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Background: While Primary Health Care has been designed to provide universal access to skilled pregnancy care for the prevention of maternal deaths in Nigeria, available evidence suggests that pregnant women in rural communities often do not use Primary Health Care Centres for skilled care. The objective of this study was to investigate the reasons why women do not use PHC for skilled pregnancy care in rural Nigeria., Methods: Qualitative data were obtained from twenty focus group discussions conducted with women and men in marital union to elicit their perceptions about utilisation of maternal and child health care services in PHC centres. Groups were constituted along the focus of sex and age. The group discussions were tape-recorded, transcribed verbatim and analyzed thematically., Results: The four broad categories of reasons for non-use identified in the study were: 1) accessibility factors - poor roads, difficulty with transportation, long distances, and facility not always open; 2) perceptions relating to poor quality of care, including inadequate drugs and consumables, abusive care by health providers, providers not in sufficient numbers and not always available in the facilities, long waiting times, and inappropriate referrals; 3) high costs of services, which include the inability to pay for services even when costs are not excessive, and the introduction of informal payments by staff; and 4) Other comprising partner support and misinterpretation of signs of pregnancy complications., Conclusion: Addressing these factors through adequate budgetary provisions, programs to reduce out-of-pocket expenses for maternal health, adequate staffing and training, innovative methods of transportation and male involvement are critical in efforts to improve rural women's access to skilled pregnancy care in primary health care centres in the country.

Purpose: Out-of-pocket expenses associated with facility-based deliveries are a well-known barrier to health care access. However, there is extremely limited contemporary information on delivery-related household out-of-pocket expenditure in sub-Saharan Africa. We assess the financial burden of delivery for the most remote Zambian women and compare differences between delivery locations (primary health center, hospital, or home)., Methods: We conducted household surveys and in-depth interviews among randomly selected remote Zambian women who delivered a baby within the last 13 months. Women reported expenditures for their most-recent delivery for delivery supplies, transportation, and baby clothes, among others. Expenditures were converted to US dollars for analysis., Results: Of 2280 women sampled, 2223 (97.5%) reported spending money on their delivery. Nearly all respondents in the sample (95.9%) spent money on baby clothes/blanket, while over 80% purchased delivery supplies such as disinfectant or cord clamps, and a third spent on transportation. Women reported spending a mean of USD28.76 on their delivery, with baby clothes/blanket (USD21.46) being the main expenditure and delivery supplies (USD3.81) making up much of the remainder. Compared to women who delivered at home, women who delivered at a primary health center spent nearly USD4 (p<0.001) more for their delivery, while women who delivered at a level 1 or level 2 hospital spent over USD7.50 (p<0.001) more for delivery., Conclusion: These expenses account for approximately one third of the monthly household income of the poorest Zambian households. While the abolition of user fees has reduced the direct costs of delivering at a health facility for the poorest members of society, remote Zambian women still face high out-of-pocket expenses in the form of delivery supplies that facilities should provide as well as unofficial policies/norms requiring women to bring new baby clothes/blanket to a facility-based delivery. Future programs that target these expenses may increase access to facility-based delivery., Competing Interests: Ms Jeanette L Kaiser, Ms Kathleen L McGlasson, Dr Peter C Rockers, Ms Rachel M Fong, Ms Thandiwe Ngoma, Dr Davidson H Hamer, Dr Godfrey Biemba, Dr Jody R Lori, and Dr Nancy A Scott report grants from MSD for Mothers, the Bill & Melinda Gates Foundation, and The ELMA Foundation, during the conduct of the study. The authors report no other conflicts of interest in this work.

Aim: The aim of the study was to explore the care-seeking pathway of rural women living with rheumatoid arthritis (RA) and attending a tertiary health-care facility in Odisha, India., Background: RA is the third leading chronic health condition and causes severe pain and immense psychosocial stress. The prevalence of RA is three to four times higher in women than in men. Furthermore, in India, women delay care seeking due to the prevailing sociocultural norms. Women report more severe symptoms and greater disability; however, there is a lack of information on their care-seeking pathways., Method: We conducted 113 in-depth interviews among RA patients those who visited specialists at the outpatients' Department of Rheumatology, SCB Medical College Hospital, a tertiary care hospital in Cuttack, Odisha, India. The grounded theory approaches were used for data analysis., Findings: The key findings included physical pain and psychosocial stress in relation to RA, cultural issues in relation to RA, mapping of the health-care providers for RA, the first point of cares and changes in care-seeking pathways, the perceived challenge for seeking health-care, and coping strategies of patients and social supports. This study explored that the RA patients seek care from multiple providers - untrained, trained and specialist without any gatekeeping. However, the primary health centers were the first point of care for maximum patients due to accessibility and affordability. Furthermore, follow-up care is significant to prevent complication among RA patients; the primary health centers are the gateway for keeping RA patients. Hence, the availability of RA trained providers at primary health center including interprofessional care, such as physiotherapy providers, and proper referral system is essential to convalesce care-seeking pathways.

Breast cancer is the leading cause of female cancer in Canada. However, there is limited research on the health and supportive needs of rural women living with this illness. The purpose of this qualitative study was to arrive at an increased understanding of the supportive care experiences of rural women requiring treatment for invasive breast cancer who reside in rural Manitoba. To explore this phenomenon, an interpretive descriptive qualitative study was completed. Twenty women from four regional health authorities participated in the study. Data were collected using face-to-face, semi-structured interviews and analyzed by content analysis through an interpretative qualitative lens. The findings presented emphasize a holistic overview of the experiences of women living with breast cancer that captured both the positive aspects of living rurally and the described rural challenges. Pragmatic recommendations have been generated from the study findings that have implications for nursing practice and service delivery., (© 2019 Canadian Association of Nurses in Oncology (CANO).)

Background: Rural midlife and older women have high rates of cardiovascular disease (CVD) risk factors and lower access to healthy living resources. The Strong Hearts, Healthy Communities (SHHC) intervention, tailored to the needs of rural women, demonstrated effectiveness on many outcomes. The purpose of the Strong Hearts for New York (SHNY) study is to evaluate the efficacy of an enhanced version of the curriculum (SHHC-2.0)., Methods: SHNY is a randomized controlled efficacy intervention, comparing participants receiving the SHHC-2.0 curriculum with a delayed intervention control group. SHHC, informed by formative research, includes core elements from three evidence-based programs. Changes based on extensive outcome and process evaluation data were made to create SHHC-2.0. Classes will meet twice weekly for 24 weeks and include individual, social, and environmental components. Overweight women age 40 and over will be recruited from 11 rural, medically underserved communities in New York; data will be collected at baseline and 12, 24, 36, and 48 weeks across individual, social, and environmental levels. Primary outcome is body weight. Secondary outcomes include Simple 7 (composite CVD risk score), anthropometric, physiologic, biochemical, physical activity, and dietary intake measures; healthy eating and exercise self-efficacy and attitudes; and self-efficacy of the social network of participants., Discussion: The aims of this study are to evaluate the efficacy of the enhanced SHHC-2.0 program for participants, changes among participants' social networks, and the difference in outcomes when participants are and are not provided with technological tools (Fitbit and body composition scale)., (Copyright © 2019 Elsevier Inc. All rights reserved.)

The purpose of the study is the socio-hygienic characteristics of the lifestyle and living conditions of urban and rural women and the assessment of their importance in the formation of health. The materials of the study were: the number of newly registered chronic diseases for 5 years, the average number of complaints about diseases during the year, the results of the survey. A socio-hygienic study shows that among urban women there are more divorced women than among rural women, fewer widows, urban women have higher levels of education, more permanent jobs, low physical activity, etc. Rural women were distinguished from urban women by lower level of education, low medical activity, frequent alcohol consumption, lower income, etc. Among urban women, more than in the first health assessment group (18.4% of women), among rural women 14.6% and less than in the third health assessment group (30.2%). Among rural women, 36.0% were in the third health assessment group. It was found that the greatest impact on the health of urban women have irrational nutrition, low physical activity, low medical activity, harmful production factors, frequent stress at work and at home, on the health of rural women: low income, low medical activity, mainly physical labor, irrational nutrition, frequent alcohol consumption.

Previous studies found associations between impairments of immune functions and exposure to polycyclic aromatic hydrocarbons (PAHs) in ambient air pollution in the U. S. and China. However, the results remain inconclusive due to the limitations of these studies. In this study, we aimed to examine the direction and magnitude of immune changes related to PAH exposure from household air pollution among rural women living in Gansu, China. Healthy village women (n = 34) were recruited and enrolled in the study. Questionnaires were administered. Blood and urine samples were collected and analyzed during non-heating (September 2017, "summer") and heating (January 2018, "winter") seasons. Urinary 1-hydroxypyrene (1-OHP) was quantified as the biomarker of PAH exposure. To evaluate Treg cell related immune functions, we examined immunoglobulin E (IgE), percent of T-regulatory (Treg) cells, and gene expression of following: forkhead box transcription factor 3 (Foxp3), transforming growth factor-β (TGF-β), interleukin 10 (IL-10), and interleukin 35 (IL-35), composed of interleukin-12 alpha (IL-12α) and Epstein-Barr-virus-induced gene 3 (EBi3). Urinary 8-hydroxy-2-deoxyguanosine (8-OHdG) was measured to evaluate oxidative DNA damage. The results showed that the concentration of 1-OHP increased from 0.90 to 17.4 μmol mol-Cr -1 from summer to winter (p < 0.001). Meanwhile, average percent of Treg cells decreased from 5.01% to 1.15% (p < 0.001); IgE and mRNA expressions of Foxp3, TGF-β, IL-10, IL-12α and EBi3 all significantly decreased (p < 0.001); Urinary 8-OHdG increased from 12.7 to 30.3 ng mg-Cr -1 (p < 0.001). The changes in 8-OHdG, Foxp3 and TGF-β were significantly associated with the increase of 1-OHP. The results suggested that we observed a substantial increase of PAH exposure in winter, which was significantly associated with the repression on Treg cell function and oxidative DNA damage. Exposure to PAHs in household air pollution possibly induced immune impairments among rural women in northwest China., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: In comparison to their urban and suburban counterparts, midlife and older rural women are less likely to consume adequate fruit and vegetables (F&V). The present study aimed to examine the relationships between psychological, social, and environmental factors and F&V intake among midlife and older rural women in the United States., Methods: This cross-sectional study utilized data from 513 midlife and older rural women (mean age = 67.0, mean BMI = 26.8) living in 22 states. Linear regression models were used to examine the associations between women's daily F&V intake and cooking confidence, healthy eating self-efficacy, perceived stress, healthy eating social support, and perceived food environment., Results: Cooking confidence (p < 0.001) and healthy eating self-efficacy (p < 0.001) were positively associated with F&V intake. Perceived stress, healthy eating social support, and perceived food environment were not associated with F&V intake (p > 0.05). When all the independent variables were analyzed simultaneously, only healthy eating self-efficacy remained positively associated with F&V intake (p < 0.001)., Conclusions: Findings from our study provide important information on the influences of rural women's healthy eating self-efficacy and cooking confidence on their F&V intake. Our results may be useful to inform and evaluate targeted strategies to improve the dietary health of rural women., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Purpose: In recognition of the growing burden of noncommunicable diseases (NCDs), including cancer, we assessed the knowledge, attitudes, and practices of rural women in low-resourced countries toward common NCDs and the barriers they face in receiving NCD early detection services., Patients and Methods: The study was conducted in a rural block of India using the Rapid Assessment and Response Evaluation ethnographic assessment, which included in-depth interviews of key health officials; focus group discussions with women, men, teachers, and health workers from the block; and a knowledge, attitudes, and practices questionnaire survey. The home-based survey was conducted among 1,192 women selected from 50 villages of the block using a two-stage randomization process and stratified to 30- to 44-year and 45- to 60-year age-groups., Results: Our study revealed low awareness among women with regard to tobacco as a risk factor; hypertension, diabetes, and cancer as major health threats; and the importance of their early detection. Only 4.8% of women reported to have ever consumed tobacco, and many others consumed smokeless tobacco without knowing that the preparations contained tobacco. Only 27.3% and 11.5% of women had any knowledge about breast and cervical cancer, respectively, and only a few could describe at least one common symptom of either cancer. Self-reported diagnosis of hypertension and diabetes was significantly lower than the reported national prevalence. Only 0.9% and 1.3% of women reported having had a breast examination or gynecologic checkup, respectively, in the past 5 years. Low female empowerment and misconceptions were major barriers., Conclusion: Barriers need to be addressed to improve uptake of NCD early detection services.

Objectives: To explore barriers to free cervical cancer screening among rural women in China from the perspective of women, healthcare providers and women's husbands to inform intervention planning., Design: A qualitative study framed around potential policy and practice options, drawing on the concepts of descriptive phenomenology and implementation research., Setting: This study was carried out at township level within two counties in Jining Prefecture of eastern China., Participants and Data Collection: Semi-structured in-depth interviews with 21 women and five healthcare providers, focus group discussions with nine healthcare providers and key informant interviews with four husbands of women eligible for screening., Results: Thematic analysis generated five major themes: (1) gaps in knowledge of cervical cancer and health awareness, (2) fear of cancer and screening outcomes, (3) cultural barriers including reticence for intimate examinations, (4) influence of close contacts on screening decisions and (5) inconvenience. These demonstrate key knowledge gaps challenging current community health education. Important barriers, including fear of treatment cost and the time needed for screening, were also raised., Conclusion: Our study details important barriers to cervical cancer screening relating to knowledge gaps, attitudes of fear or embarrassment and the role of contacts and service models. These provide data for policy and planning to improve the screening that will decrease the incidence and mortality rates of cervical cancer in China., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Purely web-based weight loss and weight-loss maintenance interventions show promise to influence behavior change. Yet, little is known about user engagement with features of web-based interventions that predict clinically meaningful weight loss (≥5% bodyweight loss). This study examines level of website feature engagement with the likelihood of attaining ≥5% bodyweight loss after 6 and 18 months participation in a web-based intervention, among rural women at high risk of obesity-related diseases and disability., Methods: In this secondary analysis of clinical trial data of 201 rural women, we examined weight change and user engagement, measured as clicks on specific web-based intervention features (messaging and self-tracking), as associated with clinically meaningful weight loss (baseline to 6 months) and weight-loss maintenance (6 to 18 months)., Results: Generalized estimating equations, adjusted for age, intervention group, and intervention phase, revealed high engagement with messaging predicted whether women achieved ≥5% weight loss at 6 months and at 18 months. There was no effect of self-tracking., Conclusions: Being engaged with messages was associated with attaining clinically meaningful short-term and longer-term weight loss. This trial is registered with NCT01307644.

Background: Despite increased interest in developing mobile technology-based interventions, little research has examined preferences and beliefs about using smartphones for psychosocial or health behavior change interventions, particularly among women with overweight/obesity residing in rural communities., Purpose: The aims of this study were to examine the beliefs of pre- and interconceptional women about using smartphones and to examine the extent to which women's preferences for using smartphones changed as a result of participating in study interviews., Methods: Forty women ( M age = 28.2 years; M BMI = 31.4; 50% obese) participated in one-time 90 minute interviews and completed questionnaires before and after the interviews. Descriptive statistics were used to examine the frequency of women's preferences for using smartphones and applications. Interviews were downloaded and transcribed; principles of thematic analysis were used to code the interviews and identify themes., Results: Women identified advantages of using smartphones for behavioral interventions, including being convenient, useful, and able to provide social support. Primary disadvantages were annoyances and needing technology support for phone problems. Participating in interviews also resulted in significant improvements in participant willingness to use smartphones in health behavior change interventions., Discussion: The study findings highlight the importance of understanding beliefs about using smartphones before designing effective smartphone-based interventions, especially for use with pre- and interconceptional women with overweight/obesity who may have unique challenges with study adherence. These findings also suggest beliefs about smartphone utility can be improved over the course of a brief interview that taps into technology-related preferences., Conclusion: Identifying advantages/disadvantages of smartphone use can inform intervention design. Future research should explore how to capitalize on strategies that enable the benefits of technology (e.g., convenience, social support) while minimizing participant barriers (e.g., distractions) to promote behavior change and facilitate intervention compliance., Competing Interests: Disclosure Statement: The authors report no conflicts of interest. No competing financial interests exist.

Objectives: There is absolute lacking of evidences on atherogenic index of plasma (AIP) and its association with cardiovascular disease (CVD) risk factors among postmenopausal women of Bangladesh. This prompted us to investigate this association between AIP and CVD risk factors among postmenopausal women in a rural setting., Methods: This cross-sectional study recruited 265 postmenopausal women aged 40-70 years who visited a primary health-care center of Bangladesh. We used modified STEP-wise approach for the Surveillance of Noncommunicable diseases risk factors questionnaire of the World Health Organization to collect data on sociodemographic and behavioral risk factors. Physical measurements were carried out following the method described in the 'noncommunicable disease risk factors survey Bangladesh 2010'. AIP was determined by the logarithmic transformation of triglyceride to high-density lipoprotein ratio, and association with CVD risk factors were examined by multiple linear regression analysis., Results: Overall 35.5% respondents had a high risk level of AIP with a mean of 0.16 ± 0.25. After adjusting the confounders, CVD risk factors including duration of menopause (β = 0.606, p = 0.043), waist-hip ratio (β = 0.165, p = 0.003), 2-h plasma glucose (β = 0.118, p = 0.04), total cholesterol (β = 1.082, p < 0.001), low-density lipoprotein cholesterol (β = -1.044, p < 0.001), and metabolic equivalent of tasks (β = -0.171, p = 0.003) showed a significant association with AIP., Conclusion: High AIP and its significant association with CVD risk factors demand proper lifestyle intervention for postmenopausal women of Bangladesh., (Copyright © 2019 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.)

Introduction: Maternal morbidity and mortality is still a major public health challenge. Lack of proper birth plan and delay in identification of pregnancy complications is one of the major causes of maternal morbidities and deaths, especially in the rural areas., Aim: The study was conducted with the aim to evaluate the health-seeking behaviour for obstetric care services among the antenatal and postnatal mothers in a rural area of Tamil Nadu., Materials and Methods: This descriptive cross-sectional study was done among antenatal and postnatal mothers registered in the Rural Health Training Centre, in Sripuram area of Kancheepuram district, Tamil Nadu during 2017. About 150 antenatal and 150 postnatal mothers were selected by simple random sampling method. A pre-tested structured questionnaire was used to collect relevant data which was analysed using the SPSS version 22., Results: Only 21% of the study participants had adequate knowledge regarding the danger signs of pregnancy and the major determinants were maternal literacy and adequate prenatal care. Regarding the health-seeking behaviour, 62.3% of them preferred primary health centres as preferred place of delivery, 87.3% of them had received adequate prenatal care and it was found to have statistically significant association with adequate gestational weight gain, exclusive breastfeeding, proper weaning practices and consumption of iron and folic acid supplements., Conclusion: The study shows the need to provide health education regarding the danger signs of pregnancy and importance of adequate prenatal care to all pregnant women and expectant mothers, to make them aware of when and how to seek medical care, which in turn could reduce the overall maternal morbidity and mortality., Competing Interests: There are no conflicts of interest.

Background: Menopause is the universal physiological process of women's midlife and exhibits a wide variety of symptoms. However, there is little data on the menopausal symptoms and factors associated with their severity among rural Indian women., Aim: To evaluate the prevalence of menopausal symptoms during the different transition phases of menopause among rural women of North India., Subjects and Methods: This cross-sectional study consisted of 351 women aged 35-55 years (mean age 44.6 years) residing in rural areas of North India. A structured questionnaire was used to collect data regarding menopausal status, demographic profile and reproductive history of the participants. Frequency and severity of menopausal symptoms were evaluated using the Greene Climacteric Scale in different stages of menopause. All statistical procedures were accomplished using SPSS version 19.0., Results: In the present study the mean ages of attainment of menarche and menopause were 14.3 years and 47.2 years, respectively. Mean score of total Greene Climacteric Scale was highest among perimenopausal women (16.12 ± 8.1) over post-menopausal (14.78 ± 7.3) and pre-menopausal women (11.08 ± 6.1). Logistic regression analysis revealed that advancing age, low educational attainment, low socioeconomic status, menopausal status, later age at menarche and higher BMI were all associated with more severe menopausal symptoms., Conclusion: The climacteric symptoms were more prevalent among women who were perimenopausal followed by post-menopausal women and were the lowest in pre-menopausal women. Age, menopausal status, socio-economic status, and reproductive factors significantly influenced the severity of menopausal symptoms.

Introduction: Iodine is an essential element for thyroid function; it is necessary in minute amounts for normal growth, development, and well-being of all humans. There is gap in the utilization of adequately iodized salt in the rural areas due to nonavailability, poverty, poor knowledge of iodine deficiency diseases, and faulty storage practices., Objective: The objective was to find out knowledge, attitude, and practices (KAP) regarding iodized salt consumption and association of sociodemographic factors, if any, among rural women of Tripura., Materials and Methods: This community-based study was conducted among 270 rural women residing at Madhupur village, Tripura. A self-made pretested schedule (Cronbach's alpha = 0.7) was used as the study tool to collect information on KAP regarding iodized salt consumption., Results: Majority of the participants belonged to 31-40 years (30.4%), with a mean age of 38.6 (±13.8) years; all were predominantly Hindus (90.4%). Knowledge and attitude regarding iodized salt consumption were significantly associated with age groups ≤36 years, literacy, and general caste ( P < 0.05), but practice was not significant ( P > 0.05). Good knowledge and attitude regarding use of iodized packed salt were less than half (46.7% and 41.1%, respectively), but higher level (83.3%) of correct practice was found ( P > 0.05)., Conclusion: The existing knowledge and attitude of participants toward iodized salt usage were less, but majority were consuming iodized salt without knowing its benefits. Hence, there is a need to educate rural people through nutrition education or knowledge, with active participation of grassroot level workers in generating awareness about the health benefits of consuming adequately iodized salt., Competing Interests: There are no conflicts of interest.

Objective: There is poor adherence to antihypertensive therapies among women in India. To determine its socioeconomic barriers we performed a qualitative study on Indian rural women with hypertension., Methods: In-depth interviews with women having hypertension and presenting to outpatient department at a teaching hospital were performed in 30 women aged 35-65 years, using a questionnaire focused on reasons for nonadherence and poor lifestyle modification. Low to medium adherence was observed in two-thirds of women., Results: Majority of women were from low socioeconomic status and were illiterate. Awareness of hypertension and its complications was poor. Knowledge and practices of cessation of smoking and tobacco use and salt restriction in hypertension were low. Efforts to increase physical activity and decrease dietary fat and sugar intake were largely absent. Local follow-up at rural community health centres was not practiced due to physician nonavailability and about half used alternative systems of medicine. None had health insurance or access to free medicines. All the women had to pay out-of-pocket for medicines and were concerned with cost of therapy as well as pill burden. Half of the women borrowed money from relatives or friends to reach the hospital and pay for medicines., Conclusions: Socioeconomic barriers for low adherence to antihypertensive medication in women in India are low awareness of hypertension and complications, poor access to care, out-of-pocket payments, borrowing money, lack of insurance, and cost of medicines.

The current study examines protective factors for women who transition from county jails to rural Appalachian communities, areas with limited health and behavioral health services. The study included drug-using women recruited from three jails in rural Appalachia and were followed 12-months post-release. Analyses focused on differences between women who remained in the community and those who returned to custody, as well as a multivariate model to determine protective factors for re-entry success. At the bivariate level, staying out of jail was associated with being older, having a job, not using drugs, stable housing, receiving health treatment, and having prosocial peers. In the multivariate model, the most robust predictors of staying out of jail were drug use abstinence, health care utilization, and prosocial peers. Most research on criminogenic needs associated with re-entry success have focused on men, and most focused on re-entry to urban communities where services and resources are more accessible. These findings have important implications for criminal justice systems to implement re-entry programs for women offenders during the transition to the community., Competing Interests: Declaration of Interest Declarations of interest: none. We acknowledge that none of the authors of this paper have any conflicts of interest to report.

The prevalence of depression among rural women is nearly twice the national average, yet limited mental health services and extensive social barriers restrict access to needed treatment. We conducted key informant interviews with community health workers (CHWs) and diverse health care professionals who provide care to Appalachian women with depression to better understand the potential roles that CHWs may play to improve women's treatment engagement. In the gap created by service disparities and social barriers, CHWs can offer a substantial contribution through improving recognition of depression; deepening rural women's engagement within existing services; and offering sustained, culturally appropriate support.

Background: Anemia is a major public health problem that adversely affects pregnancy outcomes. The prevalence of anemia among pregnant women before conception is not well known in Tanzania. The aim of this study was to determine the prevalence, types, and risk factors of preconception anemia in women of reproductive age from a rural Tanzanian setting., Methods: Trained field workers visited households to identify all female residents aged 18-40 years and invited them to the nearby health facility for screening and enrolment into this study. Baseline samples were collected to measure hemoglobin levels, serum ferritin, vitamin B12, folate, C-reactive protein, alanine amino-transferase, the presence of malaria, HIV, and soil transmitted helminth infections. Anthropometric and socio-economic data were recorded alongside with clinical information of participants. Logistic regression analysis was used to determine the adjusted odds ratios (AOR) for the factors associated with preconception anemia., Findings: Of 1248 women enrolled before conception, 36.7% (95% confidence interval (CI) 34.1-39.4) had anemia (hemoglobin <12 g/dL) and 37.6% (95% CI 34.9-40.4) had iron deficiency. For more than half of the anemic cases, iron deficiency was also diagnosed (58.8%, 95% CI 54.2-63.3). Anemia was independently associated with increased age (AOR 1.05, 95% CI 1.03-1.07), malaria infection at enrolment (AOR 2.21, 95% CI 1.37-3.58), inflammation (AOR 1.77, 95% CI 1.21-2.60) and iron deficiency (AOR 4.68, 95% CI 3.55-6.17). The odds of anemia were reduced among women with increased mid-upper arm circumference (AOR 0.90, 95% CI 0.84-0.96)., Conclusion: Anemia among women of reproductive age before conception was prevalent in this rural setting. Increased age, iron deficiency, malaria infection and inflammation were significant risk factors associated with preconception anemia, whereas increased mid-upper arm circumference was protective against anemia. Interventions to ensure adequate iron levels as well as malaria control before conception are needed to prevent anemia before and during pregnancy and improve birth outcomes in this setting., Trial Registration: NCT02191683., Competing Interests: The authors have declared that no competing interest exist.

Objectives: The role of physical inactivity in relation to cardiovascular disease (CVD) among postmenopausal women is understudied. The main objective of this study was to measure the physical activity levels (PALs) and evaluate its relation to other CVD risk factors among postmenopausal rural women of Bangladesh., Methods: A cross-sectional study was conducted among 265 postmenopausal women aged 40-70 years who visited the outpatient department of a primary health-care center situated in the village Karamtola of Gazipur district. A pretested modified questionnaire of STEP-wise approach to Surveillance (STEPS) of noncommunicable disease risk factors was used to collect data on sociodemographic and lifestyle factors. PAL was determined by the Estimated Energy Requirement (EER) equation of the Dietary Reference Intakes (DRIs) Committee, and association with CVD risk factors was examined by Spearman's rank correlation., Results: More than half (58.1%) of the postmenopausal women were identified as sedentary with high prevalence of central obesity (73.2%) among them. CVD risk factors including age (r = -0.228, p < 0.01), age at menopause (r = -0.129, p < 0.05), duration of menopause (r = -0.183, p < 0.05), 2-h plasma glucose (r = -0.148, p < 0.05), total cholesterol (r = -0.138, p < 0.05), low-density lipoprotein cholesterol (r = -0.122, p < 0.05), and triglyceride (r = -0.168, p < 0.01) showed a significant as well as inverse association with Metabolic Equivalent of Task (MET) of physical activity., Conclusion: Low PAL and significant inverse correlation with various CVD risk factors demand interventions to maintain higher PAL among postmenopausal women of Bangladesh., (Copyright © 2018 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.)

Introduction: Rapid urbanisation is one of the greatest challenges for Sustainable Development Goals. We compared socioeconomic inequalities in urban and rural women's access to skilled birth attendance (SBA) and to assess whether the poorest urban women have an advantage over the poorest rural women., Methods: The latest available surveys (DemographicHealth Survey, Multiple Indicators Cluster Surveys) of 88 countries since 2010 were analysed. SBA coverage was calculated for 10 subgroups of women according to wealth quintile and urban-rural residence. Poisson regression was used to test interactions between wealth quintile index and urban-rural residence on coverage. The slope index of inequality (SII) and concentration index were calculated for urban and rural women., Results: 37 countries had surveys with at least 25 women in each of the 10 cells. Average rural average coverage was 72.8 % (ranging from 17.2% % in South Sudan to 99.9 % in Jordan) and average urban coverage was 80.0% (from 23.6% in South Sudan to 99.7% in Guyana. In 33 countries, rural coverage was lower than urban coverage; the difference was significant (p<0.05) in 15 countries. The widest urban/rural coverage gap was in the Central African Republic (32.8% points; p<0.001). Most countries showed narrower socioeconomic inequalities in urban than in rural areas. The largest difference was observed in Panama, where the rural SII was 77.1% points larger than the urban SII (p<0.001). In 31 countries, the poorest rural women had lower coverage than the poorest urban women; in 20 countries, these differences were statistically significant (p<0.05)., Conclusion: In most countries studied, urban areas present a double advantage of higher SBA coverage and narrower wealth-related inequalities when compared with rural areas. Studies of the intersectionality of wealth and residence can support policy decisions about which subgroups require special efforts to reach universal coverage., Competing Interests: Competing interests: None declared.

This qualitative study assessed psychosocial concerns that rural women with HIV who had multiple psychosocial vulnerabilities were able to express and communicate during a mobile phone intervention delivered by nurses. The study is part of a pilot randomised controlled trial of an mHealth self-care intervention by nurses for women living with HIV in rural India. For the trial, 60 women were randomised to receive the mHealth intervention. All calls were recorded and call logs were maintained. Call logs of 59 women based on 1186 calls were scanned for psychosocial themes. Audio recordings of 400 calls rich in content were then transcribed and translated for analysis. Themes and subthemes were identified by two independent raters. Majority of the women had low literacy and more than half were widowed. Clinical depression was found in 18.6%. Of the 1186 call logs analysed, 932 calls had a record of at least one psychosocial concern and 493 calls recorded two psychosocial concerns. Some of the major themes that women discussed with nurses included worries about their own and their children's future; loneliness; stigma; inadvertent disclosure; death and dying; abandonment by partner; financial difficulties; body image; poor social support; emotions such as sadness, guilt, and anger; and need for social services. Almost all expressed appreciation for the intervention. Findings indicate the usefulness of mHealth-based self-care interventions delivered by nurses in hard to reach women in low- and middle-income countries, especially those with multiple psychosocial vulnerabilities.

Introduction: Postmenopausal bleeding (PMB) is a common and early symptom of cervical and endometrial cancer. Its early detection can improve the cure rate and reduces mortality., Objectives: The objective of the study is to find out the prevalence and determinants of PMB in a rural community setting and the reasons for not undergoing cervical cancer screening among postmenopausal women., Materials and Methods: A sequential exploratory mixed methods study where qualitative (group interviews) phase followed quantitative (survey) phase in the community. The survey was undertaken among the representative sample of 1,530 postmenopausal women in 34 villages of Villupuram district, Tamil Nadu. Data were collected by house-to-house survey., Analysis: Bivariate and multivariate analysis was done using SPSS 24 software package., Results: The prevalence of PMB was found to be 1.8%. Only 5.6% women had undergone screening. The majority did not go for screening due to lack of awareness, or they did not have any symptoms or feared about negative results. Occupation (daily wage laborers), use of oral contraceptive pills at least for 1 year, recurrent abortions (> three abortions), reproductive tract infection (more than 10 episodes in lifetime), abdominal obesity (increased waist-hip ratio), and underweight were identified as significant risk factors for PMB., Conclusion and Recommendations: Nearly 2% of women have PMB, and most of the factors identified as determinants are preventable. Cervical cancer screening rate was poor among the respondents and lack of awareness was stated as the major reason for it. Hence, the promotion of healthy lifestyles and contraceptives in early reproductive life and awareness for the need of early screening is recommended., Competing Interests: There are no conflicts of interest.

Background: Knee pain is common with obesity and weight gain being important risk factors. Previous clinical trials have focused on overweight or obese adults with knee pain and osteoarthritis and demonstrated modest effects of intense weight loss programs on reducing knee pain despite very significant weight loss. There has been no lifestyle intervention that targets community-based adults to test its effect on prevention of knee pain. We aimed to determine the effect of a simple low-intensity self-management lifestyle intervention (HeLP-her), proven in randomised controlled trials to improve lifestyle and prevent weight gain, on knee pain in community-based young to middle-aged rural women., Methods: A 1-year pragmatic, cluster randomised controlled trial was conducted in 649 community-based women (aged 18-50 years) to receive either the HeLP-her program (consisting of one group session, monthly SMS text messages, one phone coaching session, and a program manual) or one general women's health education session. Secondary analyses were performed in 390 women who had knee pain measured using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) at baseline and 12-month follow-up. "Any knee pain" was defined as a WOMAC pain score ≥ 1. Knee pain worsening was defined as an increase in WOMAC pain score over 12 months., Results: Thirty-five percent of women had "any knee pain" at baseline. The risk of knee pain worsening did not differ between the intervention and control groups over 12 months. For women with any knee pain at baseline, those in the intervention arm had a lower risk of knee pain worsening compared with those in the control arm (OR 0.37, 95% CI 0.14-1.01, p = 0.05), with a stronger effect observed in women with body mass index ≥ 25 kg/m 2 (OR 0.28, 95% CI 0.09-0.87, p = 0.03)., Conclusions: In community-based young to middle-aged women, a simple low-intensity lifestyle program reduced the risk of knee pain worsening in those with any knee pain at baseline, particularly in those overweight or obese. Pragmatic lifestyle programs such as HeLP-her may represent a feasible lifestyle intervention to reduce the burden of knee pain in the community., Trial Registration: ACTRN12612000115831 , registered 24 January 2012.

Objective: The objective of the study was recognition of the opinions of rural women living in the Bieszczady region of south-eastern Poland, concerning their perception of the degree of severity of work. The study was conducted among the inhabitants of the Cisna commune., Material and Methods: The basic research instrument was a questionnaire form containing 15 items. The study covered 101 women living in the Cisna commune in the Bieszczady. The self-reported degree of work load on a farm was analyzed among women who were occupationally active, and those who were not occupationally active. The effect of assistance from family members on the severity of work perceived by women was considered., Results: The women in the study focused on agro-tourism, a few of them were engaged in agricultural work and the majority worked in household gardens. The study showed that occupationally active women work considerably longer, on average, and are the most loaded, compared to those not engaged in occupational activity. The mean daily time devoted to duties on a farm did not significantly differ between occupationally active and non-active women, and amounted to 380 and 320 minutes, respectively. The majority of women who were non-active occupationally evaluated their household chores as the highest work load. In turn, the women who undertook occupational activity assessed them as most burdensome, despite great help from their family. The body positions assumed while performing field work were: standing, standing-bent-over, and walking. The mean evaluations of work load while standing and standing-bent-over did not significantly differ, but affected the work load among women who, however, could not assess the severity of their work resulting from the body position assumed.

Rural women living with HIV/AIDS (WLHA) in India experience challenges self-managing HIV/AIDS in their rural communities. The purpose of this qualitative study was to explore factors influencing their care and antiretroviral treatment (ART) adherence. Themes that emerged from the qualitative focus groups among WLHA (N = 24) in rural Prakasam, Andhra Pradesh, India, included: (1) coming to know about HIV and other health conditions, (2) experiences being on ART, (3) challenges maintaining a nutritious diet, (4) factors affecting health care access and quality, and (5) seeking support for a better future. Chronic disease self-management in rural locales is challenging, given the number of barriers which rural women experience on a daily basis. These findings suggest a need for individual- and structural-level supports that will aid in assisting rural WLHA to self-manage HIV/AIDS as a chronic illness.

Coal combustion and passive smoking are two important contributors to indoor air pollution (IAP) in rural areas of northern China. Although the association between outdoor air pollutants and hypertension risk had been widely reported, fewer studies have examined the relationship between IAP and hypertension risk. This study evaluated the association between IAP and hypertension risk in housewives in rural areas of northern China and the potential mediation pathway of metal elements. Our cross-sectional study, conducted in Shanxi Province, China, enrolled 367 subjects without taking anti-hypertensive drugs, including 142 subjects with hypertension (case group) and 225 subjects without hypertension (control group). We collected information on energy use characteristics and lifestyle using questionnaires. An IAP exposure index was developed to indicate the population exposure to coal combustion and passive smoking. Scalp hair samples were collected from the housewives and various trace and major metal elements were measured. Our results revealed that the IAP index was positively correlated with systolic and diastolic blood pressure. A significant association between the IAP index and hypertension risk was found both without [odds ratio (95% confidence interval, CI) = 2.08 (1.30-3.31)] and with [OR (95% CI) = 2.52 (1.46-4.36)] adjustment for confounders. We also observed that the IAP index was positively correlated with the arsenic, lead, and rare earth element levels in hair samples, and negatively correlated with the levels of some other trace elements (i.e., chromium, cobalt, nickel, and tin) and alkaline earth elements (i.e., calcium, magnesium, and barium) with an overall p value of <0.01. We concluded that IAP may contribute to the development of hypertension in rural housewives in northern China, possibly by interfering with the uptake of metal elements., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

This pilot study assessed the feasibility, acceptability, and initial efficacy of a skills-focused treatment delivered via video teleconferencing (VTC) to women veterans living in rural areas who had experienced military sexual trauma (MST). The Skills Training in Affective and Interpersonal Regulation (STAIR) program focuses on teaching emotion management and interpersonal skills in 8 to 10 sessions. The STAIR program may be a good fit for individuals in rural areas for whom social isolation and low social support are particularly problematic. Clinic-to-clinic VTC was used to connect a STAIR therapist with veterans for weekly individual therapy sessions. The participants (n = 10) reported high satisfaction with the intervention and would recommend the program to others. There were significant pretreatment to posttreatment improvements in social functioning, Hedge's g = 1.41, as well as in posttraumatic stress disorder symptoms, Hedge's g = 2.35; depression, Hedge's g = 1.81; and emotion regulation, Hedge's g = 2.32. This is the first report of the successful application of a skills-focused treatment via VTC for women veterans., (© 2018 International Society for Traumatic Stress Studies.)

Purpose: In this paper, the association between polymorphisms of IFN-γ +874T/A (rs2430561), IFN-γR1 -56 T/C (rs2234711), IFN-γR1 +95 C/T (rs7749390), and IFN-γR1 -611A/G (rs 1327474) and human papillomavirus (HPV) susceptibility was investigated in rural women from Luohe, Henan, China., Patients and Methods: A total of 520 rural women were enrolled from Luohe, including 260 with HPV infection and mild dysplasia or less and 260 without HPV infection. Single-nucleotide polymorphisms (SNPs) of IFN-γ +874T/A, IFN-γR1 -56 T/C, IFN-γR1 +95 C/T and IFN-γR1 -611A/G were genotyped using TaqMan Pre-Designed SNP Genotyping Assays. Serum IFN-γ levels were measured using Human IFN-γ Quantikine ELISA Kit. Multivariate logistic regression analysis was performed to identify the SNPs associated with HPV susceptibility. Serum IFN-γ levels were compared between different genotypes., Results: The polymorphism of IFN-γ +874T/A was associated with HPV susceptibility and +874A carriers had an increased risk. Moreover, the odds ratio was higher in +874 AA carriers than in +874 AT carriers (1.672 vs 2.874). Serum IFN-γ levels were highest in IFN-γ +874 TT carriers, intermediate in AT carriers, and lowest in AA carriers (2.86±1.14 vs 1.57±0.79 vs 0.41±0.22 pg/mL, all P <0.05)., Conclusion: The polymorphism of IFN-γ +874T/A was associated with HPV susceptibility in rural women from Luohe, Henan, China, and +874A carriers had an increased risk. The possible mechanism was that +874A carriers had a low production of IFN-γ., Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Objective: To study the hemoglobin concentration, anemia status and its determinant factors among Chinese rural women of reproductive age in 2012. Methods: This was a cross-sectional study. The data was obtained from the National Free Preconception Health Examination Project (NFPHEP). A total of 712 101 Chinese rural reproductive age women aged 21-49 years old who came from 193 counties of 30 provinces were included. The demographic characteristics were obtained from questionnaires. Hemoglobin concentration was measured using the cyanomethemoglobin method. The definition of anemia we used was recommended by World Health Organization, and was adjusted according to altitude level. The hemoglobin concentration level, the prevalence of anemia and its 95% CI was calculated. Determinant factors of anemia such as demographic characteristics and histories of pregnancy and miscarriage were analyzed using logistic regression. Results: In 2012, the level of hemoglobin concentration in Chinese rural women of reproductive age was (127.77±13.47) g/L, with the lowest in 21-24 years group, which was (127.54±13.54) g/L, and highest in 35-39 years group, which was (128.39±14.12) g/L. In terms of region, the hemoglobin concentration level was lowest in central south, which was (125.79±12.00) g/L, and highest in southwest, which was (129.91±14.37) g/L. The prevalence of anemia in Chinese rural women of reproductive age was 24.80%, with the highest seen in 21-24 years, which was 25.92% (95% CI: 25.74%-26.11%), and lowest in 30-34 years, which was 23.61% (95% CI: 23.37%-23.85%). The prevalence in northwest (28.31%, 95% CI: 28.01%-28.61%) was the highest among all regions, and the prevalence in east (20.88%, 95% CI: 20.68%-21.09%) was the lowest. Conclusions: The prevalence of anemia in Chinese rural reproductive age women was 24.80% in 2012. The anemia prevalence was higher among women who were young, had low educational level, and lived in northwest region.

Background: Central obesity is a common health disorder, and the main objective of this study was to compare its changings among rural women in the north of Iran, between the years 2004 and 2013., Methods: Two cross-sectional studies were established on the 2839 and 2478 subjects in 2004 (first stage) and 2013 (second stage), respectively. Among 118 villages, 20 were selected using random sampling; they were the same in two studies. Central obesity was defined as waist circumference (WC) > 88 cm, waist-to-hip ratio (WHR) > 0.8, and waist-to-height ratio (WHtR) > 0.5., Results: The prevalence of central obesity in 2013 based on WC, WHR, and WHtR were 37.4%, 73.5%, and 67.8%, respectively. Compared with 2004, the prevalence of central obesity based on WHR increased as 5.4% (68.1% vs. 73.5%) (P = 0.001), whereas morbid obesity (WHtR > 0.6) based on WHtR decreased as 3.7% in 2013 (28.8% vs. 25.1%) (P = 0.004). Central obesity based on WHR significantly decreased in less or equal 24-year-old group (76.6% vs. 70.1%) (P = 0.003), while it increased in 25-34- (65.1% vs. 74.0%) and in equal or more than 35-year-old group (54.1% vs. 78.9%) (P = 0.001 for all). Moreover, morbid obesity decreased in all age, economic, and education groups (except uneducated one) (P < 0.050 for all)., Conclusion: Despite the decrease in central obesity based on WC and WHR indices in 2004-2013 duration, we found the evidence of a decline in sever obesity based on WHtR in that period. These trends have an alarm for health policy makers, not only in this area but also in same communities. Comprehensive studies are recommended to determine the best obesity indicator related to health in future.

Timely treatment of premenstrual syndrome (PMS) is not always available for rural women, because the local medical resources are insufficient. The efficacy of remote intervention by smartphone on PMS has not been confirmed.A retrospective analysis was performed on rural PMS patients between January 2014 and December 2015. After a propensity score matched analysis, 60 patients were enrolled and evenly divided into remote group and outpatient group. Multidisciplinary therapy including cognitive-behavioral therapy (CBT), oral medication, and physical exercise education was used individually, in accordance with their symptoms evaluated by Daily Record of Severity of Problems (DRSP) questionnaire. Patients in remote group utilized WeChat software by smartphone for therapy guidance, while those in outpatient group attended face-to-face interview. Their DRSP scores in 5 new menstrual cycles after therapy were recorded. Then, they were followed up for 1 year.Total DRSP scores of the cases in both groups after initial intervention were less than those before therapy (P < .001), without group difference (P > .05). However, patients in remote group indicated a higher satisfactory rate than the outpatient group (P = .03). On the 1-year follow up, patients in both groups demonstrated similar DRSP scores (P = .07), but the satisfactory rate in remote group was encouragingly higher than that in the outpatient group (P = .02).The efficacy of remote intervention using smartphone on PMS is noninferior to traditional outpatient visits. Nevertheless, high-quality trials are needed.

Associations of physical function and health-related quality of life in 297 rural women, ages 40-69 years (body mass index of 28-45 kg/m 2 ) who met activity criterion were examined using cross-sectional baseline data from the Women Weigh-in for Wellness trial (ClinicalTrials.gov NCT01307644). Assessments included demographics, 400-m walk, timed chair stands, and health-related quality of life using the Patient-Reported Outcomes Measurement Information System (PROMIS-29). Women were classified as active if they had ≥500 metabolic equivalent·min/week by the Behavioral Risk Factor Surveillance System survey (n = 103, 34.7%), or ≥150 weekly minutes of greater than or equal to moderate intensity activity by accelerometry (n = 222, 74.8%). Ordinal logistic regression models adjusted for age, comorbidities, and body mass index were calculated. Meeting activity guidelines per self-report was associated with perceptions of less fatigue and greater satisfaction with social roles, whereas meeting guidelines as measured by accelerometry was associated with faster gait speed.

Background: In China, about 53.4 million women (11%) have type 2 diabetes (T2DM). Women with prior 2 (GDM) are at a high risk for T2DM. Postpartum lifestyle interventions have been effective in reducing T2DM for this population, but the evidence is limited to interventions provided in urban areas, despite the fact that a higher prevalence of undiagnosed T2DM was found in rural areas in China. The primary purpose of this proposed study is to examine the effect of a postpartum intensive lifestyle modification (ILSM) program on physiological health outcomes (T2DM development, insulin resistance, and weight-related variables), weight-related health behaviors (dietary intake and physical activity), and psychosocial outcomes (self-efficacy, perceived stress, social support, and health-related quality of life) compared to usual care at 3, 6, and 18 months post baseline assessment. The secondary outcomes are to identify potential mediators and moderators on change of physiological health outcomes., Methods/design: A multi-site randomized clinical trial (RCT) will be conducted to examine the efficacy of an evidence-based Intensive Lifestyle Modification (ILSM) program compared with usual care for women with prior GDM living in rural areas in China. A total sample of 256 participants will be recruited in the study. The intervention consists of six bi-weekly in-person group sessions, five bi-weekly telephone consultation sessions, and three monthly telephone consultations to encourage behavior change. The usual care provided to the control group will utilize current clinical guideline and recommendations for T2DM prevention. Outcome measures include physiological variables (OGTT-2 h, HbA1c, weight, and waist circumference); weight-related health behavioral (dietary intake and physical activities); and psychosocial variables (self-efficacy and social support) at 3-, 6- and 18- month after baseline. We will also assess the potential cost-effectiveness of ILSM (net cost per T2DM case and per DALY averted) compared with usual care., Discussion: If successful, this ILSM program can be adapted and used in rural areas as a blueprint for clinical guidelines to decrease T2DM by improving postpartum GDM care in China. Findings of this study are expected to make a significant contribution to public health practice and health policy related to T2DM prevention in China., Trial Registration: Chinese Clinical Trial Registry, ChiCTR1800015023 . Registered 1 March 2018 - Retrospectively registered, http://apps.who.int/trialsearch/default.aspx .

Objective: In many low-resource settings around the world utilization of long-acting reversible contraception (LARC) is low, in part due to access barriers. We sought to explore LARC utilization patterns as well as factors associated with LARC initiation by women seeking contraception in rural Guatemala from a program working to reduce contraception access barriers., Study Design: We analyzed data from a program that provides family planning in six remote, primarily indigenous, villages in Guatemala with limited access to alternative health services. Methods are free and delivered directly within villages by culturally competent providers. We conducted a retrospective chart review of all 288 women who initiated a contraceptive method over a 16-month period and conducted a logistic regression to obtain adjusted odds ratios (OR) for predictors of LARC uptake., Results: Overall 79.2% of women elected a LARC method. More than half of women (49.8%) switched to LARC from short-acting hormonal methods. In the univariate analysis prior use of short-acting method (p = 0.014), number of prior methods (p = 0.049), and current contraceptive use (p<0.01) were significantly associated with choosing a LARC. In the logistic regression model current use of contraception remained significant (OR 3.29, 95% CI 1.67-8.04). Report of abnormal bleeding or other side effects from prior short-acting method use did not predict LARC uptake (p = 0.82 and p = 0.079)., Conclusions: Most women in this marginalized population opted for a LARC method., Implications: Low utilization of LARCs may be related to service delivery factors. Further research is needed to validate these conclusions prospectively and in less selected populations., Competing Interests: The authors have declared that no competing interests exist.

Background: In the past fifteen years, Afghanistan has made substantial progress in extending primary health care. However, coverage of essential health interventions proven to improve maternal and neonatal health outcomes, particularly skilled birth attendance, remains unacceptably low. This is especially true for those in the poorest quintile of the population. This cross-sectional quantitative and qualitative study assessed barriers associated with care-seeking for institutional delivery among rural Afghan women in three provinces., Methods: The study was conducted from November to December 2016 in 12 districts across three provinces - Badghis, Bamyan, and Kandahar - which are predominately rural. Districts were used as the primary sampling unit with district-level sample sizes reflecting the ratio of that district's population to provincial population. Villages within these districts, the secondary sampling units, were randomly selected. A household survey was used to collect data on: demographics, socio-economic status, childbearing history, health transport and service costs, maternal health seeking behavior and barriers to service uptake. Data on barriers to facility delivery were compared across provinces using chi square tests., Results: Of the 2479 women of child bearing age interviewed, one-third were from each province (33% n = 813 Badghis, 34% n = 840 Bamyan, 33% n = 824 Kandahar). Among those respondents who had delivered none of their children in a health center, money to pay for services appeared to be most important barrier to accessing institutional delivery (56%, n = 558). No transportation available was the second most widely cited reason (37%, n = 368), followed by family restrictions (n = 30%, n = 302). Respondents in Badghis reported the highest levels of barriers compared to the other two provinces. Respondents in Badghis were more likely to report familial or cultural constraints as the most important barrier to institutional delivery (43%) compared to Bamyan (2%) and Kandahar (12%) (p < 0.001)., Conclusions: Despite the socio-demographic and geographic diversity of the three provinces under study, the top barriers to institutional delivery reported in all three areas are consistent with available evidence, namely, that distance, transport cost and transport availability are the main factors limiting institutional delivery. Proven and promising approaches to overcome these barriers to institutional delivery in Afghanistan should be explored and studied.

Purpose The purpose of this paper is to examine the drug use and criminal justice factors related to hepatitis C virus (HCV) antibody reactivity among rural women in the USA recruited from local jails. Design/methodology/approach Analyses included 277 women with a history of injection drug use from three rural jails in Kentucky. Participants completed health and drug use questionnaires and received antibody testing for HCV. Findings The majority of women tested reactive to the HCV antibody (69 percent). Reactivity was associated with risk factors, such as unsterile needle use. Criminal justice variables, including an increased likelihood of prison incarceration, an earlier age of first arrest, and a longer incarceration history, were associated with HCV reactive tests. Participants also endorsed several barriers to seeking healthcare before entering jail that were more prevalent in women testing HCV reactive regardless of HCV status awareness before entering jail. Originality/value Injection and high-risk sharing practices as well as criminal justice factors were significantly associated with HCV reactivity. Future research and practice could focus on opportunities for linkages to HCV treatment during incarceration as well as during community re-entry to help overcome real or perceived treatment barriers. The current study highlights the importance of the criminal justice system as a non-traditional, real-world setting to examine drug use and related health consequences such as HCV by describing the association of high-risk drug use and criminal justice consequences with HCV among rural women recruited from local jails.

Background: While focused antenatal care (ANC) has served as an entry point in the continuum of care for both mothers and children, fewer than a third of pregnant women in the most remote and poorest communities of Zambia achieve the four ANC visits recommended by the World Health Organization. Current evidence suggests that attending ANC provided by a skilled healthcare worker at least once is common and associated with skilled birth attendance. The aim of this study was to explain why one ANC visit with a skilled provider seemed more common than four ANC visits among women in the remote and poorest districts of Zambia., Methods: A qualitative case study design was conducted in 2012 among 84 participants in the selected remote and poorest districts of Zambia. Focus group discussions were conducted with mothers and community health volunteers, while key informant interviews were conducted with healthcare providers. Thematic analysis was conducted., Results: Most women delayed starting antenatal care visits due to uncertainties about the timing for initiation of ANC and due to waiting for confirmation of the pregnancy by an elderly woman. Attendance of ANC once with a skilled provider was due to the need to assess their health status and that of their baby. In some facilities, attendance of ANC at least once was enforced by financial charges imposed on women for late ANC initiation, and/or incentives provided by nongovernmental organisations. Unavailability of services at health posts closest to these remote communities led to failure to return for subsequent ANC visits. Women's livelihoods such as nomadic lifestyles made it harder for them to initiate and make additional ANC visits., Conclusion: The popularity of ANC attendance once by a skilled provider among the remote and poorest women of Zambia was explained through perceived unavoidable social and economic barriers to care, and the punitive and incentive procedures implemented by health services. Maximising comprehensive care by skilled healthcare workers in the one visit a woman makes at the health facility, may lead to optimal utilisation of quality focused ANC. Enhancing community-based interventions may increase the potential to reach the vulnerable populations.

High blood pressure is an increasingly problematic public health concern in many developing countries due to the associated cardiovascular and renal complications. This study set out to investigate the drivers of blood pressure among urban and rural women using the 2014 Ghana Demographic and Health Survey data. Diastolic blood pressure (DBP) and systolic blood pressure (SBP) were the outcomes of interest. Our findings showed that body mass index (BMI) had a significant positive effect on DBP and SBP in both urban and rural settings, with the largest effect occurring among women in the 75 th quantile. Arm circumference also had a positive effect on DBP and SBP across all quantiles in both settings. Age had an increasing positive effect along the entire conditional DBP and SBP distribution in both settings. Women who were pregnant had lower DBP and SBP relative to those who were not pregnant in both settings. These results highlight the important drivers of DBP and SBP, and the differential effects of these drivers on blood pressure (BP) among women in urban and rural settings. To increase their effectiveness, interventions to address high BP should take into account these differential effects.

Background: Approximately 22% of women in the United States live in rural areas with limited access to obstetric care. Despite declines in hospital-based obstetric services in many rural communities, midwifery care at home and in free standing birth centers is available in many rural communities. This study examines maternal and neonatal outcomes among planned home and birth center births attended by midwives, comparing outcomes for rural and nonrural women., Methods: Using the Midwives Alliance of North America Statistics Project 2.0 dataset of 18 723 low-risk, planned home, and birth center births, rural women (n = 3737) were compared to nonrural women. Maternal outcomes included mode of delivery (cesarean and instrumental delivery), blood transfusions, severe events, perineal lacerations, or transfer to hospital and a composite (any of the above). The primary neonatal outcome was a composite of early neonatal intensive care unit or hospital admissions (longer than 1 day), and intrapartum or neonatal deaths. Analysis involved multivariable logistic regression, controlling for sociodemographics, antepartum, and intrapartum risk factors., Results: Rural women had different risk profiles relative to nonrural women and reduced risk of adverse maternal and neonatal outcomes in bivariable analyses. However, after adjusting for risk factors and confounders, there were no significant differences for a composite of maternal (adjusted odds ratio [aOR] 1.05 [95% confidence interval {CI} 0.93-1.19]) or neonatal (aOR 1.13 [95% CI 0.87-1.46]) outcomes between rural and nonrural pregnancies., Conclusion: Among this sample of low-risk women who planned midwife-led community births, no increased risk was detected by rural vs nonrural status., (© 2017 Wiley Periodicals, Inc.)

Objective: The aim of this study was to evaluate a multilevel cardiovascular disease (CVD) prevention program for rural women., Methods: This 6-month, community-based, randomized trial enrolled 194 sedentary rural women aged 40 or older with BMI ≥ 25 kg/m 2 . Intervention participants attended 6 months of twice-weekly exercise, nutrition, and heart health classes (48 total) that included individual-, social-, and environment-level components. An education-only control program included didactic healthy lifestyle classes once a month (six total). The primary outcome measures were change in BMI and weight., Results: Within-group and between-group multivariate analyses revealed that only intervention participants decreased BMI (-0.85 units; 95% CI: -1.32 to -0.39; P = 0.001) and weight (-2.24 kg; 95% CI: -3.49 to -0.99; P = 0.002). Compared with controls, intervention participants decreased BMI (difference: -0.71 units; 95% CI: -1.35 to -0.08; P = 0.03) and weight (1.85 kg; 95% CI: -3.55 to -0.16; P = 0.03) and improved C-reactive protein (difference: -1.15 mg/L; 95% CI: -2.16 to -0.15; P = 0.03) and Simple 7, a composite CVD risk score (difference: 0.67; 95% CI: 0.14 to 1.21; P = 0.01). Cholesterol decreased among controls but increased in the intervention group (-7.85 vs. 3.92 mg/dL; difference: 11.77; 95% CI: 0.57 to 22.96; P = 0.04)., Conclusions: The multilevel intervention demonstrated modest but superior and meaningful improvements in BMI and other CVD risk factors compared with the control program., (© 2018 The Obesity Society.)

This study examined whether the closure of several inpatient obstetric units in rural New Hampshire affected birth outcomes. It is a secondary analysis of birth certificate data from 2005 through 2012 and includes 5881 births. There were no changes in perinatal outcomes. When examining outcomes based on distance travelled to place of birth, controlling for closures, women who traveled greater than 30 miles had fewer prenatal visits and lower birth weight and gestational age infants. Community services that provide prenatal care and/or home visiting are even more important when obstetric units are not available in the community.

Objective: Geophagia, the deliberate consumption of rocks, soil, or clay, is prevalent in developing countries, particularly sub-Saharan Africa. Health risks associated with this behavior include parasitosis, heavy metal poisoning, nutrient deficiencies, and poor birth outcomes. This pilot study was designed to reduce geophagic practices and improve nutrition among rural Kenyan women., Methods: The researchers used snowball sampling to recruit participants (n = 135; aged 15-49 years) from low socioeconomic areas who consumed geophagic materials. Interviews were carried out before and after a nutrition intervention implemented by trained community health volunteers., Results: Nutrition education focusing on geophagia significantly (P < .001) decreased the practice in 77% of participants. Postintervention interviews also demonstrated substantial improvement in understanding the concept of making half the plate vegetables using the healthy plate model., Conclusions and Implications: Nutrition education can be useful for reducing geophagia (a largely ignored, unsafe dietary behavior) and enhancing nutritional knowledge in African women., (Copyright © 2017 Society for Nutrition Education and Behavior. Published by Elsevier Inc. All rights reserved.)

Rural women in Southern Mexico link their diabetes to distressful life experiences rooted in ordinary violence. While much has been written on the use that diabetes sufferers make of their morbid condition as an idiom of distress, I investigate the personal and social effects that such an idiom has on women. As I illustrate, diabetes reflects an ambivalence that helps women to speak about the unspeakable and, at the same time, reinforces their ideas of culpability, namely that they are to blame for both the gendered violence that they endure and the diabetes from which they suffer.

Background: Underutilisation of antenatal care services due to intimate partner violence during pregnancy has been well documented elsewhere, but it is understudied in Nepal. Our study aimed at exploring the impact of intimate partner violence on antenatal care service utilisation in southern Terai of Nepal., Method: A community-based cross-sectional study was performed in 6 village development committees in Dhanusha district, Nepal. A total of 426 pregnant women in their second trimester were selected using a multistage cluster sampling method. Multivariable regression analyses were used to examine the association between exposure to intimate partner violence and selected antenatal care services, adjusting for covariates., Results: Among 426 pregnant women, almost three out of ten women (28.9%) were exposed to intimate partner violence at some point during their pregnancy. Pregnant women who were exposed to intimate partner violence were less likely to: register for antenatal care (OR 0.31; 95% CI (0.08-0.50)), take iron and folic acid (OR 0.55; 95% CI (0.12-0.90)), report dietary diversity (middle vs low: OR 0.34; 95% CI (0.11-0.58) and high vs low: OR 0.18; 95% CI (0.08-0.37)), have rest and sleep during day time (OR 0.47; 95% CI (0.61-0.58)), and attend mother's group meetings (OR 0.29; 95% CI (0.10-0.83))., Conclusions: Intimate partner violence during pregnancy is associated with low utilisation of antenatal care services. Therefore, effective strategies to prevent or reduce intimate partner violence during pregnancy is needed, which may lead to improved antenatal care service utilization in Nepal with healthier mothers and children's outcome., (Copyright © 2017 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Introduction: The social-contextual model of tobacco control and the potential mechanisms of the maintenance or cessation of smoking behavior among disadvantaged women, including rural residents, have yet to be comprehensively studied. The purpose of this study was to determine the association between selected individual, interpersonal, workplace, and neighborhood characteristics and smoking status among women in Appalachia, a US region whose residents experience a disproportionate prevalence of tobacco-related health disparities. These findings may assist in efforts to design and test scientifically valid tobacco control interventions for this and other disadvantaged populations., Methods: Women, 18 years of age and older, residing in three rural Ohio Appalachian counties, were recruited using a two-phase address-based sampling methodology for a cross-sectional interview-administered survey between August 2012 and October 2013 (N=408). Multinomial logistic regression was employed to determine associations between select multilevel factors (independent variables) and smoking status (dependent variable). The sample included 82 (20.1%) current smokers, 92 (22.5%) former smokers, and 234 (57.4%) women reporting never smoking (mean age 51.7 years)., Results: In the final multivariable multinomial logistic regression model, controlling for all other significant associations, constructs at multiple social-contextual levels were associated with current versus either former or never smoking. At the individual level, for every additional year in age, the odds of being a former or never smoker increased by 7% and 6% (odds ratio (OR) (95% confidence interval(CI)): 1.07 (1.0-1.11) and 1.06 (1.02-1.09)), respectively, as compared to the odds of being a current smoker. With regard to depression, for each one unit increase in the Center for Epidemiologic Studies Depression Scale score, the odds of being a former or never smoker were 5% and 7% lower (OR(95%CI): 0.95(0.91-0.999) and 0.93(0.88-0.98)), respectively. Five interpersonal factors were associated with smoking status. As the social influence injunctive norm score increased by one unit, indicating perception of smoking to be more acceptable, the odds of being a former or never smoker decreased by 23% and 30%, respectively. For every one unit increase in the social participation score, indicating past-year engagement in one additional activity type, the odds of being a former or never smoker increased by 17% and 36%, respectively. For every 10% increase in the percentage of social ties in the participant's advice network who smoked, the odds of being a former or never smoker were 24% and 28% less, respectively. For every 0.1 unit increase in the E/I index, indicating increasing homophily on smoking in one's social network, the odds of being a former or never smoker were 20% and 24% less, respectively, in the time network, and 18% and 20% less, respectively, in the advice network. At the neighborhood level, for every one unit increase in neighborhood cohesion score, indicating increasing cohesion, the odds of being a former smoker or never smoker were 12% and 14% less, respectively., Conclusions: These findings indicate that a social-contextual approach to tobacco control may be useful for narrowing a widening trajectory of smoking disparity for rural women. Interpersonal context, in particular, must be considered in the development of culturally targeted cessation interventions for Ohio Appalachian women.

Objectives: To estimate the prevalence of intimate partner violence (IPV) among a sample of rural Chinese women and to explore associated factors., Design: Cross-sectional study., Setting: Rural areas of Guangyuan City, Sichuan, China., Participants: We recruited 1501 women, aged 16 years and older, who had been living locally for at least 2 years and reported being married or in a relationship during the past 12 months. They were among a sample of 1898 potential participants from our larger parent study on the prevalence of depressive-distress symptoms., Methods: Participants completed demographic and social economic measures, the Short Form of the Revised Conflict Tactics Scale and the Duke Social Support Index. We applied χ 2 test, analysis of variance and confirmatory factor analysis for analysis., Results: The overall prevalence of IPV in the past 12 months was 29.05%; the prevalence of physical, psychological and sexual violence was 7.66%, 26.58% and 3.20%, respectively. The overall prevalence was highest among women aged 16-29 years, and was more common among those without a high school diploma and who saw their family's financial status as very poor or stagnant. Women who were not victims of IPV had higher levels of social support. Confirmatory factor analysis showed that the total effects of social support on physical, psychological and sexual violence were -0.12, -0.35 and -0.12, respectively. The indirect effects of objective economic status on physical, psychological and sexual violence were -0.047, -0.014 and -0.047, respectively, but the total effect was not significant. The indirect effect of education on psychological violence was -0.056., Conclusion: IPV is common in rural Guangyuan. Our data are comparable with the findings from north-west of China. Social support is an important protective factor. Future work is needed to develop, test and later disseminate potential IPV interventions, with a focus on building actual and perceived supportive social networks., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Reviews have assessed studies of breast and cervical cancer screening access and utilization for rural women, but none analyze interventions to increase screening rates. A mixed methods literature search identified studies of breast and/or cervical cancer prevention education and patient navigation interventions for rural women. Rural areas need greater implementation and evaluation of screening interventions as these services address the challenges of delivering patient-centered cancer care to un-/underserved communities. The lack of intervention studies on breast and cervical cancer education and patient navigation programs compared to urban studies highlights the need for validation of these programs among diverse, rural populations.

Objective: to identify the constituent services of the network to combat violence against rural women in municipalities in the northwestern region of Rio Grande do Sul and to analyze the articulation and communication of services in search of the resolution of situations of violence., Method: descriptive-exploratory, qualitative study, carried out through semi-structured interviews with 26 professionals from intersectoral services, as well as managers and/or those responsible for these services. Data were systematized through content analysis., Results: although the professionals collectively discuss and plan coping actions, difficulties were identified in the approximation between services, related to the definition of flow, knowledge of actions/referrals, fear of seeing and reporting violence, understanding that it is not a question of demand of their field of action, and women's access to services., Final Considerations: it is evident the need to implement public policies that address the singularities of violence against women in rural settings.