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Anupa Rijal, Tara Ballav Adhikari, Arja R Aro Unit for Health Promotion Research, Faculty of Health Sciences, University of Southern Denmark, Esbjerg, Denmark Abstract: Sex trafficking, where individuals are traded for sex purposes and abused sexually, physically, mentally, and economically leading to repercussions in individual liberty, social life, and health and well-being, is one of the worst forms of infringement of human rights. Despite the growing global concern against sex trafficking, thousands of individuals, mostly girls and women, are trafficked annually, especially from low- and middle-income countries like Nepal. This article discusses the public health issues related to sex trafficking and the different ethical approaches – libertarianism, paternalism, stewardship, and virtue ethics – on perspectives concerning combating sex trafficking in Nepal. Along with the legal standpoint, awareness-raising activities, transit monitoring, and limited rehabilitative programs, Nepal also needs to enhance its stewardship approaches by addressing the gender-sensitive nature of the problem through empowerment and livelihood programs for girls and women from vulnerable communities to combat sex trafficking effectively. Keywords: women, exploitation, public health, libertarianism, paternalism, stewardship, Nepal

Anastasia Samara,1 Anne Nistrup,1 Tamader Y AL-Rammah,2 Arja R Aro11Unit for Health Promotion and Research, University of Southern Denmark, Esbjerg, Denmark; 2Faculty of Rehabilitation and Health Sciences, Princess Nora Bint Abdul Rahman University, Riyadh, Kingdom of Saudi ArabiaPurpose: The Kingdom of Saudi Arabia is experiencing a dramatic increase in physical inactivity, with women having higher levels of inactivity than men among all age groups. It is assumed that factors such as dress codes, restrictions on going outdoors, and conservative norms are the main reasons for women’s low physical activity. Our aim was to explore the different parameters related to physical activity, including self-efficacy, as well as the perceived barriers to and benefits of physical activity in young Saudi females.Patients and methods: Ninety-four first-year female Saudi university students in Riyadh, Kingdom of Saudi Arabia, participated in the present study in 2014. The students were from eight bachelor’s programs in health and well-being, and each completed a questionnaire with questions divided into five parts as follows: 1) socioeconomic status, 2) physical activity, 3) self-efficacy 4) social factors, and 5) barriers and facilitators related to physical activity.Results: The students exercised at home and alone, and there was low self-efficacy for physical activity (mean score =42±14). Among social factors, attending university was the only factor that hindered physical activity (32%). Physical activity was positively perceived overall (mean score =131±10). Students showed awareness of the benefits of physical activity for health and well-being. The most important barrier was the lack of designated areas available for physical activity. Students disagreed that family or the Islamic community were barriers to physical activity.Conclusion: The lack of facilities and lack of encouragement from the university, but not a lack of knowledge

Bishal Gyawali,1 June Keeling,2 Edwin van Teijlingen,3 Liladhar Dhakal,4 Arja R Aro1 1Unit for Health Promotion Research, University of Southern Denmark, Esbjerg, Denmark; 2Faculty of Health and Social Care, University of Chester, Bebington, 3Centre for Midwifery, Maternal and Perinatal Health, Bournemouth University, UK; 4Health for Life Project, Lalitpur, Kathmandu, NepalAbstract: Cervical cancer is the leading cause of cancer deaths for women worldwide. Cervical screening and early treatment can help to prevent cervical cancers. Cervical screening programs in Nepal are often associated with a number of socioeconomic, cultural, and ethical challenges. This paper discusses some central ethical challenges in providing cervical cancer screening in the Nepalese context and culture. It is necessary to address these challenges for successful implementation of such screening programs.Keywords: public health screening, ethics, women, South Asia

Shanti Kadariya, Arja R AroUnit for Health Promotion Research, University of Southern Denmark, Esbjerg, DenmarkAbstract: Chhaupadi practice, which is characterized by banishment of women during menstruation from their usual residence due to supposed impurity, is in existence in the mid- and far-western regions of Nepal. It has been criticized for violation of basic human rights of women and also for its associated physical and mental health impacts. Despite having been outlawed, it continues to exist due to illiteracy, superstitious beliefs, gender disparity and community endorsement of the practice. This article presents an analysis of the Chhaupadi practice from the perspectives of human rights and public health as well as ethical theories of liberalism and communitarianism. It is necessary to increase the ongoing social awareness among affected Nepali communities about the natural character of menstruating and the harmful practice of Chhaupadi in order to eliminate this violence against women while also addressing the community’s concerns.Keywords: menstruation, ethics, communitarianism, liberalism, human rights, public health

Liladhar Dhakal, Gabriele Berg-Beckhoff, Arja R AroUnit of Health Promotion Research, University of Southern Denmark, Esbjerg, DenmarkIntroduction: Violence against women perpetrated by their intimate partners is a social problem with adverse health consequences. Intimate partner violence has acute and chronic as well as direct and indirect health consequences related to physical, psychological, and reproductive health. Studies exploring relationships of intimate partner violence and health consequences are rare in Nepal. Hence, this study aimed to examine the relationships between intimate partner violence and sexually transmitted infections.Method: This study used data from the nationally representative Nepal Demographic Health Survey 2011, which collected data through a two-stage complex sampling technique. Women 15–49 years were asked about domestic violence including intimate partner violence. For this analysis, 3,084 currently married women were included. Questions about domestic violence were adapted from the Conflict Tactic Scale. Relationships between different forms of physical and sexual intimate partner violence and reported signs and symptoms of sexually transmitted infections were examined using multiple logistic regression analysis.Results: Approximately 15% of currently young and middle-aged married women experienced some form of violence in the last 12 months. About one in four women who were exposed to physical and sexual intimate partner violence reported sexually transmitted infection in the last 12 months. The odds of getting sexually transmitted infection were 1.88 [95% CI:1.29, 2.73] times higher among women exposed to any form of intimate partner violence in the last 12 months compared to women not exposed to any form of intimate partner violence.Conclusion: Intimate partner violence was common among currently married women in Nepal. Being exposed to intimate partner violence and getting signs and symptoms of sexually transmitted di

Ahmed Ibrahim1, Arja R Aro1, Vibeke Rasch2, Eero Pukkala3,41Unit for Health Promotion Research, University of Southern Denmark, Esbjerg, Denmark; 2Department of Obstetrics and Gynecology, Odense University Hospital, Odense, Denmark; 3Finnish Cancer Registry, Institute for Statistical and Epidemiological Cancer Research, Helsinki, Finland; 4School of Public Health, University of Tampere, Tampere, FinlandObjective: To determine the feasibility of visual inspection with the use of acetic acid (VIA) as a screening method for cervical cancer, an alternative to the Pap smear used in primary health care setting in Sudan, and to compare sensitivity, specificity, positive and negative predictive values, and histological diagnosis of positive cases of both tests.Methods: A cross-sectional study of 934 asymptomatic women living in Khartoum, Sudan, was conducted during 2009–2010. A semi-structured questionnaire containing socio-economic and reproductive variables was used to collect data from each participant. Methods of screening used were VIA and conventional Pap smear, followed by colposcopy and biopsy for confirmation of the positive results of both screening tests.Results: The tests identified altogether 119 (12.7%) positive women. VIA detected significantly more positive women than Pap smear (7.6% versus 5.1%; P = 0.004), with an overlap between the two screening tests in 19% of positive results. There was no significant difference between VIA and Pap smear findings and sociodemographic and reproductive factors among screened women. Use of colposcopy and biopsy for positive women confirmed that 88/119 (73.9%) were positive for cervical intraepithelial neoplasia. VIA had higher sensitivity than Pap smear (74.2% versus 72.9%; P = 0.05) respectively. Out of 88 confirmed positive cases, 22 (25.0%) cases were invasive cervical cancer in stage 1, of which 19 versus three were detected by VIA and Pap smear respectively (P = 0.001). VIA had higher sensitivity and lower

Wondimu Shanko Yirga1,2, Nega Assefa Kassa2, Mengistu Welday Gebremichael2, Arja R Aro31University of Southern Denmark, Faculty of Health Sciences, Esbjerg, Denmark; 2Haramaya University College of Health Sciences, Harar, Ethiopia; 3University of Southern Denmark, Unit for Health Promotion Research, Esbjerg, DenmarkBackground: Female genital mutilation (FGM) is nontherapeutic surgical modification of the female genitalia. It is an ancient tradition in large parts of Africa, including Ethiopia, especially in the eastern part of the country. This study aimed to identify the prevalence, perceptions, perpetuators, reasons for conducting FGM, and factors associated with this practice with regard to women's health.Methods: Community-based cross-sectional house-to-house interviews were conducted during 2008 among 858 females of reproductive age (15–49 years), in Kersa district, East Hararge, Oromia region, Ethiopia. Proportions and Chi-square tests were used to describe the data and logistic regression was used to describe statistical associations. Statistical significance was set at P < 0.05.Results: FGM was reported to be known by 327 (38.5%) of the interviewees. The majority (n = 249, 76.1%) reported that local healers were the main performers of FGM, and 258 (78.9%) respondents stated that the clitoris was the part removed during circumcision. The main reason for the practice of FGM was reduction of female sexual hyperactivity (reported by 198 women [60.3%]). Circumcision of daughters was reported by 288 (88.1%) respondents, and this showed a statistically significant association with the Christian religion (P = 0.003), illiteracy (P = 0.01), and Amhara ethnicity (P = 0.012). The majority of the respondents (792, 92.3%) were themselves circumcised and 68.8% did not know of any health-related problems associated with FGM.Conclusion: In spite of FGM being a common practice in the study area, only one third of the respondents stated that they knew

Christina M Rad,l Ranjita Rajwar, Arja R AroUniversity of Southern Denmark, Esbjerg, DenmarkAbstract: Uterine prolapse is a major reproductive health issue in Nepal. There is a wide range of literature available on the causes and risk factors of uterine prolapse and on the ways to prevent and treat it. There is still a lack of published evidence on what prevention and treatment services are working well or the attitudes toward them. This paper presents the findings of a qualitative study on primary and secondary prevention of uterine prolapse in Eastern Nepal.Method: The study involved eight focus group discussions with 71 women in six villages of the eastern districts of Siraha and Saptari and 14 qualitative interviews with health professionals from the local to central level. The group discussions and interviews covered the awareness levels of uterine prolapse and its prevention and treatment, as well as participants' opinions on and experiences with the services offered.Results: It was found that patriarchy, gender discrimination, and cultural traditions such as early marriage and pregnancy make it difficult for people to discontinue uterine prolapse risk behaviors. Women are aware of risk factors, prevention, and treatment, but are powerless to change their situations. Health professionals and women are fond of surgery as treatment, but opinions on the use of ring pessaries and pelvic floor muscle training are split.Conclusion: The main recommendation that can be drawn from this study is that research on the effectiveness of early treatments, such as ring pessaries and exercise, should be conducted. Furthermore, the involvement of other target groups (husbands, adolescents, and mothers-in-law) needs to be increased in order to make it easier for women to adapt low-risk behaviors. Finally, uterine prolapse prevention should be better integrated in national reproductive health services. Enforcing transparency, monitoring systems, and collaborations are imp

Ahmed Ibrahim1, Vibeke Rasch2, Eero Pukkala3, Arja R Aro11Unit for Health Promotion Research, University of Southern Denmark, Esbjerg, Denmark; 2Department of Obstetrics and Gynecology, Odense University Hospital, Odense, Denmark; 3Institute for Statistical and Epidemiological Cancer Research, Finnish Cancer Registry, Helsinki, FinlandObjectives: To assess the risk factors of cervical cancer and the feasibility and acceptability of a visual inspection with acetic acid (VIA) screening method in a primary health center in Khartoum, Sudan.Methods: A cross-sectional prospective pilot study of 100 asymptomatic women living in Khartoum State in Sudan was carried out from December 2008 to January 2009. The study was performed at the screening center in Khartoum. Six nurses and two physicians were trained by a gynecologic oncologist. The patients underwent a complete gynecological examination and filled in a questionnaire on risk factors and feasibility and acceptability. They were screened for cervical cancer by application of 3%–5% VIA. Women with a positive test were referred for colposcopy and treatment.Results: Sixteen percent of screened women were tested positive. Statistically significant associations were observed between being positive with VIA test and the following variables: uterine cervix laceration (odds ratio [OR] 18.6; 95% confidence interval [CI]: 4.64–74.8), assisted vaginal delivery (OR 13.2; 95% CI: 2.95–54.9), parity (OR 5.78; 95% CI: 1.41–23.7), female genital mutilation (OR 4.78; 95% CI: 1.13–20.1), and episiotomy (OR 5.25; 95% CI: 1.15–23.8). All these associations remained statistically significant after adjusting for age, educational level, employment, and potential confounding factors such as smoking, number of sexual partners, and use of contraceptive method. Furthermore, the VIA screening method was found to be feasible and acceptable to participants.Conclusion: This pilot study showed

Ahmed Ibrahim1, Vibeke Rasch2, Eero Pukkala3, Arja R Aro1 1Unit for Health Promotion Research, University of Southern Denmark, Esbjerg, Denmark; 2Department of Obstetrics and Gynaecology, Odense University Hospital, Odense, Denmark; 3Finnish Cancer Registry, Institute for Statistical and Epidemiological Cancer Research, Helsinki, Finland Background: Cervical cancer is the second most common cancer among women in Sudan, with more than two-thirds of all women with invasive cervical cancer being diagnosed at an advanced stage (stages III and IV). The lack of a screening program for cervical cancer in Sudan may contribute to the late presentation of this cancer, but other factors potentially associated with advanced stages of cervical cancer at diagnosis are unknown. The purpose of this research was to investigate the relationship between age, marital status, ethnicity, health insurance coverage, residence in an urban vs a rural setting, and stage (at diagnosis) of cervical cancer in Sudan. Methods: This was a cross sectional study of 197 women diagnosed with different stages of cervical cancer. Data was obtained from the cancer registry unit at the Radiation and Isotopes Centre in Khartoum for all women diagnosed with cervical cancer in 2007. Results: There was an association between older age and advanced stage (at diagnosis) of cervical cancer (odds ratio [OR]: 1.03, 95% confidence interval [CI]: 1.01–1.05). Being of African ethnicity was associated with 76% increased odds (OR: 1.76, 95% CI: 1.01–3.05), living in a rural area was associated with 13% increased odds (OR: 1.13, 95% CI: 1.78–5.50), and being uninsured was associated with an almost eight-fold increase in odds (OR: 7.7, 95% CI: 3.76–15.38). Marital status and education level were not associated with an advanced stage of cervical cancer at diagnosis. Conclusion: Women with cervical cancer who are elderly, not covered by health insurance, of African ethnicity, and livi