A community-based qualitative study on the experience and understandings of intimate partner violence and HIV vulnerability from the perspectives of female sex workers and male intimate partners in North Karnataka state, India.

BACKGROUND: Research has increasingly documented the important role that violence by clients and the police play in exacerbating HIV vulnerability for women in sex work. However few studies have examined violence in the intimate relationships of women in sex work, or drawn on community partnerships to explore the social dynamics involved. A community-based participatory research study was undertaken by community and academic partners leading intimate partner violence (IPV) and HIV prevention programs in Bagalkot district, Karnataka state, India. The purpose was to explore the experience and understandings of intimate partner violence and HIV/AIDS among women in sex work and their intimate partners in Bagalkot that would inform both theory and practice. METHODS: A community-based, interpretive qualitative methodology was used. Data was collected between July and October 2014 through in-depth interviews with 38 participants, including 10 couples, 13 individual female sex workers, and 5 individual male intimate partners. Purposive sampling was done to maximize variation on socio-demographic characteristics. Thematic content analysis was conducted through coding and categorization for each interview question in NVivo 10.0, followed by collaborative analysis to answer the research questions. RESULTS: The results showed that an array of interrelated, multi-level factors underlay the widespread acceptance and perpetuation of violence and lack of condom use in participants' intimate relationships. These included individual expectations that justified violence and reflected societal gender norms, compounded by stigma, legal and economic constraints relating to sex work. The results demonstrate that structural vulnerability to IPV and HIV must be addressed not only on the individual and relationship levels to resolve relevant triggers of violence and lack of condom use, but also the societal-level to address gender norms and socio-economic constraints among women in sex work and their partners. CONCLUSION: The study contributes to a better understanding on the interplay of individual agency and structural forces at a time when researchers and program planners are increasingly pondering how best to address complex and intersecting social and health issues. Ongoing research should assess the generalizability of the results and the effectiveness of structural interventions aiming to reduce IPV and HIV vulnerability in other contexts.

Incident diabetes, hypertension and dyslipidemia in a Manitoba First Nation.

BACKGROUND: Diabetes and diabetes complications are substantially higher among Canadian First Nations populations compared with the general Canadian population. However, incidence data using detailed individual assessments from a population-based cohort have not been undertaken. OBJECTIVE: We sought to describe incident diabetes, hypertension and dyslipidemia in a population-based cohort from a Manitoba Ojibway First Nation community. DESIGN: Study data were from 2 diabetes screening studies in Sandy Bay First Nation in Manitoba, Canada, collected in 2002/2003 and 2011/2012. The cohort comprised of respondents to both screening studies (n=171). Health and demographic data were collected using a questionnaire. Fasting blood samples, blood pressure and anthropometric data were also collected objectively. Incident diabetes, hypertension and dyslipidemia were determined. Generalized linear models with Poisson distribution were used to estimate risk of incident diabetes and cardiometabolic conditions according to age and sex. RESULTS: There were 35 (95% CI: 26, 45) new cases of diabetes among 128 participants without diabetes at baseline (27 or 3.3% per year). While participants who were 50 years and older at baseline had a significantly higher risk of incident diabetes at follow-up compared with participants aged 18-29 at baseline (p=0.012), more than half of the incident cases of diabetes occurred among participants aged less than 40 at baseline. There were 28 (95% CI: 20, 37) new cases of dyslipidemia at follow-up among 112 without dyslipidemia at baseline (25%). There were 36 (95% CI: 31, 42) new cases of hypertension among 104 participants without hypertension at baseline (34.6%). Women had half the risk of developing hypertension compared with men (p=0.039). CONCLUSIONS: Diabetes incidence is very high, and the number of new cases among those younger than 40 is a concern. Additional public health and primary care efforts are needed to address the diabetes burden in this First Nation community.

Between a rock and a hard place: Smoking trends in a Manitoba First Nation.

OBJECTIVES: The purpose of this study is to estimate and compare smoking prevalence over two time periods in a Manitoba First Nation community. METHODS: Data fromtwo independent Diabetes Screening Studies in Sandy Bay First Nation, collected in 2002/2003 (n = 482) and 2011/2012 (n = 596),were used. Crude prevalence of current and ever smoking as well as current smoke exposure was estimated. Change over time was tested using a χ² statistic. RESULTS: The crude prevalence of current smoking was 74.0% (95% confidence interval [CI]: 70.1, 78.0) in 2002/2003 and 80.0% (95% CI: 76.8, 83.2) in 2011/2012. The crude prevalence of ever smoking was 83.0% in 2002/2003 and 91.4% in 2011/2012. The prevalence of both current smoking status and ever smoking were significantly higher in 2011/2012 compared to 2002/2003 (p = 0.020 and p < 0.001 respectively). Among participants who were not current smokers, 58.5% (95% CI: 49.6, 67.4) and 76.5% (95% CI: 68.9, 84.1) reported at least one person who smoked in the home in 2002/2003 and 2011/2012 respectively (p = 0.003). In 2011/2012, 96.5% (95% CI: 94.8, 98.2) of those who reported having any children under the age of 18 living in the home were either a current smoker and/or reported that someone else smoked in the home. CONCLUSION: Public health and policy initiatives are needed to address the increase in smoking prevalence in the study community.

Preferences for infant delivery site among pregnant women and new mothers in Northern Karnataka, India.

BACKGROUND: The National Rural Health Mission (NRHM) of India aims to increase the uptake of safe and institutional delivery among rural communities to improve maternal, neonatal and child health (MNCH) outcomes. Previous studies in India have found that while there have been increasing numbers of institutional deliveries there are still considerable barriers to utilization and quality of services, particularly in rural areas, that may mitigate improvements achieved by MNCH interventions. This paper aims to explore the factors influencing preference for home, public or private hospital delivery among rural pregnant and new mothers in three northern districts of Karnataka state, South India. METHODS: In-depth qualitative interviews were conducted in 2010 among 110 pregnant women, new mothers (infants born within past 3 months), their husbands and mothers-in-law. Interviews were conducted in the local language (Kannada) and then translated to English for analysis. The interviews of pregnant women and new mothers were used for analysis to ultimately develop broader themes around definitions of quality care from the perspective of service users, and the influence this had on their delivery site preferences. RESULTS: Geographical and financial access were important barriers to accessing institutional delivery services in all districts, and among those both above and below the poverty line. Access issues of greatest concern were high costs at private institutions, continuing fees at public hospitals and the inconsistent receipt of government incentives. However, views on quality of care that shaped delivery site preferences were deeply rooted in socio-cultural expectations for comfortable, respectful and safe care that must ultimately be addressed to change negative perceptions about institutional, and particularly public hospital, care at delivery. CONCLUSIONS: In the literature, quality of care beyond access has largely been overlooked in favour of support for incentives on the demand side, and more trained doctors, facilities and equipment on the supply side. Taking a comprehensive approach to quality of care in line with cultural values and community needs is imperative for improving experiences, utilization, and ultimately maternal and neonatal health outcomes at the time of delivery.

Self-rated health and ethnicity: focus on indigenous populations.

OBJECTIVES: Self-rated health (SRH) is a commonly used measure in surveys to assess general health status or health-related quality of life. Differences have been detected in how different ethnic groups and nationalities interpret the SRH measure and assess their health. This review summarizes the research conducted on SRH within and between ethnic groups, with a focus on indigenous groups. STUDY DESIGN AND METHODS: A search of published academic literature on SRH and ethnicity, including a comprehensive review of all relevant indigenous research, was conducted using PubMed and summarized. RESULTS: A wide variety of research on SRH within ethnic groups has been undertaken. SRH typically serves as an outcome measure. Minority respondents generally rated their health worse than the dominant population. Numerous culturally-specific determinants of SRH have been identified. Cross-national and cross-ethnicity comparisons of the associations of SRH have been conducted to assess the validity of SRH. While SRH is a valid measure within a variety of ethnicities, differences in how SRH is assessed by ethnicities have been detected. Research in indigenous groups remains generally under-represented in the SRH literature. CONCLUSIONS: These results suggest that different ethnic groups and nationalities vary in SRH evaluations, interpretation of the SRH measure, and referents employed in rating health. To effectively assess and redress health disparities and establish culturally-relevant and effective health interventions, a greater understanding of SRH is required, particularly among indigenous groups, in which little research has been conducted.

Prevalence, risk factors and awareness of albuminuria on a Canadian First Nation: a community-based screening study.

BACKGROUND: Both diabetic and non-diabetic end stage renal disease (ESRD) are more common among Canadian First Nations people than among the general Canadian population. The purpose of this research was to determine the prevalence of and risk factors for albuminuria in a Canadian First Nation population at high risk for ESRD and dialysis. METHODS: Data from a community-based screening study of 483 residents of a Plains Ojibway First Nation in Manitoba was used. Participants provided random urine samples. Proteinuria was defined as any dipstick positive for protein (≥1 g/L) or those with ACR in the macroalbuminuric range (≥30 mg/mmol) on at least one sample. Microalbuminuria was defined as ACR ≥2 mg/mmol for males and ≥2.8 mg/mmol for females. Other measures included fasting glucose, haemoglobin A1c, triglycerides, cholesterol, blood pressure, height, weight and waist and hip circumferences. RESULTS: Twenty percent of study participants had albuminuria, (5% proteinuria and 15% microalbuminuria). Of participants with diabetes, 42% (56/132) had albuminuria compared to 26% (7/27) among those with impaired fasting glucose and 10% (30/303) among those with normal glucose tolerance. Only 5.3% of those with albuminuria were aware of any degree of renal disease. In a multivariate logistic regression, independent associations with albuminuria were male gender [p = 0.002], increasing fasting glucose [p <0.0001], years diagnosed with diabetes [p = 0.03], increasing systolic blood pressure [p = 0.009], and increasing body mass index (BMI) [p = 0.04]. CONCLUSIONS: The independent association between BMI and albuminuria has not been previously reported among indigenous populations. There is a high prevalence of albuminuria in this Canadian First Nation population; the high proportion of patients with diabetes and undiagnosed kidney disease demonstrates the need for screening, education and intervention to halt the progression and development of albuminuria and ultimately ESRD and CVD.

Obesity and obesity-related comorbidities in a Canadian First Nation population.

INTRODUCTION: Rates of obesity are higher among Canada's Aboriginal First Nations populations than among non-First Nations populations. We studied obesity and obesity-related illness in a Manitoba First Nation community. METHODS: We conducted a screening study of diabetes and diabetes complications in 2003, from which we drew a representative sample of Manitoba First Nations adults (N = 483). We assessed chronic disease and chronic disease risk factors. RESULTS: Prevalence of obesity and associated comorbidities was higher among women than men. By using multivariate analysis, we found that factors significantly associated with obesity among women were diastolic blood pressure, insulin resistance, and employment status. Among men, factors were age, apolipoprotein A1 level, apolipoprotein B level, and insulin resistance. Seventy-five percent of study participants had at least 1 of the following conditions: obesity, dyslipidemia, hypertension, or diabetes. Comorbidity was high even among the youngest age groups; 22% of men and 43% of women aged 18 to 29 had 2 or more chronic conditions. Twenty-two percent of participants had undiagnosed hypertension. Participants with undiagnosed hypertension had significantly more chronic conditions and were more likely to have microalbuminuria than were those without hypertension. The number of chronic conditions was not significantly different for participants with newly diagnosed hypertension than for those with previously diagnosed hypertension. CONCLUSION: The prevalence of obesity and other chronic conditions in the study community is high, especially considering the number of young people. Community-based interventions are being undertaken to reduce the excessive rate of illness.

Cardiovascular risk according to plasma apolipoprotein and lipid profiles in a Canadian First Nation.

INTRODUCTION: Despite high diabetes rates among Canadian First Nations people, little is known about their cardiovascular disease risk. Our aim was to describe the apolipoprotein profile with respect to cardiovascular risk in a Canadian First Nation community. METHODS: In 2003, a representative sample of adult members of a Manitoba First Nation (N = 483) participated in a screening study for diabetes and diabetes complications. We assessed their cardiovascular risk factors. RESULTS: Sixty percent of women were at increased cardiovascular risk because of low apolipoprotein A1 (apoA1) levels, compared with 35% of men. The proportion of women with low apoA1 levels decreased with age, but the proportion with low high-density lipoprotein levels remained stable across age groups. Both apoB and apoA1 were significantly associated with obesity when age, sex, diastolic blood pressure, homocysteine, diabetes, and insulin resistance were controlled for. CONCLUSION: Apolipoprotein and lipid profiles in this First Nation population suggest high cardiovascular risk. Future research should characterize the lipoprotein particle size in this population.

Prevalence and risk factors for neuropathy in a Canadian First Nation community.

OBJECTIVE: The purpose of this study was to determine the prevalence of and risk factors for diabetic neuropathy in a Canadian First Nation population. RESEARCH DESIGN AND METHODS: This was a community-based screening study of 483 adults. Measures included glucose, A1C, cholesterol, triglycerides, homocysteine, hypertension, waist circumference, height, weight, and foot examinations. Neuropathy was defined as loss of protective sensation determined through application of a 10-g monofilament. RESULTS: Twenty-two percent of participants had a previous diagnosis of diabetes, and 14% had new diabetes or impaired fasting glucose (IFG). The prevalence of neuropathy increased by glucose level: 5% among those with normal glucose levels, 8% among those with new IFG and diabetes, and 15% among those with established diabetes (P < 0.01). Those with neuropathy were more likely to have foot deformities (P < 0.01) and callus (P < 0.001) than those without neuropathy. Among those with dysglycemia (>or=6.1 mmol/l), the mean number of foot problems for those with insensate feet was 3 compared with 0.3 among those with sensation (P < 0.001). In multivariate logistic regression female sex, low education, A1C, smoking, and homocysteine were independently associated with neuropathy, after controls for age. CONCLUSIONS: Neuropathy prevalence is high, given the young age of our participants (mean 40 years) and was present among those with undiagnosed diabetes. The high number and type of foot problems places this population at increased risk for ulceration; the low level of foot care in the community increases the risk. Homocysteine is a risk factor that may be related to lifestyle and requires further investigation.