The role of primary healthcare professionals in oral cancer prevention and detection.

AIM: To investigate current knowledge, examination habits and preventive practices of primary healthcare professionals in Scotland, with respect to oral cancer, and to determine any relevant training needs. SETTING: Primary care. METHOD: Questionnaires were sent to a random sample of 357 general medical practitioners (GMPs) and 331 dental practitioners throughout Scotland. Additionally, focus group research and interviews were conducted amongst primary healthcare team members. RESULTS: Whilst 58% of dental respondents reported examining regularly for signs of oral cancer, GMPs examined patients' mouths usually in response to a complaint of soreness. The majority of GMPs (85%) and dentists (63%) indicated that they felt less than confident in detecting oral cancer, with over 70% of GMPs identifying lack of training as an important barrier. Many practitioners were unclear concerning the relative importance of the presence of potentially malignant lesions in the oral cavity. A high proportion of the GMPs indicated that they should have a major role to play in oral cancer detection (66%) but many felt strongly that this should be primarily the remit of the dental team. CONCLUSION: The study revealed a need for continuing education programmes for primary care practitioners in oral cancer-related activities. This should aim to improve diagnostic skills and seek to increase practitioners' participation in preventive activities.

A survey of Scottish primary care dental practitioners' oral cancer-related practices and training requirements.

OBJECTIVE: The study sought to investigate current examination habits and preventive practices of Scottish dental primary care professionals, with respect to oral cancer, and to determine any training needs of these practitioners in relation to the disease. BASIC RESEARCH DESIGN: A questionnaire was sent to a random sample of 331 general dental practitioners and community dental officers throughout Scotland, achieving an overall response rate of 68%. MAIN OUTCOME MEASURES: The study investigated examination and health promotion practices in relation to oral cancer. Confidence in, and barriers to, participating in these activities were studied, and information sought both on past training and future education needs regarding oral cancer. RESULTS: Although 58% of respondents reported examining regularly for signs of oral cancer in those aged >16 years, 63% indicated they felt less than confident in detecting oral cancer, with only 43% expressing confidence about discussing suspicious findings with patients. Practitioners were well aware of the importance of smoking and alcohol as risk factors, but had mixed views on the health-promoting role of the dentist regarding these issues. Furthermore, while only 3% reported training on these topics, over half expressed a desire to develop appropriate counselling skills. Overall, 87% and 79% of respondents wanted further training in oral cancer detection and prevention, respectively. CONCLUSION: The study indicated a need for continuing education programmes for dental primary care practitioners in oral cancer-related activities. Postgraduate education, utilising a variety of media formats, should aim to improve diagnostic skills and seek to increase practitioners' participation in both smoking and alcohol counselling.

The influence of maternal intergenerational education on health behaviors of women in peri-urban Bolivia.

The influence of maternal education on infant mortality has been demonstrated repeatedly in health and social science literature. Less explored is the influence of the education level of the mother's mother. In the present paper the authors examine the possible effect of grandmother's education on maternal behaviors. The relationship between intergenerational education and selected health behaviors, including utilization of health services for prenatal care, breast-feeding and family planning, are reported. The data were collected in peri-urban Santa Cruz, Bolivia among mothers of infants between 0 and 18 months of age. It appears that grandmother's education does exert an effect on health behaviors above and beyond the effect of maternal education. This effect is more pronounced for health services which fall clearly in the domain of the formal health care system. While the results are exploratory, the results suggest the worth of further study and consideration of the influence of mothers' mothers in the design of culturally sensitive quality health services.

The role of the general dental practitioner in detection and prevention of oral cancer: a review of the literature.

Over the last two decades little progress appears to have been made in reducing the incidence and number of deaths associated with oral cancer. The most recently available Scottish data indicate a steady rise in both incidence of, and mortality rates from, tongue and 'mouth' cancer, supporting previous observations of a steady rise in the incidence of oral cancer since the mid 1970s. Very little improvement in 5-year survival rates for oral cancer has been observed in England and Wales and, over the last 30 years, survival rates in Scotland have actually declined. Although many dentists are committed to examining the mouth for oral cancer, the majority still feel uncomfortable with involvement in patient education. Clearly scope exists for dental practitioners to improve patient awareness of both oral cancer itself and the risk factors associated with the disease. Dental teams should be aware of the opportunities within dental practice to contribute to preventive initiatives--such as smoking cessation.

From efficacy to effectiveness: selecting indicators for a community-based lactational amenorrhoea method promotion programme.

This paper reviews the results of clinical trials and community studies of lactational amenorrhoea and its role as a contraceptive method (LAM). Indicators which are used in efficacy trials and effectiveness interventions are compared and sets of indicators of effectiveness appropriate to community-based LAM programmes are recommended. A five-tiered ecological framework is used to facilitate selection of indicators which range from individual to policy level outcomes. The indicator framework is intended as a tool for health practitioners in family planning and maternal and child health service delivery settings who are interested in designing programmatic interventions for the promotion of LAM, particularly among less well-educated women of lower socioeconomic communities.

PIP: If lactational amenorrhea (LAM) is to reach its full potential as a method of child spacing, additional programmatic interventions must be conducted at the community level--especially in developing countries--to demonstrate its effectiveness. A review of clinical trials and community studies of LAM conducted both before and after the Bellagio Consensus Conference was undertaken in order to develop a set of indicators for the effectiveness of LAM promotion efforts under a range of field conditions. The resultant framework is intended as a tool for health professionals in family planning and maternal-child health service delivery settings who are interested in designing community-based LAM programs. A 5-tiered (individual, interpersonal, community, health system, and macro-policy factors) ecological systems model was used as the framework for indicator development. Laboratory, physiological, and behavioral measures were rated and weighted according to their scientific rigor (quality of data collected, technical feasibility), administrative feasibility (cost to administer, time required and likelihood of compliance), and community appropriateness (cultural sensitivity, contribution to women's knowledge and skills). Included among the suggested indicators are hormonal levels in urine or blood samples, timing of first vaginal bleed, duration of breast feeding, use of pacifiers or nipples, breast feeding knowledge and cultural influences, number of breast feeds per 24 hours, and frequency of intercourse.

Integrated use of qualitative and quantitative methods to elicit women's differential knowledge of breastfeeding and lactational amenorrhea in periurban Bolivia.

PIP: Exclusive and extended breast feeding is responsible for much of the fertility limitation and child spacing throughout the world. In many developing countries, where breast feeding is almost universal and of long duration, postpartum amenorrhea protects women from closely spaced subsequent pregnancies. However, at the same time, increased pressures toward modernization, rapid rural-to-urban migration, frequent advertisements of powdered milk substitutes, and the increased employment of women outside of the home are adversely affecting traditional breast feeding practices. In Bolivia, almost all women breast feed their newborn infants, for periods up to 2 years. This paper reports findings which describe and compare patterns of women's differential knowledge of breast feeding and lactational amenorrhea resulting from data collection using a survey instrument and a focus group guide. The findings are part of a larger study on infant feeding and child spacing conducted in periurban communities in Bolivia. Current and historical trends with regard to paradigm and methodology in social science research are reviewed and the survey/focus group research method is described.^ieng

Progestin-only oral contraception: a comprehensive review.

PIP: In order to provide information for the appropriate package insert labeling of progestin-only oral contraceptives (POC) in the US, a comprehensive review was made of norgestrel (0.075 mg) and norethindrone (0.35 mg), with the clinical differences indicated where applicable. The goal of this review was to cite primary sources for virtually all research specific to POPs since 1975. Conclusions and the types of studies which support these conclusions are given for each major section. The introductory chapter discusses the advantages and disadvantages of POCs and the magnitude and prevalence of their use. Future trends are also predicted. Chapter 2 considers the mode of action, including ovulation prevention; suppression of midcycle gonadotropin peaks; changes in cervical mucus, the endometrium, and the fallopian tubes; and clinical implications. Chapter 3 covers pharmacology (pharmacokinetics, pharmacodynamics and potency, and clinical implications). The next chapter presents information on efficacy and pregnancy outcomes in terms of pregnancy rates, compliance and efficacy, ectopic pregnancies, the outcome of pregnancies conceived while using POCs, and fertility following discontinuation. Chapter 5 focuses on metabolic effects, specifically lipid metabolism, carbohydrate metabolism and diabetes, coagulation factors, and blood pressure. Cardiovascular disease is considered in the next chapter, and chapter 7 presents findings on endometrial, ovarian, cervical, breast, and other cancers. A host of other medical considerations are discussed in chapter 8, including persistent ovarian follicles; reproductive tract infections; abnormal vaginal bleeding; uterine fibroids; gestational trophoblastic disease; benign breast disease; diseases of the liver, gallbladder, and bowel; endocrine dysfunction; epilepsy; bone density; sickle cell disease; ocular effects; surgery; and overdose. The last 4 chapters cover interactions with drugs and laboratory tests, common side effects, breast feeding, and effective use of POCs. Information on precautions and contraindications, indications, use instructions, and instructions for appropriate actions after missing a pill is appended.^ieng

Infant feeding in Bolivia: a critique of the World Health Organization indicators applied to demographic and health survey data.

Infant feeding is a multidimensional activity that can be described and analysed in many different ways. The World Health Organization (WHO) has recently issued recommended indicators for assessing infant feeding practices. This paper presents these indicators and demonstrates their applications using the 1989 Demographic and Health Survey (DHS) data for Bolivia. The results indicate that, although most Bolivian infants are breastfed and two-thirds are breastfed for > 1 year, supplementary feeding practices deviate considerably from international recommendations. Only 58% of infants < 4 months old are receiving breastmilk alone (the 'exclusive breastfeeding rate') and a similarly low percentage (54.7%) of 6-9 month olds are receiving the recommended combination of breast milk plus solid or semi-solid foods (the 'timely complementary feeding rate'). Furthermore, almost half of breastfed infants < 12 months old are also receiving bottle feeds. The infant feeding practices of city residents are least likely to conform to the infant feeding recommendations, while practices of mothers who have always lived in the country are most likely to be similar to the WHO guidelines. Mothers who have moved to the city since the age of 12 are most likely to be giving their infants other milks in addition to breast milk and to be bottle feeding their infants. The WHO infant feeding indicators provide a useful framework for quantifying infant feeding practices, and most of the indicators can readily be applied to DHS data. Nonetheless, improvements can be made in both the indicators themselves and the DHS questionnaire to improve reporting of internationally comparable infant feeding information.

PIP: 1989 Demographic and Health Survey data for Bolivia is used to examine trends in World Health Organization (WHO) designated breast feeding measures. WHO measures are evaluated. WHO measures are the exclusive breast feeding rate (under 4 months), predominant breast feeding with supplementation of nonmilk liquids (under 4 months), timely complementary feeding rate, continuous breast feeding rate for children aged 12-15 months, bottle feeding rate, ever breast fed rate, and median duration of breast feeding. The timely complementary feeding rate or those 6-9 months receiving solid or semisolid foods is 55%. The continuous feeding rate is 66% for the 12-15 month old infants, and just under 50% for infants aged 20-23 months. Almost 50% of breast feeding infants also receive bottle feeding. 97% are ever breast fed. The median duration of breast feeding is 17 months. At under 4 months 57.6% receive both breast milk and other milk and not solids, and 8% are not breast fed. At 6-9 months 54.7% are receiving breast milk and solids, and almost 33% receive breast milk and other milk. About 15% are not being breast fed. At 10-11 months about 15% are still being exclusively breast fed, and almost 25% are not being breast fed at all. At 12 months about 4% receive breast milk and no solids. Exclusive breast feeding occurs among just under 50% of mothers who have always lived in the city and among those who migrated to the city. The highest rates are among women who lived in the country. The greatest differences in breast feeding are among mothers who always either lived in a city or the country. The lowest complementary feeding rate occurs in the city-always group (39.3%). The highest complementary feeding rate occurs among the town group (73.1%). Continued breast feeding is lowest in the city-always group. The highest proportion of infants receiving bottles is among infants with mothers who migrated to the city (72.0%) followed by city-always mothers (60.1%). The WHO indicators are found to be useful standards for guiding research and developing policy and practice norms.

Validation of self-report of literacy among periurban women in Bolivia.

Many surveys ask women to rate their literacy level, but the validity of these self-reports is not usually evaluated. In this study of infant health, conducted in Cochabamba, Bolivia, maternal literacy was assessed by the mother herself and by the interviewer, based on the mother's reading a short text aloud. The two ratings were highly correlated (P < 0.001). This finding suggests that maternal self-reports of literacy are very reliable.

Occupational and environmental hazards in art.

Artists and craftspeople, art teachers, hobbyists, and children often use art materials containing toxic chemicals without suitable precautions and often without the knowledge that their art materials are hazardous. The Center for Safety in the Arts, a national clearinghouse for research and education on hazards in the visual and performing arts, answers telephoned and written inquiries on art hazards, distributes publications, publishes a newsletter, and offers educational programs and consultative services to arts organizations.

Oral contraceptive use and cervical intraepithelial neoplasia.

To explore the somewhat controversial relationship between oral contraceptives and pre-invasive cervical cancer, 103 cases of biopsy-confirmed cervical intraepithelial neoplasia (CIN) II or CIN III were compared with 258 controls who had normal cervical cytology. Cases were slightly less likely than controls to have ever used oral contraceptives; the odds ratio, controlling for age, socioeconomic status, barrier method use, smoking history, age at first sexual intercourse, number of sex partners, current marital status, and number of Pap smears, was 0.7 (95% CI 0.3-1.6). Recency, latency, duration, and age at first oral contraceptive use were evaluated and in no instance was oral contraceptive use positively associated with CIN. This study adds to the body of knowledge that oral contraceptives are not associated with pre-invasive cervical cancer. Further, if oral contraceptive users continue to be regularly screened, their risk of developing the more invasive lesions should be very low.

PIP: Between September 1987 and November 1988, 103 University of North Carolina Hospitals (UNCH) Dysplasia Clinic patients with newly diagnosed, biopsy-confirmed cervical intraepithelial neoplasia (CIN) II or CIN III were enrolled as cases. They were 18-45 years old, black or white, nonpregnant North Carolina residents. 40 cases were CIN II and 63 cases were CIN III confirmed histologically. The controls were 258 UNCH Family Practice Center patients with normal cervical cytology. All subjects participated in a 15-minute structured interview. The Hollingshead Index was used as a proxy for socioeconomic status (SES). Known risk factors for cervical neoplasia were found to be risk factors for CIN II and CIN III. Compared with controls, cases were younger (odds ratio [OR] = 3.4 for those under 25 years of age), less educated (OR - 13.3 for 13 years), and of lower SES. Cases were more likely to have been divorced (OR - 2.7), to be cigarette smokers (OR = 3.4), to have ever been pregnant (OR - 2.6), to have had more than 2 sex partners (OR = 5.0), to have reported having had a sexually transmitted disease (gonorrhea, chlamydia, herpes, venereal warts, or pelvic inflammatory disease) (OR = 2.9), and to have had at least 3 Pap smears in the 5 years prior to study recruitment (OR = 1.7). Cases were less likely to have used a barrier method of contraception (OR = 0.3). 80.6% of cases and 81.0% of controls had ever used oral contraceptives (OCs); thus, the crude OR was 1.0. Adjustment of the OR for all confounders (age, SES, ever-use of barrier methods, smoking history, age at 1st sexual intercourse, lifetime number of male sex partners, current marital status, and number of Pap smears) reduced the OR to 0.7 (95% confidence interval 0.3-1.6). Recency, latency, duration, and age at 1st OC use were compared without finding any positive association between OC use and CIN.

Active and passive cigarette smoke exposure and cervical intraepithelial neoplasia.

This case-control analysis presents odds ratios for active and passive cigarette smoke exposure and cervical intraepithelial neoplasia of levels II and III (CIN II and CIN III) while controlling for confounders. From 1987 to 1988, 103 biopsy-conformed incident cases of CIN II or III and 268 controls with normal cervical cytology were enrolled. Seventy % of cases were cigarette smokers, while only 30% of controls had ever smoked. The adjusted odds ratio for current cigarette smoking was 3.4 (95% confidence interval, 1.7-7.0). The following confounders were included in logistic regression models: age, race, education, number of sex partners, contraceptive use, sexually transmitted disease history, and Pap smear history. The risk of CIN II/III increased with increasing years of cigarette smoking and with increasing pack-years of exposure. Smoking was associated more strongly with CIN III than CIN II. The effect of passive cigarette smoke exposure was explored separately for smokers and nonsmokers and was found not to be consistently associated with CIN II/III when controlling for confounders.

Nicotine and cotinine in the cervical mucus of smokers, passive smokers, and nonsmokers.

Although epidemiological studies suggest that cigarette smoking is a risk factor for cervical cancer, further evidence is required to document the biological plausibility of this relationship. This study obtained cervical mucus, using a cervical flush technique, from 50 patients in a neoplasia clinic. Nicotine was detected in the cervical mucus of all 25 smokers and cotinine in the mucus of 84% of the smokers; nicotine and cotinine levels were correlated (P < or = 0.10) with both the number of cigarettes usually smoked and the number smoked in the last 24 h. Nicotine and cotinine levels for passive smokers and nonexposed women were much lower than for women who currently smoked, with little difference found between the nonsmoking women who did and did not report passive smoke exposure. In the one woman who reported smokeless tobacco use, both nicotine and cotinine were detected at much higher levels than for other nonsmoking women. These results indicate that tobacco constituents do indeed reach the uterine cervix, suggesting that they could play a causal role in the development of cervical cancer.

Barrier methods of contraception and cervical intraepithelial neoplasia.

This North Carolina-based case-control study examined risk factors for cervical intraepithelial neoplasia (CIN). Cases were 103 women with biopsy-confirmed CIN II or III who were recruited from a referral dysplasia clinic. Controls were 258 family practice patients with normal cervical cytology. All subjects were interviewed regarding their sexual and reproductive history, Pap smear screening, active and passive cigarette exposures, and contraceptive use patterns. When compared with controls, cases were half as likely to have ever used barrier methods of contraception; the adjusted odds ratio was 0.5 (95% CI 0.2-0.9). The risk of CIN II/III decreased further with increasing years of barrier method use. Recency, latency, and age at first barrier method use were all associated with a reduced risk of CIN. Men and women should carefully consider the range of benefits of barrier method use as a means to reduce their risk of unwanted pregnancies, sexually transmitted diseases, and cervical neoplasia.

PIP: The risk of cervical intraepithelial neophasia (CIN II and III) and use of barrier methods was assessed in a case control study among 103 biopsy confirmed CIN II and II patients in a North Carolina hospital clinic. Determinants considered were 1) the ever use of any barrier method (condoms, spermicides, or diaphragms), 2) duration of use, 3) time since last use, 4) time since 1st use, 5) age at 1st use, and 6) ever use of each specific type of barrier method. The hypothesis was that barrier use prevented cervical neoplasia; also explored was the effect of ever use of each method separately. Confounding variables were age, race, current marital status, ever use of OCs, active cigarette smoking history, age at 1st sexual intercourse, lifetime number of male sex partners, number of Pap smears, history of ever having genital warts, SES (Hollingshead Index), and years of education. Multiple logistic regression was used to estimate the maximum likelihood estimates of the odds ratios and 95% confidence intervals. The results were that the adjusted risk of CIN II/III. SES did not affect the strength of the relationship. These findings support other findings, but differ in that spermicide use alone was not associated with a reduced risk. Other spermicide findings are discussed. Spermicides by definition were significantly associated with a reduced risk because of their use with the diaphragm. Another difference is the lack of support for SES effects. The lowest odds were found to among the lowest SES strata. Since the focus is on preinvasive cervical cancer, the results are not generalizable to studies of invasive cervical cancer. However, if a continuum is accepted with CIN at the beginning, then a clearer picture of etiologic factors is revealed. Misclassification of disease was reduced by using only biopsy confirmed cases of CIN II and III. The only controls that were used had normal cervical cytology at the time of enrollment. Respondents with any history of CIN were excluded. All laboratory tests were read in the same place. The small sample size is a limitation. Use of barrier methods may however reduce risks of unwanted pregnancies, sexually transmitted disease, and cervical neoplasia.

Maternal and infant feeding practices in rural Bolivia.

Seventy-four members of mothers' clubs in a rural area outside of La Paz, Bolivia, were interviewed in order to learn more about maternal and infant nutritional practices and use of child health services. Most of the women used a combination of western and traditional child health services, though a substantial percentage used only traditional services. Almost all of their deliveries were attended solely by family members, most notably the pregnant woman's husband. All the interviewed mothers breast-fed their infants, although most gave them other prelacteal liquids in the immediate postpartum period. Breast milk supplementation generally began when the infants were between four and eight months old, occasionally later. Most of those interviewed said they stopped breast-feeding when they knew they were pregnant again; some continued breast-feeding through all or part of the pregnancy; only a small number stopped breast-feeding before they knew that they were pregnant. Almost all the women increased their food intake when they were breast-feeding, primarily by consuming additional liquids. These findings suggest that some current maternal and infant nutritional practices in the study area (such as universal breast-feeding and increased consumption of liquids by lactating mothers) should be encouraged, while others (particularly prelacteal feeding of liquids other than breast milk and late supplementation) should be discouraged. Both traditional and western health providers should be mobilized to perform this task.

The effects of a progestin-only oral contraceptive (levonorgestrel 0.03 mg) on breast-feeding.

This study was a non-randomized clinical trial which compared the breast-feeding experience of 250 Argentine women taking levonorgestrel 0.03 mg daily (begun one week after delivery) with that of 250 women using non-hormonal contraceptives. Weight gain of unsupplemented infants, the most important of the several criteria used to assess breast-feeding performance, was similar for the two contraceptive groups. Levonorgestrel users began supplementary feeding of their infants significantly later than did non-hormonal users; levonorgestrel users were also somewhat less likely to discontinue breast-feeding during the study period. The two contraceptive groups were similar with regard to several other measures of breast-feeding performance: growth of all infants (regardless of supplementation), patterns of contraceptive discontinuation, mothers' subjective impressions of breast-milk sufficiency, and comparison of supplementation initiation with previous experience.

PIP: This study was a non-randomized clinical trial which compared the breast-feeding experience of 250 Argentine women taking levonorgestrel 0.03mg daily (begun one week after delivery) with that of 250 women using non-hormonal contraceptives. Weight gain of unsupplemented infants, the most important of the several criteria used to assess breast-feeding performance, was similar for the 2 contraceptive groups. Levonorgestrel users began supplementary feeding of their infants significantly later than did non-hormonal users; levonorgestrel users were also somewhat less likely to discontinue breast-feeding during the study period. The 2 contraceptive groups were similar with regard to several other measures of breast-feeding performance; growth of all infants (regardless of supplementation), patterns of contraceptive discontinuation, mothers' subjective impressions of breast-milk sufficiency, and comparison of supplementation initiation with previous experience.

An epidemiologic study of contraception and preeclampsia.

The primary hypothesis of this study was that contraceptive methods that prevent exposure to sperm and seminal fluid (condoms, diaphragms, spermicides, withdrawal) are associated with an increased risk of developing preeclampsia during the subsequent pregnancy. A case-control study was conducted comparing the contraceptive and reproductive histories of 110 primiparous women with preeclampsia with 115 pregnant women without preeclampsia, aged 15 to 35 years, who gave birth at North Carolina Memorial Hospital, Chapel Hill, between 1984 and 1987. Controls were frequency matched to cases by age, race, and distance from the hospital. Unconditional logistic regression analysis indicated a 2.37-fold (95% confidence interval, 1.01 to 5.58) increased risk of preeclampsia for users of contraceptives that prevent exposure to sperm. A dose-response gradient was observed, with increasing risk of preeclampsia for those with fewer episodes of sperm exposure. These results were supportive of the hypothesis that birth control methods that prevent sperm exposure may play a role in the etiology of preeclampsia.

Effects of breastfeeding on IUD performance.

The effect that lactation might have on intrauterine device (IUD) performance was investigated by using data from a series of multicenter clinical trials. Life-table methods were applied to compare breastfeeding and non-breastfeeding women with respect to IUD expulsion, accidental pregnancy, IUD removal for various reasons, and overall continuation of IUD use. Results indicate that breastfeeding does not increase the risk of expulsion or other events, whether the device is inserted immediately (within ten minutes) or more than 42 days after delivery. (Am J Public Health 1983; 73:384-388.)