Feminism, gender equity and sexual/reproductive health in the Middle East and North Africa (MENA) region

Sexual/reproductive/health and rights are crucial public health concerns that have been specifically integrated into the Millennium Development Goals to be accomplished by 2015. These issues are related to several health outcomes, including HIV/AIDS and gender-based violence (GBV) among women. The Middle East and North Africa (MENA) region comprises Algeria, Bahrain, Egypt, Iran, Iraq, Israel, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Qatar, Saudi Arabia, Syria, Tunisia, United Arab Emirates (UAE), West Bank and Gaza (WBG), and Yemen. This region is primarily Arabic speaking (except for Israel and Iran), and primarily Muslim (except for Israel). Some traditional and cultural views and practices in this region engender gender inequalities, which manifest themselves in the economic, political and social spheres. HIV and gender-based violence in the region may be interlinked with gender inequalities which breed justification for partner violence and honour killings, and increase the chance that HIV will transform into an epidemic in the region if not addressed. A feminist framework, focused on economic, political and social empowerment for women would be useful to consider applying to sexual/reproductive health in the region.^

Characteristics of a spina bifida population including North American Caucasian and Hispanic individuals.

BACKGROUND: Meningomyelocele (MM) is a common human birth defect. MM is a disorder of neural development caused by contributions from genes and environmental factors that result in the NTD and lead to a spectrum of physical and neurocognitive phenotypes. METHODS: A multidisciplinary approach has been taken to develop a comprehensive understanding of MM through collaborative efforts from investigators specializing in genetics, development, brain imaging, and neurocognitive outcome. Patients have been recruited from five different sites: Houston and the Texas-Mexico border area; Toronto, Canada; Los Angeles, California; and Lexington, Kentucky. Genetic risk factors for MM have been assessed by genotyping and association testing using the transmission disequilibrium test. RESULTS: A total of 509 affected child/parent trios and 309 affected child/parent duos have been enrolled to date for genetic association studies. Subsets of the patients have also been enrolled for studies assessing development, brain imaging, and neurocognitive outcomes. The study recruited two major ethnic groups, with 45.9% Hispanics of Mexican descent and 36.2% North American Caucasians of European descent. The remaining patients are African-American, South and Central American, Native American, and Asian. Studies of this group of patients have already discovered distinct corpus callosum morphology and neurocognitive deficits that associate with MM. We have identified maternal MTHFR 667T allele as a risk factor for MM. In addition, we also found that several genes for glucose transport and metabolism are potential risk factors for MM. CONCLUSIONS: The enrolled patient population provides a valuable resource for elucidating the disease characteristics and mechanisms for MM development.

Reactions of African immigrants living in Houston, Texas, to the American media and legislation regarding female circumcision

Female circumcision was almost unheard of in the United States a few years ago. The recent influx of African immigrants has increased media attention to the subject, leading to laws criminalizing female circumcision. This study examines the reactions of African immigrants living in Houston, Texas, to media portrayal and legislation regarding female circumcision in an attempt to understand the effectiveness of U.S. laws, and media messages in deterring the practice. ^ Through literature reviews the study looks at how female circumcision is portrayed in the Houston Chronicle, and gives detailed discussion of laws regarding it. Attitudes, beliefs, experiences and reactions of African immigrants towards the practice and American's perceptions of female circumcision is examined via a series of case studies. ^ Data show that media and laws portray female circumcision negatively and make little attempt to understand the cultural practice, generating outrage among Africans who would like to see changes in the practice. ^

Stress and coping in African American grandparents who are raising grandchildren

Over the years, substantial increases have occurred in the number of children being raised by their grandparents. A small number of studies have reported that grandparents raising grandchildren experience an increase in stress due to the demands of caregiving. The primary objectives of this study were to: (1) determine the degree of stress in African American (AA) grandparents who are raising their grandchildren age 12 years or younger; (2) identify the variables pertaining to the demographic characteristics of the grandparent caregiver and characteristics of the caregiving situation; (3) identify the coping strategies reported by AA grandparents; and (4) identify the relative importance of demographic and situational variables pertaining to the grandparent caregiver and caregiving situation, and coping strategies in influencing the degree of stress experienced. ^ An exploratory, descriptive, cross sectional design was used to study stress and coping in 50 AA grandparents who ranged in age from 44–87 years (M = 63.12). Data were collected via one personal interview in January/February 2001 at area senior centers or churches which the grandparent attends in Harris County, Texas. Five home interviews were done as requested by grandparents. ^ The instruments used to measure stress and coping were the Parenting Stress Index developed by Abidin and Folkman and Lazarus' Ways of Coping Questionnaire. Results of the study found that the grandparents is this study were a highly stressed group. Ninety-four percent of the sample demonstrated a “clinically significant” level of stress. Situational variables associated with lower stress levels were use of counseling, use of special school programs such as tutoring and special education, and increased length of caregiving (>5 years). ^ The most frequently used coping strategies overall were seeking social support and positive reappraisal. Six coping strategies were significantly correlated to lower reported stress: positive reappraisal, accepting responsibility, confrontive coping, self-control, planful problem solving, and distancing. ^ The findings from this study have limited generalizability. Nonetheless, this study was useful in adding to the limited amount of literature on AA grandparents who are rearing their grandchildren. The results clearly suggest the need for affordable counseling, support groups, education related to available resources, stress management, and interventions that increase the use of coping strategies found to reduce perceived stress. Future research should investigate levels of stress in AA and other grandparent caregivers longitudinally, as well as focus on stress and coping in grandparents raising grandchildren with special needs. ^

The determinants of sexually transmitted infection screening uptake among African American young adults: A systematic review

Objective. To conduct a systematic review of literature to determine the factors associated with STI including HIV screening uptake among African American young adults in the United States. ^ Methods. The electronic databases OVID Medline and OVID PsycINFO were systematically searched to identify potentially relevant articles. Ninety-six articles were initially identified, five of which were included in the final review. ^ Results. The results of this review were inconclusive. There was no definitive evidence to suggest which determinants were predictive of screening uptake. ^ Conclusions. There is a limited body of literature examining the demographic and behavioral risk factors associated with uptake or non-uptake of STI including HIV screening among African American young adult populations. This finding points to the need for more quality research to be conducted in this area. ^

The effect of African Americans' ethnographic paradigms and cultural explanatory model of breast cancer in framing the male partner's attitudes and behaviors about the woman's breast cancer diagnosis

The disparate burden of breast cancer-related morbidity and mortality experienced by African American women compared with women of other races is a topic of intense debate in the medical and public health arenas. The anomaly is consistently attributed to the fact that at diagnosis, a large proportion of African American women have advanced-stage disease. Extensive research has documented the impacts of cultural factors and of socioeconomic factors in shaping African American women's breast-health practices; however, there is another factor of a more subtle influence that might have some role in establishing these women's vulnerability to this disease: the lack of or perceived lack of partner support. Themes expressed in the research literature reflect that many African American breast cancer patients and survivors consider their male partners as being apathetic and nonsupportive. ^ The purpose of this study was to learn how African American couples' ethnographic paradigms and cultural explanatory model of breast cancer frame the male partners' responses to the women's diagnosis and to assess his ability to cope and willingness to adapt to the subsequent challenges. The goal of the study was to determine whether these men's coping and adaptation skills positively or negatively affect the women's self-care attitudes and behaviors. ^ This study involved 4 African American couples in which the woman was a breast cancer survivor. Participants were recruited through a community-based cancer support group and a church-based cancer support group. Recruitment sessions were held at regular meetings of these organizations. Accrual took 2 months. In separate sessions, each male partner and each survivor completed a demographic survey and a questionnaire and were interviewed. Additionally, the couples were asked to participate in a communications activity (Adinkra). This activity was not done to fulfill any part of the study purpose and was not included in the data analysis; rather, it was done to assess its potential use as an intervention to promote dialogue between African American partners about the experience of breast cancer. ^ The questionnaire was analyzed on the basis of a coding schema and the interview responses were analyzed on the principles of hermeneutic phenomenology. In both cases, the instruments were used to determine whether the partner's coping skills reflected a compassionate attitude (positive response) versus an apathetic attitude (negative response) and whether his adaptation skills reflected supportive behaviors (the positive response) versus nonsupportive behaviors (the negative response). Overall, the women's responses showed that they perceived of their partners as being compassionate, yet nonsupportive, and the partner's perceived of themselves likewise. Only half of the women said that their partners' coping and adaptation abilities enabled them to relinquish traditional concepts of control and focus on their own well-being. ^ The themes that emerged indicate that African American men's attitudes and behaviors regarding his female partner's diagnosis of breast cancer and his ability to cope and willingness to adapt are influenced by their ritualistic mantras, folk beliefs, religious teachings/spiritual values, existential ideologies, socioeconomic status, and environmental factors and by their established perceptions of what causes breast cancer, what the treatments and outcomes are, and how the disease affects the entire family, particularly him. These findings imply that a culturally specific intervention might be useful in educating African American men about breast cancer and their roles in supporting their female partners, physically and psychologically, during diagnosis, treatment, and recovery. ^

The influence of socioeconomic status on the relationship between diabetes and amputations: A systematic review of the literature

This paper synthesizes the current knowledge available regarding the impact of socioeconomic status on diabetes and amputations. In September 2009, searches in the OVID Medline and PubMed databases were performed using keywords associated with race/ethnicity, educational level, insurance status, veteran status, low income, diabetes, and lower extremity amputation. Articles published between 1996 and the search date were used. The pertinent articles were analyzed, summarized, and synthesized. ^ The majority of the articles agreed that African American, American Indian, and Latino minorities experience significantly higher rates of diabetes-related lower extremity amputation (LEA) when compared to whites. Few articles suggested that the disparity experienced by minorities and others of low SES was due to biology; most articles link it to a combination of lower income, lower educational attainment, uninsured or underinsured status, and a greater prevalence of detrimental health behaviors such as smoking. These, in turn, are linked to decreased knowledge of self-care, delayed health care seeking, delayed diagnoses and treatment, discrimination, and low quality health care. Interventions focused on patient education, established regimens of treatment, foot care, and control of diabetes have been shown to be effective, although none have lowered the rate of diabetes-related LEA to rates found in the general population.^

A movement from traditional malarial chemoprophylaxis to the use of intermittent preventive treatment as a method of protection for children diagnosed with sickle-cell disease: A proposal for consideration based on a systematic review of the literature

Approximately 200,000 African children are born with sickle-cell anemia each year. Research has shown that individuals with hemoglobin disorders, particularly sickle-cell anemia, have increased susceptibility to contracting malaria. Currently it is recommended that patients diagnosed with sickle-cell anemia undergo malaria chemoprophylaxis in order to decrease their chances of malarial infection. However, studies have shown that routine administration of these drugs increases the risk of drug resistance and could possibly impair the development of naturally acquired immunity. Clinical trials have shown intermittent preventive treatment (IPT) to be an effective method of protection against malaria. The objective of this report was to review previously conducted clinical trials that study the effects of intermittent preventive treatment on malaria and anemia in infants and children. Based on the review, implications for its appropriateness as a protective measure against malaria for infants and children diagnosed with sickle-cell disease were provided.^ The 18 studies reviewed were randomized controlled trials that focused on IPT’s effect on malaria (7 studies), anemia (1 study), or both (8 studies). In addition to these 16, one study looks at IPT’s effect on molecular resistance to malaria, and another study is a follow-up to a study in order to review IPT’s potential to cause a rebound effect. The 18 th study in this review specifically looks at IPT’s protective efficacy in children with SCA. The studies in this report were restricted to randomized controlled trials that have been performed from 2000 to 2010. Reports on anemia were included to illustrate possible added benefits of the use of IPT specific to burdens associated with SCA other than malaria susceptibility. The outcomes of these studies address several issues of concern involving the administration of IPT: protective efficacy (in reference to age, seasonal versus perennial malaria regions, and overall effectiveness against malaria and anemia), drug resistance, drug rebound effect, drug side-effects, and long-term effects. Overall, these showed that IPT has a significant level of protective efficacy against malaria and/or anemia in children. More specifically, the IPT study evaluating children diagnosed with sickle-cell anemia proved IPT to be a more effective method of protection than traditional chemoprophylaxis. ^

A systematic review of literature on socioeconomic disparities in the prevalence of dental caries

Dental caries, also known as tooth decay, are a disease of the oral cavity that affects the tooth structure and leads to the occurrence of cavities in teeth. Dental caries are one of the leading chronic diseases in the population and are very common in childhood. If not treated appropriately, dental caries have debilitating effect on the oral and general health of individuals. ^ Objectives. The aims of this review are to (1) analyze and elucidate the relationship between the social and economic determinants of health like income, education and race/ethnicity and the prevalence of dental caries and (2) identify and understand the pathways/underlying causes through which these factors affect the occurrence of dental caries. This review will provide a foundation for formulation of better oral health policies in future by identifying the key socio-economic factors and pathways affecting the prevalence of dental caries. Knowledge about these socioeconomic factors could be incorporated in the design of future policies and interventions to achieve greater benefits.^ Methods. This review includes information from all pertinent articles, reviews, surveys, reports, peer reviewed literature and web sources that were published after 2000. The selection criterion includes literature focusing on individuals between the ages of 1 to 65 years, and individuals from different subgroups of community based on income, education and race/ethnicity. The analyses of literature include identifying if a relationship between income/education/race and the prevalence of dental caries exists by comparing the prevalence of dental caries in different socio-economic groups. Also included in this review are articles that are relevant to the mechanisms/pathways through which income/education/race affect the prevalence of dental caries.^ Results. Analyses of available literature suggests that disparities in the prevalence of dental caries may be attributed to differences in income, education and race/ethnicity. Higher prevalence of dental caries was observed in African-American and Mexican-American individuals, and in people with low income and low education. The leading pathways through which the socioeconomic factors affect the prevalence of dental caries are the lack of access to dental care, lack of awareness about good oral hygiene beliefs and habits, oral health, inability to afford dental care, lack of social support to maintain oral health and lack of dental insurance.^ Conclusion. Disparities in the prevalence of dental caries exist in various socio-economic groups. The relationship between socio-economic factors and dental caries prevalence should be considered in the development of future policies and interventions that are aimed at reducing the prevalence of dental caries and enhancing oral health status.^

The effect of obesity on mammography utilization in African American women

Breast cancer continues to reign as a common cause of death for women in the United States, claiming the lives of more than an estimated 40,000 women in 2009 alone (Ries et al., 2009). A mammogram, an x-ray of the breast, can aid in early detection of breast cancer and thus more successful treatment. Screening patterns indicate African American women are less likely to utilize mammography technology when compared to their Caucasian counterparts. Additionally, the obesity epidemic in the United States remains a major public health problem. Obesity trends indicate that African American women are likely to be more obese when compared to Caucasian women. Pischon, Nöthlings, & Boeing (2008) concluded there was sufficient evidence linking breast cancer and obesity. Many researchers have identified obesity as a risk factor for breast cancer. As African American women are disproportionately burdened by both breast cancer mortality and obesity, more extensive research is needed to gain more knowledge about their association. The purpose of this study was to identify the role obesity plays in lessening an African American woman’s usage of mammography technology. Data from the 2005 National Health Interview Study were analyzed using SPSS to evaluate the relationship between body mass index (BMI) and mammography utilization in the two aforementioned populations.^ After excluding respondents from the sample who did not meet the set criteria, there were 17,666 women remaining. Of the 17,666 women, 6,156 (34.8%) had a healthy weight, 6,024 (34.1%) were overweight, and 4,285 (24.3%) were obese. About 70% of the sample population reported having had a mammogram in the last two years. Another 27.6% of women reported not receiving a mammogram within this same two year time frame. Within ethnic categories, the majority of the sample was Caucasian (64.2%) while only 15.1% of the sample was African American. The relationship between mammography usage and body mass index was not statistically significant within any body mass index categories. When analyzing the relationship between mammography usage and BMI, adjusting for ethnicity, there was also no significant difference between obese African American and obese Caucasian women. The study did find significant relationships between mammography usage and body mass index when adjusting for cancer risk OR = .79 (95% CI .72 - .85), and marital status OR = 1.18 (95% CI 1.05 - 1.34). Due to insignificant findings, there was no evidence to support the hypothesis regarding differences in mammography usage based on weight or ethnicity. Mammography screening differences based on ethnicity are widely cited. Unfortunately it is still unclear exactly where these differences lie. Obesity has been widely documented in the literature as a risk factor for many chronic diseases, including certain forms of cancer. Understanding the relationship between screening behaviors and weight can assist in the development of health promotion programs aimed at high risk groups. In order to change screening behavior and reduce mortality from breast cancer, more research is needed to identify similarities within low screening populations.^

Effective interventions for lowering HbA1C in African Americans with type 2 diabetes: A review

This synthesis of the literature provides descriptive analysis and outlines current self-management interventions for African Americans with type 2 diabetes. Specifically, this study describes and explores the design of those studies whose interventions have been shown to lower HbA1C levels in this population by at least 0.5% points, an improvement that provides approximately 10% reduction in long term complications from this disease.^ Results. In total, 37 articles were reviewed and 17 articles met inclusion criteria for analysis. Analysis of each study's methodology and results was performed and selected studies with interventions that resulted in improvements in HbA1C outcomes equal to 0.5% or greater for both group 1 and 2 were summarized by intervention type in table format. Descriptive analysis, outlining the number and characteristics of proximal and distal mediating components addressed in Group 1 studies, was performed in order to determine whether mediating components may have had some relation to effectiveness of intervention on outcome HbA1C. Descriptive analysis revealed that no particular design is substantially more effective than another among Behavioral studies although, there may be an advantage in using culturally sensitive, group interventions that address greater numbers of distal mediating components. Among Process studies, structured approaches (i.e. algorithm care and scheduled follow up), as well as utilization of specialty and group care are represented as effective for African American populations. ^ Conclusions. It may be summarized that by targeting behavior and addressing provider delivery (i.e. algorithm use, group care, home care, and provider follow up) in this population, a greater yield in outcome improvements may be accomplished. However, many gaps exist in a review process that stratifies results and focuses on identifying group specific intervention successes and failures. Further research in different populations will aid researchers and practitioners in discovering the best evidence, and identifying models that could be utilized in practice to achieve the best diabetes management for at risk groups.^

Polybrominated diphenyl ether (PBDE) exposure in North Americans: Cause for concern?

Polybrominated diphenyl ethers (PBDEs) are brominated flame retardants (BFRs) that have been widely produced and used as flame retardants since the 1970’s in many consumer products such as carpet and drape linings, plastics used in electronics, computer and television casings and polyurethane foam used in chairs, sofas and mattresses. PBDEs are persistent organic pollutants (POPs), which, by definition, are toxic in nature, persistent in the environment and accumulative in living organisms. Animal studies have found PBDEs to cause health defects such as fetal malformations, delayed onset of puberty, decreased sperm count, behavioral changes, permanent learning and memory impairment, endocrine disruption, as well as cancer at high doses. Recent research involving humans reported that elevated breast milk PBDEs levels in their mothers are associated with cryptorchidism (absence of one or both testes from the scrotum) in newborn boys and adverse birth outcomes as well as elevated serum PBDE levels in mothers are associated with low sperm count in young men. There are three commonly manufactured PBDE commercial mixtures: Penta-, Octa-, and Deca-BDEs. Two of them (Octa- and Penta-BDEs) have been banned by the European Union and are being voluntarily phased out in the United States. However, Deca continues to be manufactured, used, and imported in the United States. This MPH thesis consists of a literature review of peer reviewed scientific articles concerned with PBDEs in the environment and in humans, as well as a discussion concerning different routes of exposure to PBDEs and their blood, milk and tissue levels as surrogates for body burdens in North Americans and in people from other countries. Results of this literature review shows PBDE levels in human blood, milk and tissues are higher in North Americans than people from other countries worldwide. To date, the highest level of PBDEs was found in a toddler’s blood in a California study. Despite the fact that PBDEs are associated with adverse health effects, and highest levels of PBDEs in North Americans, Deca-BDE is still manufactured, used and imported in the United States. There is an urgent need of new federal regulatory policy to ban completely the production, importation and use of all commercial mixtures of PBDEs.^

Understanding Impediments and Enablers to Physical Activity among African American Adults: A Systematic Review of Qualitative Studies

Objective: To systematically assess and summarize impediments and facilitating factors impacting physical activity participation among African American Adults. ^ Method: A systematic search of the literature was conducted, which included electronic databases, as well as reference list of relevant papers. Only qualitative studies which measured race and ethnicity and had African American as adult participants were included. The main themes and categories from the qualitative studies pertaining to impediments and facilitators to physical activity were identified and summarized, through descriptive meta-synthesis. ^ Result: Twenty nine qualitative studies were included. Twenty-one of the studies only focused on adult African American women, and the barriers and facilitators to physical activity as perceived by them. The biggest individual enabler towards physical activity was the positive health benefits associated with regular physical activity. Social support and easy access to parks and facilities were also identified as enablers. Barriers toward physical activity were lack of time, lack of motivation, long work hours, and physical disabilities. ^ Conclusions: The findings of this review study should be useful to those planning an intervention in African American communities. There is also a need for qualitative studies conducted only among African American men, to better understand their perspective on the facilitators and barriers to physical activity.^

Sudden Infant Death disparities: A systematic review on health education and policy recommendations for decreasing Sudden Infant Death in the African-American community

Objective: To perform a systematic review of the literature on SIDS and SUID deaths concentrated in the African-American community, describe health education and policy recommendations and recommend a new approach that may aid in decreasing the disparity of infant mortality in the African-American community. ^ Methods: The PubMed database was systematically searched to identify relevant articles for final review and analysis. Using the CASP 2006 system to critique literature, twelve articles were found that met inclusion and exclusion criteria. ^ Results: Evidence in the literature confirmed there was a current disparity among African Americans' infant mortality rates in comparison to other US ethnic groups. The underlying reasons for these disparities included the following maternal and infant characteristics: mothers younger than eighteen, having more than one live infant, having a high school education or less, never been married, and have infants born preterm or with low birth weight. Maternal smoking, substance abuse, and breastfeeding did not have a significant impact on infant sleep environments among African Americans. ^ Conclusion: Tailored health education programs at the community level, better access to pre-pregnancy and prenatal care, and increased maternal perception of risk that is relevant to the infants sleeping environment are all possible solutions that may decrease African American infant mortality rates.^