Systematic review of menstrual health and hygiene in Nepal employing a social ecological model.

Menstrual health and hygiene are a major public health and social issues in Nepal. Due to inadequate infrastructure to provide education, healthcare, and communication as well as religious teachings, women and girls are excluded from participation in many activities of daily living and community activities during menstruation. Evidence based research addressing menstrual health and hygiene in Nepal is scares. The objective of this paper is to review the current state of knowledge on menstrual health and hygiene in Nepal through a socio-ecological perspective. This systematic review identifies knowledge gaps and targets for future research and interventions. Studies from Nepal that examined factors contributing to menstrual health and hygiene were identified through searches across six databases (Medline, CINAHL, Web of Science, PsychInfo, Nepal Journals Online and Kathmandu University Medical Journal) in January 2019. The SEM is a public health framework that describes how health is impacted at multiple levels including the individual, interpersonal, community, organizational and policy levels. Key themes were identified, and factors contributing to menstrual health and hygiene were categorized as per the level of socio-ecological model (SEM). After a comprehensive literature review, twenty peer-reviewed publications, published between 2003 and January 2019 were included in this review. Eighteen studies were descriptive and two were interventional. The main outcomes reported were reproductive health concerns and menstrual hygiene practices. Nine studies focused on knowledge, attitude, and practices regarding menstruation, seven studies highlighted reproductive health issues, three studies focused on prevalence of culturally restrictive practices, and one on school absenteeism and intimate partner violence. Lack of awareness regarding menstrual health and hygiene, inadequate WASH facilities, no sex education and culturally restrictive practices makes menstruation a challenge for Nepali women. These challenges have negative implications on women and girls' reproductive as well as mental health and school attendance among adolescent girls. There are gaps in the evidence for high quality interventions to improve menstrual health and hygiene in Nepal. Future research and interventions should address needs identified at all levels of the SEM.

Menstrual health and hygiene are major public health and social issues in Nepal, due to a lack of health and education infrastructure, gender-based disparities and restrictive cultural and social norms. This study reviewed the current state of research on menstrual health and hygiene in Nepal. The socio-ecological model (SEM)­a public health framework that examines individual, interpersonal, community, organizational, and policy impacts on health­was employed to describe impacts on menstrual health and hygiene. After a comprehensive literature review, 20 papers were included in this analysis, of which 18 were descriptive and two were interventional. The primary menstrual health and hygiene outcomes reported were reproductive health concerns and menstrual hygiene practices. Key themes identified were knowledge, attitude, and practices regarding menstruation, reproductive health issues, prevalence of culturally restrictive practices, school absenteeism and intimate partner violence. The study results indicated lower menstrual health and hygiene challenges arose from lack of education around menstruation, lack of proper water, sanitation, and hygiene (WASH) facilities, poor sex education, and culturally restrictive practices. These challenges negatively impact women and girls' reproductive health as well as mental health and school attendance. There is need for high quality, effective interventions to improve menstrual health and hygiene in Nepal. Future research and interventions should address improvements in menstrual health and hygiene at all levels of the socio-ecological model.

Association of intimate partner violence and health-care provider-identified obesity.

The association of physical and nonphysical intimate partner violence (IPV) with obesity was examined. Women (N = 1,179) were surveyed regarding demographics, obesity, and IPV exposure using humiliate-afraid-rape-kick (HARK), an IPV screening tool. A three-level lifetime IPV exposure variable measured physical, nonphysical or no IPV. Health-care provider-identified obesity was defined if participants were told by a medical provider within the past 5 years that they were obese. Bivariate analyses examined obesity by IPV and demographics. Multivariable logistic regression assessed odds of obesity by IPV type, adjusting for age, race/ethnicity, education, and marital status. Among participants, 44% reported lifetime IPV (25% physical, 19% nonphysical), and 24% reported health-care provider-identified obesity. In unadjusted analyses, obesity was more prevalent among women exposed to physical IPV (30%) and nonphysical IPV (27%), compared to women without IPV (20%, p = .002). In multivariable models, women reporting physical IPV had 1.67 times greater odds of obesity (95% confidence interval [CI] 1.20, 2.33), and women reporting nonphysical IPV had 1.46 times greater odds of obesity (95% CI 1.01, 2.10), compared to women reporting no exposure. This study extends prior data by showing, not only an association between physical IPV and obesity, but also an association between obesity and nonphysical IPV.

Intimate partner violence screening and counseling in the health care setting: Perception of provider-based discussions as a strategic response to IPV.

Intimate partner violence (IPV) affects women worldwide, and is addressable in the health care setting not only via screening, but also through provider-based counseling and referral to legal or social services, as appropriate. We conducted a study in Pennsylvania (USA) examining factors associated with receipt of IPV screening and women's perceptions of counseling discussions as a strategic response. We found that women with past-year IPV were more likely to receive screening (aOR: 2.0, 95%CI: 1.2,3.5) and to consider counseling discussions to be a strategic response to IPV exposure (aOR: 2.7, 95%CI: 1.008,7.2) than women with a more distant history of IPV. Scholars and clinicians may learn that, especially for women with a recent history of IPV, screening may provide a conduit to meaningful counseling discussions and referrals that women view as a helpful strategy in responding to IPV.

Barriers to colorectal cancer screening among women in rural central Pennsylvania: primary care physicians' perspective.

INTRODUCTION: Colorectal cancer (CRC) is the third leading cause of death among women in the USA. Rural populations have lower rates of CRC screening than their urban counterparts, and rural women have lower screening rates compared with rural men. The purpose of this qualitative study was to identify (1) beliefs of primary care physicians (PCPs) about CRC screening in rural communities, (2) factors that may cause gender disparities in CRC screening in rural areas, and (3) solutions to overcome those barriers. METHODS: Semi-structured interviews were conducted with 17 PCPs practicing in rural central Pennsylvania. PCPs were asked about their CRC screening practices for women, availability of CRC screening services, reminder systems for CRC screening, and barriers to screening specific to their rural communities and to gender. Thematic analysis was used to identify major themes. RESULTS: All 17 PCPs endorsed the importance of CRC screening, but believed that there are barriers to CRC screening specific to women and to rural location. All PCPs identified colonoscopy as their screening method of choice, and generally reported that access to colonoscopy services in their rural areas was not a significant barrier. Barriers to CRC screening for women in rural communities were related to (1) PCPs' CRC screening practices, (2) gender-specific barriers to CRC screening, (3) patient-related barriers, (4) community-related barriers, and (5) physician practice-related barriers. Physicians overwhelmingly identified patient education as necessary for improving CRC screening in their rural communities, but believed that education would have to come from a source outside the rural primary care office due to lack of resources, personnel, and time. CONCLUSION: Overall, the PCPs in this study were motivated to identify ways to improve their ability to engage more eligible patients in CRC screening. These findings suggest several interventions to potentially improve CRC screening for women in rural areas, including encouraging use of other effective CRC screening modalities (eg fecal occult blood testing) when colonoscopy is not possible, systems-based reminders that leverage electronic resources and are not visit-dependent, and public health education campaigns aimed specifically at women in rural communities.

Prospective association between body mass index and receipt of preventive services: results from the Central Pennsylvania Women's Health Study (CePAWHS).

OBJECTIVE: We examine whether overweight and obesity are associated with disparities in clinical preventive services receipt in a unique, prospective, population-based cohort of reproductive-age women. METHOD: We used data from the Central Pennsylvania Women's Health Study (CePAWHS) longitudinal survey of women ages 18-45. The baseline random-digit-dial telephone survey was conducted in 2004-2005 and a second telephone interview two years later; 1342 participants comprised the analytic sample. Dependent variables were seven preventive services identified at follow-up. In addition to baseline body mass index (BMI) category, independent variables were selected based on the behavioral model of health services utilization. RESULTS: Forty-six percent of the sample was classified as normal weight, 28% as overweight, and 26% as obese. In adjusted analyses, women who were overweight and obese, compared to women with normal weight, were more likely to receive preventive counseling for diet/nutrition, physical activity, and weight management (p<0.01). Overweight and obese women received more cholesterol and diabetes screening (p<0.05 and p<0.01, respectively). However, there were no differences by BMI category in receipt of Pap testing or reproductive counseling. CONCLUSION: Overall, we found that women with overweight and obesity were more likely to receive preventive services, especially services relevant for overweight and obese populations.

Validity of the brief inpatient screen for intimate partner violence among adult women.

BACKGROUND: Identifying intimate partner violence in healthcare settings is becoming the standard of care. The Brief Inpatient Screen was designed to assess recent emotional, physical, and sexual abuse in a general inpatient medical-surgical setting and compared to the Composite Abuse Scale. METHODS: Researchers matched "cases" (inpatients screening Brief Inpatient Screen-positive) to up to four "controls" (inpatients screening Brief Inpatient Screen-negative). Forty-six female hospital inpatients ages 18-64 years completed a self-administered survey. The sensitivity and specificity of the Brief Inpatient Screen and its subscales were compared to the Composite Abuse Scale. Researchers examined the performance of the Brief Inpatient Screen when used as a verbal screen versus an anonymous written screen. RESULTS: Twelve of 46 participants (26%) had a positive screen. Compared to the Composite Abuse Scale, the overall sensitivity and specificity of the verbal Brief Inpatient Screen were 52.6% (95% CI 28.9-75.6) and 92.6% (95% CI 75.7-99.1), respectively. The written Brief Inpatient Screen showed improved sensitivity overall (68.4%, 95% CI 43.5-87.4) for the most severe intimate partner violence. Subscale analysis revealed greater sensitivity for emotional and severe combined intimate partner violence. CONCLUSIONS: The verbal Brief Inpatient Screen, when compared to the Composite Abuse Scale, was limited in its ability to identify intimate partner violence. An anonymous written format improved sensitivity. Future research should optimize intimate partner violence screening among inpatients.

Recent Intimate Partner Violence and Oral Contraceptive Pill Adherence in a Cohort of Reproductive-Aged Women.

Objective: Intimate partner violence (IPV) is an important public health problem that impacts reproductive decision-making. Although previous literature has reported a negative impact on contraceptive adherence overall, this study specifically aims to investigate the association between IPV and oral contraceptive pill (OCP) adherence. Methods: We analyzed baseline survey data from 373 OCP users participating in the MyNewOptions study. Recent IPV was defined as any positive response to HARK, a 4-question tool assessing emotional, sexual, and physical abuse in the past year, or self-report of sexual coercion in the past 6 months. High OCP adherence was defined by self-report of missing ≤1 pill per month, which was then corroborated by pharmacy claims data. Multivariable regression analyses were performed to assess the influence of recent IPV history and patient-level variables on OCP adherence. Results: Just over half of our participants were highly adherent to OCPs (53.6%), and approximately one-quarter reported recent IPV exposure (25.2%). Women with recent IPV were significantly less likely to be OCP adherent than those without IPV (adjusted odds ratio (AOR) 0.54, 95% confidence interval (CI): 0.32-0.92). Protestant religion was also associated with high OCP adherence (AOR 2.41, 95% CI: 1.24-4.65, compared with no religious affiliation), while younger age groups (18-25 and 26-33 years) were less likely to have high OCP adherence compared with the 34-40 age group (AOR 0.45, 95% CI: 0.20-1.00 and AOR 0.40, 95% CI: 0.18-0.91, respectively). Conclusion: Recent IPV exposure is associated with low OCP adherence among women of reproductive age. ClinicalTrials.gov identifier: NCT02100124.

The influence of patriarchy on Nepali-speaking Bhutanese women's diabetes self-management.

INTRODUCTION: The Nepali-speaking Bhutanese (NSB) community is a rapidly growing population in Central Pennsylvania. A community-based diabetes education pilot program found a large gender disparity with fewer women in attendance; participants reported that primary household cooks and caretakers were women. This may be an indication of women's status in the NSB community, their healthcare access, autonomy, and ability to manage their diabetes. Hence, this study aims to understand the manifestations of patriarchy and its impact on NSB women's diabetes self-management employing a conceptual framework based on Walby's structures of patriarchy. METHODS: An exploratory feminist qualitative inquiry was conducted. Fifteen NSB women with Type 2 Diabetes were interviewed about their diabetes self-management. Transcripts were coded for key concepts that emerged from the data. A thematic analysis was conducted. Themes were developed inductively through those categories as well as through an a priori approach using the conceptual framework. RESULTS: Cultural influences such as family structure, religious beliefs, traditional healthcare and gender roles determined NSB women's patriarchal upbringing and lifestyle. Unpaid household production was largely dependent on women. Multiple immigrations led to poor socioeconomic indicators and marginalization of NSB women. Women's access to healthcare (including diabetes) was entirely reliant on other family members due to poor autonomy. Women experienced adverse physical and emotional symptoms related to diabetes and their ability and attempts to maintain a healthy diabetes lifestyle was determined by their physical health condition, knowledge regarding good dietary practices and self-efficacy. CONCLUSION: Patriarchal practices that start early on within women's lives, such as child marriage, religious restrictions as well as women's access to education and autonomy impacted NSB women's access to healthcare, knowledge regarding their diabetes and self-efficacy. Future interventions tailored for diabetes prevention and self-management among NSB women should factor in patriarchy as an important social determinant of health.

Association of human papillomavirus vaccination with cervical cancer screening: A systematic review and meta-analysis.

INTRODUCTION: Prophylactic vaccination and routine screening are effective at preventing most cases of cervical cancer. Globally, cervical cancer is the fourth most frequently diagnosed cancer among women. The aim of this study was to investigate the association between human papillomavirus virus (HPV) vaccination (1, 2, or 3 doses) and cervical cancer screening. METHODS: PubMed (MEDLINE), Scopus, Web of Science, and Cochrane Library electronic databases were systematically searched from July 1, 2006, up to September 30, 2021. We pooled estimates using random-effects models. Heterogeneity between studies was quantified using Cochran Q test and I2 statistics. In total, 12 studies involving 2.4 million individuals were included in the meta-analysis. RESULTS: In the adjusted estimates, uptake of HPV vaccination was associated with increased cervical cancer screening (pooled relative risk [RR]: 1.35; 95% confidence interval [CI]: 1.21, 1.50; n = 12). Between-study heterogeneity was large (I2 = 99%). Compared to unvaccinated, those who received 3 doses of HPV vaccine had the highest uptake of cervical cancer screening (RR: 1.85; 95% CI: 1.58, 2.17), followed by those who received 2 doses (RR: 1.34; 95% CI: 1.21, 1.47). No statistically significant association with screening was found for those who received a single dose of the HPV vaccine. CONCLUSION: In this meta-analysis, uptake of HPV vaccination was associated with higher cervical cancer screening. It is plausible that vaccinated individuals are more likely to engage in preventive health behaviors. Healthcare providers should remind patients to continue with routine screening for cervical cancer regardless of their HPV vaccine status since vaccination does not protect against all HPV types.

Receipt of preventive counseling among reproductive-aged women in rural and urban communities.

INTRODUCTION: Preventive health interventions often occur less frequently among rural women compared to urban women. Preventive counseling is an important feature of comprehensive preventive healthcare provision, but geographic disparities in the receipt of preventive counseling services have not been fully described. In this study the framework of the behavioral model of healthcare utilization was employed to investigate the association between rurality and receiving preventive counseling. It was hypothesized that demographic differences in rural and urban communities, as well as differential healthcare resources, explain rural-urban healthcare disparities in preventive counseling. METHODS: Data were collected by telephone survey during 2004-2005 for 2002 participants aged 18-45 years in the Central Pennsylvania Women's Health Study. Measures of preventive counseling were based on US Preventive Services Task Force recommendations as of 2004. Multivariable models assessed the independent contribution of rurality to the receipt of counseling for smoking, alcohol/drug use, birth control, nutrition, weight management, and physical activity. Rurality was assessed using Rural-Urban Community Area Codes. All models controlled for variables that predispose individuals to use health services (age, race/ethnicity, educational level), variables that enable or impede healthcare access (having a usual healthcare provider, using an obstetrician-gynecologist, poverty, and continuous health insurance coverage) and need-based variables (health behaviors and indicators). RESULTS: In bivariate analysis, the rural population was older, had lower educational attainment, and was more likely to be White, non-Hispanic. Urban women tended to report seeing an obstetrician-gynecologist more frequently, and engaged more frequently in binge drinking/drug use. Preventive counseling was low among both rural and urban women, and ranged from 12% of the population for alcohol/drug use counseling, to 37% for diet or nutrition counseling. The degree of rurality appeared to impact counseling, with women in small or isolated rural areas significantly less likely than urban women and women in large rural areas to receive counseling related to smoking, alcohol/drug use and birth control. Overall, rural women reported less counseling for alcohol/drug use, smoking, birth control, nutrition and physical activity. In multivariable analysis, rurality was independently associated with lack of preventive counseling for physical activity. However, adjusting for predisposing, enabling and need-based variables fully attenuated the effect of rurality in the remaining models. Younger age, higher educational attainment, and seeing any obstetrician-gynecologist were associated with receipt of counseling in several models. CONCLUSIONS: Most women do not receive recommended preventive counseling. While rural women are less likely than urban women to receive counseling, rurality generally was not independently associated with receipt of counseling once demographics, access to health care, and health behaviors and indicators were controlled. This suggests that both demographic differences between rural and urban communities as well as aspects of healthcare access govern rural-urban healthcare disparities in preventive counseling. These results speak to important targets for reducing urban-rural healthcare disparities in receiving preventive counseling, improving the health literacy of the rural population, educating rural healthcare providers about the need for preventive counseling, and the expansion of access to obstetrician-gynecologists in rural communities.