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By: Richa Agarwal, MD

  • Instructor in the Department of Medicine


They were also informed that their responses would be anonymous and of their right to withdraw from the study at any point . Additionally , they were invited to enter themselves into a prize draw on completion of the questionnaires by providing their email address. Finally, they were given the details of support services they could contact should they become distressed whilst completing the questionnaires. The variables of the study were not disclosed at this point as it was felt knowledge about them could impact responses. They were reminded of their right to withdraw from the study now they had participated and how to withdraw. They were also reminded about the support services they could contact if they were feeling distressed having completed the questionnaires. It was thought these different sources would enable recruitment of people experiencing a range of distress levels. The researcher contacted a number of private dermatology clinics to seek their consent to advertise the study by leaving leaflets in their clinic reception areas (appendix six). Online acne support forums and groups on Facebook and Twitter were also contacted to gain consent for them to advertise the study. Additionally, people who have written blogs about their experience of acne and 35 high profile medics and dermatologists were contacted on Twitter to gain consent for them to retweet an advert for the study. All of these sources were given information about the study and were encouraged to ask any questions about it. Dependent variables were depression, anxiety, appearance-related distress, and self-esteem. A dermatological quality of life variable was also included for descriptive use only. As mentioned, some acne medications (co-cyprindiol hormonal treatment (females only) and isotretinoin tablets) have been found to have mood-altering effects, and acne can also present as part of wider physical health conditions (polycystic ovary syndrome (females only) or congenital adrenal hyperplasia) which may also impact emotional distress. As such, participants were asked to indicate which prescribed acne medication they are currently using (if any), and whether they have also been diagnosed with congenital adrenal hyperplasia or polycystic ovary syndrome. Responses were coded to enable the effects of these factors to be controlled for during analyses if warranted. Participants were 36 1 not required to provide an answer to these questions, however 99% answered the question about polycystic ovary syndrome (question only asked to females), 2 and 97% answered the question about congenital adrenal hyperplasia. It consists of 14 statements with multiple-choice response options (see appendix eight) scored from 0 to 3. The measure provides anxiety and depression sub-scores (ranging from 0 to 21 when the scores are summed for both scales). Higher scores reflect greater anxiety and depression symptomatology, with scores of 8-10 indicating borderline cases? and 11+ indicating definite cases? of anxiety and depression. This measure was chosen as it is brief, widely used in clinical practice and considered to be valid and reliable. Furthermore, the study reported good mean internal reliability coefficients for the anxiety and depression subscales (? This measure has been widely used in research conducted with primary and secondary healthcare samples. Participants are firstly asked to describe the attribute of their appearance that most concerns them, if any, and if other attributes also concern them. They are then asked to complete 24 items, which are rated on 4-point Likert scales (some items have an additional not applicable? option) examining the frequency and intensity of emotional and behavioural factors related to living with appearance difficulties (Moss et al. When summed the total scores range from 11 to 96, with higher scores indicating higher levels of appearance related distress. This measure was chosen because it is brief, has been widely used in recent research into visible difference, and has demonstrated good validity and reliability. It contains five positively-worded and five negatively-worded statements (see appendix nine). Each statement has four response options from strongly disagree (1) to strongly 38 agree (4), and the negatively-worded items are reverse scored. This measure of self-esteem was chosen because it is a widely researched instrument considered to be reliable and valid. Also of relevance here, Loney, Standage, and Lewis (2008) demonstrated acceptable internal reliability of this measure among 50 adults from a national acne support group (? It consists of ten questions pertaining to symptoms and emotions, daily activities, work/school and leisure activities, personal relationships and treatment (appendix ten). Response options are not at all? (0), a little? (1), a lot? (2), very much? (3). Scores are summed, ranging from 0 (no impairment to quality of life) to 30 (maximum impairment). For example, Clark, Goulden, Finlay and Cunliffe (1997) reported a correlation coefficient of 0. The scale (appendix 11) consists of eight statements for which there are seven Likert scale response options (1=strongly disagree to 7=strongly agree). Greater averaged scores on the scale indicate greater levels of body surveillance. Only two known studies have used this measure with a physical health sample, among which, Boquiren et al. The scale consists of eight statements for which there are seven Likert scale response options (1=strongly disagree to 7=strongly agree, see appendix 12).

Residues of banned carbofuran and methomyl were detected in cucumbers and mandarins , with all mandarin and guava sampled found to be too dangerous to eat . A comprehensivereview of food pesticide contamination studies in seven cities of Pakistan (Faheem et al2015) showed that there are samples of fruits, vegetables and meat that exceed the maximum residues level. Testing of Quaker Oats Quick 1-Minute also showed traces of the pesticide glyphosate (Business Insider 2016). In the Phillipines (Bajet 2015), carbaryl was detected in all vegetables tested while chlorpyrifos was found in 63% of the samples. Other pesticides detected were malathion, carbofuran, methomyl, traizophos, profenos, and diazinon. Pesticides have contaminated the water resource of at least six villages in northern Laos where villagers were found getting sick from drinking water (Radio Free Asia 2014). Organochlorine pesticide residueswere also found in the surface water ofBertam and Terla Rivers in Cameron Highlands,Malaysia(Abdullah et al 2015), in the rivers of China (Tan et al 2009, Zhou et al 2006), India (Malik et al 2009), Korea (Kim et al 2009), Vietnam (Hung & Thiemann 2002) and Thailand (Poolpak et al 2008; Samoh& Ibrahim 2009). Pesticidepoisoningof Asian children Numerous cases of child poisoning occur throughout the world but are particularly high in Asia, where pesticides banned in the developed countries are still in use. This was not an isolated incident as 14 children also shared the same fate in 2012 (The Daily Star2012). Cambodia In OddarMeanchey province, 67 villagers including 49 children were poisoned after eating meat and vegetables kept in inadequately washed metal tubs previously used to hold pesticide for cassava trees (The Phnom Penh Post2013). Insecticide-tainted cucumbers caused the mass poisoning of 610 villagers, 440 of whom are children, during an anti-child trafficking event for local school children in Siem Reap Province (Khmer Times2015). Although banned in the early 1990s, this rodenticide is widely used due to its availability and low cost. The hospital report established the presence of phosphine gas in the victims? bodies (Emirates 24/7 News 2014). India At least 27 children in India aged 4 to 12, were killed after eating their mid-day meal (The Times of India 2013). Forensic examination showed the presence of high toxic levels of monocrotophos, a highly hazardous pesticide. Previous incidents(The Times of India 2013) include: (i) the acute poisoning of 32 school children in 2002 due to the use of phorate in Kerala banana plantation; (ii) poisoning of students in 2006 brought about by phorate use in a Punjab sugarcane field; (ii) 30schoolchildren falling ill in an agricultural field in West Bengal in 2005; (iii)hospitalisation of a 3 year-old child of Muktsar district after consuming pesticide 11 contaminated food; and (iv) death of a Safdipur village boy after drinking pesticide contaminated water. Malaysia Carbamate-laden food caused severe poisoning of more than 30 people aged 2 to 71 in Siputeh, Batu Gajah (The Malay Mail 2016). The pesticide was found in food stall samples of nasi lemak sambal, kueyteow goreng, kuihbom and cucurbadak. Children aged 10 to 11 living near rice paddies were found chronically poisoned by an organophosphate (Hashim&Baguma 2015). The children had poor motor skills, poor hand/eye coordination, attention speed and perceptual motor speed. Pakistan the intentional contamination of baked goods and candies with pesticides due to an alleged business dispute resulted in the death of at least 33 people, including five children (Mail Online2016). A chemical examination indicated the presence of chlorfenapyrin the laddu, a baked confection. Numerous highly hazardous pesticides, such as paraquat, are produced in and exported from countries that do not allow their use. This situation is intensified by the lack of resources for prevention and control of pesticides in developing countries and lack of legislation and inspection by governments. Only one country in Asia is known to prohibit the importation of pesticides that are banned in their home country: Palestine (Watts et al. Additionally, the Palestinian Authority actively confiscates pesticides illegally imported into the Occupied West Bank, including those not registered in their country of origin. This small territory, struggling against immense odds, can be a role model for the rest of the world in this respect. Annex 2 provides information on 21 pesticides highly hazardous to children that are still in use in many countries of Asia-Pacific. Other symptoms that may occur are seizures, paralysis, coma, depression, inarticulate speech, memory loss, rapid pulse, anxiety, involuntary twitching, sweating, difficulty in walking, and uncontrolled urination (Watts 2013, Rengam et al 2007). Pesticides cause birth defects Dimethoate, carbaryl, benomyl, captan, maneb, mancozeb, propiconazole, paraquat and 2,4 D are teratogenic (Garry et al 1996, Garcia 2003). Parental exposure has been associated with congenital abnormalities (Magoon 2006, de Siqueira et al 2010) including abnormally placed urinary opening on penis, absence of one or both testes (Kristensen et al 1997, Carbone et al 2006,Rocheleau et al 2009), micropenis (Gaspari et al 2011a), missing or reduced limbs (Schwartz et al 1986, Schwartz &LoGerfo 1988), anencephaly (Lacasana et al 2006), spina bifida (Brender et al 2010), and congenital heart disease (Yu et al 2008). The critical period of maternal exposure to pesticides is from the month before conception and the first trimester (Nurminen et al 1995, Garcia et al 1998). The critical period for paternal exposure is during the three months prior to conception (Brouwers et al 2007, Pierik et al 2004). Parental exposure has been linked to stillbirths (Goulet & Theriault 1991, Rupa et al 1991, Taha & Gray 1993, Nurminem et al 1995, Pastore et al 1997, Medina-Carrilo et al 2002). The most striking evidence that pesticides cause birth defects is Shruti of Kasargod, India who manifested deformities of hands, feet and other skeletal abnormalities among other congenital diseases of the heart, brain and eyes, from parental exposure to endosulfan. Pesticides damage the brain Voluminous studies (Watts 2013) have linked parental pesticide exposure. In his review of the impact of toxins on the developing brain, Lanphear (2015) declared that we are in the midst of an epidemic of brain-based disorders? and that learning disabilities and mental disorders are now two of the most prevalent morbidities in children. Newborn infants in New York, exposed in utero to chlorpyrifos from household use, were found to have delayed cognitive and psychomotor development. It was found that these effects were independent of socio-economic factors (Lovasi et al 2011).

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Prior Pregnancy Loss: Preconceptional counseling is recommended in women who experienced a prior pregnancy loss . During the preconception period , investigate the factors that may have contributed to the previous negative outcome and attempt to assuage guilt and help patients resolve any grief from a previous loss. Provide recommendations to the patient that may reduce the chances of pregnancy loss. Also, inform patients realistically about the likelihood of successful future childbearing. Psychosocial Concerns: Psychosocial issues are nonbiomedical factors that affect mental and physical well being. Psychosocial screening should include assessment of risk factors, such as: barriers to care, unstable housing, unintended pregnancy, communication barriers, nutrition, tobacco use, substance use, depression, safety, intimate partner violence, and stress. Smoking: Health risks associated with smoking during pregnancy include intrauterine growth restriction, placenta previa, and abruption placetae. Additionally, adverse pregnancy outcomes may occur including premature rupture of membranes, low birth weight, and perinatal mortality. Smokers of reproductive age should be counseled about the associated risks of smoking and the negative outcomes associated with pregnancy. Both cessation of tobacco use and prevention of smoking relapse are key clini cal intervention strategies during preconception and pregnancy. A 5-15 minute counseling session performed by appropriately trained health care providers is most effective with pregnant women who smoke fewer than 20 cigarettes per day. Asthma: Asthma during pregnancy requires special attention and comprehensive treatment. Educating patients preconceptionally would be benefcial to the patients? pregnancy outcome. Additionally, environmental factors such as allergens (animal dander, house-dust mites, cockroaches, pollens, and indoor molds), tobacco smoke, and indoor/outdoor pollutants (wood-burning stoves of freplaces, unvented stoves, perfumes, cleaning agents) could exacerbate asthma attacks and should be discussed during preconception to limit exposures. Diabetes: Preconceptional counseling for women with pregestational diabetes mellitus is benefcial and cost-effective. Preconceptional counsel ing should focus on the importance of euglycemic control before pregnancy, as well as the adverse obstetric and maternal outcomes that can result from poorly controlled diabetes. An evaluation for underlying vasculopathy is advisable and, in selected patients, may include a retinal examination by an ophthalmologist, a 24-hour urine collection for protein excretion and creatinine clearance, and electrocardiography. Higher doses of folic acid may be benefcial in some cases, especially in the presence of other risk factors for neural tube defects. Heart Disease: Women of reproductive age living with heart disease should be counseled about the potential risks associated with pregnancy. Hypertension in pregnancy, specifcally preeclampsia and transient hypertension of pregnancy, is associated with increased rates of hypertension and coronary heart disease later in life. Hypothyroidism: Women should be counseled preconceptionally about treatment during pregnancy. Pregnancy increases maternal thyroid hormone requirements in women with hypothyroidism diagnosed before pregnancy. During pregnancy, weight reduction is not advised but counseling concerning appropriate weight gain is advisable. The goal should be towards development of lasting diet and exercise habits which will help the woman sustain a healthy weight throughout her lifetime. Oral Health: Dental care is encouraged as appropriate before and during pregnancy. Some studies have found an association between periodontal disease and poor pregnancy outcomes of premature delivery, low birth weight and preeclampsia. It has been suggested that dietary control should be implemented at least three months prior to conception to help prevent fetal structural defects, cardiac defects, low birth weight, microcephaly, and mental retardation. Sickle Cell Anemia: Pregnancy in women with sickle cell disease is associated with an increased risk of morbidity and mortality because of the combination of underlying hemolytic anemia and multiorgan dysfunction associated with this disorder. Pregnant patients with sickle cell disease need increased prenatal folic acid supplementation. A recommended 4 mg per day of folic acid should be prescribed due to the continual turnover of red blood cells. Solubility tests alone are inadequate for screening because they fail to identify important transmissible hemoglobin gene abnormalities affecting fetal outcome. If it is determined that this individual is a carrier, the other partner should be offered screening. Carrier couples should be informed of the disease manifestations, range of severity, and availabile treatment options. The patient should be encouraged to inform his or her relatives of the risk and the availability of carrier screening. The provider does not need to contact these relatives because there is no provider patient relationship with relatives and confdentiality must be maintained. Switching medication may be appropriate during the preconception period if suitable alternatives exist with less risk to the pregnant woman or fetus. General statements may be made about the teratogenetic potential of prescription drugs, however, maternal condition and treatment needs should be considered, weighing the beneft to the mother with the risk to the fetus. Food and Drug Administration has defned fve risk categories (A, B, C, D, X) that are used by manufacturers to rate their products for use during pregnancy. Some examples of drugs which should be managed carefully during the preconception period are: Isotretinoins: If used in pregnancy to treat acne, it can result in miscar riage and birth defects. Pregnancy prevention should be practiced in women of reproductive age taking these drugs. Early exposure during pregnancy could be avoided preconceptionally by switching drugs.

How does the background of women in the district influence their knowledge on contraceptive use and choice? To determine the knowledge levels of respondents on contraceptive uses and choices in relation to their social backgrounds 2 . To assess the extent to which the socio-economic characteristics of the women in Offinso District influence their decisions on the use of family planning methods 3 . To identify the factors that account for the low patronage of contraceptive methods in the district and assess the correlates among the women in the district 4. To make recommendations to major stakeholders and also suggest areas of further research. Assessment of knowledge about contraceptives therefore does not only determine the extent of awareness and sensitization (Takyi, 2000; Kongnyey et al, 2007) but further provides the background for which use of the service is further evaluated. Evaluation in this sense relates with the background characteristics, principally social, of users that influence these awareness and sensitization levels. Seventy-three percent users at the time of the survey expressed a high degree of satisfaction with the pill, although misperceptions were prevalent. Few women knew it was safe for nonsmokers to take the pill after age 35, and that the pill reduces certain cancers. When asked whether taking the pill presented fewer health risks than pregnancy, just 4% strongly agreed. Published literature on the efficacy of contraceptive counseling and education seems to reflect a significant gap between what providers think they offer and what consumers appear to receive. An audit of family planning users in Scotland revealed a 30% discrepancy between the number of women whom clinicians thought they had appropriately counseled and the number of patients who actually understood the teaching (Rajasekar et al, 1999). According to the recent Ghana Demographic Health Survey, 2003, knowledge of family planning was defined operationally as having heard of a method. Knowledge about modern and traditional contraceptive have changed over a decade and half ago. Whereas the latter was popular among Ghanaians, the former is now popular even though users of contraceptives use the traditional methods (Clemen et al 2004, Hoque, 2007). It is noted that contraceptive knowledge among unmarried women was found to be 100 percent. Condoms, diaphram, the pill, implant, foam tablet and lactational amenorrhoea were among the methods commonly identified. In a cross-sectional survey in Kinshasa, Democratic Republic of Congo, condom was the most widely known modern contraceptive method since it was cited by 43% of women; the Pill was by only 28%, Injectables 16. Teenagers and young adults (15?24 years) were less knowledgeable of modern methods (Kayembe et al, 2003). In an assessment of gender issues relating to contraceptive use in Ebo State, Nigeria, Osaemwenkha observed that educated and sexually active youth had wide spread knowledge of contraceptives and this background correlates with the number of methods known (Osaemwenkha, 2004). Even though Osaewenkha, perceived that his respondents, 800 university female students, may have had enough knowledge, he discovered that even among the enlightened, decision making on contraceptive use has the male involvement factor essential. The difficulties arise from the strength of the interplay of influences from close family relations. Furthermore, the economic dependency level of the woman on her close relations affect the decision process for the uptake of contraceptives (Benefo, 2005). The type of work and the amount of income earned by the woman in particular have a strong relation to use of contraceptives (Baiden, F. Studies during the past few decades have established a close and significant relation between contraceptive use and fertility preferences. Das and Deka (1982) have considered the cultural factors in fertility as there is evidence that the fertility behaviour changes with different cultural settings. The economic value ascribed to children enhances fertility among those who are economically poor. In several studies on modernity and fertility, education is found to be the prime influencing factor. Education may have a direct influence on fertility, since education affects the attitudinal and behavioural patterns of the individuals. Lactational amenorrhoea, which lasts for two to three years in some societies gives scope for longer birth intervals, thus affecting the fertility among such women (McNeilly, 1979). As Anand (1968) and Chandrasekhar (1972) put it, the family welfare programmes, their reception, impact and utility have affected fertility in every society in this era of rapid population growth. Results achieved so far in this direction can be attributed to the programme inputs. However, besides several cultural factors, non-availability and/or lack of knowledge, attitude towards desired family size, traditional beliefs and practices play an important role in family planning. There are other studies also in similar lines taken up among tribal and rural populations (Meerambika Mahapatro et al, 1999; Sushmita and Bhasin, 1998 and Varma et al, 2002). However, the national programme should have group specific and area specific interventions with regard to family planning. In this background, an attempt was made in that paper to study knowledge and practice of contraception? among Racha Koyas, a tribal population from Andhra Pradesh. In this connection, it is pertinent to note that in the National Health Policy?, the tribal groups need special attention as they are considered a special group. These among others account for the emphasis on the concept that contraceptive is a human rights issue. This concept does not only empower women to take control of their reproductive life but also develop themselves to be independent of others, so as to ensure their total well-being and that of their children. Many researchers have observed that, this concept is a borrowed one from the west and its adaptation in the African setting.