The potential role of patent and proprietary medicine vendors' associations in improving the quality of services in Nigeria's drug shops.

BACKGROUND: Patent and Proprietary Medicine Vendors (PPMVs) play a major role in Nigeria's health care delivery but regulation and monitoring of their practice needs appreciable improvement to ensure they deliver quality services. Most PPMVs belong to associations which may be useful in improving their regulation. However, little is known about how the PPMV associations function and how they can partner with relevant regulatory agencies to ensure members' compliance and observance of good practice. This study sought to describe the PPMV associations' structure and operations and the regulatory environment in which PPMVs function. With this information we explore ways in which the associations could help improve the coverage of Nigeria's population with basic quality health care services. METHODS: A mixed methods study was conducted across four rural local government areas (LGAs) (districts) in two Nigerian states of Bayelsa and Oyo. The study comprises a quantitative data collection of 160 randomly selected PPMVs and their shops, eight PPMV focus group discussions, in-depth interviews with 26 PPMV association executives and eight regulatory agency representatives overseeing PPMVs' practice. RESULTS: The majority of the PPMVs in the four LGAs belonged to the local chapters of National Association of Patent and Proprietary Medicine Dealers (NAPPMED). The associations were led by executive members and had regular monthly meetings. NAPPMED monitored members' activities, provided professional and social support, and offered protection from regulatory agencies. More than 80% of PPMVs received at least one monitoring visit in the previous 6 months and local NAPPMED was the organization that monitored PPMVs the most, having visited 68.8% of respondents. The three major regulators, who reached 30.0-36.3% of PPMVs reported lack of human and financial resources as the main challenge they faced in regulation. CONCLUSIONS: Quality services at drug shops would benefit from stronger monitoring and regulation. The PPMV associations already play a role in monitoring their members. Regulatory agencies and other organizations could partner with the PPMV associations to strengthen the regulatory environment and expand access to basic quality health services at PPMV shops in Nigeria.

Malaria testing and treatment knowledge among selected rural patent and proprietary medicine vendors (PPMV) in Nigeria.

BACKGROUND: Malaria is a leading cause of illness and death in Nigeria, but access of poor people to quality anti-malarial services remains low especially in the rural areas. Patent and proprietary medicine vendors (PPMVs) provide the majority of malaria treatment in rural areas, but little is known about their knowledge of malaria testing and treatment of uncomplicated malaria as recommended in the 2011 National Malaria Control Programme policy. METHODS: A cross-sectional survey was conducted in two purposively selected states (Oyo and Bayelsa) in Nigeria with each state representing a different geographic and linguistic-ethnic region in the southern part of the country. Two rural LGAs were randomly selected from each state and data were collected from 160 randomly selected PPMVS (40 per LGA) using a structured questionnaire. Data were analysed using descriptive statistics. RESULTS: The 2011 National Policy on Malaria Diagnosis and Treatment is mostly unknown to PPMVs. Although most PPMVs (89%) knew that artemisinin-based combination therapy (ACT) is recommended in the national policy, 91% also thought non-ACT were endorsed. The proportion of PPMVs who stated they would treat a malaria case with an artemisinin-based combination at the correct dose was 33% for a child under five, 47% for an adult male and 14% for a pregnant woman in her second trimester. The proportion of PPMVs who reported they would diagnose a case of malaria prior to treatment using a malaria rapid diagnostic test (RDT) kit was 1.9% for children under five, 7.5% for adult males and 3.1% for pregnant women in their first trimester due to lack of knowledge. Almost two-thirds (65.6%) would correctly refer children with severe malaria to health facility. CONCLUSIONS: Substantial knowledge gaps on the use of RDTs and treatment with artemisinin-based combinations exist among rural PPMVs. Given existing evidence regarding the effectiveness of private retail outlets in malaria case management, PPMVs should be provided with competency-based training and supervision to improve the quality of care they provide.

Mistreatment of women during childbirth in Abuja, Nigeria: a qualitative study on perceptions and experiences of women and healthcare providers.

BACKGROUND: Global efforts have increased facility-based childbirth, but substantial barriers remain in some settings. In Nigeria, women report that poor provider attitudes influence their use of maternal health services. Evidence also suggests that women in Nigeria may experience mistreatment during childbirth; however, there is limited understanding of how and why mistreatment this occurs. This study uses qualitative methods to explore women and providers' experiences and perceptions of mistreatment during childbirth in two health facilities and catchment areas in Abuja, Nigeria. METHODS: In-depth interviews (IDIs) and focus group discussions (FGDs) were used with a purposive sample of women of reproductive age, midwives, doctors and facility administrators. Instruments were semi-structured discussion guides. Participants were asked about their experiences and perceptions of, and perceived factors influencing mistreatment during childbirth. Thematic analysis was used to synthesize findings into meaningful sub-themes, narrative text and illustrative quotations, which were interpreted within the context of this study and an existing typology of mistreatment during childbirth. RESULTS: Women and providers reported experiencing or witnessing physical abuse including slapping, physical restraint to a delivery bed, and detainment in the hospital and verbal abuse, such as shouting and threatening women with physical abuse. Women sometimes overcame tremendous barriers to reach a hospital, only to give birth on the floor, unattended by a provider. Participants identified three main factors contributing to mistreatment: poor provider attitudes, women's behavior, and health systems constraints. CONCLUSIONS: Moving forward, findings from this study must be communicated to key stakeholders at the study facilities. Measurement tools to assess how often mistreatment occurs and in what manner must be developed for monitoring and evaluation. Any intervention to prevent mistreatment will need to be multifaceted, and implementers should consider lessons learned from related interventions, such as increasing audit and feedback including from women, promoting labor companionship and encouraging stress-coping training for providers.

Experiences of girls with hearing impairment in accessing reproductive health care services in Ibadan, Nigeria.

Delivery of health services to people with hearing impairment is poorly understood in Nigeria and limited research has been done to throw more light on the process involved. This study described experiences of 167 girls with hearing impairment in accessing reproductive health services in Ibadan using a validated questionnaire. Descriptive statistics and binary logistic regression were used to analyze the data. Almost 95.0% of respondents had ever visited health facility for reproductive health issues. Of these 6.2% and 4.6% went for treatment of STIs and pregnancy termination respectively; 36.7% were embarrassed to ask questions in the presence of an interpreter, communication (40.5%) and cost (10.8%) were key barriers to access and 85.6% would use facility if hearing impairment-friendly services are provided. Respondents who were currently working were 20 times more likely to receive services they wanted (OR = 20.29, CI = 1.05-392.16). Availability of certified interpreters and ensuring confidentiality are key to effective service delivery for the hearing impaired.

Capacity-Building for Stroke Genomic Research Data Collection: The African Neurobiobank Ethical, Legal, and Social Implications Project Experience.

Background: The fields of stroke genomics, biobanking, and precision medicine are rapidly expanding in sub-Saharan Africa. However, the ethical, legal, and social implications (ELSI) of emerging neurobiobanking and genomic data resources are unclear in an emerging African scientific landscape with unique cultural, linguistic, and belief systems. Objective: This article documents capacity-building experiences of researchers during the development, pretesting, and validation of data collection instruments of the African Neurobiobank for Precision Stroke Medicine-(ELSI) Project. Methods: The African Neurobiobank for Precision Stroke Medicine-ELSI project is a transnational, multicenter project implemented across seven sites in Ghana and Nigeria. Guided by the Community-Based Participatory Research framework, we conducted three workshops with key stakeholders to review the study protocol, ensure uniformity in implementation; pretest, harmonize, and integrate context-specific feedback to ensure validity and adaptability of data collection instruments. Workshop impact was assessed using an open-ended questionnaire, which included questions on experience with participation in any of the workshops, building capacity in Genetic and Genomic Research (GGR), level of preparedness toward GGR, the genomic mini-dictionary developed by the team, and its impact in enhancing understanding in GGR. Data were analyzed qualitatively using a thematic framework approach. Results: Findings revealed the usefulness of the workshop in improving participants' knowledge and capacity toward GGR implementation. It further identified local, context-specific concerns regarding quality data collection, the need to develop culturally acceptable, genomic/biobanking data collection tools, and a mini-dictionary. Participants-reported perceptions were that the mini-dictionary enhanced understanding, participation, and data collection in GGR. Overall, participants reported increased preparedness and interest in participating in GGR. Conclusion: Capacity-building is a necessary step toward ELSI-related genomic research implementation in African countries where scholarship of ELSI of genomics research is emerging. Our findings may be useful to the design and implementation of ELSI-GGR projects in other African countries.

Exclusive Breastfeeding Intentions Among Adolescents In Urban Communities In Ibadan, Nigeria.

Purpose: During adolescence, a female child makes several decisions, and the choice to breastfeed in the near future is conceivably shaped. But in sub-Saharan Africa where teenage pregnancy and teenage motherhood is on the rise, there is a dearth of information on the intention of adolescents to exclusively breastfeed (EBF) in community settings. Therefore, this study assessed exclusive breastfeeding intentions, knowledge and attitude of adolescents in urban communities in Ibadan, Nigeria. Methods: A descriptive community-based cross-sectional study was carried out, selecting 271 respondents. Data were analysed with the aid of IBM SPSS version 21 at P ≤ .05. Results: Mean age of adolescents was 17.5 ± 1.3 years, and 96.3% would breastfeed their children later in future. However, only 37.6%, 22.5% and 50.2% had the intention to exclusively breastfeed, good knowledge score and positive attitude, respectively. There were significant relationships between respondents' age, educational attainment, parents' educational attainment, level of knowledge, attitude and intention. The coefficient of knowledge and attitude were significant predictors of good intention to practise EBF. Major predictors of good intention were good knowledge [OR = 36.5; 95% CI (9.2, 145.2)] and positive attitude toward EBF [OR = 9.7; 95% CI (3.6, 25.9)]. Conclusions: The EBF intention was influenced by multiple factors and should be considered in determining the effectiveness of interventions targeting this practice. Therefore, coherent EBF education interventions that commence from adolescence to promote the practice by adulthood are urgently needed to improve knowledge, attitude and intention about EBF rate and confer the cancer-risk reducing benefits.

Biological sample donation and informed consent for neurobiobanking: Evidence from a community survey in Ghana and Nigeria.

INTRODUCTION: Genomic research and neurobiobanking are expanding globally. Empirical evidence on the level of awareness and willingness to donate/share biological samples towards the expansion of neurobiobanking in sub-Saharan Africa is lacking. AIMS: To ascertain the awareness, perspectives and predictors regarding biological sample donation, sharing and informed consent preferences among community members in Ghana and Nigeria. METHODS: A questionnaire cross-sectional survey was conducted among randomly selected community members from seven communities in Ghana and Nigeria. RESULTS: Of the 1015 respondents with mean age 39.3 years (SD 19.5), about a third had heard of blood donation (37.2%, M: 42.4%, F: 32.0%, p = 0.001) and a quarter were aware of blood sample storage for research (24.5%; M: 29.7%, F: 19.4%, p = 0.151). Two out of ten were willing to donate brain after death (18.8%, M: 22.6%, F: 15.0%, p<0.001). Main reasons for unwillingness to donate brain were; to go back to God complete (46.6%) and lack of knowledge related to brain donation (32.7%). Only a third of the participants were aware of informed consent (31.7%; M: 35.9%, F: 27.5%, p<0.001). Predictors of positive attitude towards biobanking and informed consent were being married, tertiary level education, student status, and belonging to select ethnic groups. CONCLUSION: There is a greater need for research attention in the area of brain banking and informed consent. Improved context-sensitive public education on neurobiobanking and informed consent, in line with the sociocultural diversities, is recommended within the African sub region.

Malaria knowledge and agricultural practices that promote mosquito breeding in two rural farming communities in Oyo State, Nigeria.

BACKGROUND: Agricultural practices such as the use of irrigation during rice cultivation, the use of ponds for fish farming and the storage of water in tanks for livestock provide suitable breeding grounds for anthropophylic mosquitoes. The most common anthropophylic mosquito in Nigeria which causes much of the morbidity and mortality associated with malaria is the anopheles mosquito. Farmers are therefore at high risk of malaria - a disease which seriously impacts on agricultural productivity. Unfortunately information relating to agricultural practices and farmers' behavioural antecedent factors that could assist malaria programmers plan and implement interventions to reduce risk of infections among farmers is scanty. Farmers' knowledge about malaria and agricultural practices which favour the breeding of mosquitoes in Fashola and Soku, two rural farming communities in Oyo State were therefore assessed in two rural farming communities in Oyo State. METHODS: This descriptive cross-sectional study involved the collection of data through the use of eight Focus Group Discussions (FGDs) and the interview of 403 randomly selected farmers using semi-structured questionnaires. These sets of information were supplemented with observations of agricultural practices made in 40 randomly selected farms. The FGD data were recorded on audio-tapes, transcribed and subjected to content analysis while the quantitative data were analyzed using descriptive and inferential statistics. RESULTS: Most respondents in the two communities had low level of knowledge of malaria causation as only 12.4% stated that mosquito bite could transmit the disease. Less than half (46.7%) correctly mentioned the signs and symptoms of malaria as high body temperature, body pains, headache, body weakness and cold/fever. The reported main methods for preventing mosquito bites in the farming communities included removal of heaps of cassava tuber peelings (62.3%), bush burning/clearing (54.6%) and clearing of ditches (33.7%). The dumping of cassava tuber peelings which allows the collection of pools of water in the farms storage of peeled cassava tubers soaked in water in uncovered plastic containers, digging of trenches, irrigation of farms and the presence of fish ponds were the observed major agricultural practices that favoured mosquito breeding on the farms. A significant association was observed between respondents' knowledge about malaria and agricultural practices which promote mosquito breeding. Respondents' wealth quintile level was also seen to be associated with respondents' knowledge about malaria and agricultural practices which promote mosquito breeding. CONCLUSION: Farmers' knowledge of malaria causation and signs and symptoms was low, while agricultural practices which favour mosquito breeding in the farming communities were common. There is an urgent need to engage farmers in meaningful dialogue on malaria reduction initiatives including the modification of agricultural practices which favour mosquito breeding. Multiple intervention strategies are needed to tackle the factors related to malaria prevalence and mosquito abundance in the communities.

Knowledge, perception and experience of sexual entrapment among undergraduate students of the University of Ibadan, Nigeria.

Background: Deceit into sexual activities without the victim being aware of the intended action is common in tertiary institutions as the environment promote activities that make students vulnerable, especially females, young and new students. The resulting physical, psychological and social consequences, including harassment, sexual assault, non-consensual sex, injury, psychological trauma and suicide attempts, have affected many young people. This study was aimed at exploring the knowledge, perception, experience of sexual entrapment among undergraduate students of the University of Ibadan, Ibadan, Nigeria. Methods: This multi-stage cross-sectional survey involved 422 participants using semi-structured questionnaire and an in-depth interview guide. Quantitative data were analyzed statistically, while Qualitative data was analyzed thematically. Results: Mean age of respondents was 20.5±3.0 years, 52.6% were males, 58.8% and 81% had a good knowledge and perception of sexual entrapment, respectively. Prevalence of sexual entrapment was 18%, affecting more males (55.3%) and first year students (39.5%), 59.2% of the perpetrators are friends of the victim. Students were entrapped on campus through; emotional support (42.1%), money (34.2%), accommodation assistance (7.9%), material things/gifts (21.1%), assignment assistance (10.5%), help with registration (4.0%), religious activities (6.6%), debt repayment (11.8%) and counseling (9.2%). It resulted to; unwanted sex (34%), rape (4%), pregnancy (1.3%), STDs (4%), Injury (13%), psychological trauma (27.6%), loss of trust (52.6%) and attempted suicide (23.7%) among victims. Effective coping mechanisms were adopted by 55.3% of respondents. There was a significant association between knowledge and perception; knowledge and experience; perception and experience (p<0.05). Findings from the in-depth interview revealed care, tutoring, political positions, and pretense to need help as other tactics. Conclusions: Sexual entrapment is common on campus, affecting males and females, knowledge and perception influence experience of sexual entrapment, requiring the need for a holistic approach to reduce its prevalence.

The communication and emotional support needs to improve women's experience of childbirth care in health facilities in Southwest Nigeria: A qualitative study.

OBJECTIVE: To improve women's childbirth experiences in health facilities, their psychosocial and communication needs have to be met. However, what constitutes these specific needs is poorly understood, particularly in Sub-Saharan Africa. This paper explores women's needs for communication and emotional support during facility-based childbirth. METHODS: Qualitative research was conducted in a large referral maternity hospital and its catchment communities in Akure, Nigeria. In-depth interviews (IDIs) and focus group discussions (FGDs) were conducted among women of reproductive age, midwives, doctors, and facility administrators. Thematic analysis was used to synthesize findings, and then interpreted within the context of this study and existing quality of care framework. RESULTS: Forty-two IDIs and 10 FGDs are included in this analysis. Participants reported such needs as communication in simple words in local language by healthcare staff, having their husbands as birth companions, spiritual support, and prayers from family members and healthcare providers. CONCLUSION: To increase, improve, and sustain facility-based childbirth in Nigeria, health systems should appreciate the uniqueness and importance of each woman's needs during childbirth. Practical and sustainable actions should be taken to meet these needs, within the confines of the acceptable sociocultural norms.

Healthcare providers' perspectives on labor monitoring in Nigeria and Uganda: A qualitative study on challenges and opportunities.

OBJECTIVE: To explore current practices, challenges, and opportunities in relation to monitoring labor progression, from the perspectives of healthcare professionals in low-resource settings. METHODS: Thematic analysis of qualitative data (in-depth interviews [IDIs] and focus group discussions [FDGs]) obtained from a purposive sample of healthcare providers and managers in selected health facilities in Nigeria and Uganda. RESULTS: A total of 70 IDIs and 16 FGDs with doctors, midwives, and administrators are included in this analysis. Labor monitoring encompasses a broad scope of care jointly provided by doctors and midwives. A range of contextual limitations was identified as barriers to monitoring labor progression, including staff shortages, lack of team cooperation, delays in responding to abnormal labor observations, suboptimal provider-patient dynamics, and limitations in partograph use. Perceived opportunities to improve current practices included streamlining clinical team cooperation, facilitating provider-client communication, encouraging women's uptake of offered care, bridging the gaps in the continuum of monitoring tasks between cadres, and improving skills in assessment of labor progress, and accuracy in its documentation. CONCLUSION: Healthcare providers face many challenges to effective monitoring of labor progress in low-resource settings. This analysis presents potential opportunities to improve labor monitoring practices and tools in these contexts.

Defining quality of care during childbirth from the perspectives of Nigerian and Ugandan women: A qualitative study.

OBJECTIVE: To explore what "quality of care" means to childbearing women in Nigeria and Uganda, as a means of ensuring that women's voices and opinions are prioritized when developing interventions to improve quality in maternity care provision. METHODS: Qualitative methods, with a purposive sample of women in Nigeria and Uganda. Participants were asked to define quality of care and to provide examples of when it was and was not provided. Thematic analysis was used to synthesize findings based on an a priori framework (the WHO quality of care framework). RESULTS: 132 in-depth interviews and 21 focus group discussions are included. Participants spontaneously discussed each of the WHO framework domains of quality of care. Data were richest across the domains of effective communication, respect and dignity, emotional support, competent and motivated human resources, and essential physical resources. Women believed that good quality of care ensured optimal psychological and physiological outcomes for the woman and her baby. Positive interpersonal relationships between women and health providers were important. These included supportive care, building rapport, and using positive and clear language. CONCLUSION: To provide good quality of care, maternity services should consider and act on the expectations and experiences of women and their families.

Negotiating quality standards for effective delivery of labor and childbirth care in Nigeria and Uganda.

OBJECTIVE: "Negotiated standards" describe a level of quality of care that is acceptable and achievable within a specific health system, based on consensus between key stakeholders. This paper presents the development of negotiated standards for effective labor and childbirth care in selected hospitals and communities in Nigeria and Uganda. METHODS: A four-step development process involving different methodologies. The process included: (1) review and synthesis of internationally recognized intrapartum clinical principles and practices; (2) primary qualitative research to assess values and preferences of women and healthcare providers, and practices that align with these preferences; (3) draft contextualization of effective and ineffective behaviors to reflect values and preferences; and (4) WHO-mediated negotiations between relevant stakeholders, including community members, providers, and administrators. RESULTS: The primary outcomes of this process were a comprehensive set of effective behaviors and clinical practices covering the main domains of quality of care, which are practical and easy to communicate, implement, and audit across all levels of healthcare delivery. CONCLUSION: The process demonstrates that health facilities and providers can be motivated to adopt standards of care that uphold the values and preferences of both service users and providers, while adhering to international best practices.

"By slapping their laps, the patient will know that you truly care for her": A qualitative study on social norms and acceptability of the mistreatment of women during childbirth in Abuja, Nigeria.

BACKGROUND: Many women experience mistreatment during childbirth in health facilities across the world. However, limited evidence exists on how social norms and attitudes of both women and providers influence mistreatment during childbirth. Contextually-specific evidence is needed to understand how normative factors affect how women are treated. This paper explores the acceptability of four scenarios of mistreatment during childbirth. METHODS: Two facilities were identified in Abuja, Nigeria. Qualitative methods (in-depth interviews (IDIs) and focus group discussions (FGDs)) were used with a purposive sample of women, midwives, doctors and administrators. Participants were presented with four scenarios of mistreatment during childbirth: slapping, verbal abuse, refusing to help the woman and physical restraint. Thematic analysis was used to synthesize findings, which were interpreted within the study context and an existing typology of mistreatment during childbirth. RESULTS: Eighty-four IDIs and 4 FGDs are included in this analysis. Participants reported witnessing and experiencing mistreatment during childbirth, including slapping, physical restraint to a delivery bed, shouting, intimidation, and threats of physical abuse or poor health outcomes. Some women and providers considered each of the four scenarios as mistreatment. Others viewed these scenarios as appropriate and acceptable measures to gain compliance from the woman and ensure a good outcome for the baby. Women and providers blamed a woman's "disobedience" and "uncooperativeness" during labor for her experience of mistreatment. CONCLUSIONS: Blaming women for mistreatment parallels the intimate partner violence literature, demonstrating how traditional practices and low status of women potentiate gender inequality. These findings can be used to facilitate dialogue in Nigeria by engaging stakeholders to discuss how to challenge these norms and hold providers accountable for their actions. Until women and their families are able to freely condemn poor quality care in facilities and providers are held accountable for their actions, there will be little incentive to foster change.

Infant weaning methods: an intergenerational view from Igbo-Ora Nigeria.

This study documents and compares the methods by which mothers and grandmothers feed children under 2 years of age in a southwest Nigerian town and the factors which influence their choice of weaning methods. The study was exploratory in design and stratified sampling was done to select respondents from all six wards of the town studied. Two hundred and forty mothers with children under 2 years of age and 246 grandmothers were interviewed. Data analysis was done using EPI INFO Software. Mothers were more likely to have used feeding bottles than grandmothers, while the reverse was true for hand- or forced-feeding. Although most women had used cups and spoons to feed their children, this was more common among current mothers. Over three-quarters of mothers said there were dangers associated with forced-feeding. Grandmothers perceived more social support and encouragement to practice hand-feeding than mothers, while the opposite was true for bottle-feeding. Both groups felt equally encouraged to use cups and spoons. In conclusion, child feeding methods in Igbo-Ora town of Oyo State may be changing with succeeding generations. Forced-feeding appears to be less popular among mothers, and grandmothers are using cups and spoons with feeding bottles. The current generation of mothers in Igbo-Ora would benefit from health education to reinforce safe ways of feeding their children.

Observations of barbers' activities in Oyo State Nigeria: implications for HIV/AIDS transmission.

In Nigeria, most studies concerning HIV/AIDS transmission have looked at the sexual route from both epidemiological and behavioral perspectives. A few have examined the role of blood transfusion and the potential for indigenous surgical practices. None have specifically looked at the transmission of potential barbers. This study distinguished between indigenous barbers who function as surgeons and "modern" barbers who cut hair, and focused on the latter through observations of barbering practices in 77 shops in Igbo-Ora and Apete communities in Oyo State. Igbo-Ora is headquarters of a rural local government, while Apete is a peri-urban community near Ibadan, the state capital. Five barbering sessions were observed in each shop using a checklist during evening hours when shops are busiest. All barbers used clippers to cut hair, either electric or manual. On average, barbers sterilized the clippers in a commercial disinfectant, Jik, or with methylated spirits prior to 4.2 barberings. Sex and age of customer were not associated with wether the clippers were sterilized. Three shop characteristics appeared to influence sterilization behavior. Clippers were more likely to be sterilized if the shop was in Apete, if the shop owner was male, and if the shop had two or more of the following electrical appliances: fan, TV, or radio/cassette layer. There were only two observed cases of the barbers causing a cut, and in both cases the clippers had been sterilized. Overall, 63 (16.3%) of the 385 customers were barbed with non-sterilized clippers. The relatively short time gap between customers implies that the potential for disease transmission exists, though it was not within the scope of this study to study disease transmission itself. In-service training that involves the barbers themselves and addresses both gender and town differences is recommended.