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author:("Aro, area R")
1.  Intimate partner violence (physical and sexual) and sexually transmitted infection: results from Nepal Demographic Health Survey 2011 
Violence against women perpetrated by their intimate partners is a social problem with adverse health consequences. Intimate partner violence has acute and chronic as well as direct and indirect health consequences related to physical, psychological, and reproductive health. Studies exploring relationships of intimate partner violence and health consequences are rare in Nepal. Hence, this study aimed to examine the relationships between intimate partner violence and sexually transmitted infections.
This study used data from the nationally representative Nepal Demographic Health Survey 2011, which collected data through a two-stage complex sampling technique. Women 15–49 years were asked about domestic violence including intimate partner violence. For this analysis, 3,084 currently married women were included. Questions about domestic violence were adapted from the Conflict Tactic Scale. Relationships between different forms of physical and sexual intimate partner violence and reported signs and symptoms of sexually transmitted infections were examined using multiple logistic regression analysis.
Approximately 15% of currently young and middle-aged married women experienced some form of violence in the last 12 months. About one in four women who were exposed to physical and sexual intimate partner violence reported sexually transmitted infection in the last 12 months. The odds of getting sexually transmitted infection were 1.88 [95% CI:1.29, 2.73] times higher among women exposed to any form of intimate partner violence in the last 12 months compared to women not exposed to any form of intimate partner violence.
Intimate partner violence was common among currently married women in Nepal. Being exposed to intimate partner violence and getting signs and symptoms of sexually transmitted disease were found to be associated. Integration of intimate partner violence prevention and reproductive health programs is needed to reduce the burden of sexually transmitted disease among currently married women.
PMCID: PMC3901740  PMID: 24470776
intimate partner violence; socio-demographic; sexually transmitted disease; Nepal
2.  Uterine prolapse prevention in Eastern Nepal: the perspectives of women and health care professionals 
Uterine prolapse is a major reproductive health issue in Nepal. There is a wide range of literature available on the causes and risk factors of uterine prolapse and on the ways to prevent and treat it. There is still a lack of published evidence on what prevention and treatment services are working well or the attitudes toward them. This paper presents the findings of a qualitative study on primary and secondary prevention of uterine prolapse in Eastern Nepal.
The study involved eight focus group discussions with 71 women in six villages of the eastern districts of Siraha and Saptari and 14 qualitative interviews with health professionals from the local to central level. The group discussions and interviews covered the awareness levels of uterine prolapse and its prevention and treatment, as well as participants’ opinions on and experiences with the services offered.
It was found that patriarchy, gender discrimination, and cultural traditions such as early marriage and pregnancy make it difficult for people to discontinue uterine prolapse risk behaviors. Women are aware of risk factors, prevention, and treatment, but are powerless to change their situations. Health professionals and women are fond of surgery as treatment, but opinions on the use of ring pessaries and pelvic floor muscle training are split.
The main recommendation that can be drawn from this study is that research on the effectiveness of early treatments, such as ring pessaries and exercise, should be conducted. Furthermore, the involvement of other target groups (husbands, adolescents, and mothers-in-law) needs to be increased in order to make it easier for women to adapt low-risk behaviors. Finally, uterine prolapse prevention should be better integrated in national reproductive health services. Enforcing transparency, monitoring systems, and collaborations are important factors that should be considered as well.
PMCID: PMC3422110  PMID: 22927768
uterine prolapse; primary prevention; secondary prevention; awareness; Nepal
3.  Knowledge, attitudes and practices related to avian influenza among poultry workers in Nepal: a cross sectional study 
Avian influenza is a considerable threat to global public health. Prevention and control depend on awareness and protective behaviours of the general population as well as high risk-groups. This study aims to explore the knowledge, attitudes and practices related to avian influenza among poultry workers in Nepal.
The study was based on a cross-sectional study design, using a structured questionnaire administered in face-to-face interviews with 96 poultry workers age 15 and above from the Rupandehi district in Nepal.
The majority of respondents were male (80%), mean age was 35 (SD = 11.6). Nearly everybody was aware that AI cases had been detected in Nepal and that poultry workers were at risk for infection. The major sources of AI information were radio, TV and newspapers. Knowledge about preventive measures was high with regard to some behaviours (hand washing), but medium to low with regard to others (using cleaning and disinfecting procedures or protective clothing). Poultry workers who got their information from TV and newspapers and those who were more afraid of contracting AI had higher knowledge than those who did not. Being employed as compared to being an owner of a poultry farm as well as having a high level of knowledge was associated with practising more preventive behaviours. While on one hand many specific government control measures found a high degree of acceptance, a majority of study participants also thought that government control and compensation measures as a whole were insufficient.
The study provides information about knowledge and practices regarding avian influenza among poultry workers in Nepal. It highlights the importance of targeting lack of knowledge as well as structural-material barriers to successfully build preparedness for a major outbreak situation.
PMCID: PMC3342178  PMID: 22458535
4.  Cervical cancer screening in primary health care setting in Sudan: a comparative study of visual inspection with acetic acid and Pap smear 
To determine the feasibility of visual inspection with the use of acetic acid (VIA) as a screening method for cervical cancer, an alternative to the Pap smear used in primary health care setting in Sudan, and to compare sensitivity, specificity, positive and negative predictive values, and histological diagnosis of positive cases of both tests.
A cross-sectional study of 934 asymptomatic women living in Khartoum, Sudan, was conducted during 2009–2010. A semi-structured questionnaire containing socio-economic and reproductive variables was used to collect data from each participant. Methods of screening used were VIA and conventional Pap smear, followed by colposcopy and biopsy for confirmation of the positive results of both screening tests.
The tests identified altogether 119 (12.7%) positive women. VIA detected significantly more positive women than Pap smear (7.6% versus 5.1%; P = 0.004), with an overlap between the two screening tests in 19% of positive results. There was no significant difference between VIA and Pap smear findings and sociodemographic and reproductive factors among screened women. Use of colposcopy and biopsy for positive women confirmed that 88/119 (73.9%) were positive for cervical intraepithelial neoplasia. VIA had higher sensitivity than Pap smear (74.2% versus 72.9%; P = 0.05) respectively. Out of 88 confirmed positive cases, 22 (25.0%) cases were invasive cervical cancer in stage 1, of which 19 versus three were detected by VIA and Pap smear respectively (P = 0.001). VIA had higher sensitivity and lower specificity than Pap smear (60.2% versus 47.7%) and (41.9% versus 83.8%) respectively. The combination of VIA/Pap has better sensitivity and specificity than each independent test (82.6% and 92.2%).
The findings of this study showed that VIA has higher sensitivity and lower specificity compared to Pap smear, but a combination of both tests has greater sensitivity and specificity than each test independently. It indicates that VIA is useful for screening of cervical cancer in the primary health care setting in Sudan, but positive results need to be confirmed by colposcopy and biopsy.
PMCID: PMC3302762  PMID: 22423181
cervical; cancer; screening; VIA; Pap smear; colposcopy; sensitivity; specificity; predictive value; primary health care setting
5.  Female genital mutilation: prevalence, perceptions and effect on women’s health in Kersa district of Ethiopia 
Female genital mutilation (FGM) is nontherapeutic surgical modification of the female genitalia. It is an ancient tradition in large parts of Africa, including Ethiopia, especially in the eastern part of the country. This study aimed to identify the prevalence, perceptions, perpetuators, reasons for conducting FGM, and factors associated with this practice with regard to women’s health.
Community-based cross-sectional house-to-house interviews were conducted during 2008 among 858 females of reproductive age (15–49 years), in Kersa district, East Hararge, Oromia region, Ethiopia. Proportions and Chi-square tests were used to describe the data and logistic regression was used to describe statistical associations. Statistical significance was set at P < 0.05.
FGM was reported to be known by 327 (38.5%) of the interviewees. The majority (n = 249, 76.1%) reported that local healers were the main performers of FGM, and 258 (78.9%) respondents stated that the clitoris was the part removed during circumcision. The main reason for the practice of FGM was reduction of female sexual hyperactivity (reported by 198 women [60.3%]). Circumcision of daughters was reported by 288 (88.1%) respondents, and this showed a statistically significant association with the Christian religion (P = 0.003), illiteracy (P = 0.01), and Amhara ethnicity (P = 0.012). The majority of the respondents (792, 92.3%) were themselves circumcised and 68.8% did not know of any health-related problems associated with FGM.
In spite of FGM being a common practice in the study area, only one third of the respondents stated that they knew about it. Local healers were the main performers of FGM. Some of the women knew about the negative reproductive health effects of FGM and some had also experienced these themselves. However, only a few had tried to stop the practice and the majority had taken no steps to do so. This may be attributable to the fear of becoming alienated from the cultural system and fear of isolation.
PMCID: PMC3282605  PMID: 22371659
female genital mutilation; reasons; health consequences; Ethiopia
6.  Physical activity and change in quality of life during menopause -an 8-year follow-up study 
Background and objectives
The aim of this study was to study the role of menopausal status and physical activity on quality of life.
A total of 1,165 Finnish women aged 45-64 years from a national representative population-based study were followed up for 8 years. Study participants completed the Health 2000 study questionnaire and follow-up questionnaire in 2008. Ordinal logistic regression analysis was used to measure the effect of menopausal status on global quality of life (QoL). Other variables included in the analyses were age, education, change of physical activity as assessed with metabolic equivalents, change of weight and hormone therapy (HRT) use.
Peri- and postmenopausal women increased their physical activity (28% and 27%) during the eight-year follow up period slightly more often than premenopausal (18%) women (p = 0.070). Menopausal status was not significantly correlated with change of QoL. QoL of the most highly educated women was more likely to improve than among the less educated (eb = 1.28, 95%CI 1.08 to 1.51 p = 0.002). Women whose physical activity increased or remained stable had greater chances for improved QoL than women whose physical activity decreased (eb = 1.49, 95%CI 1.23 p < 0.001 to 1.80, eb = 1.46, 95%CI 1.24 to 1.73 p < 0.001 respectively). Women whose weight remained stable during follow-up also improved their QoL compared to women who gained weight (eb = 1.26, 95%CI 1.07 to 1.50 p > 0.01). Women who had never used HRT had 1.26 greater odds for improved QoL (95%CI 1.02 to 1.56 p = < 0.05).
Improvement of global QoL is correlated with stable or increased physical activity, stable weight and high education, but not with change in menopausal status.
PMCID: PMC3311608  PMID: 22269072
Menopause; physical activity; longitudinal study
7.  Predictors of cervical cancer being at an advanced stage at diagnosis in Sudan 
Cervical cancer is the second most common cancer among women in Sudan, with more than two-thirds of all women with invasive cervical cancer being diagnosed at an advanced stage (stages III and IV). The lack of a screening program for cervical cancer in Sudan may contribute to the late presentation of this cancer, but other factors potentially associated with advanced stages of cervical cancer at diagnosis are unknown. The purpose of this research was to investigate the relationship between age, marital status, ethnicity, health insurance coverage, residence in an urban vs a rural setting, and stage (at diagnosis) of cervical cancer in Sudan.
This was a cross sectional study of 197 women diagnosed with different stages of cervical cancer. Data was obtained from the cancer registry unit at the Radiation and Isotopes Centre in Khartoum for all women diagnosed with cervical cancer in 2007.
There was an association between older age and advanced stage (at diagnosis) of cervical cancer (odds ratio [OR]: 1.03, 95% confidence interval [CI]: 1.01–1.05). Being of African ethnicity was associated with 76% increased odds (OR: 1.76, 95% CI: 1.01–3.05), living in a rural area was associated with 13% increased odds (OR: 1.13, 95% CI: 1.78–5.50), and being uninsured was associated with an almost eight-fold increase in odds (OR: 7.7, 95% CI: 3.76–15.38). Marital status and education level were not associated with an advanced stage of cervical cancer at diagnosis.
Women with cervical cancer who are elderly, not covered by health insurance, of African ethnicity, and living in a rural area are more likely to be diagnosed at an advanced stage of cervical cancer in Sudan. These women should be targeted for cervical cancer screening and a health education program, and encouraged to have health insurance.
PMCID: PMC3225468  PMID: 22140326
predictors; cervical cancer; diagnosis; advanced; health insurance; Sudan
8.  Cervical cancer risk factors and feasibility of visual inspection with acetic acid screening in Sudan 
To assess the risk factors of cervical cancer and the feasibility and acceptability of a visual inspection with acetic acid (VIA) screening method in a primary health center in Khartoum, Sudan.
A cross-sectional prospective pilot study of 100 asymptomatic women living in Khartoum State in Sudan was carried out from December 2008 to January 2009. The study was performed at the screening center in Khartoum. Six nurses and two physicians were trained by a gynecologic oncologist. The patients underwent a complete gynecological examination and filled in a questionnaire on risk factors and feasibility and acceptability. They were screened for cervical cancer by application of 3%–5% VIA. Women with a positive test were referred for colposcopy and treatment.
Sixteen percent of screened women were tested positive. Statistically significant associations were observed between being positive with VIA test and the following variables: uterine cervix laceration (odds ratio [OR] 18.6; 95% confidence interval [CI]: 4.64–74.8), assisted vaginal delivery (OR 13.2; 95% CI: 2.95–54.9), parity (OR 5.78; 95% CI: 1.41–23.7), female genital mutilation (OR 4.78; 95% CI: 1.13–20.1), and episiotomy (OR 5.25; 95% CI: 1.15–23.8). All these associations remained statistically significant after adjusting for age, educational level, employment, and potential confounding factors such as smoking, number of sexual partners, and use of contraceptive method. Furthermore, the VIA screening method was found to be feasible and acceptable to participants.
This pilot study showed that women who have uterine cervix laceration, assisted vaginal delivery, female genital mutilation, or episiotomy are at an increased risk of cervical cancer. It also showed that VIA is a feasible and acceptable cervical cancer screening method in a primary health care setting.
PMCID: PMC3089429  PMID: 21573147
cervical cancer; screening; visual inspection; acetic acid; feasibility
9.  Perceived Threat, Risk Perception, and Efficacy Beliefs Related to SARS and Other (Emerging) Infectious Diseases: Results of an International Survey 
To study the levels of perceived threat, perceived severity, perceived vulnerability, response efficacy, and self-efficacy for severe acute respiratory syndrome (SARS) and eight other diseases in five European and three Asian countries.
A computer-assisted phone survey was conducted among 3,436 respondents. The questionnaire focused on perceived threat, vulnerability, severity, response efficacy, and self-efficacy related to SARS and eight other diseases.
Perceived threat of SARS in case of an outbreak in the country was higher than that of other diseases. Perceived vulnerability of SARS was at an intermediate level and perceived severity was high compared to other diseases. Perceived threat for SARS varied between countries in Europe and Asia with a higher perceived severity of SARS in Europe and a higher perceived vulnerability in Asia. Response efficacy and self-efficacy for SARS were higher in Asia compared to Europe. In multiple linear regression analyses, country was strongly associated with perceived threat.
The relatively high perceived threat for SARS indicates that it is seen as a public health risk and offers a basis for communication in case of an outbreak. The strong association between perceived threat and country and different regional patterns require further research.
PMCID: PMC2691522  PMID: 19125335
Risk perception; SARS; Infectious diseases; Efficacy beliefs; Risk communication; International comparison
10.  Avian Influenza Risk Perception, Europe and Asia 
Emerging Infectious Diseases  2007;13(2):290-293.
During autumn 2005, we conducted 3,436 interviews in European and Asian countries. We found risk perceptions of avian influenza to be at an intermediate level and beliefs of efficacy to be slightly lower. Risk perceptions were higher in Asia than Europe; efficacy beliefs were lower in Europe than Asia.
PMCID: PMC2725846  PMID: 17479894
Avian influenza; influenza pandemic; risk perception; risk communication; behavior change; dispatch
11.  SARS Risk Perception, Knowledge, Precautions, and Information Sources, the Netherlands 
Emerging Infectious Diseases  2004;10(8):1486-1489.
Severe acute respiratory syndrome (SARS)–related risk perceptions, knowledge, precautionary actions, and information sources were studied in the Netherlands during the 2003 SARS outbreak. Although respondents were highly aware of the SARS outbreak, the outbreak did not result in unnecessary precautionary actions or fears.
PMCID: PMC3320399  PMID: 15496256
SARS; knowledge; risk perceptions; precautionary behavior; information sources; dispatch

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