Knowledge and practice of family planning among pregnant tribal women in Southern India: an observational study.

BACKGROUND: There are over 700 Scheduled Tribes (ST) living in 30 Indian states. As with other indigenous groups across the world, Indian ST have some of the poorest infant and child health outcomes of any communities in India. A child born to an ST family is 19% more likely to die in the first month of life and has a 45 percent risk of dying in their first year compared with other Indian populations. Research suggests that early conception, high fertility, and low use of family planning methods are large contributors to these disparities. METHODS: A cross sectional survey in Kannada was conducted among 303 pregnant tribal women in Mysore, India after obtaining informed consent. Univariate and multivariable analyses were carried out to determine the demographic and psychosocial factors associated with knowledge of contraceptive methods using Stata 14.0. RESULTS: There was widespread knowledge about female sterilization, while only 39.3% of women reported hearing about one or more forms of temporary contraception, and 36.3% knew where to get them. The largest proportion of women had heard about copper-T (33.0%), followed by oral contraceptive pills (23.8%), condoms (11.9%), and injectables (4.6%). Only 2.7% of women reported ever using any form of temporary contraception. Results from the multivariable logistic regression indicated that knowledge of at least one form of temporary contraception was linked to higher age (adjusted odds ratio[AOR]: 1.09; 95% CI: 1.02, 1.17), greater number of years of marriage (AOR: 0.90; 95% CI: 0.85, 0.96), and last birth in a government facility (AOR: 3.67; 95% CI: 1.99, 6.82). CONCLUSIONS: The study revealed poor knowledge and utilization of temporary contraceptive methods among a tribal population in rural Mysore, India. Interventions aiming to increase knowledge of contraceptive options are important for birth spacing in this population and should target younger women and those without contact with government health facilities.

Motivational interviewing experiences from a community health worker-led HIV prevention and care intervention in rural Uganda: a qualitative study.

Motivational Interviewing (MI) and Community Health Workers (CHWs) are increasingly utilized in global settings to improve HIV outcomes, yet research exploring implementation strategies using MI and CHWs is lacking. We examined the experiences of CHWs and their clients in a counseling intervention which used MI-informed counseling to increase engagement in HIV prevention and treatment. This study was nested within the mLAKE cluster-randomized trial in a high HIV prevalence fishing community in rural Rakai District, Uganda. We conducted in-depth interviews with purposively-sampled CHWs (n = 8) and clients (n = 51). Transcripts were analyzed thematically to characterize CHWs' implementation of the intervention. Main themes identified included use of specific MI strategies (including evocation, guidance towards positive behavior change, active listening, and open-ended questions), and MI spirit (including collaboration, power-sharing, trust, and non-judgmental relationship building). Through these specific MI mechanisms, CHWs supported client behavior change to facilitate engagement with HIV services. This study provides evidence from a low-resource setting that CHWs with no previous experience in MI can successfully implement MI-informed counseling that is well-received by clients. CHW-led MI-informed counseling appears to be a feasible and effective approach to increase uptake of HIV prevention and care services in low-resource, HIV endemic regions.

Dissolution of transactional sex relationships during COVID-19: a qualitative study of Ugandan men's experiences during COVID-19 lockdowns.

The COVID-19 pandemic and subsequent mitigation measures led to social disruption and negative economic shocks for a large proportion of Uganda's population. The social and economic consequences of COVID-19 on Ugandan men's sexual behaviours, including transactional sex relationships, are unclear. We conducted in-depth interviews between November 2021-February 2022 with 26 men in a high HIV prevalence region of Uganda. Data were analysed thematically to understand how sexual relationships, including transactional sex, were impacted by COVID-19. We found that COVID-19 mitigation measures had far-reaching social and economic impacts on most respondents, particularly those employed in the informal economy. Men described experiencing job loss, food insecurity and restricted mobility, which limited opportunities to provide for and meet with transactional sex partners. Inability to provide financial resources meant that men could not form new transactional sex relationships and men who could no longer provide for their existing transactional sex partners consistently reported relationship dissolution. Men who reported stable employment during the pandemic described few changes in transactional sex relationships. Similarly, men in non-transactional relationships did not report relationship dissolution despite decreased financial provision. Further research should assess the potential short- and long-term impacts of COVID-19 mitigation measures on transactional sex relationships.

Educational approaches to teach students to address colonialism in global health: a scoping review.

INTRODUCTION: The enduring legacy of colonisation on global health education, research and practice is receiving increased attention and has led to calls for the 'decolonisation of global health'. There is little evidence on effective educational approaches to teach students to critically examine and dismantle structures that perpetuate colonial legacies and neocolonialist control that influence in global health. METHODS: We conducted a scoping review of the published literature to provide a synthesis of guidelines for, and evaluations of educational approaches focused on anticolonial education in global health. We searched five databases using terms generated to capture three concepts, 'global health', 'education' and 'colonialism'. Pairs of study team members conducted each step of the review, following Preferred Reporting Items for Systematic reviews and Meta-Analyse guidelines; any conflicts were resolved by a third reviewer. RESULTS: This search retrieved 1153 unique references; 28 articles were included in the final analysis. The articles centred North American students; their training, their evaluations of educational experiences, their individual awareness and their experiential learning. Few references discussed pedagogical approaches or education theory in guidelines and descriptions of educational approaches. There was limited emphasis on alternative ways of knowing, prioritisation of partners' experiences, and affecting systemic change. CONCLUSION: Explicit incorporation of anticolonial curricula in global health education, informed by antioppressive pedagogy and meaningful collaboration with Indigenous and low-income and middle-income country partners, is needed in both classroom and global health learning experiences.

Impact of community health worker intervention on PrEP knowledge and use in Rakai, Uganda: A mixed methods, implementation science evaluation.

BACKGROUND: Effective models of support for HIV pre-exposure prophylaxis (PrEP) are needed for populations at elevated risk. In a hyperendemic Ugandan fishing community, PrEP counseling was provided through a situated Information, Motivation, and Behavioral Skills (sIMB)-based community health worker (CHW) intervention. We evaluated the intervention using a mixed-methods, implementation science design. METHODS: We surveyed all community members aged 15-49 through the Rakai Community Cohort Study. We used multivariable logistic regressions with generalized estimating equations to estimate the intervention's effect on PrEP knowledge and utilization. To understand intervention experiences and mechanisms, we conducted 74 qualitative interviews with 5 informant types (clients, CHWs, program staff, community leaders, health clinic staff) and analyzed data using an iterative, deductive approach. A mobile phone application provided intervention process implementation data. RESULTS: Individuals self-reporting receipt of the CHW intervention showed significantly higher PrEP knowledge (N = 1848, PRR: 1.10, 95% CI: 1.06-1.14, p = <.0001), PrEP ever use (N = 1176, PRR: 1.77, 95% CI: 1.33-2.36, p = <.0001), and PrEP current use (N = 1176, PRR: 1.86, 95% CI: 1.22-2.82, p = 0.0039) compared to those who did not. Qualitative findings attributed positive PrEP outcomes to CHW counseling and effective use of motivational interviewing skills by CHWs. Salient themes across the RE-AIM framework included support for the CHW intervention and PrEP across clients, community, and implementers. Mobile application data demonstrated consistent delivery of the PrEP module throughout implementation. CONCLUSIONS: CHWs improved PrEP knowledge and use among clients in an HIV hyperendemic fishing community. Mixed-methods, implementation science evaluations can inform adaptation of similar PrEP implementation strategies.

Barriers and Facilitators to Cervical Cancer Screening in Western Kenya: a Qualitative Study.

About nine out of 10 cervical cancer deaths occur in low-resource countries, with a particularly high burden in sub-Saharan Africa. The objectives of this study were to assess barriers and facilitators to cervical cancer screening in western Kenya from the perspectives of community members and healthcare providers. We conducted two focus groups with female community members (n = 24) and one with providers (n = 12) in Migori County, Kenya. Discussion guides queried about knowledge and awareness of cervical cancer prevention; structural, social, and personal barriers; and facilitators towards cervical cancer screening uptake. Group discussions were recorded, transcribed, and analyzed for emerging themes. Participants in both groups reported low awareness of HPV and cervical cancer screening in the community, and identified that as a main barrier to screening. Community members reported fear of pain and embarrassment as significant barriers to a screening pelvic exam. They also reported that providers' lack of knowledge and discomfort with a sensitive subject were significant barriers. A personal connection to cervical cancer and/or screening was associated with willingness to screen and awareness. Providers reported workload and lack of supplies and trained staff as significant barriers to offering services. Based on these findings, we identified three intervention components to address these facilitators and barriers to screening. They include utilizing existing social networks to expand awareness of cervical cancer risk and screening, training non-physician health workers to meet the demand for screening, and employing female-driven screening techniques such as self-collection of specimens for HPV testing. Cervical cancer prevention programs must take into account the local realities in which they occur. In low-resource areas in particular, identifying low-cost, effective, and culturally appropriate strategies for addressing poor screening uptake is important given limited funding. This study took a formative approach to identify facilitators and barriers to cervical cancer screening based on focus groups and interviews with community members and healthcare providers.

Community-based Mobile Cervical Cancer Screening Program in Rural India: Successes and Challenges for Implementation.

BACKGROUND: The aim of this study is to demonstrate the feasibility; mention the challenges encountered and highlight the success of implementing a community-based mobile cervical cancer-screening program in rural India. METHODS: Communities were mobilized through extensive peer education and by screening in existing community spaces using a mobile clinic model. An initial "screen and treat" protocol was transitioned to "screen, test, and treat" using Pap smears for confirmatory testing, and cryotherapy or Loop Electrosurgical Excision Procedure (LEEP) for treatment. We trained 50 Peer Educators and conducted 190 screening camps in 58 locations. RESULTS: Of 3,821 registered women, 3,544 (92.8%) accepted screening. Overall, 440/3544 (12.4%, 95% CI 11.3-13.5%) women had VIA-positive lesions. Under "screen and treat", 56/156 (35.9%) women accepted same-day treatment. Under "screen, test, and treat", 555/762 (72.8%) women received a Pap smear. Overall, 83 women underwent cryotherapy (n=56) and LEEP (n=27). Of those, 49 (59.0%) participants were followed up, with normal VIA results up to two years after treatment. In summary, the peer educators promoted awareness of cervical cancer and helped in gaining buy-in from communities. Acceptance of same-day treatment was low and accompanied by loss to follow-up, limiting the utility of VIA in these studies. CONCLUSIONS: Mobile infrastructure utilized in community spaces brought screening directly to rural women. Culturally appropriate methods to increase linkage to treatment and additional screening options such as HPV DNA testing should be explored.

HPV self-sampling for cervical cancer screening: a systematic review of values and preferences.

INTRODUCTION: The WHO recommends human papillomavirus (HPV) cervical self-sampling as an additional screening method and HPV DNA testing as an effective approach for the early detection of cervical cancer for women aged ≥30 years. This systematic review assesses end user's values and preferences related to HPV self-sampling. METHODS: We searched four electronic databases (PubMed, Cumulative Index to Nursing and Allied Health Literature, Latin American and Caribbean Health Sciences Literature and Embase) using search terms for HPV and self-sampling to identify articles meeting inclusion criteria. A standardised data extraction form was used to capture study setting, population, sample size and results related to values and preferences. RESULTS: Of 1858 records retrieved, 72 studies among 52 114 participants published between 2002 and 2018 were included in this review. Almost all studies were cross-sectional surveys. Study populations included end users who were mainly adolescent girls and adult women. Ages ranged from 14 to 80 years. Most studies (57%) were conducted in high-income countries. Women generally found HPV self-sampling highly acceptable regardless of age, income or country of residence. Lack of self-confidence with collecting a reliable sample was the most commonly cited reason for preferring clinician-collected samples. Most women preferred home-based self-sampling to self-sampling at a clinic. The cervical swab was the most common and most accepted HPV DNA sampling device. CONCLUSIONS: HPV self-sampling is generally a highly accepted method of cervical cancer screening for end users globally. End user preferences for self-sampling device, method and setting can inform the development of new and expanded interventions to increase HPV screening.

Acceptability and Concordance of Self- Versus Clinician- Sampling for HPV Testing among Rural South Indian Women.

BACKGROUND: Despite being largely preventable, HPV-related cervical cancers continues to be the second highest cause of cancer deaths among Indian women. HPV testing using self-sampled samples may offer an opportunity to expand cervical cancer screening in India where there is currently a shortage of providers and facilities for cervical cancer screening. The study examines acceptability and concordance of self vs. clinician collected samples for HPV-relted cervical cancer screening among rural South Indian women. METHODS: Between May and August 2017, eight mobile screening clinics were conducted among 120 eligible women in rural villages in Mysore District, India. Women over the age of 30 underwent informed consent process and then self-sampled a sample for cervicovaginal HPV DNA testing. Next, the women underwent clinical exam where the clinician collected a cervicovaginal HPV DNA sample. Following the clinical exam, all participants answered an interviewer-administered questionnaire to assess their history of cervical cancer screening and acceptability of self- and clinician-sampling methods. To assess diagnostic accuracy, concordance of self- and clinician-sampled HPV DNA specimens was calculated in addition to five measures of acceptability (feeling of caring, privacy, embarrassment, genital discomfort, and genital pain). RESULTS: Study participants had a median age 39 years, about four-in-ten (41.7%) had a secondary education or above, the vast majority (87.5%) were married and only 3.4% reported having screened for cervical cancer. For all measures of participant acceptability, self-sampling was rated significantly higher than clinician-sampling. Cohen's kappa was 0.73 (95% CI: 0.34, 1.00), indicating substantial agreement between self- and clinician-sampling. CONCLUSION: This study demonstrates that HPV self-sampling for cervical cancer screening is feasible and acceptable in a community setting among South Indian rural women. Concordance between self-sampling and clinician-sampling was adequate for screening in community settings.  
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Evaluating the feasibility of utilizing Gynocular-triage-to-diagnose application with VIA (Visual inspection with Acetic acid) in community cervical cancer screening programs in rural Mysore, India.

BACKGROUND: Cervical cancer is the third most common cancer among women in India. The aim of the study is to determine the feasibility of using the Gynocular-triage-to-diagnose (Gynocular T2D/GT2D) in conjunction with visual inspection with acetic acid (VIA) in community-based cervical cancer screening programs in rural Mysore, India. METHODS: Between November 2015 and August 2016, the Public Health Research Institute of India (PHRII) implemented a mobile cervical cancer-screening in Mysore district using VIA and GT2D. Women underwent speculum exams and VIA positive cases were identified. Swede score was assessed using GT2D and a score >4 indicated further monitoring or referral for treatment. Papanicolaou (Pap) smears were conducted for selected cases. Statistical analysis was performed using Chi-square and Fisher's exact tests. RESULTS: Among 199 women registered in the camp, 176 were included in the final analysis. 23 women were excluded due to vaginal bleeding. The average age of women was 39 years (range = 27-59 years). Among the 176 cases, 38 (21.6%) were VIA positive and 138 (78.4%) were VIA negative. Swede score of >4 was observed in 6 VIA positive and 7 VIA negative women. Two cases among VIA negative with a score of >4 were suggested biopsy. CONCLUSION: Gynocular triaging prevented overtreatment of 32 (18.1%) participants, and identified 7 subjects with >4 Swede score even in VIA negative cases, which would have been ignored if VIA alone was used. In summary, our study demonstrates that Gynocular triaging is feasible in community cervical cancer screening programs.

Time to Modernize: Local Public Health Transitions to Population-Level Interventions.

OBJECTIVES: To identify facilitating factors that guide local health departments (LHDs) in their transition from direct clinical service provision to population-level interventions addressing the social determinants of health. DESIGN: Key informant interviews with LHD leaders and their staff were conducted using a semistructured interview guide. Thematic qualitative analysis was used to identify common characteristics and strategies among the LHD leaders and staff. PARTICIPANTS: LHDs represented both rural and urban communities with population sizes from 9746 to 919 628 and agencies in Illinois, Montana, North Carolina, Oregon, Tennessee, Washington, and West Virginia. OUTCOME MEASURE: The impetus and facilitators for transitioning health department services from clinical to population health. RESULTS: Leaders from 7 LHDs emphasized that an impetus for their transition from direct clinical services to population-level interventions was that it was "time to modernize." Among LHDs interviewed, most included the 10 Essential Public Health Services or Public Health 3.0 in their strategic plan. Adding this focus to their strategic plan facilitated buy-in from local government and the ability to maintain the LHDs' focus on population-level interventions. We found that strong relationships and open communication with community members and partner organizations (eg, federally qualified health centers) were critical facilitators of transition. Themes from interviews were used to identify an initial set of 8 key elements of an effective transition: partnership/leadership, vision/goals, communication, community engagement, interventions, data/evaluation, workforce issues, and sustainability. CONCLUSIONS: Prevention systems suffer from a lack of adequate health promotion and access to quality care for their community's residents. There is a need for LHDs to access technical support to strategically address complexity and ensure core population-focused prevention. The results shared provide replicable solutions, practices, and methods that enable successful transitions of LHDs toward maximizing their role in population health.

Reframing HIV Stigma and Fear : Considerations from Social-ecological and Evolutionary Theories of Reproduction.

HIV stigma and fears surrounding the disease pose a challenge for public health interventions, particularly those that target pregnant women. In order to reduce stigma and improve the lives of vulnerable populations, researchers have recognized a need to integrate different types of support at various levels. To better inform HIV interventions, the current study draws on social-ecological and evolutionary theories of reproduction to predict stigma and fear of contracting HIV among pregnant women in South India. The aims of this study were twofold: compare the social-ecological model to a modified maternal-fetal protection model and test a combined model that included strong predictors from each model. The study took place in 2008-2011 in Mysore District, Karnataka, India. Using data from a cross-sectional survey and biological indicators of health, we statistically modeled social-ecological variables representing individual, interpersonal, and community/institutional levels. Participants were 645 pregnant women. The social-ecological and combined models were the best-fitting models for HIV-related stigma, and the combined model was the best fit for HIV-related fear. Our findings suggest that combining reproductive life history factors along with individual, interpersonal, and community/institutional factors are significant indicators of HIV-related stigma and fear. Results of this study support a multifaceted approach to intervention development for HIV-related stigma and fear. The combined model in this study can be used as a predictive model for future research focused on HIV stigma and fear, with the intent that dual consideration of social-ecological and evolutionary theories will improve public health communication efforts.

Remooring: A Qualitative Focus Group Exploration of How Educators Maintain Identity in a Sea of Competing Demands.

PURPOSE: Longitudinal faculty development programs (LFDPs) are communities of practice (CoPs) that support development of participants' educator identity (EID). This study explored how program graduates negotiated their newly formed EIDs among competing identities and demands in academic medicine. METHOD: In this multicenter, cross-sectional, qualitative study, graduates of two LFDP cohorts (one and five years post graduation) were invited in 2015 to participate in a one-hour, cohort-specific focus group. The focus group included questions about views of themselves as educators, experiences of transition out of the LFDP, and sustainability of their EID following program participation. Researchers analyzed transcripts using Wenger's CoP and Tajfel's social identity theories to guide interpretation of findings. RESULTS: Thirty-seven graduates, 17 from one year and 20 from five years post graduation, participated in eight focus groups. They described developing a new EID in their LFDP CoPs. Three major themes emerged: context, agency, and identity. A push-pull relationship among these themes influenced faculty members' EID trajectory over time. Graduates described feeling unmoored from their LFDP community after graduation and relied on individual agency to remoor their new identities to supports in the larger institutional context. CONCLUSIONS: LFDP graduation represented a transition point. Graduates found it challenging to lose supports from their time-limited CoP and remoor their EIDs to workplace supports. Remooring required individual agency and external support and affirmation. Faculty development programs must be designed with transition periods and sustainability in mind to ensure that participants and institutions can benefit from their transformative effects over time.

A Medical Student Inquiry Behavior Assessment Tool: Development and Validity Evidence.

PURPOSE: The University of California, San Francisco (UCSF) School of Medicine's Bridges curriculum is designed to teach inquiry: the process of approaching problems with curiosity, challenging current concepts, and creating new knowledge. The authors aimed to develop and gather validity evidence for a tool to guide development of medical student inquiry behaviors in small groups. METHOD: The authors reviewed the literature to identify inquiry behaviors, verified findings with an expert focus group, and synthesized the results into 40 behaviors. In a modified two-round Delphi survey in 2016, faculty and students rated the behaviors for inclusion in the tool. Feedback from cognitive interviews and a pilot helped refine the tool. In 2016-2017, the authors implemented the final tool for 152 first-year UCSF medical students in inquiry small groups as a faculty assessment and a student self-assessment each quarter. RESULTS: The two-round response rate was 77% (36/47). Five behaviors were selected for inclusion in the tool: select relevant questions to pursue; justify explanations with evidence; critically evaluate his/her explanation in light of alternative possibilities; allow for the possibility that his/her own knowledge may not be completely correct; and collaborate well with peers. During implementation, faculty and student scores increased on most items, indicating skills development over time. Content, response process, internal structure, and consequential validity evidence is presented. CONCLUSIONS: The tool's five items are observable, measurable core inquiry behaviors. The tool is ready for use by small-group facilitators within inquiry-based curricula to promote student self-assessment and guide feedback to students.

Determinants of exclusive breastfeeding in rural South India.

BACKGROUND: While breastfeeding rates have improved globally, disparities in breastfeeding practices persist particularly in rural and low resource settings. In India, only 56% of Indian mothers practice exclusive breastfeeding (EBF) for the recommended six months. As India leads the world in the number of preterm births, under 5 years of age malnutrition and neonatal mortality, understanding the factors associated with EBF can help improve the nutritional status for millions of infants. We assessed the factors associated with EBF in rural Mysore, India. METHODS: This cross-sectional analysis was nested within a cohort study assessing the feasibility and uptake of mobile prenatal care and HIV counseling and testing intervention in Mysore District. Multivariable logistic regression was used to identify the factors associated with EBF for infants between birth and six months. Exclusive breastfeeding was defined as breastfeeding with no other liquids or breastfeeding substitutes given to infants exceptfor medicine or oral rehydration solution, between birth and 6 months and was assessed at six months postpartum. RESULTS: We surveyed mothers who delivered in rural Mysore taluk between 2008 and March 2011. A total of 1292 mothers participated in the study. The overall breastfeeding rate at six months postpartum was 74.9% and the EBF rate was 48.5%. Factors associated with EBF included higher maternal age (Adjusted Odds Ratio[aOR] 1.04; 95% Confidence Interval [CI] 1.00, 1.09), lower maternal education (aOR1.56, 95% CI 1.10, 2.21), and 7-10 antenatal visits (aOR 1.57; 95% CI 1.09, 2.27). The most common reason for non-exclusive breastfeeding was the mother's feeling that she did not have enough milk (23.7%). Infants that were not exclusively breastfed were most commonly fed formula/animal milk (42.6%) or castor oil/ghee (18.4%). CONCLUSIONS: Less than half of the mothers in our sample reported exclusive breastfeeding in a rural region of Karnataka, India in the first six months, a rate lower than national and state level rates. Future interventions should evaluate whether antenatal education can improve breastfeeding outcomes. The only modifiable factor was number of antenatal visits. Breastfeeding education should be emphasized at every antenatal visit so that even mothers with fewer than 7-10 antenatal visits can learn the best techniques and benefits of breastfeeding.

Competency assessment form to improve feedback.

BACKGROUND: In-training evaluation reports are a commonly used assessment method for clinical learners that can characterise the development of competence in essential domains of practice. Strategies to increase the usefulness and specificity of written narrative comments about learner performance in these reports are needed to guide their learning. Soliciting narrative comments by competency domain from supervising doctors on in-training evaluation reports could improve the quality of written feedback to students. METHODS: This is a pre-post study examining narrative comments derived from assessments of core clerkship students by faculty members and resident supervisors in seven clerkships using two assessment forms in academic years 2013/14 (pre; two comments fields - summative, constructive) and 2014/15 (post; seven comments fields - six competency domains, constructive comments). Using a purposive sample of 60 students based on overall clerkship performance, we conducted content analysis of written comments to compare comment quality based on word count, competencies addressed and reinforcing or constructive content. Differences between the two forms across these three components of quality were compared using Student's t-tests. RESULTS: The revised form elicited more narrative comments in all seven clerkships, with more competencies addressed. The revised form led to a decrease in the proportion of constructive comments about the students' performances. In-training evaluation reports are a commonly used assessment method for clinical learners DISCUSSION: Structural changes to a medical student assessment form to elicit narrative comments by competency improved some measures of the quality of narrative comments provided by faculty members and residents. Additional study is needed to determine how learners use this information to improve their clinical practice.

Suboptimal Breastfeeding Practices among Women in Rural and Low-Resource Settings: a Study of Women in Rural Mysore, India.

BACKGROUND: Breastfeeding rates are progressively increasing worldwide while optimal breastfeeding practices are lagging behind, especially in rural and low resource settings like India. OBJECTIVES: This study estimated the prevalence of and factors associated with suboptimal breastfeeding practices among mother-infant dyads in rural southern India. METHODS: This is a cross-sectional analysis of data collected in Mysore District from 2008-2011 from 1294 mother-infant dyads. All women answered an interviewer-administered survey, which included maternal, infant, and sociodemographic information and breastfeeding-related characteristics. Logistic regressions were conducted to determine factors associated with suboptimal breastfeeding practice. FINDINGS: About 20% (n = 281) of mothers reported delayed initiation of breastfeeding. Mothers who were unsatisfied with the infant's gender had higher odds of delayed breastfeeding (adjusted odds ratio [AOR]: 1.42, 95% confidence interval [CI]: 1.00, 2.00). Odds of delayed initiation were significantly lower among mothers who received 7-10 antenatal checkups (AOR: 0.59, 95% CI: 0.41, 0.87) and assistance during breastfeeding (AOR: 0.73, 95% CI: 0.57, 0.95). About half (51.4%) the sample did not breastfeed exclusively for the first 6 months. Older age was associated with lower odds of nonexclusive breastfeeding (AOR: 0.95, 95% CI: 0.92, 1.00). Compared with mothers with no education, mothers with primary education (AOR: 1.94, 95% CI: 1.35, 2.79) or more than primary education (AOR: 1.58, 95% CI: 1.10, 2.26) had higher odds of nonexclusive breastfeeding. CONCLUSIONS: Optimal breastfeeding practices were influenced by a multitude of factors, including maternal age, education, number of antenatal checkups, receiving assistance with breastfeeding, and satisfaction with the infant's gender. Health promotion efforts should focus on encouraging mothers to attend antenatal care visits. Early antenatal education and counseling should include breastfeeding education in early antenatal visits. Further research should examine how to mitigate the effect of gender preference on initiation of breastfeeding.

Identification of core objectives for teaching sustainable healthcare education.

BACKGROUND: Physicians will be called upon to care for patients who bear the burden of disease from the impact of climate change and ecologically irresponsible practices which harm ecosystems and contribute to climate change. However, physicians must recognize the connection between the climate, ecosystems, sustainability, and health and their responsibility and capacity in changing the status quo. Sustainable healthcare education (SHE), defined as education about the impact of climate change and ecosystem alterations on health and the impact of the healthcare industry on the aforementioned, is vital to prevention of adverse health outcomes due to the changing climate and environment. OBJECTIVE: To systematically determine which and when a set of SHE objectives should be included in the medical education continuum. DESIGN: Fifty-two SHE experts participated in a two-part modified-Delphi study. A survey was developed based on 21 SHE objectives. Respondents rated the importance of each objective and when each objective should be taught. Descriptive statistics and an item-level content validity index (CVI) were used to analyze data. RESULTS: Fifteen of the objectives achieved a content validity index of 78% or greater. The remaining objectives had content validity indices between 58% and 77%. The preclinical years of medical school were rated as the optimal time for introducing 13 and the clinical years for introducing six of the objectives. Respondents noted the definition of environmental sustainability should be learned prior to medical school and identifying ways to improve the environmental sustainability of health systems in post-graduate training. CONCLUSIONS: This study proposes SHE objectives for the continuum of medical education. These objectives ensure the identity of the physician includes the requisite awareness and competence to care for patients who experience the impact of climate and environment on health and advocate for sustainability of the health systems in which they work. ABBREVIATIONS: CVI: Content validity index; SHE: Sustainable healthcare education.