Provider bias and family planning in Upper Egypt: a simulated client approach.

BACKGROUND: Provider bias is a main barrier that extensively violates the right of free family planning method choice. Egypt is one of the countries that shows skewness in its method mix. Provider bias and insufficiency of alternative methods are identified as potential factors underlying this phenomenon which contributes to high unmet needs and discontinuation rates. Provider bias may be influenced by cultural beliefs and societal trends and is usually overlooked as a possible cause of this skewed method mix. This study aims to explore the presence of provider bias in rural Upper Egypt and its potential causes, a community with conservative cultural beliefs and least contraceptive prevalence rates. METHODS: This is a qualitative study using the "simulated client's approach." The study was conducted in 16 villages in Assiut and Sohag governorates in Egypt. The simulated clients visited 30 clinics, 15 in each governorate, including primary healthcare units and private clinics. Three scenarios were used to explore the physicians-imposed restrictions for contraceptive use with different clients' eligibility criteria. Data was analyzed using the grounded theory methodology. RESULTS: Recommending a contraceptive method for the mystery clients was not based on informed choice. Most providers had method or client bias. Copper IUD was the most favorable contraceptive method recommended by providers, with negative attitude towards using hormonal contraception. Nulliparous and young clients were discouraged to use contraception before proving fertility or offered temporary methods as emergency contraception or condoms. Providers have shown misconceptions related to infertility-associated complications of contraceptive use, especially for the young and nulliparous women. CONCLUSION: In this study, providers had a clear bias towards recommending IUD rather than all other contraceptive methods, which was hindered in some cases by the lack of insertion skills. Interventions to reduce provider bias should go beyond technical training. Moreover, training on reproductive rights should be a main component of routine training. Providers should regularly receive research results and be oriented toward recent medical eligibility criteria of contraceptive methods use. Moreover, the sociocultural beliefs of providers that may affect their practice should be explored and addressed.

Intention of pregnant women for the postpartum use of intrauterine devices in Upper Egypt's rural communities.

OBJECTIVES: This study aims to assess pregnant women's intention in rural Upper Egypt to use the copper-bearing intrauterine device (IUD) and to identify the factors influencing their intention to use the method. METHODS: The study was a household survey of 400 pregnant women in 16 villages in Assiut and Sohag Governorates in Upper Egypt. RESULTS: Only one third of the study participants (30.8%) had the intention to use IUD. Reasons of not intending to use IUD were; perceived pain during IUD insertion or removal (37.5%), perceived side effects (21.3%) and misconceptions (15.2%), husbands' disapproval for using the method (15.8%) and the desire for future fertility (12.3%). Having a secondary or a higher level of education (OR (95% CI) = 1.726 (1.085-2.746), p = 0.01) and previous use of IUD (OR (95% CI) = 2.277 (1.108-4.678), p = 0.02) were the positive predictors of the intention to use IUD, while perception of husband opposition to IUD use (OR (95% CI) = 0.604 (0.379-0.964), p = 0.03) and perception of IUD related myths (OR (95% CI) = 0.893 (0.836-0.955), p = 0.004) were the negative predictors of the intention to use IUD. CONCLUSION: The intention to use IUD is relatively low among pregnant women in rural Upper Egypt. Targeting pregnant women and their husbands with proper counselling regarding IUD use during antenatal care visits would greatly impact increasing their use of the method.

Activation of Janus kinase signaling pathway in acne lesions.

The Janus kinase/signal transducer and activator of transcription (JAK/STAT) signaling pathway has been linked to the pathogenesis of many inflammatory skin diseases; however, the role of JAKs in the pathogenesis of acne vulgaris has not been previously elucidated. We aimed to analyze the cutaneous expression of JAK1/2/3 proteins in acne vulgaris and investigate the possible role of JAK signaling in acne pathogenesis. This case-control study was carried out on 28 patients with inflammatory acne vulgaris vs 20 age- and sex-matched healthy volunteers. Acne severity was assessed using Global acne severity grading system (GAGS). Skin biopsies were collected from lesional and non-lesional skin of patients and from control group. The expression of JAK1/2/3 proteins was examined by real-time quantitative polymerase chain reaction. JAK1 and JAK3 were overexpressed in acne lesions, compared to non-lesional skin and the control group. No significant difference was found in JAK2 expression between patients and controls. JAK1 and JAK3 showed no significant relation with the patients' age, sex, family history, duration of acne, or GAGS score. Our results suggest the activation of JAK pathway in acne lesions, indicating that it may play a pivotal role in the inflammatory disease process. JAK1 and JAK3 may be possible new targets for acne therapy.

Cutaneous JAK Expression in Vitiligo.

BACKGROUND: The Janus kinase-signal transducer and activator of transcription signaling pathway has been suggested as a promising therapeutic target in vitiligo. However, limited data is available on the cutaneous expression of JAK in vitiligo. AIM: This study is designed to analyze the cutaneous expression patterns of JAK1, 2, and 3 in vitiligo and investigate their relation to the disease clinical parameters. METHODS: This case-control study recruited 24 patients having active vitiligo and 20 age, sex, and skin type-matched healthy volunteers. Skin biopsies were obtained from patients (lesional, perilesional and nonlesional) and controls for assessment of JAK1, 2, and 3 expression using RT-PCR. RESULTS: JAK1 and JAK3 were overexpressed in patients' skin compared to control skin and showed a stepwise pattern of upregulation from control to nonlesional, perilesional and lesional skin. However, JAK3 showed much stronger expression. In contrast JAK2 expression showed no significant difference in any of lesional, perilesional or nonlesional skin compared to control skin. JAK1 and JAK3 expression levels showed no correlation with neither the disease activity nor severity. CONCLUSION: JAK1 and more prominently JAK3 are upregulated in vitiliginous skin and possibly contribute to the pathogenesis of the disease. Accordingly, selective JAK3/1 inhibition may provide a favorable therapeutic opportunity for vitiligo patients.This study is registered on the ClinicalTrials.gov Identifier: NCT03185312.

Hepatitis C virus associated skin manifestations in upper Egypt: Before and after direct acting antiviral treatment.

Egypt displays a high-hepatitis C virus (HCV) burden and almost 20% of the patients develop cutaneous manifestations HCV-related. Direct acting antivirals (DAAs) drastically changed HCV patient's morbidity and mortality but their impact of the cutaneous manifestations remains elusive. Our aim was to find out the prevalence of different dermatological manifestations accompaning HCV infection in Egyptian patients. Also, to highlight the impact of DAAs on such manifestations and any potential dermatological side effects. A descriptive study was carried out at the Department of Tropical medicine and Gastroenterology in collaboration with the Department of Dermatology, Venerology and Andrology, Assiut University Hospitals. Medical history, full general, dermatological examination and photography were performed for all patients before the start of treatment with the full regimen of DAAs, every month and 3 months after reaching sustained virological response (SVR), and the changes of skin lesions were recognized and rated by two blinded dermatologists. Out of 1000 examined patient, 36.9% had skin manifestation. Itching was the commonenst presented in 190 patients (51.5%). Three months after reaching SVR, skin examination revealed improvement in the majority of patients (23 764.22%). Pruritis had significant clinical improvement in 152(80%) of patients with significant change in the Visual Analog Score (P = .000). Also, patients with both cutaneous vasculitis and eczema experienced improvement in their skin manifestations. Skin manifestations are common in Egyptian patients with HCV infection. Pruritis is the commonest. The use of DAAs in treatment of HCV is associated with significant improvement of skin lesions with very limited cutaneous adverse effects.

Spousal violence and its determinants among married adolescent girls in Upper Egypt.

INTRODUCTION: In Egypt, many girls are still married before the age of 18, which is a fundamental violation of the girls' human rights. Early marriage is associated with an alarmingly elevated risk of all types of intimate partner violence that have various negative consequences. The purpose of this study was to identify the predictors of exposure to spousal violence among the early married girls in rural Upper Egypt. METHODS: A household survey was carried out and covered 23 villages in Assiut and Sohag governorates reaching to a sample of 729 married girls before the age of 20. Listing and enumeration of 4 districts was done to identify the study participants. Data was collected by personal interviews using a structured questionnaire. Bivariate and stepwise regression analyses were performed to identify the predictors of exposure to spousal violence. RESULTS: It was found that 15.2% of the study participants were exposed to physical violence while 17.8% were exposed to sexual violence and 7.3% were exposed to both types. Girls married before the age of 18 were more exposed to spousal violence. Stepwise regression analysis found that girls' acceptance to get married was a protective factor against exposure to physical (ß = - 1.07, OR 0.34) and sexual (ß = - 0.68, OR 0.51) violence. The perceived attitude of husbands and mothers-in-law about considering wife beating "a husband's right" was found to be a risk factor of exposure to physical and sexual violence. Longer duration till the first pregnancy was also associated with more exposure to sexual violence (ß = 0.04, OR 1.04). CONCLUSION: Married adolescent girls (MAGs) are highly exposed to physical and sexual violence. This is mainly due to ignoring girls' preference to postpone their marriage, cultural concepts of accepting violence against women, and low sexual satisfaction. This study shows that most determinants of spousal violence were related to culture issues. Identifying these determinants is required to combat such a crucial public health problem that has serious consequences on adolescent health.

Workplace sexual harassment among nurses of a university hospital in Egypt.

OBJECTIVES: To assess the magnitude of sexual harassment, its effect on nurses, and to identify the predictors of workplace sexual harassment in one of the university hospitals of Upper Egypt. METHODS: A cross -sectional study of 296 nurses working at Sohag University Hospital was completed between November 2018 and March 2019. Nurses selected by systematic random sampling were invited to complete a self-administered questionnaire covering personal, workplace, and other determinants of sexual harassment. Logistic regression analysis was performed to identify predictors of sexual harassment. RESULTS: More than half of the nurses (58.1%) were exposed to at least one form of sexual harassment. The most recent incident of sexual harassment was verbal in the majority of cases (53.5%), followed by non-verbal (mainly sexual gestures) (28.5%) and lastly physical (18%). Two-thirds (69.8%) of the nurses exposed to sexual harassment reported that they were negatively affected by the incident. Low job satisfaction was the main complaint reported by more than half of the harassed nurses (64.2%). Predictors of sexual harassment were being single, working in open units, and having fewer years of work experience. CONCLUSION: Workplace sexual harassment among nurses was high, and was associated with lower job satisfaction. The study findings suggest that sexual harassment at work may result in the intention of nurses to leave their jobs and negatively impact the nurse working force.

Health care providers' perceptions and practices of screening for domestic violence in Upper Egypt.

OBJECTIVES: To explore the attitude of health care providers about screening for and dealing with domestic violence in the health care setting and to assess the physicians screening behavior. METHODS: We surveyed physicians and nurses working in different departments of Assiut University Hospital using a self-administered questionnaire. Two focus group discussions with physicians and nurses were also conducted. RESULTS: 44.3% and 46.5% of physicians and nurses mentioned time constraints as a barrier for DV screening. Physicians believed that it is not important to screen for DV because it is a socially accepted problem and because of the unavailability of the necessary referrals to help victims (30.2% and 20.0%, respectively). The unsuitability of the outpatient clinics to screen for DV was also mentioned by 65.6% and 75.5% of physicians and nurses respectively. Only 36.7% of physicians perceived having the communication skills to facilitate disclosure of DV exposure. Regarding practice, only 35.0% of physicians have screened for DV in the three months preceding data collection. Urban residence, perception of the negative health consequence of DV exposure and perception of the physicians to have the required communication skills predicted positive attitude towards DV screening, while feeling distressed to discuss exposure to DV was associated with negative physicians' attitude. CONCLUSION: In-service training of health care providers to identify and manage victims of DV and establishing supportive system would have great implications for reducing the physical and mental negative consequences of DV exposure.

Factors associated with first-year discontinuation of Implanon in Upper Egypt: clients' and providers' perspectives.

BACKGROUND: The etonogestrel implant Implanon is a favourable and cost-effective contraceptive method for women in developing countries, and expansion of its use represents a priority for the family planning (FP) programme in Egypt. We studied the factors affecting first-year Implanon discontinuation from clients' and providers' perspectives. METHODS: We used a mixed quantitative-qualitative methodology. We conducted a household survey of Implanon clients and three focus group discussions with FP physicians and directors. RESULTS: We found that 13.5% of Implanon users discontinued its use in the first year. Survival analysis found that clients who had previously used Implanon (HR 0.36, 95% CI 0.15 to 0.88) and whose husbands had secondary or a higher level of education (HR 0.36,95% CI 0.19 to 0.69) were less likely to discontinue Implanon use after the first year, while clients who experienced side effects of Implanon use were more likely to discontinue it (HR 3.6,95% CI 1.60 to 8.11). Other causes of discontinuation which emerged in the qualitative analysis were the unjustified advice for Implanon removal by non-gynaecologists, due to unrelated users' complaints, and deficient pre-insertion counselling. CONCLUSIONS: Implanon has a low first-year discontinuation rate as compared with other contraceptive methods. FP clients should be given sufficient pre-insertion counselling about side effects of Implanon and duration of protection. Physicians should offer Implanon mainly to clients seeking long-term contraception in order to decrease its discontinuation rate and increase its cost effectiveness.

Maternal mortality in an academic institution in Upper Egypt.

Maternal mortality is a worldwide problem. Measuring maternal mortality and identifying its causes is essential, and should be assessed regularly for the purpose of planning, monitoring and evaluation of provided maternal health care. Quality of care indicators such as case fatality rate is used to measure the facility performance, in particular, quality and promptness of care. This descriptive study aimed to calculate maternal mortality ratio, quality of care indicators such as maternal mortality index, case fatality and direct obstetric case fatality rate for the Women's Health Hospital and identify causes of maternal mortality, and the main deficits in medical records. The Maternal mortality ratio was alarmingly high in Women's Health Hospital, Assiut University, Egypt reaching 225/100,000, however, those who delivered in the hospital, the MMR was 100.5/100,000. The leading causes of maternal death were obstetric haemorrhage (38.3%), complications of caesarean sections (27.7%) and pre-eclampsia/eclampsia (23.4%). Nearly half (42%) of the deaths occurred during vacations. Quality indicators revealed poor quality of health care.

Mobile clinics for women's and children's health.

BACKGROUND: The accessibility of health services is an important factor that affects the health outcomes of populations. A mobile clinic provides a wide range of services but in most countries the main focus is on health services for women and children. It is anticipated that improvement of the accessibility of health services via mobile clinics will improve women's and children's health. OBJECTIVES: To evaluate the impact of mobile clinic services on women's and children's health. SEARCH METHODS: For related systematic reviews, we searched the Database of Abstracts of Reviews of Effectiveness (DARE), CRD; Health Technology Assessment Database (HTA), CRD; NHS Economic Evaluation Database (NHS EED), CRD (searched 20 February 2014).For primary studies, we searched ISI Web of Science, for studies that have cited the included studies in this review (searched 18 January 2016); WHO ICTRP, and ClinicalTrials.gov (searched 23 May 2016); Cochrane Central Register of Controlled Trials (CENTRAL), part of The Cochrane Library. www.cochranelibrary.com (including the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register) (searched 7 April 2015); MEDLINE, OvidSP (searched 7 April 2015); Embase, OvidSP (searched 7 April 2015); CINAHL, EbscoHost (searched 7 April 2015); Global Health, OvidSP (searched 8 April 2015); POPLINE, K4Health (searched 8 April 2015); Science Citation Index and Social Sciences Citation Index, ISI Web of Science (searched 8 April 2015); Global Health Library, WHO (searched 8 April 2015); PAHO, VHL (searched 8 April 2015); WHOLIS, WHO (searched 8 April 2015); LILACS, VHL (searched 9 April 2015). SELECTION CRITERIA: We included individual- and cluster-randomised controlled trials (RCTs) and non-RCTs. We included controlled before-and-after (CBA) studies provided they had at least two intervention sites and two control sites. Also, we included interrupted time series (ITS) studies if there was a clearly defined point in time when the intervention occurred and at least three data points before and three after the intervention. We defined the intervention of a mobile clinic as a clinic vehicle with a healthcare provider (with or without a nurse) and a driver that visited areas on a regular basis. The participants were women (18 years or older) and children (under the age of 18 years) in low-, middle-, and high-income countries. DATA COLLECTION AND ANALYSIS: Two review authors independently screened the titles and abstracts of studies identified by the search strategy, extracted data from the included studies using a specially-designed data extraction form based on the Cochrane EPOC Group data collection checklist, and assessed full-text articles for eligibility. All authors performed analyses, 'Risk of bias' assessments, and assessed the quality of the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS: Two cluster-RCTs met the inclusion criteria of this review. Both studies were conducted in the USA.One study tested whether offering onsite mobile mammography combined with health education was more effective at increasing breast cancer screening rates than offering health education only, including reminders to attend a static clinic for mammography. Women in the group offered mobile mammography and health education may be more likely to undergo mammography within three months of the intervention than those in the comparison group (55% versus 40%; odds ratio (OR) 1.83, 95% CI 1.22 to 2.74; low certainty evidence).A cost-effectiveness analysis of mammography at mobile versus static units found that the total cost per patient screened may be higher for mobile units than for static units. The incremental costs per patient screened for a mobile over a stationary unit were USD 61 and USD 45 for a mobile full digital unit and a mobile film unit respectively.The second study compared asthma outcomes for children aged two to six years who received asthma care from a mobile asthma clinic and children who received standard asthma care from the usual (static) primary provider. Children who receive asthma care from a mobile asthma clinic may experience little or no difference in symptom-free days, urgent care use and caregiver-reported medication use compared to children who receive care from their usual primary care provider. All of the evidence was of low certainty. AUTHORS' CONCLUSIONS: The paucity of evidence and the restricted range of contexts from which evidence is available make it difficult to draw conclusions on the impacts of mobile clinics on women's and children's health compared to static clinics. Further rigorous studies are needed in low-, middle-, and high-income countries to evaluate the impacts of mobile clinics on women's and children's health.