverty, poor housing, overcrowding, poor environment, and high prevalence of communicable diseases. Unfortunately, comparisons between women living in slums and those not living in slums are very limited in Bangladesh. The objectives of the study were to examine the association of living in slums (dichotomized as slum versus non-slum) with selected public health-related variables among women, first without adjusting for the influence of other factors and then in the presence of socio-economic variables.
Methods
Secondary data was used in this study. 120 women living in slums (as cases) and 480 age-matched women living in other areas (as controls) were extracted from the Bangladesh Demographic and Health Survey 2004. Many socio-economic and demographic variables were analysed. SPSS was used to perform simple as well as multiple analyses. P-values based on t-test and Wald test were also reported to show the significance level.
Results
Unadjusted results indicated that a significantly higher percent of women living in slums came from country side, had a poorer status by household characteristics, had less access to mass media, and had less education than women not living in slums. Mean BMI, knowledge of AIDS indicated by ever heard about AIDS, knowledge of avoiding AIDS by condom use, receiving adequate antenatal visits (4 or more) during the last pregnancy, and safe delivery practices assisted by skilled sources were significantly lower among women living in slums than those women living in other areas. However, all the unadjusted significant associations with the variable slum were greatly attenuated and became insignificant (expect safe delivery practices) when some socio-economic variables namely childhood place of residence, a composite variable of household characteristics, a composite variable of mass media access, and education were inserted into the multiple regression models. Taken together, childhood place of residence, the composite variable of mass media access, and education were the strongest predictors for the health related outcomes.
Conclusion
Reporting unadjusted findings of public health variables in women from slums versus non-slums can be misleading due to confounding factors. Our findings suggest that an association of childhood place of residence, mass media access and public health education should be considered before making any inference based on slum versus non-slum comparisons.
doi:10.1186/1471-2458-8-254
PMCID: PMC2496908  PMID: 18651946
2.  Prevalence and correlates of smoking among urban adult men in Bangladesh: slum versus non-slum comparison 
BMC Public Health  2009;9:149.
Background
Smoking is one of the leading causes of premature death particularly in developing countries. The prevalence of smoking is high among the general male population in Bangladesh. Unfortunately smoking information including correlates of smoking in the cities especially in the urban slums is very scarce, although urbanization is rapid in Bangladesh and slums are growing quickly in its major cities. Therefore this study reported prevalences of cigarette and bidi smoking and their correlates separately by urban slums and non-slums in Bangladesh.
Methods
We used secondary data which was collected by the 2006 Urban Health Survey. The data were representative for the urban areas in Bangladesh. Both slums and non-slums located in the six City Corporations were considered. Slums in the cities were identified by two steps, first by using the satellite images and secondly by ground truthing. At the next stage, several clusters of households were selected by using proportional sampling. Then from each of the selected clusters, about 25 households were randomly selected. Information of a total of 12,155 adult men, aged 15–59 years, was analyzed by stratifying them into slum (= 6,488) and non-slum (= 5,667) groups. Simple frequency, bivariable and multivariable logistic regression analyses were performed using SPSS.
Results
Overall smoking prevalence for the total sample was 53.6% with significantly higher prevalences among men in slums (59.8%) than non-slums (46.4%). Respondents living in slums reported a significantly (P < 0.001) higher prevalence of smoking cigarettes (53.3%) as compared to those living in non-slums (44.6%). A similar pattern was found for bidis (slums = 11.4% and non-slums = 3.2%, P < 0.001). Multivariable logistic regression revealed significantly higher odds ratio (OR) of smoking cigarettes (OR = 1.12, 95% CI = 1.03–1.22), bidis (OR = 1.90, 95% CI = 1.58–2.29) and any of the two (OR = 1.23, 95% CI = 1.13–1.34) among men living in slums as compared to those living in non-slums when controlled for age, division, education, marital status, religion, birth place and types of work. Division, education and types of work were the common significant correlates for both cigarette and bidi smoking in slums and non-slums by multivariable logistic regressions. Other significant correlates of smoking cigarettes were marital status (both areas), birth place (slums), and religion (non-slums). Similarly significant factors for smoking bidis were age (both areas), marital status (slums), religion (non-slums), and birth place (both areas).
Conclusion
The men living in the urban slums reported higher rates of smoking cigarettes and bidis as compared to men living in the urban non-slums. Some of the significant correlates of smoking e.g. education and division should be considered for prevention activities. Our findings clearly underscore the necessity of interventions and preventions by policy makers, public health experts and other stakeholders in slums because smoking was more prevalent in the slum communities with detrimental health sequelae.
doi:10.1186/1471-2458-9-149
PMCID: PMC2705350  PMID: 19463157
3.  Community Mobilization in Mumbai Slums to Improve Perinatal Care and Outcomes: A Cluster Randomized Controlled Trial 
PLoS Medicine  2012;9(7):e1001257.
David Osrin and colleagues report findings from a cluster-randomized trial conducted in Mumbai slums; the trial aimed to evaluate whether facilitator-supported women's groups could improve perinatal outcomes.
Introduction
Improving maternal and newborn health in low-income settings requires both health service and community action. Previous community initiatives have been predominantly rural, but India is urbanizing. While working to improve health service quality, we tested an intervention in which urban slum-dweller women's groups worked to improve local perinatal health.
Methods and Findings
A cluster randomized controlled trial in 24 intervention and 24 control settlements covered a population of 283,000. In each intervention cluster, a facilitator supported women's groups through an action learning cycle in which they discussed perinatal experiences, improved their knowledge, and took local action. We monitored births, stillbirths, and neonatal deaths, and interviewed mothers at 6 weeks postpartum. The primary outcomes described perinatal care, maternal morbidity, and extended perinatal mortality. The analysis included 18,197 births over 3 years from 2006 to 2009. We found no differences between trial arms in uptake of antenatal care, reported work, rest, and diet in later pregnancy, institutional delivery, early and exclusive breastfeeding, or care-seeking. The stillbirth rate was non-significantly lower in the intervention arm (odds ratio 0.86, 95% CI 0.60–1.22), and the neonatal mortality rate higher (1.48, 1.06–2.08). The extended perinatal mortality rate did not differ between arms (1.19, 0.90–1.57). We have no evidence that these differences could be explained by the intervention.
Conclusions
Facilitating urban community groups was feasible, and there was evidence of behaviour change, but we did not see population-level effects on health care or mortality. In cities with multiple sources of health care, but inequitable access to services, community mobilization should be integrated with attempts to deliver services for the poorest and most vulnerable, and with initiatives to improve quality of care in both public and private sectors.
Trial registration
Current Controlled Trials ISRCTN96256793
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Substantial progress is being made to reduce global child mortality (deaths of children before the age of 5 years) and maternal mortality (deaths among women because of complications of pregnancy and childbirth)—two of the Millennium Development Goals agreed by world leaders in 2000 to end extreme poverty. Even so, worldwide, in 2010, 7.6 million children died before their fifth birthday and there were nearly 360,000 maternal deaths. Almost all child and maternal deaths occur in developing countries—a fifth of under-five deaths and more than a quarter of neonatal deaths (deaths during the first month of life, which account for two-fifths of all child deaths) occur in India alone. Moreover, most child and maternal deaths are caused by avoidable conditions. Specifically, the major causes of neonatal death—complications of preterm delivery, breathing problems during or after delivery, and infections of the blood (sepsis) and lungs (pneumonia)—and of maternal deaths—hemorrhage (abnormal bleeding), sepsis, unsafe abortion, obstructed labor, and hypertensive diseases of pregnancy—could all be largely prevented by improved access to reproductive health services and skilled health care workers.
Why Was This Study Done?
Experts believe that improvements to maternal and newborn health in low-income settings require both health service strengthening and community action. That is, the demand for better services, driven by improved knowledge about maternal and newborn health (perinatal issues), has to be increased in parallel with the supply of those services. To date, community mobilization around perinatal issues has largely been undertaken in rural settings but populations in developing countries are becoming increasingly urban. In India, for example, 30% of the population now lives in cities. In this cluster randomized controlled trial (a study in which groups of people are randomly assigned to receive alternative interventions and the outcomes in the differently treated “clusters” are compared), City Initiative for Newborn Health (CINH) researchers investigate the effect of an intervention designed to help women's groups in the slums of Mumbai work towards improving local perinatal health. The CINH aims to improve maternal and newborn health in slum communities by improving public health care provision and by working with community members to improve maternal and newborn care practices and care-seeking behaviors.
What Did the Researchers Do and Find?
The researchers enrolled 48 Mumbai slum communities of at least 1,000 households into their trial. In each of the 24 intervention clusters, a facilitator supported local women's groups through a 36-meeting learning cycle during which group members discussed their perinatal experiences, improved their knowledge, and took action. To measure the effect of the intervention, the researchers monitored births, stillbirths, and neonatal deaths in all the clusters and interviewed mothers 6 weeks after delivery. During the 3-year trial, there were 18,197 births in the participating settlements. The women in the intervention clusters were enthusiastic about acquiring new knowledge and made substantial efforts to reach out to other women but were less successful in undertaking collective action such as negotiations with civic authorities for more amenities. There were no differences between the intervention and control communities in the uptake of antenatal care, reported work, rest, and diet in late pregnancy, institutional delivery, or in breast feeding and care-seeking behavior. Finally, the combined rate of stillbirths and neonatal deaths (the extended perinatal mortality rate) was the same in both arms of the trial, as was maternal mortality.
What Do These Findings Mean?
These findings indicate that it is possible to facilitate the discussion of perinatal health care by urban women's groups in the challenging conditions that exist in the slums of Mumbai. However, they fail to show any measureable effect of community mobilization through the facilitation of women's groups on perinatal health at the population level. The researchers acknowledge that more intensive community activities that target the poorest, most vulnerable slum dwellers might produce measurable effects on perinatal mortality, and they conclude that, in cities with multiple sources of health care and inequitable access to services, it remains important to integrate community mobilization with attempts to deliver services to the poorest and most vulnerable, and with initiatives to improve the quality of health care in both the public and private sector.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001257.
The United Nations Childrens Fund (UNICEF) works for children's rights, survival, development, and protection around the world; it provides information on the reduction of child mortality (Millennium Development Goal 4); its Childinfo website provides information about all the Millennium Development Goals and detailed statistics about on child survival and health, newborn care, and maternal health (some information in several languages)
The World Health Organization also has information about Millennium Development Goal 4 and Millennium Development Goal 5, the reduction of maternal mortality, provides information on newborn infants, and provides estimates of child mortality rates (some information in several languages)
Further information about the Millennium Development Goals is available
Information on the City Initiative for Newborn Health and its partners and a detailed description of its trial of community mobilization in Mumbai slums to improve care during pregnancy, delivery, postnatally and for the newborn are available
Further information about the Society for Nutrition, Education and Health Action (SNEHA) is available
doi:10.1371/journal.pmed.1001257
PMCID: PMC3389036  PMID: 22802737
4.  Newborn care practices among slum dwellers in Dhaka, Bangladesh: a quantitative and qualitative exploratory study 
Background
Urbanization is occurring at a rapid pace, especially in low-income countries. Dhaka, Bangladesh, is estimated to grow to 50 million by 2015, with 21 million living in urban slums. Although health services are available, neonatal mortality is higher in slum areas than in urban non-slum areas. The Manoshi program works to improve maternal, newborn, and child health in urban slums in Bangladesh. This paper describes newborn care practices in urban slums in Dhaka and provides program recommendations.
Methods
A quantitative baseline survey was conducted in six urban slum areas to measure newborn care practices among recently delivered women (n = 1,256). Thirty-six in-depth semi-structured interviews were conducted to explore newborn care practices among currently pregnant women (n = 18) and women who had at least one delivery (n = 18).
Results
In the baseline survey, the majority of women gave birth at home (84%). Most women reported having knowledge about drying the baby (64%), wrapping the baby after birth (59%), and cord care (46%). In the in-depth interviews, almost all women reported using sterilized instruments to cut the cord. Babies are typically bathed soon after birth to purify them from the birth process. There was extensive care given to the umbilical cord including massage and/or applying substances, as well as a variety of practices to keep the baby warm. Exclusive breastfeeding was rare; most women reported first giving their babies sweet water, honey and/or other foods.
Conclusion
These reported newborn care practices are similar to those in rural areas of Bangladesh and to urban and rural areas in the South Asia region. There are several program implications. Educational messages to promote providing newborn care immediately after birth, using sterile thread, delaying bathing, and ensuring dry cord care and exclusive breastfeeding are needed. Programs in urban slum areas should also consider interventions to improve social support for women, especially first time mothers. These interventions may improve newborn survival and help achieve MDG4.
doi:10.1186/1471-2393-9-54
PMCID: PMC2784437  PMID: 19919700
5.  Prevalence and determinants of unintended pregnancy among women in Nairobi, Kenya 
Background
The prevalence of unintended pregnancy in Kenya continues to be high. The 2003 Kenya Demographic and Health Survey (KDHS) showed that nearly 50% of unmarried women aged 15–19 and 45% of the married women reported their current pregnancies as mistimed or unwanted. The 2008–09 KDHS showed that 43% of married women in Kenya reported their current pregnancies were unintended. Unintended pregnancy is one of the most critical factors contributing to schoolgirl drop out in Kenya. Up to 13,000 Kenyan girls drop out of school every year as a result of unintended pregnancy. Unsafe pregnancy termination contributes immensely to maternal mortality which currently estimated at 488 deaths per 100 000 live births. In Kenya, the determinants of prevalence and determinants of unintended pregnancy among women in diverse social and economic situations, particularly in urban areas, are poorly understood due to lack of data. This paper addresses the prevalence and the determinants of unintended pregnancy among women in slum and non-slum settlements of Nairobi.
Methods
This study used the data that was collected among a random sample of 1262 slum and non-slum women aged 15–49 years in Nairobi. The data was analyzed using simple percentages and logistic regression.
Results
The study found that 24 percent of all the women had unintended pregnancy. The prevalence of unintended pregnancy was 21 per cent among women in slum settlements compared to 27 per cent among those in non-slum settlements. Marital status, employment status, ethnicity and type of settlement were significantly associated with unintended pregnancy. Logistic analysis results indicate that age, marital status and type of settlement had statistically significantly effects on unintended pregnancy. Young women aged 15–19 were significantly more likely than older women to experience unintended pregnancy. Similarly, unmarried women showed elevated risk for unintended pregnancy than ever-married women. Women in non-slum settlements were significantly more likely to experience unintended pregnancy than their counterparts in slum settlements.
The determinants of unintended pregnancy differed between women in each type of settlement. Among slum women, age, parity and marital status each had significant net effect on unintended pregnancy. But for non-slum women, it was marital status and ethnicity that had significant net effects.
Conclusion
The study found a high prevalence of unintended pregnancy among the study population and indicated that young and unmarried women, irrespective of their educational attainment and household wealth status, have a higher likelihood of experiencing unintended pregnancy. Except for the results on educational attainments and household wealth, these results compared well with the results reported in the literature.
The results indicate the need for effective programs and strategies to increase access to contraceptive services and related education, information and communication among the study population, particularly among the young and unmarried women. Increased access to family planning services is key to reducing unintended pregnancy among the study population. This calls for concerted efforts by all the stakeholders to improve access to family planning services among the study population. Increased access should be accompanied with improvement in the quality of care and availability of information about effective utilization of family planning methods.
doi:10.1186/1471-2393-13-69
PMCID: PMC3607892  PMID: 23510090
Unintended pregnancy; Determinants; Slum; Non-slum settlements; Urban; Nairobi; Kenya
6.  Knowledge, Attitudes, and Practices Surrounding Breast Cancer and Screening in Female Teachers of Buraidah, Saudi Arabia 
Background :
Breast cancer is by far the most frequent cancer of women. However the preventive measures for such problem are probably less than expected. The objectives of this study are to assess breast cancer knowledge and attitudes and factors associated with the practice of breast self examination (BSE) among female teachers of Saudi Arabia.
Patients and Methods:
We conducted a cross-sectional survey of teachers working in female schools in Buraidah, Saudi Arabia using a self-administered questionnaire to investigate participants’ knowledge about the risk factors of breast cancer, their attitudes and screening behaviors. A sample of 376 female teachers was randomly selected. Participants lived in urban areas, and had an average age of 34.7 ±5.4 years.
Results:
More than half of the women showed a limited knowledge level. Among participants, the most frequently reported risk factors were non-breast feeding and the use of female sex hormones. The printed media was the most common source of knowledge. Logistic regression analysis revealed that high income was the most significant predictor of better knowledge level. Knowing a non-relative case with breast cancer and having a high knowledge level were identified as the significant predictors for practicing BSE.
Conclusions:
The study points to the insufficient knowledge of female teachers about breast cancer and identified the negative influence of low knowledge on the practice of BSE. Accordingly, relevant educational programs to improve the knowledge level of women regarding breast cancer are needed.
PMCID: PMC3068667  PMID: 21475453
breast cancer; Saudi Arabia; knowledge; screening; self examination of breast
7.  Women’s Reproductive Health in Slum Populations in India: Evidence From NFHS-3 
The urban population in India is one of the largest in the world. Its unprecedented growth has resulted in a large section of the population living in abject poverty in overcrowded slums. There have been limited efforts to capture the health of people in urban slums. In the present study, we have used data collected during the National Family Health Survey-3 to provide a national representation of women’s reproductive health in the slum population in India. We examined a sample of 4,827 women in the age group of 15–49 years to assess the association of the variable slum with selected reproductive health services. We have also tried to identify the sociodemographic factors that influence the utilization of these services among women in the slum communities. All analyses were stratified by slum/non-slum residence, and multivariate logistic regression was used to analyze the strength of association between key reproductive health services and relevant sociodemographic factors. We found that less than half of the women from the slum areas were currently using any contraceptive methods, and discontinuation rate was higher among these women. Sterilization was the most common method of contraception (25%). Use of contraceptives depended on the age, level of education, parity, and the knowledge of contraceptive methods (p < 0.05). There were significant differences in the two populations based on the timing and frequency of antenatal visits. The probability of ANC visits depended significantly on the level of education and economic status (p < 0.05). We found that among slum women, the proportion of deliveries conducted by skilled attendants was low, and the percentage of home deliveries was high. The use of skilled delivery care was found to be significantly associated with age, level of education, economic status, parity, and prior antenatal visits (p < 0.05). We found that women from slum areas depended on the government facilities for reproductive health services. Our findings suggest that significant differences in reproductive health outcomes exist among women from slum and non-slum communities in India. Efforts to progress towards the health MDGs and other national or international health targets may not be achieved without a focus on the urban slum population.
doi:10.1007/s11524-009-9421-0
PMCID: PMC2845837  PMID: 20148311
Slum; India; National Family Health Survey-3; Contraception; Antenatal care; Skilled delivery care
8.  Breast Self-Examination and breast cancer awareness in women in developing countries: a survey of women in Buea, Cameroon 
BMC Research Notes  2012;5:627.
Background
Breast cancer is one of the leading causes of cancer morbidity and mortality worldwide. In Cameroon, breast cancer causes as many as 10.7 deaths per 100,000 women making it the second cause of cancer mortality. Better documenting women’s knowledge and practices on breast cancer and breast self-exam (BSE) would be useful in the design of interventions aimed at preventing breast cancer. This study sought to 1. describe Cameroonian women’s knowledge of breast self-examination (BSE); 2. assess their impression on the practice of BSE and 3. describe their perceptions on the causes, risk factors and prevention of breast cancer.
Methods
A cross-sectional survey was conducted in a volunteer sample of 120 consenting women in Buea, Cameroon. Data were collected using a structured questionnaire self-administered by study participants.
Results
The sample was fairly educated with close to three quarters (70.83%) having completed high school. Nearly three quarters (74.17%) of participants had previously heard about BSE, however as many as 40% had never done a BSE. Although 95% of participants believed that breast cancer could be prevented, only 36.67% recognized breast examination as a prevention method. A substantial 13.33% thought that breast cancer could be prevented with a vaccine while 45% thought that dieting or exercising would prevent breast cancer. Similarly, 70% of participants thought that breast cancer could be treated, with 35.83% thinking that it could be treated medically while 34.17% thought it could be treated traditionally or spiritually.
Conclusions
The practice of BSE while perceived as being important is not frequent in these women in Buea, Cameroon. Health education campaigns are imperative to elucidate the public on the causes, risk factors and prevention of breast cancer. Further studies need to explore what interventions could be best used to improve the uptake and practice of BSE.
doi:10.1186/1756-0500-5-627
PMCID: PMC3522012  PMID: 23140094
Breast cancer; Breast Self-Exam; Knowledge; Practices; Cameroon
9.  Home visits to improve breast health knowledge and screening practices in a less privileged area in Jordan 
BMC Public Health  2014;14:428.
Background
Breast cancer is the most common cancer afflicting women in Jordan. This study aimed to assess the effects of an educational intervention through home visits, including offering free mammography screening vouchers, on changing women’s breast health knowledge and screening practices for early detection of breast cancer in a less privileged area in Jordan.
Methods
Two thousand four hundred breast health awareness home visits were conducted and 2363 women aged 20-79 years (median: 41) answered a pre-test interview-administrated questionnaire to assess their breast health knowledge and practices at the baseline. After a home-based educational session, 625 women aged 40 years or older were referred to free mammography screening. Five hundred and ninety six homes were revisited six months later and out of these 593 women participated in a post-test. The women’s retained breast health knowledge, the changes in their reported breast health practices and their usage of the free mammography voucher, were assessed.
Results
The mean knowledge score increased significantly (p < 0.001) from 11.4 in the pre-test to 15.7 in the post-test (maximum score: 16). At the six month follow-up the post-test showed significant (p < 0.001) improvement in women’s perceived breast self-examination (BSE) knowledge, reported BSE practice and mammography screening. Out of 625 women that received a voucher for free mammography screening 73% attended the mammography unit, while only two women without a voucher went for mammography screening at the assigned unit. Women who received a follow-up visit were more likely to use the free mammography voucher compared to those who were not followed-up (83% vs. 67%; p < 0.001).
Conclusions
Home visits by local community outreach workers that incorporated education about breast cancer and breast health in addition to offering free mammography screening vouchers were effective in improving women’s breast health knowledge and practices in a less privileged area in Jordan.
doi:10.1186/1471-2458-14-428
PMCID: PMC4031932  PMID: 24885063
10.  Prevalence and correlates of physical spousal violence against women in slum and non-slum areas of urban Bangladesh 
Journal of interpersonal violence  2011;26(13):10.1177/0886260510388282.
This study explored the prevalence and correlates of past-year physical violence against women in slum and non-slum areas of urban Bangladesh. We used multivariate logistic regression to analyze data from the 2006 Urban Health Survey, a population-based survey of 9122 currently married women aged 15–49 selected using a multi-stage cluster sampling design. The prevalence of reported past-year physical spousal violence was 31%. Prevalence of past-year physical spousal violence was higher in slums (35%) than in non-slums (20%). Slapping/arm-twisting and pushing/shaking/throwing something at the women were the most commonly reported acts of physical abuse. Multivariate analysis showed that the risk of physical spousal abuse was lower among older women, women with post-primary education, and those belonging to rich households and women whose husband considered their opinion in decision-making. Women were at higher risk of abuse if they had many children, believed that married woman should work if the husband is not making enough money, and approved wife beating norms. This study serves to confirm the commonness of physical spousal abuse in urban Bangladesh demonstrating the seriousness of this multifaceted phenomenon as a social and public health issue. The present findings suggest the need for comprehensive prevention and intervention strategies that capitalize on the interplay of individual and sociocultural factors that cause physical spousal violence. Our study adds to a growing literature documenting domestic violence against women in urban areas of developing south Asian nations.
doi:10.1177/0886260510388282
PMCID: PMC3845968  PMID: 21831870
11.  Implementing academic detailing for breast cancer screening in underserved communities 
Background
African American and Hispanic women, such as those living in the northern Manhattan and the South Bronx neighborhoods of New York City, are generally underserved with regard to breast cancer prevention and screening practices, even though they are more likely to die of breast cancer than are other women. Primary care physicians (PCPs) are critical for the recommendation of breast cancer screening to their patients. Academic detailing is a promising strategy for improving PCP performance in recommending breast cancer screening, yet little is known about the effects of academic detailing on breast cancer screening among physicians who practice in medically underserved areas. We assessed the effectiveness of an enhanced, multi-component academic detailing intervention in increasing recommendations for breast cancer screening within a sample of community-based urban physicians.
Methods
Two medically underserved communities were matched and randomized to intervention and control arms. Ninety-four primary care community (i.e., not hospital based) physicians in northern Manhattan were compared to 74 physicians in the South Bronx neighborhoods of the New York City metropolitan area. Intervention participants received enhanced physician-directed academic detailing, using the American Cancer Society guidelines for the early detection of breast cancer. Control group physicians received no intervention. We conducted interviews to measure primary care physicians' self-reported recommendation of mammography and Clinical Breast Examination (CBE), and whether PCPs taught women how to perform breast self examination (BSE).
Results
Using multivariate analyses, we found a statistically significant intervention effect on the recommendation of CBE to women patients age 40 and over; mammography and breast self examination reports increased across both arms from baseline to follow-up, according to physician self-report. At post-test, physician involvement in additional educational programs, enhanced self-efficacy in counseling for prevention, the routine use of chart reminders, computer- rather than paper-based prompting and tracking approaches, printed patient education materials, performance targets for mammography, and increased involvement of nursing and other office staff were associated with increased screening.
Conclusion
We found some evidence of improvement in breast cancer screening practices due to enhanced academic detailing among primary care physicians practicing in urban underserved communities.
doi:10.1186/1748-5908-2-43
PMCID: PMC2266776  PMID: 18086311
12.  Preventive health care, 2001 update: Should women be routinely taught breast self-examination to screen for breast cancer? 
Objectives
To evaluate the evidence relating to the effectiveness of breast self-examination (BSE) to screen for breast cancer and to provide recommendations for routine teaching of BSE to women in various age groups as part of a periodic health examination.
Options
Routine teaching of BSE to women.
Evidence
The electronic databases MEDLINE, PreMEDLINE, CINAHL, HealthSTAR, Current Contents and the Cochrane Library were searched for abstracts and full reports of studies published from 1966 to October 2000 that evaluated the effectiveness of BSE in reducing breast cancer mortality. In addition, references of key papers were searched and experts consulted to ensure that all relevant articles had been identified.
Outcomes
Prevention of death from breast cancer was viewed as the most important outcome; other outcomes examined included the stage of cancer detected, the rate of benign biopsy results, the number of patient visits for breast complaints, and psychological benefits and harms.
Values
The recommendations of this report reflect the commitment of the Canadian Task Force on Preventive Health Care to provide a structured, evidence-based appraisal of whether a manoeuvre should be included in the periodic health examination.
Benefits, harms and costs
Breast cancer is the most frequently diagnosed cancer among Canadian women, accounting for 30% of all new cancer cases each year. In 2000 an estimated 19 200 Canadian women would have been diagnosed with breast cancer, and 5500 would have died from the disease. To date, 2 large randomized controlled trials, a quasi-randomized trial, a large cohort study and several case–control studies have failed to show a benefit for regular performance of BSE or BSE education, compared with no BSE. In contrast, there is good evidence of harm from BSE instruction, including significant increases in the number of physician visits for the evaluation of benign breast lesions and significantly higher rates of benign biopsy results.
Recommendations
· Women aged 40–49 years: Because there is fair evidence of no benefit, and good evidence of harm, there is fair evidence to recommend that routine teaching of BSE be excluded from the periodic health examination of women in this age group (grade D recommendation). · Women aged 50–69 years: Because there is fair evidence of no benefit, and good evidence of harm, there is fair evidence to recommend that routine teaching of BSE be excluded from the periodic health examination of women in this age group (grade D recommendation). · The lack of sufficient evidence to evaulate the effectiveness of the manoeuvre in women younger than 40 years and those 70 years and older precludes making recommendations for teaching BSE to women in these age groups. The following issues may be important to consider: Women younger than 40 years: There is little evidence for effectiveness specific to this group. Because the incidence of breast cancer is low in this age group, the risk of net harm from BSE and BSE instruction is even more likely. Women 70 years and older: Although the incidence of breast cancer is high in this group, there is insufficient evidence to make a recommendation concerning BSE for women 70 years and older. · Important note: Although the evidence indicates no benefit from routine instruction, some women will ask to be taught BSE. The potential benefits and harms should be discussed with the woman, and if BSE is taught, care must be taken to ensure she performs BSE in a proficient manner.
Validation
The findings of this analysis were reviewed through an iterative process by the members of the Canadian Task Force on Preventive Health Care. The task force sent the final review and recommendations to 4 independent experts, and their feedback was incorporated in the final draft of the manuscript.
Sponsors
The Canadian Task Force on Preventive Health Care is funded through a partnership between the Provincial and Territorial Ministries of Health and Health Canada.
PMCID: PMC81191  PMID: 11450279
13.  The knowledge and attitudes of breast self-examination and mammography in a group of women in a rural area in western Turkey 
BMC Cancer  2006;6:43.
Background
Breast cancer appears to be a disease of both the developing and developed worlds. Among Turkish women, breast cancer is the second leading cause of cancer-related deaths. The aims of this cross-sectional study were to determine levels of knowledge about breast cancer and to evaluate health beliefs concerning the model that promotes breast self- examination (BSE) and mammography in a group of women aged 20–64 in a rural area of western Turkey.
Methods
244 women were recruited by means of cluster sampling in this study. The questionnaire consisted of sociodemographic variables, a risk factors and signs of breast cancer form and the adapted version of Champion's Health Belief Model Scale (CHBMS). Bivariate correlation analysis, Chi square test, Mann-Whitney U test and logistic regression analysis were performed throughout the data analysis.
Results
The mean age of the women was 37.7 ± 13.7. 49.2% of women were primary school graduates, 67.6% were married. Although 76.6% of the women in this study reported that they had heard or read about breast cancer, our study revealed that only 56.1% of them had sufficient knowledge of breast cancer, half of whom had acquired the information from health professionals.
Level of breast cancer knowledge was the only variable significantly associated with the BSE and mammography practice (p = 0.011, p = 0.007). BSE performers among the study group were more likely to be women who exhibited higher confidence and perceived greater benefits from BSE practice, and those who perceived fewer barriers to BSE performance and possessed knowledge of breast cancer.
Conclusion
By using the CHBMS constructs for assessment, primary health care providers can more easily understand the beliefs that influence women's BSE and mammography practice.
doi:10.1186/1471-2407-6-43
PMCID: PMC1403793  PMID: 16504119
14.  Beliefs and practices during pregnancy and childbirth in urban slums of Dhaka, Bangladesh 
BMC Public Health  2012;12:791.
Background
Worldwide urbanization has become a crucial issue in recent years. Bangladesh, one of the poorest and most densely-populated countries in the world, has been facing rapid urbanization. In urban areas, maternal indicators are generally worse in the slums than in the urban non-slum areas. The Manoshi program at BRAC, a non governmental organization, works to improve maternal, newborn, and child health in the urban slums of Bangladesh. This paper describes maternal related beliefs and practices in the urban slums of Dhaka and provides baseline information for the Manoshi program.
Methods
This is a descriptive study where data were collected using both quantitative and qualitative methods. The respondents for the quantitative methods, through a baseline survey using a probability sample, were mothers with infants (n = 672) living in the Manoshi program areas. Apart from this, as part of a formative research, thirty six in-depth semi-structured interviews were conducted during the same period from two of the above Manoshi program areas among currently pregnant women who had also previously given births (n = 18); and recently delivered women (n = 18).
Results
The baseline survey revealed that one quarter of the recently delivered women received at least four antenatal care visits and 24 percent women received at least one postnatal care visit. Eighty-five percent of deliveries took place at home and 58 percent of the deliveries were assisted by untrained traditional birth attendants. The women mostly relied on their landladies for information and support. Members of the slum community mainly used cheap, easily accessible and available informal sectors for seeking care. Cultural beliefs and practices also reinforced this behavior, including home delivery without skilled assistance.
Conclusions
Behavioral change messages are needed to increase the numbers of antenatal and postnatal care visits, improve birth preparedness, and encourage skilled attendance at delivery. Programs in the urban slum areas should also consider interventions to improve social support for key influential persons in the community, particularly landladies who serve as advisors and decision-makers.
doi:10.1186/1471-2458-12-791
PMCID: PMC3532223  PMID: 22978705
Beliefs and practices; Maternal care; Urban-slum; Bangladesh
15.  Effectiveness of personalised, home-based nutritional counselling on infant feeding practices, morbidity and nutritional outcomes among infants in Nairobi slums: study protocol for a cluster randomised controlled trial 
Trials  2013;14:445.
Background
Nutrition in the first 1,000 days of life (during pregnancy and the first two years) is critical for child growth and survival. Poor maternal, infant and young child nutrition (MIYCN) practices are widely documented in Kenya, with potential detrimental effects on child growth and survival. This is particularly a problem in slums, where most urban residents live. For example, exclusive breastfeeding for the first six months is only about two per cent. Innovative strategies to reach slum residents are therefore needed. Strategies like the Baby Friendly Hospital Initiative have proven effective in some settings but their effectiveness in resource-limited settings, including slums where many women do not deliver in hospital, is questionable. We propose to test the effectiveness of a home-based intervention on infant feeding practices, nutrition and health outcomes of infants born in two slums in Nairobi, Kenya.
Methods/Design
The study, employing a cluster-randomised study design, will be conducted in two slums in Nairobi: Korogocho and Viwandani where 14 community units (defined by the Government’s health care system) will form the unit of randomization. A total of 780 pregnant women and their respective child will be recruited into the study. The mother-child pair will be followed up until the child is one year old. Recruitment will last approximately one year and three months from September 2012 to December 2013. The mothers will receive regular, personalised, home-based counselling by trained Community Health Workers on MIYCN. Regular assessment of knowledge, attitudes and practices on MIYCN will be done, coupled with assessments of nutritional status of the mother-child pairs and diarrhea morbidity for the children. Statistical methods will include analysis of covariance and multinomial logistic regression. Additionally, cost-effectiveness analysis will be done. The study is funded by the Wellcome Trust and will run from March 2012 to February 2015.
Discussion
Interventions aimed at promoting optimal breastfeeding and complementary feeding practices are considered to have high impact and could prevent a fifth of the under-five deaths in countries with high mortality rates. This study will inform policy and practice in Kenya and similar settings regarding delivery mechanisms for such high-impact interventions, particularly among urban poor populations.
Trial registration
ISRCTN83692672
doi:10.1186/1745-6215-14-445
PMCID: PMC3879433  PMID: 24370263
Breastfeeding; Infant feeding practices; Child nutrition; Cluster randomised controlled trials; Kenya; Sub-Saharan Africa; Urban slums
16.  Awareness and attitudes regarding breast cancer and breast self-examination among female Jordanian students 
Background:
Despite huge efforts to increase the level of breast cancer awareness, breast self-examination (BSE) is still poorly practiced across Jordan. This baseline study aimed to assess the awareness of female Jordanian students about breast cancer and their practice of BSE.
Materials and Methods:
Using a cross-sectional research design, a self-administered survey was used, via a pre-validated pre-piloted questionnaire was distributed to 900 female students aged between 18 and 37 years recruited from the University of Jordan in Amman. The questionnaire was divided into four domains: Socio-demographic characteristics; the respondent's knowledge of breast cancer and BSE; their attitude towards risk factors for breast cancer; their experience of breast cancer screening and BSE. Statistical analysis was performed using Epi-Info version 6.4 statistical Software.
Results:
The overall response rate was 93.3%. Approximately half of the respondents 435 (51.8%) were aware of breast cancer. Of these, 99 (22.7%) believed that it was caused by a medical condition, followed by old age (71; 16.4%), lack of breastfeeding (58; 13.3%), heredity (56; 12.8%), late marriage (44; 10.3%), pregnancies in older women (33; 7.5%), the use of brassieres (18; 4.1%), excessive breastfeeding (17; 3.9%), being unmarried (14; 3.2%), and spirituality (11; 2.6%). Overall, 152 participants (34.9%) were aware of BSE, but only 93 (11%) had performed it.
Conclusions:
The current status of awareness of breast cancer in Jordanian students and their use of BSE are insufficient. Women need to be encouraged to self-monitor in order to detect abnormalities in their breasts. Appropriate educational interventions are urgently required to encourage women to engage in regular BSE.
doi:10.4103/0976-0105.139730
PMCID: PMC4160723  PMID: 25278670
Awareness; breast cancer; knowledge; practice; self-examination
17.  Childhood vaccination in informal urban settlements in Nairobi, Kenya: Who gets vaccinated? 
BMC Public Health  2011;11:6.
Background
Recent trends in global vaccination coverage have shown increases with most countries reaching 90% DTP3 coverage in 2008, although pockets of undervaccination continue to persist in parts of sub-Saharan Africa particularly in the urban slums. The objectives of this study were to determine the vaccination status of children aged between 12-23 months living in two slums of Nairobi and to identify the risk factors associated with incomplete vaccination.
Methods
The study was carried out as part of a longitudinal Maternal and Child Health study undertaken in Korogocho and Viwandani slums of Nairobi. These slums host the Nairobi Urban Health and Demographic Surveillance System (NUHDSS) run by the African Population and Health Research Centre (APHRC). All women from the NUHDSS area who gave birth since September 2006 were enrolled in the project and administered a questionnaire which asked about the vaccination history of their children. For the purpose of this study, we used data from 1848 children aged 12-23 months who were expected to have received all the WHO-recommended vaccinations. The vaccination details were collected during the first visit about four months after birth with follow-up visits repeated thereafter at four month intervals. Full vaccination was defined as receiving all the basic childhood vaccinations by the end of 24 months of life, whereas up-to-date (UTD) vaccination referred to receipt of BCG, OPV 1-3, DTP 1-3, and measles vaccinations within the first 12 months of life. All vaccination data were obtained from vaccination cards which were sighted during the household visit as well as by recall from mothers. Multivariate models were used to identify the risk factors associated with incomplete vaccination.
Results
Measles coverage was substantially lower than that for the other vaccines when determined using only vaccination cards or in addition to maternal recall. Up-to-date (UTD) coverage with all vaccinations at 12 months was 41.3% and 51.8% with and without the birth dose of OPV, respectively. Full vaccination coverage (57.5%) was higher than up-to-date coverage (51.8%) at 12 months overall, and in both slum settlements, using data from cards. Multivariate analysis showed that household assets and expenditure, ethnicity, place of delivery, mother's level of education, age and parity were all predictors of full vaccination among children living in the slums.
Conclusions
The findings show the extent to which children resident in slums are underserved with vaccination and indicate that service delivery of immunization services in the urban slums needs to be reassessed to ensure that all children are reached.
doi:10.1186/1471-2458-11-6
PMCID: PMC3024932  PMID: 21205306
18.  EFFECT OF A BREAST CANCER HEALTH EDUCATION PROGRAM ON THE AWARENESS AND PRACTICE OF JEDDAH FEMALE SECONDARY SCHOOL STUDENTS 
Objective:
To identify the effect of a school health education program on the knowledge of secondary school girls in Jeddah, Saudi Arabia, of breast cancer and breast self-examination (BSE) and their practice of BSE.
Methodology:
A pre-tested, self-administered questionnaire was administered to secondary students before the commencement of the health education to assess their knowledge on breast cancer and their practice of BSE. The same questionnaire was handed 6 months later to a smaller group of these students as a post-test. As the post-test group was smaller than the pre-test group, an equal sample size from the pre-test group was drawn for comparison. Random sampling and further analysis was done using the SPSS program, and for the comparison of the two groups, the student t-test and chi square were used.
Results:
The post-test was answered by 1372 students. The sampled re-test group comprised 1400 students (N= 7663) forming a sample of 18.3%. The ages for both groups ranged between 16-25 years (mean = 18.4; SD=1.9). Saudi nationals formed 73.4% of both groups and the proportion of married students was 8.4%. Those who reported that they had relatives with breast mass were 11.2%. The mean knowledge indexes on breast cancer reached 19.7 for the pre-test group and 43.0 for the post-group (t=31.2; p<0.0001). Correct answers for BSE rose significantly among the post-test group. A proportion of 27.2% students from the post-group reported that they had been motivated to practice BSE at least 3 times during the last 6 month.
Conclusion and recommendation:
The outcome of the school health education program on breast cancer had been successful in raising the awareness of secondary school girls and in helping them to practice BSE more. Hence, it is recommended that the programme be implemented in all female secondary schools and colleges.
PMCID: PMC3439736  PMID: 23008611
Breast cancer; breast self-examination; health education; student knowledge
19.  The Health of the Poor: Women Living in Informal Settlements 
Ghana Medical Journal  2012;46(2):104-112.
Summary
Objectives
A large share of the urban population in developing countries lives in informal settlements or “slums” today. This study investigates the association between slum residence and health among adult Ghanaian women residing in the Accra Metropolitan Area.
Methods
Health data collected as part of the Women's Health Study of Accra round II (WHSA-II) was combined with data from the Household and Welfare Study of Accra (HAWS) to compare the health of female slum dwellers to the health of female non-slum dwellers living in the Accra Metropolitan Area. Group means were calculated and multivariate linear regression models were estimated to compare eight domains of health as measured by the short-form 36 (SF-36) questionnaire.
Results
Women living in informal settlements were found to display consistently better health. Conditional on all observable characteristics, women living in informal settlements scored higher on all self-reported health outcomes than women living in non-slum areas. The differences appear largest for general health as well as for the physical role functioning domains, and appear smallest for the social role functioning and bodily pain domains.
Conclusions
The results presented suggest that slum residence does not have a negative effect on self-reported health among women in Accra. Three factors may contribute to the generally positive association between slum residence and observed outcomes: i) self-selection of individuals with strong health into informal settlements and an accordingly small impact of environmental factors on health ii) self-selection of more driven and ambitious individuals into slum neighborhoods who may have a generally more positive view of their health and iii) the geographic placement of slum neighborhoods in central neighborhoods with relatively easy access to health facilities.
PMCID: PMC3426377  PMID: 22942458
slums; urban health; informal settlements; short-form 36 (SF-36)
20.  Knowledge, attitude and practice of Nigerian women towards breast cancer: A cross-sectional study 
Background
Late presentation of patients at advanced stages when little or no benefit can be derived from any form of therapy is the hallmark of breast cancer in Nigerian women. Recent global cancer statistics indicate rising global incidence of breast cancer and the increase is occurring at a faster rate in populations of the developing countries that hitherto enjoyed low incidence of the disease. Worried by this prevailing situation and with recent data suggesting that health behavior may be influenced by level of awareness about breast cancer, a cross-sectional study was designed to assess the knowledge, attitude and practices of community-dwelling women in Nigeria towards breast cancer.
Methods
One thousand community-dwelling women from a semi-urban neighborhood in Nigeria were recruited for the study in January and February 2000 using interviewer-administered questionnaires designed to elicit sociodemographic information and knowledge, attitude and practices of these women towards breast cancer. Data analysis was carried out using Statistical Analysis Software (SAS) version 8.2.
Results
Study participants had poor knowledge of breast cancer. Mean knowledge score was 42.3% and only 214 participants (21.4%) knew that breast cancer presents commonly as a painless breast lump. Practice of breast self examination (BSE) was low; only 432 participants (43.2%) admitted to carrying out the procedure in the past year. Only 91 study participants (9.1%) had clinical breast examination (CBE) in the past year. Women with higher level of education (X2 = 80.66, p < 0.0001) and those employed in professional jobs (X2 = 47.11, p < 0.0001) were significantly more knowledgeable about breast cancer. Participants with higher level of education were 3.6 times more likely to practice BSE (Odds ratio [OR] = 3.56, 95% Confidence interval [CI] 2.58–4.92).
Conclusion
The results of this study suggest that community-dwelling women in Nigeria have poor knowledge of breast cancer and minority practice BSE and CBE. In addition, education appears to be the major determinant of level of knowledge and health behavior among the study participants. We recommend the establishment and sustenance of institutional framework and policy guidelines that will enhance adequate and urgent dissemination of information about breast cancer to all women in Nigeria.
doi:10.1186/1477-7819-4-11
PMCID: PMC1397833  PMID: 16504034
21.  Impact Monitoring of the National Scale Up of Zinc Treatment for Childhood Diarrhea in Bangladesh: Repeat Ecologic Surveys 
PLoS Medicine  2009;6(11):e1000175.
Charles Larson and colleagues find that 23 months into a national campaign to scale up zinc treatment for diarrhea in children under age 5 years, only 10% of children with diarrhea in rural areas and 20%–25% in urban/municipal areas were getting the treatment.
Background
Zinc treatment of childhood diarrhea has the potential to save 400,000 under-five lives per year in lesser developed countries. In 2004 the World Health Organization (WHO)/UNICEF revised their clinical management of childhood diarrhea guidelines to include zinc. The aim of this study was to monitor the impact of the first national campaign to scale up zinc treatment of childhood diarrhea in Bangladesh.
Methods/Findings
Between September 2006 to October 2008 seven repeated ecologic surveys were carried out in four representative population strata: mega-city urban slum and urban nonslum, municipal, and rural. Households of approximately 3,200 children with an active or recent case of diarrhea were enrolled in each survey round. Caretaker awareness of zinc as a treatment for childhood diarrhea by 10 mo following the mass media launch was attained in 90%, 74%, 66%, and 50% of urban nonslum, municipal, urban slum, and rural populations, respectively. By 23 mo into the campaign, approximately 25% of urban nonslum, 20% of municipal and urban slum, and 10% of rural under-five children were receiving zinc for the treatment of diarrhea. The scale-up campaign had no adverse effect on the use of oral rehydration salt (ORS).
Conclusions
Long-term monitoring of scale-up programs identifies important gaps in coverage and provides the information necessary to document that intended outcomes are being attained and unintended consequences avoided. The scale-up of zinc treatment of childhood diarrhea rapidly attained widespread awareness, but actual use has lagged behind. Disparities in zinc coverage favoring higher income, urban households were identified, but these were gradually diminished over the two years of follow-up monitoring. The scale up campaign has not had any adverse effect on the use of ORS.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Diarrheal disease is a significant global health problem with approximately 4 billion cases and 2.5 million deaths annually. The overwhelming majority of cases are in developing countries where there is a particularly high death rate among children under five years of age. Diarrhea is caused by bacterial, parasitic, or viral pathogens, which often spread in contaminated water. Poor hygiene and sanitation, malnutrition, and lack of medical care all contribute to the burden of this disease. Replacing lost fluids and salts is a cheap and effective method to rehydrate people following dehydration caused by diarrhea. Clinical trials show that zinc, as part of a treatment for childhood diarrhea, not only helps to reduce the severity and duration of diarrhea but also reduces the likelihood of a repeat episode in the future. Zinc is now included in the guidelines by the World Health Organization (WHO)/UNICEF for treatment of childhood diarrhea.
Why Was This Study Done?
Zinc treatment together with traditional oral rehydration salts therapy following episodes of diarrhea could potentially benefit millions of children in areas where diarrheal disease is prevalent. The “Scaling Up of Zinc for Young Children” (SUZY) project was established in 2003 to provide zinc treatment for diarrhea in all children under five years of age in Bangladesh. The project was supported by a partnership of public, private, nongovernmental organization, and multinational sector agencies during its scale up to a national campaign across Bangladesh. The partners helped to develop the scale-up campaign, produce and distribute zinc tablets, train health professionals to provide zinc treatment, and create media campaigns (such as advertisements in TV, radio, and newspapers) to raise awareness and promote the use of zinc for diarrhea. The researchers wanted to monitor how effective and successful the national campaign was at promoting zinc treatment for childhood diarrhea. Also, they wanted to highlight any potential problems during the implementation of health care initiatives in areas with deprived health systems.
What Did the Researchers Do and Find?
The researchers set up survey sites to monitor results from the first two years of the SUZY campaign. Four areas, each representing different segments of the population across Bangladesh were surveyed; urban slums, urban nonslums, municipal (small city), and rural. There are approximately 1.5 million children under the age of five across these sites. Households in each survey site were selected at random, and seven surveys were conducted at each site between September 2006 and October 2008—about 3,200 children with diarrhea for each survey. Over 90% of parents used private sector providers of drug treatment so the campaign focused on distribution of zinc tablets in the private sector. They were also available free of charge in the public health sector. TV and radio campaigns for zinc treatment rapidly raised awareness across Bangladesh. Awareness was less than 10% in all communities prelaunch and peaked 10 months later at 90%, 74%, 66%, and 50% in urban nonslum, municipal, urban slum, and rural sites, respectively. However, after 23 months only 25% of urban nonslum, 20% of municipal and urban slum, and 10% of rural children under five years of age were actually using zinc for childhood diarrhea. Use of zinc was shown to be safe, with few side-effects, and did not affect the use of traditional treatments for diarrhea. Researchers also found that many children were not given the correct ten-day course of treatment; 50% of parents were sold seven or fewer zinc tablets.
What Do These Findings Mean?
These findings show that the first national campaign promoting zinc treatment for childhood diarrhea in Bangladesh has had some success. Addition of zinc tablets for diarrhea treatment did not interfere with existing therapies. Mass media campaigns, using TV and radio, were useful for promoting health care initiatives nationwide alongside the education of health care providers and care-givers. The study also identified areas where more work is needed. Surveys in more remote, hard to reach sites in Bangladesh would provide better representation of the country as a whole. High awareness of zinc did not translate into high use. Repeated surveying in the same subdistricts may have overestimated actual awareness levels. Furthermore, mass media messages must link with messages from health care providers to help to reinforce and promote understanding of the use of zinc. A change in focus of media messages from awareness to promoting household decision-making may aid the adoption of zinc treatment for childhood diarrhea and improve adherence.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000175
The International Centre for Diarrhoeal Disease Research, Bangladesh Web site has information about the study
The World Health Organisation provides information on diarrhea
The study was sponsored by the Bill & Melinda Gates Foundation
doi:10.1371/journal.pmed.1000175
PMCID: PMC2765636  PMID: 19888335
22.  Using formative research to develop MNCH programme in urban slums in Bangladesh: experiences from MANOSHI, BRAC 
BMC Public Health  2010;10:663.
Background
MANOSHI, an integrated community-based package of essential Maternal, Neonatal and Child Health (MNCH) services is being implemented by BRAC in the urban slums of Bangladesh since 2007. The objective of the formative research done during the inception phase was to understand the context and existing resources available in the slums, to reduce uncertainty about anticipated effects, and develop and refine the intervention components.
Methods
Data were collected during Jan-Sept 2007 in one of the earliest sites of programme intervention in the Dhaka metropolitan area. A conceptual framework guided data collection at different stages. Besides exploring slum characteristics, studies were done to map existing MNCH service providing facilities and providers, explore existing MNCH-related practices, and make an inventory of community networks/groups with a stake in MNCH service provision. Also, initial perception and expectations regarding the community delivery centres launched by the programme was explored. Transect walk, observation, pile sorting, informal and focus group discussions, in-depth interviews, case studies, network analysis and small quantitative surveys were done to collect data.
Results
Findings reveal that though there are various MNCH services and providers available in the slums, their capacity to provide rational and quality services is questionable. Community has superficial knowledge of MNCH care and services, but this is inadequate to facilitate the optimal survival of mothers and neonates. Due to economic hardships, the slum community mainly relies on cheap informal sector for health care. Cultural beliefs and practices also reinforce this behaviour including home delivery without skilled assistance. Men and women differed in their perception of pregnancy and delivery: men were more concerned with expenses while women expressed fear of the whole process, including delivering at hospitals. People expected 'one-stop' MNCH services from the community delivery centres by skilled personnel. Social support network for health was poor compared to other networks. Referral linkages to higher facilities were inadequate, fragmentary, and disorganised.
Conclusions
Findings from formative research reduced contextual uncertainty about existing MNCH resources and care in the slum. It informed MANOSHI to build up an intervention which is relevant and responsive to the felt needs of the slum population.
doi:10.1186/1471-2458-10-663
PMCID: PMC3091574  PMID: 21044335
23.  Maternal care practices among the ultra poor households in rural Bangladesh: a qualitative exploratory study 
Background
Although many studies have been carried out to learn about maternal care practices in rural areas and urban-slums of Bangladesh, none have focused on ultra poor women. Understanding the context in which women would be willing to accept new practices is essential for developing realistic and relevant behaviour change messages. This study sought to fill in this knowledge gap by exploring maternal care practices among women who participated in a grant-based livelihood programme for the ultra poor. This is expected to assist the designing of the health education messages programme in an effort to improve maternal morbidity and survival towards achieving the UN millennium Development Goal 5.
Methods
Qualitative method was used to collect data on maternal care practices during pregnancy, delivery, and post-partum period from women in ultra poor households. The sample included both currently pregnant women who have had a previous childbirth, and lactating women, participating in a grant-based livelihood development programme. Rangpur and Kurigram districts in northern Bangladesh were selected for data collection.
Results
Women usually considered pregnancy as a normal event unless complications arose, and most of them refrained from seeking antenatal care (ANC) except for confirmation of pregnancy, and no prior preparation for childbirth was taken. Financial constraints, coupled with traditional beliefs and rituals, delayed care-seeking in cases where complications arose. Delivery usually took place on the floor in the squatting posture and the attendants did not always follow antiseptic measures such as washing hands before conducting delivery. Following the birth of the baby, attention was mainly focused on the expulsion of the placenta and various maneuvres were adapted to hasten the process, which were sometimes harmful. There were multiple food-related taboos and restrictions, which decreased the consumption of protein during pregnancy and post-partum period. Women usually failed to go to the healthcare providers for illnesses in the post-partum period.
Conclusion
This study shows that cultural beliefs and norms have a strong influence on maternal care practices among the ultra poor households, and override the beneficial economic effects from livelihood support intervention. Some of these practices, often compromised by various taboos and beliefs, may become harmful at times. Health behavior education in this livelihood support program can be carefully tailored to local cultural beliefs to achieve better maternal outcomes.
doi:10.1186/1471-2393-11-15
PMCID: PMC3056829  PMID: 21362164
24.  Breast self-examination: Resistance to change 
Canadian Family Physician  2005;51(5):699.
OBJECTIVE
To investigate whether Canadian family practitioners routinely teach breast self-examination (BSE) after publication of the 2001 Canadian Preventive Health Task Force guideline advising them to exclude teaching BSE from periodic health examinations.
DESIGN
Self-administered cross-sectional mailed survey.
SETTING
Canada.
PARTICIPANTS
A random sample of English-speaking general practitioners and physicians certified by the College of Family Physicians of Canada.
MAIN OUTCOME MEASURES
Current and past BSE practices and opinions on the value of BSE.
RESULTS
Response rate was 47.4%. Most respondents (88%) were aware of the new recommendations, yet only 16% had changed their usual practice of routinely teaching BSE. Most physicians agreed that before the recommendation they almost always taught BSE (74.3%). Only 9.5% agreed that physicians should follow the recommendation and not routinely teach BSE. A few also agreed that they now spend less time discussing BSE (25.7%) and that the recommendation has influenced them to stop teaching (12.4%) and encouraging (12.9%) women to practise BSE. Physicians who had changed their BSE practices were less likely to agree that BSE increases early detection of breast cancer and more likely to agree that BSE increases benign breast biopsies. They were also more likely to agree that screening mammography in women older than 50 decreases mortality from breast cancer.
CONCLUSION
This survey, which assessed routine teaching of BSE, revealed poor adherence by Canadian family physicians to a well publicized evidence-based guideline update. Resistance to change could in part be attributed to a lack of knowledge of the supporting evidence, a lack of confidence in the evidence to date, and personal experiences with patients within their practices.
PMCID: PMC1472923  PMID: 16926925
25.  Barriers to breast cancer screening among a sample of Egyptian females 
Background:
Breast cancer (BC) is usually diagnosed in late stages in countries with limited resources. Early detection of BC is likely to improve the outcome of the disease for women in these areas.
Objective:
The aim of this study was to understand the possible personal, economic, and systems barriers to BC screening in a sample of Egyptian women.
Materials and Methods:
A cross-sectional study was conducted in family health centers representing the seven districts of Alexandria governorate, Egypt. A total of 612 women were randomly selected from the chosen centers.
Results:
In this sample of Egyptian women, the most frequently identified potential barriers to BC screening were the following: 81.8% would not seek care until they were ill, 77% were unwilling to have a mammogram until it was recommended by the doctor, 71.4% blamed the, lack of privacy, 69.2% thought that medical checkups were not worthwhile, and 64.6% blamed the cost of services. The study further revealed that women of lower education, women in the lower income category, women who did not do paid work, those who had poor knowledge of the risks of BC, and women with no family history of BC were more likely to perceive different screening barriers compared with their counterparts.
Conclusion:
Many potential personal, economic, and health system barriers were identified. Addressing these barriers by increasing the awareness of BC and dealing with the misconceptions that the women have can help the policy makers to design more culturally relevant strategies to motivate women to utilize screening services.
doi:10.4103/2230-8229.134771
PMCID: PMC4073560  PMID: 24987281
Breast cancer; barriers; Egypt; screening

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