Search results for: military sexual assault

Authors: Charlotte K. Lee, Henrique R. N. Aguiar, Ralph Smith, James Baldock, Sam Botchey

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Background: Femoral neck stress fractures (FNSF) are uncommon, making up 1 to 7.2% of stress fractures in healthy subjects. FNSFs are prevalent in young women, military recruits, endurance athletes, and individuals with energy deficiency syndrome or female athlete triad. Presentation is often non-specific and is often misdiagnosed following the initial examination. There is limited research addressing the return–to–activity time after FNSF. Previous studies have demonstrated prognostic time predictions based on various imaging techniques. Here, (1) OxSport clinic FNSF practice standards are retrospectively reviewed, (2) FNSF cohort demographics are examined, (3) Regression models were used to predict return–to–activity prognosis and consequently determine bone stress risk factors. Methods: Patients with a diagnosis of FNSF attending Oxsport clinic between 01/06/2020 and 01/01/2020 were selected from the Rheumatology Assessment Database Innovation in Oxford (RhADiOn) and OxSport Stress Fracture Database (n = 14). (1) Clinical practice was audited against five criteria based on local and National Institute for Health Care Excellence guidance, with a 100% standard. (2) Demographics of the FNSF cohort were examined with Student’s T-Test. (3) Lastly, linear regression and Random Forest regression models were used on this patient cohort to predict return–to–activity time. Consequently, an analysis of feature importance was conducted after fitting each model. Results: OxSport clinical practice met standard (100%) in 3/5 criteria. The criteria not met were patient waiting times and documentation of all bone stress risk factors. Importantly, analysis of patient demographics showed that of the population with complete bone stress risk factor assessments, 53% were positive for modifiable bone stress risk factors. Lastly, linear regression analysis was utilized to identify demographic factors that predicted return–to–activity time [R2 = 79.172%; average error 0.226]. This analysis identified four key variables that predicted return-to-activity time: vitamin D level, total hip DEXA T value, femoral neck DEXA T value, and history of an eating disorder/disordered eating. Furthermore, random forest regression models were employed for this task [R2 = 97.805%; average error 0.024]. Analysis of the importance of each feature again identified a set of 4 variables, 3 of which matched with the linear regression analysis (vitamin D level, total hip DEXA T value, and femoral neck DEXA T value) and the fourth: age. Conclusion: OxSport clinical practice could be improved by more comprehensively evaluating bone stress risk factors. The importance of this evaluation is demonstrated by the population found positive for these risk factors. Using this cohort, potential bone stress risk factors that significantly impacted return-to-activity prognosis were predicted using regression models.

Keywords: eating disorder, bone stress risk factor, femoral neck stress fracture, vitamin D

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Authors: Priyanka Manghani, Manthan Patel, Rahul Peddawad

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Cervical Cancer is a major public health hurdle in the area of women’s health. The most common cause of Cervical Cancer is the Human Papilloma Virus (HPV). Human papilloma virus has various genotypes, with HPV 16 and HPV 18 being the major etiological factor causing carcinoma of the Cervix. Early screening and detection by Papanicolaou Smears (PAP) is an effective method for identifying premalignant and malignant lesions. In case of existing pre- malignant lesions /cervical dysplasia’s found with HPV 16 or 18, appropriate follow up can be done to prevent it from developing into a neoplasm. Aims and Objectives: Primary Aim; To study various abnormal cervical cytology reports as detected by Pap Smear Tests, using the Bethesda System in women at a Tertiary Care Hospital. Secondary Aim; To discuss the importance of Pap smear in Cervical Cancer Screening Program. Materials and Methods: Our study is a prospective study, based on 101 women who attended the Out-patient department of Obstetrics and Gynecology at a tertiary care hospital in age group 20-40 years with chief complaints of white/foul vaginal discharge, post-coital Bleeding, low back pain, irregular menstruation, etc. 60 women, who were tested, of the total no of women, were commercial sex workers, thus being a high-risk group for HPV infection. All women underwent conventional cytology. For all the abnormal smears, further cervical biopsies were done, and the final diagnosis was done on the basis of histopathology (gold standard). Results: In all these patients, 16 patients presented with normal smears out of which 2 belonged to the category of commercial sex workers (3.33%) and 14 being from the normal/control group (34.15%). 44 women presented with inflammatory smears out of which 30 were commercial sex workers (50%) and 14 from the control Group (34.15%). A total of 11 women presented with infectious etiology with 6 being commercial sex workers (10%) and 5 (12.2%) being in the control group. A total of 8 patients presented with low-grade squamous intra epithelial lesion (LSIL) with 7 (11.7%) being commercial sex workers and 1(2.44%) patient belonging to the control group. A Total of 7 patients presented with high-grade squamous intraepithelial lesion (HSIL) with 6 (10%) being commercial sex workers and 1 (2.44%) belonging to the control group. 9 patients in total presented with atypical squamous cells of undetermined significance (ASCUS) with 6(10%) being commercial sex workers and 3 (7.32%) belonging to the control group. Squamous cell carcinoma(SCC) presence was found only in 1(1.7%) commercial sex worker. Conclusion – We conclude that HSIL, LSIL, SCC and sexually related infections are comparatively more common in vulnerable groups such as sex workers due to a variety of factors such as multiple sexual partners and poor genital hygiene. Early screening and follow up interventions are highly needed for them along with Health education for risk factors and to emphasize on the importance of Pap smear screening.

Keywords: cervical cancer, papanicolaou (pap) smear, bethesda system, neoplasm

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Authors: Pedro Llanos, Diego García

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This paper is addressed to expanding our understanding of the effects of hypoxia training on our bodies to better model its dynamics and leverage some of its implications and effects on human health. Hypoxia training is a recommended practice for military and civilian pilots that allow them to recognize their early hypoxia signs and symptoms, and Scientist Astronaut Candidates (SACs) who underwent hypobaric hypoxia (HH) exposure as part of a training activity for prospective suborbital flight applications. This observational-analytical study describes physiologic responses and symptoms experienced by a SAC group before, during and after HH exposure and proposes a model for assessing predicted versus observed physiological responses. A group of individuals with diverse Science Technology Engineering Mathematics (STEM) backgrounds conducted a hypobaric training session to an altitude up to 22,000 ft (FL220) or 6,705 meters, where heart rate (HR), breathing rate (BR) and core temperature (Tc) were monitored with the use of a chest strap sensor pre and post HH exposure. A pulse oximeter registered levels of saturation of oxygen (SpO₂), number and duration of desaturations during the HH chamber flight. Hypoxia symptoms as described by the SACs during the HH training session were also registered. This data allowed to generate a preliminary predictive model of the oxygen desaturation and O₂ pressure curve for each subject, which consists of a sixth-order polynomial fit during exposure, and a fifth or fourth-order polynomial fit during recovery. Data analysis showed that HR and BR showed no significant differences between pre and post HH exposure in most of the SACs, while Tc measures showed slight but consistent decrement changes. All subjects registered SpO₂ greater than 94% for the majority of their individual HH exposures, but all of them presented at least one clinically significant desaturation (SpO₂ < 85% for more than 5 seconds) and half of the individuals showed SpO₂ below 87% for at least 30% of their HH exposure time. Finally, real time collection of HH symptoms presented temperature somatosensory perceptions (SP) for 65% of individuals, and task-focus issues for 52.5% of individuals as the most common HH indications. 95% of the subjects experienced HH onset symptoms below FL180; all participants achieved full recovery of HH symptoms within 1 minute of donning their O₂ mask. The current HH study performed on this group of individuals suggests a rapid and fully reversible physiologic response after HH exposure as expected and obtained in previous studies. Our data showed consistent results between predicted versus observed SpO₂ curves during HH suggesting a mathematical function that may be used to model HH performance deficiencies. During the HH study, real-time HH symptoms were registered providing evidenced SP and task focusing as the earliest and most common indicators. Finally, an assessment of HH signs of symptoms in a group of heterogeneous, non-pilot individuals showed similar results to previous studies in homogeneous populations of pilots.

Keywords: slow onset hypoxia, hypobaric chamber training, altitude sickness, symptoms and altitude, pressure cabin

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Authors: Ani Eda Njwe

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Cameroon is a bilingual and bijural country in West and Central Africa. The current president has been in power since 1982, which makes him the longest-serving president in the world. The length of his presidency is one of the major causes of the ongoing political instability in the country. The preamble of the Cameroonian constitution commits Cameroon to respect international law and human rights. It provides that these laws should be translated into national laws, and respected by all spheres of government and public service. Cameroon is a signatory of several international human rights laws and conventions. In theory, the citizens of Cameroon have adequate legal protection against the violation of their human rights for political reasons. The ongoing political crisis in Cameroon erupted after the Anglophone lawyers and teachers launched a protest against the hiring of Francophone judges in Anglophone courts; and the hiring of Francophone teachers in Anglophone schools. In retaliation, the government launched a military crackdown on protesters and civilians, conducted arbitrary arrests on Anglophones, raped and maimed civilians, and declared a state of emergency in the Anglophone provinces. This infuriated the Anglophone public, causing them to create a secessionist movement, requesting the Independence of Anglophone Cameroon and demanding a separate country called Ambazonia. The Ambazonian armed rebel forces have ever since launched guerrilla attacks on government troops. This fighting has deteriorated into a war between the Ambazonians and the Cameroon government. The arbitrary arrests and unlawful imprisonments have continued, causing the closure of Anglophone schools since November 2016. In October 2018, Cameroon held presidential elections. Before the electoral commission announced the results, the opposition leader, a Francophone, declared himself winner, following a leak of the polling information. This led to his imprisonment. This research has the objective of finding out whether the government’s reactions to protesters and opposition is lawful, under national and international laws. This research will also verify if the prison conditions of political prisoners meet human rights standards. Furthermore, this research seeks detailed information obtained from current political prisoners and detainees on their experiences. This research also aims to highlight the effort being made internationally, towards bringing awareness and finding a resolution to the war in Cameroon. Finally, this research seeks to elucidate on the efforts which human rights organisations have made, towards overseeing the respect of human rights in Cameroon. This research adopts qualitative methods, whereby data were collected using semi-structured interviews of political detainees, and questionnaires. Also, data was collected from secondary sources such as; scholarly articles, newspaper articles, web sources, and human rights reports. From the data collected, the findings were analysed using the content analysis research technique. From the deductions, recommendations have been made, which human rights organisations, activists, and international bodies can implement, to cause the Cameroonian government to stop unlawful arrests and reinstate the respect of human rights and the rule of law in Cameroon.

Keywords: arbitrary arrests, Cameroon, human rights, political

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Authors: Anum Rafiq

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Adolescence is a vulnerable period for youth across the world. It is a period of new learning with opportunities to understand and develop perspectives on health and well-being. With youth beginning to engage in intimate relationships at an earlier age in the 21st century, concentrating on the learning opportunity they have in school is paramount. The nature of what has been deemed important to teach in schools has changed throughout history, and the focus has shifted from home/family skills to teaching youth how to be competitive in the job market. Amidst this emphasis, opportunities for them exist to learn about building healthy intimate relationships, one of the foundational elements of most people’s lives. Using an Institutional Ethnography (IE), the lived experiences of youth in how they understand intimate relationships and how their learning experience is organized through the high school Health and Physical Education (H&PE) course is explored. An empirical inquiry into how the actual work of teachers and youth are socially organized by a biomedical, employment-related, and efficiency-based discourse is provided. Through thirty-two qualitative interviews with teachers and youth, a control of ruling relations such as institutional accountability circuits, performance reports, and timetabling over the experience of teachers and youth is found. One of the facets of the institutional accountability circuit is through the social organization of teaching and learning about healthy intimate relationships being framed through a biomedical discourse. In addition, the role of a hyper-focus on performance and evaluation is found as paramount in situating healthy intimacy discussions as inferior to neoliberally charged productivity measures such as employment skills. Lastly, due to the nature of institutional policies such as regulatory guidelines, teachers are largely influenced to avoid diving into discussions deemed risky or taboo by society, such as healthy intimacy in adolescence. The findings show how texts such as the H&PE curriculum, the Ontario College of Teachers (OCT) guidelines, Ministry of Education Performance Reports, and the timetable organize the day-to-day activities of teachers and students and reproduce different disjunctures for youth. This disjuncture includes some of their experiences being subordinated, difficulty relating to curriculum, and an experience of healthy living discussions being skimmed over across sites. The findings detail that the experience of youth in learning about healthy intimate relationships is not akin to the espoused vision outlined in policy documents such as the H&PE (2015) curriculum policy. These findings have implications for policymakers, activists, and school administration alike, which call for an investigation into who is in power when it comes to youth’s learning needs, as a pivotal period where youth can be equipped with life-changing knowledge is largely underutilized. A restructuring of existing institutional practices that allow for the social and institutional flexibility required to broach the topic of healthy intimacy in a comprehensive manner is required.

Keywords: health policy, intimate relationships, youth, education, ruling relations, sexual education, violence prevention

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Authors: Shawn Baker-Garcia, Janna O. Schaeffer

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As the global and national communities and governments strive to address ongoing and evolving threats to humanity and pervasive or emerging “shared” global priorities on environmental, economic, political, and security, it is more urgent than ever before to understand each other, communicate effectively with one another, identify models of cooperation that yield improved, mutually reinforcing outcomes across and within cultures. It is within the backdrop of this reality that the presentation examines whether cultural training as we have approached it in recent decades is sufficiently meeting our current needs and what changes may be applied to foster better and more productive and sustainable intercultural interactions. Domestic and global relations face multiple challenges to peaceable cooperation. The last two years, in particular, have been defined by a travel-restricted COVID-19 pandemic yielding increased intercultural interactions over virtual platforms, polarized politics dividing nations and regions, and the commensurate rise in weaponized social and traditional media communication. These societal and cultural fissures are noticeably challenging our collective and individual abilities to constructively interact both at home and abroad. It is within this pressure cooker environment that the authors believe it is time to reexamine existing and broadly accepted inter- and cross- cultural training approaches and concepts to determine their level of effectiveness in setting conditions for optimal human understanding and relationships both in the national and international context. In order to better understand the amount and the type of intercultural training practitioners professionally engaging in international partnership building have received throughout their careers and its perceived effectiveness, a survey was designed and distributed to US and international professionals presently engaged in the fields of diplomacy, military, academia, and international business. The survey questions were deigned to address the two primary research questions investigators posed in this exploratory study. Research questions aimed to examine practitioners’ view of the role and effectiveness of current and traditional cultural training and education as a means to fostering improved communication, interactions, understanding, and cooperation among inter, cross, or multi-cultural communities or efforts.Responses were then collected and analyzed for themes present in the participants’ reflections. In their responses, the practitioners identified the areas of improvement and desired outcomes in regards to intercultural training and awareness raising curricular approaches. They also raised issues directly and indirectly pertaining to the role of foreign language proficiency in intercultural interactions and a need for a solid grasp on cultural and regional issues (regional expertise) to facilitate such an interaction. Respondents indicated knowledge, skills, abilities, and capabilities that the participants were not trained on but learned through ad hoc personal and professional intercultural interactions, which they found most valuable and wished they had acquired prior to the intercultural experience.

Keywords: cultural training, improved communication, intercultural competence, international cooperation

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Authors: Etibar Guliyev

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The breakdown of the Soviet Union in 1991 has led to a considerable rise in the religious self-consciousness of Muslim population of the Central Asia. Additionally, huge amount of money spent by various states further facilitated the spread of religious ideas. According to some sources, Saudi Arabia spent 87 billion dollars to propagate Wahhabism abroad during two decades, whereas the Communist Party of the Soviet Union spent just over 7 billion dollars to spread its ideology worldwide between 1921 and 1991. As the result, today once a remote area from international politics has turned into third major source of recruitment of fighters for global terrorist organizations. In order to illustrate to scope of the involvement of the Central Asian residents in international terrorist networks it is enough to mention the name of Colonel Gulmorod Khalimov, the former head of the Tajik special police forces who served as ISIS war minister between 2016 and 2017. The importance of the topic stems from the fact that the above-mentioned republics with a territory of 4 million square km and the population of around 80 million people borders Russia, Iran Afghanistan and China. Moreover, the fact that political and military activities motivated with religious feelings in those countries have implications not only for domestic but also for regional and global political relations and all of them has root in politics of religions adds value to the research. This research aims to provide an in-depth analyses of the marked features of the state policies to regulate religious activities and approach this question both from individual, domestic, regional and global levels of analyses. The research will enable us to better understand what implications have the state of religious freedom in post-Soviet Muslim republics for international relations and the rise of global jihadi terrorism. The paper tries to find a linkage between the mentioned terror attacks and underground rise of religious extremism in Central Asia. This research is based on multiple research methods, mainly on qualitative one. The process tracing method is also employed to review religious policies implemented from 1918-1991 and after the collapse of the Soviet Union in a chronological way. In terms of the quantitative method, it chiefly will be used in a bid to process various statistics disseminated in academic and official sources. The research mostly explored constructivist, securitization and social movement theories. Findings of the research suggests that the endemic problems peculiar to authoritarian regimes of Central Asia such as crackdown on the expression of religious believe and any kind of opposition, economic decline, instrumental use of religion and corruption and tribalism further accelerated the recruitment problem. Paper also concludes that the Central Asian states in some cases misused counter-terrorism campaign as a pretext to further restrict freedom of faith in their respective countries.

Keywords: identity, political Islam, religious extremism, security, terrorism

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Authors: Lalanthica Yogendran, Manassa Hany, Saira Pasha, Benjamin Chaucer, Simarpreet Kaur, Christopher Janusz

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Children and adolescent patients visit the Psychiatric Emergency Department (ED) for multiple reasons. Visiting the Psychiatric ED itself can be a traumatic experience that can affect an adolescents mental well-being, regardless of a history of mental illness. Despite this, limited research exists in this domain. Prospective studies have correlated adverse psychosocial determinants among adolescents to risk factors for poor well-being and unfavorable behavior outcomes. Studies have also shown that physiological stress is a contributor in the development of health problems and an increase in substance abuse in adolescents. This study aimed to retrospectively determine which psychosocial factors are associated with an increase in psychiatric ED visits. 600 charts of patients who had a psychiatric ED and inpatient admission visit from January 2014 through December 2014 were reviewed. Sociodemographics, diagnoses, ED visits and inpatient admissions were collected. Descriptive statistics, chi-square tests and independent t-test analyses were utilized to examine differences in the sample to determine which factors affected ED visits and admissions. The sample was 50% female, 35.2% self-identified black, and had a mean age of 13 years. The majority, 85%, went to public school and 17% were in special education. Attention Deficit Hyperactivity Disorder was the most common admitting diagnosis, found in 132(23%) responders. Most patients came from single parent household 305 (53%). The mean ages of patients that were sexually active, with legal issues, and reporting marijuana substance abuse were 15, 14.35, and 15 years respectively. Patients from two biological parent households had significantly fewer ED visits (1.2 vs. 1.7, p < 0.01) and admissions (0.09 vs. 0.26, p < 0.01). Among social factors, those who reported sexual, physical or emotional abuse had a significantly greater number of ED visits (2.1 vs. 1.5, p < 0.01) and admissions (0.61 vs. 0.14, p < 0.01) than those who did not. Patients that were sexually active or had legal issues or substance abuse with marijuana had a significantly greater number of admissions (0.43 vs. 0.17, p < 0.01), (0.54 vs. .18, p < 0.01) and (0.46 vs. 0.18, p < 0.01) respectively. This data supports the theory of the stability of a two parent home. Dual parenting plays a role in creating a safe space where a child can develop; this is shown by subsequent decreases in psychiatric ED visits and admissions. This may highlight the psychological protective role of a two parent household. Abuse can exacerbate existing psychiatric illness or initiate the onset of new disease. Substance abuse and legal issues result in early induction to the criminal system. Results show that this causes an increase in frequency of visits and severity of symptoms. Only marijuana, but not other illicit substances, correlated with higher incidence of psychiatric ED visits. This may speak to the psychotropic nature of tetrahydrocannabinols and their role in mental illness. This study demonstrates the array of psychosocial factors that lead to increased ED visits and admissions in children and adolescents.

Keywords: adolescent, child psychiatry, emergency department, substance abuse

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Authors: Sanaa Riaz

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The free people, Amazigh (plural Imazighen), often known by the more popular exonym, Berber, are spread across several North African countries with the highest population in Morocco have been substantially misunderstood and differentially showcased by entities from western-school educated scholars to human, health and women’s rights organizations, to the State to the international community. This paper is an examination of the various conceptualization of the Imazighen. With the popularity of the Arab Spring movement to oust monarchical and dictatorial rulers across the Middle East and North Africa in Morocco, the Moroccan monarchy introduced various reform programs to win public favor. These included social, economic and educational reforms to incorporate marginalized groups such as the Imazighen. The monarchy has ushered Amazigh representation in public offices and landscape through Amazigh script, even though theirs has been an oral culture. After the Arab Spring, the Justice and Development party, an Islamist party took over in Morocco due to its accessibility to the masses, In Sept. 2021, unlike the case of Egypt and Tunisia where military and constitutional means were sought, Morocco successfully removed it from power through the ballot, resulting in a real victory for the neutral monarchy and its representation as a moderate, secular and liberal force for the nation. As a result, supporting the perpetuation of Amazigh linguistic identity also became synonymous to making a secular statement as a Muslim. It has led to the telling of Amazigh identity at state museums as one representing the indigenous, pure, diverse, culturally-rich and united Morocco. Reform efforts have also prioritized an amiable look towards the economic and familial links of Moroccan Jews with the few thousand families still left in the country and a showcasing through museums and cultural centers of the Jewish identity as Moroccan first. In that endeavor, it is interesting to note the coverage of Jews as the indigenous of Morocco through the embracing of their “folk” cultural and religious practices, those that are not continued outside Morocco. In this epistemology, the concept of the Moroccan Jew becomes similar to the indigenous Amazigh, both cherished as the oldest peoples of Morocco and symbols of its unity and resilience. In the urban discourse, Amazigh identity is a concept that continues to be part of the deliberations of elites and scholars graduating from French schools on the incorporation of rural and illiterate Morocco in economic and educational advancement. Yet, with the constant influx of migrants from Western Sahara into cities like Fez and Marrakesh, Amazigh has often been described as the umbrella term of those of “mixed” ethnic ancestry who constitute the country’s free population. In sum, Amazigh identity highlights the changing discourse on marginalized communities, human rights, representation, Moroccan nationhood, and regional and transnational politics. The aim of this paper is to analyze perceptions of Amazigh identity in Morocco post-2021 ousting of the Islamist party using data from state-sponsored museum displays and cultural centers collected in Summer 2022 and scholarly analyses of Amazigh identity, representation and rights in Morocco.

Keywords: Amazigh identity, Morocco, representation, state politics

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Authors: P.V. Lostelius, M.Mattebo, E. Thors Adolfsson, A. Söderlund, Å. Revenäs

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Adolescents are vulnerable in healthcare settings. Early detection of poor health in young people is important to support a good quality of life and adult social functioning. Youth Health Clinics (YHCs) in Sweden provide healthcare for young people ages 13-25 years old. Using an overall mixed methods approach, the project’s main objective was to develop and evaluate an electronic health system, including a health questionnaire, a case report form, and an evaluation questionnaire to assess young people’s health risks in early stages, increase health, and quality of life. In total, 72 young people, 16-23 years old, eleven healthcare professionals and eight researchers participated in the three project studies. Results from interviews with fifteen young people gave that an electronic health questionnaire should include questions about physical-, mental-, sexual health and social support. It should specifically include questions about self-harm and suicide risk. The young people said that the questionnaire should be appealing, based on young people’s needs and be user-friendly. It was important that young people felt safe when responding to the questions, both physically and electronically. Also, they found that it had the potential to support the face-to face-meeting between young people and healthcare professionals. The electronic health report system was developed by the researchers, performing a structured development of the electronic health questionnaire, construction of a case report form to present the results from the health questions, along with an electronic evaluation questionnaire. An Information Technology company finalized the development by digitalizing the electronic health system. Four young people, three healthcare professionals and seven researchers evaluated the usability using interviews and a usability questionnaire. The electronic health questionnaire was found usable for YHCs but needed some clarifications. Essentially, the system succeeded in capturing the overall health of young people; it should be able to keep the interest of young people and have the potential to contribute to health assessment planning and young people’s self-reflection, sharing vulnerable feelings with healthcare professionals. In advance of effect studies, a feasibility study was performed by collecting electronic questionnaire data from 54 young people and interview data from eight healthcare professionals to assess the feasibility of the use of the electronic evaluation questionnaire, the case report form, and the planned recruitment method. When merging the results, the research group found that the evaluation questionnaire and the health report were feasible for future research. However, the COVID-19 pandemic, commitment challenges and drop-outs affected the recruitment of young people. Also, some healthcare professionals felt insecure about using computers and electronic devices and worried that their workload would increase. This project contributes knowledge about the development and use of electronic health tools for young people. Before implementation, clinical routines need for using the health report system need to be considered.

Keywords: adolescent health, developmental studies, electronic health questionnaire, mixed methods research

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Authors: Binbin Chen, Dennis Y. C. Leung

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Aluminium (Al) -air cell holds a high volumetric capacity density of 8.05 Ah cm-3, benefit from the trivalence of Al ions. Additional benefits of Al-air cell are low price and environmental friendliness. Furthermore, the Al energy conversion process is characterized of 100% recyclability in theory. Along with a large base of raw material reserve, Al attracts considerable attentions as a promising material to be integrated within the global energy system. However, despite the early successful applications in military services, several problems exist that prevent the Al-air cells from widely civilian use. The most serious issue is the parasitic corrosion of Al when contacts with electrolyte. To overcome this problem, super-pure Al alloyed with various traces of metal elements are used to increase the corrosion resistance. Nevertheless, high-purity Al alloys are costly and require high energy consumption during production process. An alternative approach is to add inexpensive inhibitors directly into the electrolyte. However, such additives would increase the internal ohmic resistance and hamper the cell performance. So far these methods have not provided satisfactory solutions for the problem within Al-air cells. For the operation of alkaline Al-air cell, there are still other minor problems. One of them is the formation of aluminium hydroxide in the electrolyte. This process decreases ionic conductivity of electrolyte. Another one is the carbonation process within the gas diffusion layer of cathode, blocking the porosity of gas diffusion. Both these would hinder the performance of cells. The present work optimizes the above problems by building an Al-air cell operation system, consisting of four components. A top electrolyte tank containing fresh electrolyte is located at a high level, so that it can drive the electrolyte flow by gravity force. A mechanical rechargeable Al-air cell is fabricated with low-cost materials including low grade Al, carbon paper, and PMMA plates. An electrolyte waste tank with elaborate channel is designed to separate the hydrogen generated from the corrosion, which would be collected by gas collection device. In the first section of the research work, we investigated the performance of the mechanical rechargeable Al-air cell with a constant flow rate of electrolyte, to ensure the repeatability experiments. Then the whole system was assembled together and the feasibility of operating was demonstrated. During experiment, pure hydrogen is collected by collection device, which holds potential for various applications. By collecting this by-product, high utilization efficiency of aluminum is achieved. Considering both electricity and hydrogen generated, an overall utilization efficiency of around 90 % or even higher under different working voltages are achieved. Fluidic electrolyte could remove aluminum hydroxide precipitate and solve the electrolyte deterioration problem. This operation system provides a low-cost strategy for harvesting energy from the abundant secondary Al. The system could also be applied into other metal-air cells and is suitable for emergency power supply, power plant and other applications. The low cost feature implies great potential for commercialization. Further optimization, such as scaling up and optimization of fabrication, will help to refine the technology into practical market offerings.

Keywords: aluminium-air cell, high efficiency, hydrogen, mechanical recharge

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Authors: Faith O. Olanrewaju

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Internal displacement and the vulnerability of women are two critical aspects of forced migration that have dominated both global and local discourses. Statistics show that in November 2021, there were over 2.1 million internally displaced persons (IDPs) in Nigeria. Literature also states that displaced women and girls are more vulnerable than displaced men. They are susceptible to adversative experiences, including various forms of sexual violence and rape. As a result, the displaced women and girls are faced with psychological and physical traumas, including HIV/AIDS as well as unexpected or poorly spaced pregnancies. In addition, the poor condition of living of internally displaced women in IDP camps affects their reproductive health, pregnancy outcomes, and maternal mortality levels. Incontrovertibly, internally displaced women constitute an imperative contributor to the ills of Nigeria's maternal health status, which is the second worse globally and the worst in Africa. World Health Organisation statistics showed that approximately 536,000 girls and women die from pregnancy-related causes globally, and Nigeria accounts for 14% of the global maternal deaths. Undeniably, this supports the claims that maternal mortality remains a challenge in Nigeria and can be exacerbated by internal displacement crises. Therefore, maternal mortality remains a critical impediment to the actualisation of the 3.1 SDG target. Owing to this, concerns arise about the quality of the policy in Nigeria’s health sector. More specifically, this study is concerned with the maternal health care services displaced women receive in IDP camps in the three states affected by internal displacement in north-central Nigeria, an understudied area. The novelty of the study also lies in its comparative investigation of maternal healthcare service delivery in three different camp structures (faith-based, government, and informal IDP camps), a pattern that is absent in literature. Therefore, this study will investigate how the camp structures affect access to maternal health services in the study areas; analyse the successes and challenges in the delivery of maternal health care services to displaced women in the various camps; and recommendation and strategies for reducing maternal healthcare disparities/gaps across IDP camps in Nigeria (should they exist). It will adopt a mixed-method approach and multi-stage sampling technique. A total of 1,152 copies of the study questionnaire will be distributed to displaced pregnant and nursing mothers (PNM); nine focus group discussions will also be held with the displaced PNM; in-depth interviews will be conducted with humanitarian actors, policymakers, and health professionals. The quantitative and qualitative data will be analysed using Statistical Package for Social Science (SPSS) 21.0 and thematic analysis, respectively. The findings of the study will be used to develop a model of care that will address the fragmentations in Nigeria's healthcare system. The findings will also inform the development of best policies and practices in the maternal health of displaced women.

Keywords: forced displacement, internally displaced women, maternal healthcare, maternal mortality

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Authors: Mariam Anwaar, Kiran B. Ahmad

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Borderline Personality Disorder (BPD) is an invasive presence of affect instability, disturbance in self-concept and attachment in relationships. The profound indicator is the dichotomous approach of the world in which the ego categorizes individuals, especially their significant others, into secure or threatful beings, leaving little room for a complex combination of characteristics in one person. This defense mechanism of splitting their world has been described through the explanatory model of unconscious conflict theorized by Sigmund Freud’s Electra Complex in the Phallic Stage. The central role is of the father with whom the daughter experiences penis envy, thus identifying with the mother’s characteristics to receive the father’s attention. However, Margret Mahler, an object relation theorist, elucidates the central role of the mother and that the split occurs during the pre-Electra complex stage. Amid the 14 and 24 months of the infant, it acknowledges the world away from the mother as they have developed milestones such as crawling. In such novelty, the infant crawls away from the mother creating a sense of independence (individuation). On the other hand, being distant causes anxiety, making them return to their original object of security (separation). In BPD, the separation-individuation stage is disrupted, due to contradictory actions of the caregiver, which results in splitting the object into negative and positive aspects, repressing the former and adhering to the latter for survival. Thus, with time, the ego distorts the reality into dichotomous categories, using the splitting defenses, and the mental representation of the self is distorted due to the internalization of the negative objects. The explanatory model was recognized in the case study of Fizza, at 21-year-old Pakistani female, residing in Karachi. Her marital status is single with an occupation being a dental student. Fizza lives in a nuclear family but is surrounded by her extended family as they all are in close vicinity. She came with the complaints of depressive symptoms for two-years along with self-harm due to severe family conflicts. Through the intervention of Dialectical Behavior Therapy (DBT), the self-harming actions were reduced, however, this libidinal energy transformed into claustrophobic symptoms and, along with this, Fizza has always experienced vivid dreams. A retrospective method of Jungian dream-analysis was applied to locate the origins of the splitting in the unconscious. The result was the revelation of a sexual harassment trauma at the age of six-years which was displaced in the form of self-harm. In addition to this, the presence of a conflict at the separation-individuation stage was detected during the dream-analysis, and it was the underlying explanation of the claustrophobic symptoms. This qualitative case study implicates the use of a patient’s subjective experiences, such as dreams, to journey through the spiral of the unconscious in order to not only detect repressed memories but to use them in psychotherapy as a means of healing the patient.

Keywords: borderline personality disorder, dream-analysis, Electra complex, separation-individuation, splitting, unconscious

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Authors: Beverly Black

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Background: Adolescent dating abuse (ADA) is widespread throughout the world and negatively impacts many adolescents. ADA is associated with lower self-esteem, poorer school performance, lower employment opportunities, higher rates of depression, absenteeism from school, substance abuse, bullying, smoking, suicide, pregnancy, eating disorders, and risky sexual behaviors, and experiencing domestic violence later in life. ADA prevention is sometimes addressed through school programming; yet, parental responses to ADA can also be an important vehicle for its prevention. In this exploratory study, the author examined how mothers, including abused mothers, responded to scenarios of ADA involving their children. Methods: Six focus groups were conducted between December, 2013 and June, 2014 with mothers (n=31) in the southern part of the United States. Three of the focus groups were comprised of mothers (n=17) who had been abused by their partners. Mothers were recruited from local community family agencies. Participants were provided a series of four scenarios about ADA and they were asked to explain how they would respond. Focus groups lasted approximately 45 minutes. All participants were given a gift card to a major retailer as a ‘thank you’. Using QSR-N10, two researchers’ analyzed the focus group data first using open and axial coding techniques to find overarching themes. Researchers triangulated the coded data to ensure accurate interpretations of the participants’ messages and used the scenario questions to structure the coded results. Results: Almost 30% of 699 comments coded as mothers’ recommendations for responding to ADA focused on the importance of providing advice to their children. Advice included breaking up, going to police, ignoring or avoiding the abusive partner, and setting boundaries in relationships. About 22% of comments focused on the need for educating teens about healthy and unhealthy relationships and seeking additional information. About 13% of the comments reflected the view that parents should confront abuser and/or abusers’ parents, and less than 2% noted the need to take their child to counseling. Mothers who had been abused offered similar responses as parents who had not experienced abuse. However, their responses were more likely to focus on sharing their own experience exercising caution in their responses, as they knew from their own experiences that authoritarian responses were ineffective. Over half of the comments indicated that parents would react stronger, quicker, and angrier if a girl was being abused by a boy than vice versa; parents expressed greater fear for their daughters than their sons involved in ADA. Conclusions. Results suggest that mothers have ideas about how to respond to ADA. Mothers who have been abused draw from their experiences and are aware that responding in an authoritarian manner may not be helpful. Because parental influence on teens is critical in their development, it is important for all parents to respond to ADA in a helpful manner to break the cycle of violence. Understanding responses to ADA can inform prevention programming to work with parents in responding to ADA.

Keywords: abused mothers' responses to dating abuse, adolescent dating abuse, mothers' responses to dating abuse, teen dating violence

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Authors: Serhat Tüzün, Tufan Demirel

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Decision Support Systems (DSS) have been investigated by researchers and technologists for more than 35 years. This paper analyses the developments in the architecture and software of these systems, provides a systematic analysis for different Web-based DSS approaches and Intelligent Decision-making Technologies (IDT), with the suggestion for future studies. Decision Support Systems literature begins with building model-oriented DSS in the late 1960s, theory developments in the 1970s, and the implementation of financial planning systems and Group DSS in the early and mid-80s. Then it documents the origins of Executive Information Systems, online analytic processing (OLAP) and Business Intelligence. The implementation of Web-based DSS occurred in the mid-1990s. With the beginning of the new millennia, intelligence is the main focus on DSS studies. Web-based technologies are having a major impact on design, development and implementation processes for all types of DSS. Web technologies are being utilized for the development of DSS tools by leading developers of decision support technologies. Major companies are encouraging its customers to port their DSS applications, such as data mining, customer relationship management (CRM) and OLAP systems, to a web-based environment. Similarly, real-time data fed from manufacturing plants are now helping floor managers make decisions regarding production adjustment to ensure that high-quality products are produced and delivered. Web-based DSS are being employed by organizations as decision aids for employees as well as customers. A common usage of Web-based DSS has been to assist customers configure product and service according to their needs. These systems allow individual customers to design their own products by choosing from a menu of attributes, components, prices and delivery options. The Intelligent Decision-making Technologies (IDT) domain is a fast growing area of research that integrates various aspects of computer science and information systems. This includes intelligent systems, intelligent technology, intelligent agents, artificial intelligence, fuzzy logic, neural networks, machine learning, knowledge discovery, computational intelligence, data science, big data analytics, inference engines, recommender systems or engines, and a variety of related disciplines. Innovative applications that emerge using IDT often have a significant impact on decision-making processes in government, industry, business, and academia in general. This is particularly pronounced in finance, accounting, healthcare, computer networks, real-time safety monitoring and crisis response systems. Similarly, IDT is commonly used in military decision-making systems, security, marketing, stock market prediction, and robotics. Even though lots of research studies have been conducted on Decision Support Systems, a systematic analysis on the subject is still missing. Because of this necessity, this paper has been prepared to search recent articles about the DSS. The literature has been deeply reviewed and by classifying previous studies according to their preferences, taxonomy for DSS has been prepared. With the aid of the taxonomic review and the recent developments over the subject, this study aims to analyze the future trends in decision support systems.

Keywords: decision support systems, intelligent decision-making, systematic analysis, taxonomic review

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Authors: Tesfaldet Mekonnen Estifanos, Chen Hui, Afewerki Weldezgi

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Background: Intimate partner violence (hereafter IPV) is a major global public health challenge that tortures and disables women in the place where they are ought to be most secure within their own families. The fact that the family unit is commonly viewed as a private circle, violent acts towards women remains undermined. There are limited research and knowledge about the influencing factors linked to IPV in Sierra Leone. This study, therefore, estimates the prevalence rate and the predicting factors associated with IPV. Methods: Data were taken from Sierra-Leone Demographic and Health Survey (SDHS, 2013): the first in its form to incorporate information on domestic violence. Multistage cluster sampling research design was used, and information was gathered by a standard questionnaire. A total of 5185 respondents selected were interviewed, out of whom 870 were never been in union, thus excluded. To analyze the two dependent variables: experience of IPV, ‘ever’ and 'last 12 months prior to the survey', a total of 4315 (currently or formerly married) and 4029 women (currently in union) were included respectively. These dependent variables were constructed from the three forms of violence namely physical, emotional and sexual. Data analysis was applied using SPSS version 23, comprising three-step process. First, descriptive statistics were used to show the frequency distribution of both the outcome and explanatory variables. Second, bivariate analysis adopting chi-square test was applied to assess the individual relationship between the outcome and explanatory variables. Third, multivariate logistic regression analysis was undertaken using hierarchical modeling strategy to identify the influence of the explanatory variables on the outcome variables. Odds ratio (OR) and 95% confidence interval (CI) were utilized to examine the association of the variables considering p-values less than 0.05 statistically significant. Results: The prevalence of lifetime IPV among ever married women was 48.4%, while 39.8% of those currently married experienced IPV in the previous year preceding the survey. Women having 1 to 4 and more than 5 number of ever born babies were almost certain to encounter lifetime IPV. However, women who own a property, and those who referenced 3-5 reasons for which wife-beating is acceptable were less probably to experience lifetime IPV. Attesting parental violence, partner’s dominant marital behavior, and women afraid of their partner were the variables related to both experience of IPV ‘ever’ and ‘the previous year prior to the survey’. Respondents who concur that wife-beating is sensible in certain situations and occupations under the professional category had diminished chances of revealing IPV in the year prior to the data collection. Conclusion: This study indicated that factors significantly correlated with IPV in Sierra-Leone are mostly linked with husband related factors specifically, marital controlling behaviors. Addressing IPV in Sierra-Leone requires joint efforts that target men raise awareness to address controlling behavior and empower security in affiliations.

Keywords: husband behavior, married women, partner violence, Sierra Leone

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Authors: Alejandra Sierra, Gloria Valadez, Adriana Dávalos, Mirliana Ramírez

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For years, the Pan American Health Organization/World Health Organization and other organizations have made efforts to the improve access and the quality of prenatal care as part of comprehensive programs for maternal and neonatal health, the standards of care have been renewed in order to migrate from a medical perspective to a holistic perspective. However, despite the efforts currently antenatal care models have not been verified by a scientific evaluation in order to determine their effectiveness. The teenage pregnancy is considered as a very important phenomenon since it has been strongly associated with inequalities, poverty and the lack of gender quality; therefore it is important to analyze the antenatal care that’s been given, including not only the clinical intervention but also the activities surrounding the advertising and the health education. In this study, the objective was to describe if the previously established activities (on the prenatal care models) are being performed in the care of pregnant teenagers attending prenatal care in health institutions in two cities in México and Chile during 2013. Methods: Observational and descriptive study, of a transversal cohort. 170 pregnant women (13-19 years) were included in prenatal care in two health institutions (100 women from León-Mexico and 70 from Chile-Coquimbo). Data collection: direct survey, perinatal clinical record card which was used as checklists: WHO antenatal care model WHO-2003, Official Mexican Standard NOM-007-SSA2-1993 and Personalized Service Manual on Reproductive Process- Chile Crece Contigo; for data analysis descriptive statistics were used. The project was approved by the relevant ethics committees. Results: Regarding the fulfillment of interventions focused on physical, gynecological exam, immunizations, monitoring signs and biochemical parameters in both groups was met by more than 84%; the activities of guidance and counseling pregnant teenagers in Leon compliance rates were below 50%, on the other hand, although pregnant women in Coquimbo had a higher percentage of compliance, no one reached 100%. The topics that less was oriented were: family planning, signs and symptoms of complications and labor. Conclusions: Although the coverage of the interventions indicated in the prenatal care models was high, there were still shortcomings in the fulfillment of activities to orientation, education and health promotion. Deficiencies in adherence to prenatal care guidelines could be due to different circumstances such as lack of registration or incomplete filling of medical records, lack of medical supplies or health personnel, absences of people at prenatal check-up appointments, among many others. Therefore, studies are required to evaluate the quality of prenatal care and the effectiveness of existing models, considering the role of the different actors (pregnant women, professionals and health institutions) involved in the functionality and quality of prenatal care models, in order to create strategies to design or improve the application of a complete process of promotion and prevention of maternal and child health as well as sexual and reproductive health in general.

Keywords: adolescent health, health systems, maternal health, primary health care

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Authors: Alessandra Swiny, Yiorgos Hadjichristou

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There exists an on-going geographical scar creating a division through the Island of Cyprus and its capital, Nicosia. The currently amputated city center is accessed legally by the United Nations convoys, infiltrated only by Turkish and Greek Cypriot army scouts and illegal traders and scavengers. On Christmas day 1963 in Nicosia, Captain M. Hobden of the British Army took a green chinagraph pencil and on a large scale Joint Army-RAF map ‘marked’ the division. From then on this ‘buffer zone’ was called the ‘green line.' This once dividing form, separating the main communities of Greek and Turkish Cypriots from one another, has now been fully reclaimed by an autonomous intruder. It's currently most captivating inhabitant is nature. She keeps taking over, for the past fifty years indigenous and introduced fauna and flora thrive; trees emerge from rooftops and plants, bushes and flowers grow randomly through the once bustling market streets, allowing this ‘no man’s land’ to teem with wildlife. And where are its limits? The idea of fluidity is ever present; it encroaches into the urban and built environment that surrounds it, and notions of ownership and permanence are questioned. Its qualities have contributed significantly in the search for new ‘identities,' expressed in the emergence of new living conditions, be they real or surreal. Without being physically reachable, it can be glimpsed at through punctured peepholes, military bunker windows that act as enticing portals into an emotional and conceptual level of inhabitation. The zone is mystical and simultaneously suspended in time, it triggers people’s imagination, not just that of the two prevailing communities but also of immigrants, refugees, and visitors; it mesmerizes all who come within its proximity. The paper opens a discussion on the issues and the binary questions raised. What is natural and artificial; what is private and public; what is ephemeral and permanent? The ‘green line’ exists in a central fringe condition and can serve in mixing generations and groups of people; mingling functions of living with work and social interaction; merging nature and the human being in a new-found synergy of human hope and survival, allowing thus for new notions of place to be introduced. Questions seek to be answered, such as, “Is the impossibility of dwelling made possible, by interweaving these ‘in-between conditions’ into eloquently traced spaces?” The methodologies pursued are developed through academic research, professional practice projects, and students’ research/design work. Realized projects, case studies and other examples cited both nationally and internationally hold global and local applications. Both paths of the research deal with the explorative understanding of the impossibility of dwelling, testing the limits of its autonomy. The expected outcome of the experience evokes in the user a sense of a new urban landscape, created from human topographies that echo the voice of an emerging identity.

Keywords: urban wildlife, human topographies, buffer zone, no man’s land

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Authors: Priyoth Kittiteerasack, Alana Steffen, Alicia K. Matthews

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Depression is a leading cause of the worldwide burden of disability and disease burden. Notably, lesbian, gay, bisexual, and transgender (LGBT) populations are more likely to be a high-risk group for depression compared to their heterosexual and cisgender counterparts. To date, little is known about the rates and predictors of depression among Thai LGBT populations. As such, the purpose of this study was to: 1) measure the prevalence of depression among a diverse sample of Thai LGBT adults and 2) determine the influence of minority stress variables (discrimination, victimization, internalized homophobia, and identity concealment), general stress (stress and loneliness), and coping strategies (problem-focused, avoidance, and seeking social support) on depression outcomes. This study was guided by the Minority Stress Model (MSM). The MSM posits that elevated rates of mental health problems among LGBT populations stem from increased exposures to social stigma due to their membership in a stigmatized minority group. Social stigma, including discrimination and violence, represents unique sources of stress for LGBT individuals and have a direct impact on mental health. This study was conducted as part of a larger descriptive study of mental health among Thai LGBT adults. Standardized measures consistent with the MSM were selected and translated into the Thai language by a panel of LGBT experts using the forward and backward translation technique. The psychometric properties of translated instruments were tested and acceptable (Cronbach’s alpha > .8 and Content Validity Index = 1). Study participants were recruited using convenience and snowball sampling methods. Self-administered survey data were collected via an online survey and via in-person data collection conducted at a leading Thai LGBT organization. Descriptive statistics and multivariate analyses using multiple linear regression models were conducted to analyze study data. The mean age of participants (n = 411) was 29.5 years (S.D. = 7.4). Participants were primarily male (90.5%), homosexual (79.3%), and cisgender (76.6%). The mean score for depression of study participant was 9.46 (SD = 8.43). Forty-three percent of LGBT participants reported clinically significant levels of depression as measured by the Beck Depression Inventory. In multivariate models, the combined influence of demographic, stress, coping, and minority stressors explained 47.2% of the variance in depression scores (F(16,367) = 20.48, p < .001). Minority stressors independently associated with depression included discrimination (β = .43, p < .01) victimization (β = 1.53, p < .05), and identity concealment (β = -.54, p < .05). In addition, stress (β = .81, p < .001), history of a chronic disease (β = 1.20, p < .05), and coping strategies (problem-focused coping β = -1.88, p < .01, seeking social support β = -1.12, p < .05, and avoidance coping β = 2.85, p < .001) predicted depression scores. The study outcomes emphasized that minority stressors uniquely contributed to depression levels among Thai LGBT participants over and above typical non-minority stressors. Study findings have important implications for nursing practice and the development of intervention research.

Keywords: depression, LGBT, minority stress, sexual and gender minority, Thailand

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Authors: Neha Joshi, Srikanth Jois, Hector J. Peughero, Poornima Jayakrishna, Moulya R., Purnima Madivanan, Kiran Kumar K. Salagame

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Transgenders are a marginalized section of the community, who are at high risk of mental health problems due to their stigmatization, abandonment by family, prejudice, discrimination by society at large, and the physical, emotional, and sexual abuse from both within and outside their community. Their mental healthcare needs remain largely unaddressed due to lack of access, discrimination by healthcare professions, and lack of resources, including time and money, to seek conventional medical and psychotherapeutic treatments. Meditation is increasingly receiving acceptance as a tool for managing stress and anxiety by the patients as well as mental healthcare professionals. “Meditation on Twin Hearts” is a no cost, self-administered intervention that a person can practice anywhere and at any time of the day. This pilot study evaluates the need for alternate traditional and ingenious interventions like “Meditation of Twin Hearts” to address the mental healthcare needs of the transgender community and acceptance of such an intervention by the community. Thirteen individuals identifying themselves as transgender were invited to participate in one (Hunsur Taluk) of the five scheduled free meditation camps in Mysore. After obtaining informed consent for participation in the study, their mental health status is captured using an anonymous survey using standard, validated, self-reported questionnaires Generalised Anxiety Disorders (GAD)-7 for anxiety, Patient Health Questionnaire (PHQ-9) for depression, and Suicidal Behavior Questionnaire-Revised for suicidality. Then, they were requested to attend a session on “Meditation on Twin Hearts.” After the session, their feedback on willingness to further explore the meditation technique for managing their mental healthcare need was assessed through another survey form. Out of the 13 participants, 92% scored for anxiety (4 mild, and 8 moderate anxiety). In the depression scale, 5 scored for mild and 5 for moderate depression, with a total of 77% (10/13) scoring positively on depression scale. Nearly 70% of participants (9/13), scored greater than the clinical cutoff for the need for clinical intervention. The proportion of individuals at risk for suicide was particularly high in this group, with 8/ 13 (61.5%) participants scoring the clinical cutoff score of ≥ 7. Surprisingly, none of the participants had ever consulted a mental healthcare professional. All the participants (13/13; 100%) responded in affirmative to the question, “Will you be willing to continue meditation for management of your anxiety?” Six out of 13 participants described their experience of meditation as “happy” and 3 described it as “peaceful”. None of the participants reported any negative beliefs or experience regarding the meditation. The study provides evidence for the urgent yet unmet mental healthcare need of the transgender community. The findings of the study also supports the rationale of conducting future systematic research to evaluate and explore ingenious and traditional practices, such as meditation, to meet the healthcare needs, especially in marginalized populations in a low income setting such as Lower and Middle Income countries. Based on these preliminary findings, the Principal Investigator (PI) is planning to cover 4 more areas of Mysore district.

Keywords: anxiety, depression, meditation on twin heart, suicidality, transgender

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Authors: S. MacDougall-Davis, S. Wysling, R. Willmore

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Background: The application of good non-technical skills, also known as crew resource management (CRM), is central to the delivery of safe, effective healthcare. The authors have been running remote trauma courses for over 10 years, primarily focussing on developing participants’ CRM in time-critical, high-stress clinical situations. The course has undergone an iterative process over the past 10 years. We employ a number of experiential learning techniques for improving CRM, including small group workshops, military command tasks, high fidelity simulations with reflective debriefs, and a ‘flipped classroom’, where participants are asked to create their own simulations and assess and debrief their colleagues’ CRM. We created a randomised simulation study to assess the impact of our course on UK medical students’ CRM, both at an individual and a teams level. Methods: Sixteen students took part. Four clinical scenarios were devised, designed to be of similar urgency and complexity. Professional moulage effects and experienced clinical actors were used to increase fidelity and to further simulate high-stress environments. Participants were block randomised into teams of 4; each team was randomly assigned to one pre-course simulation. They then underwent our 5 day remote trauma CRM course. Post-course, students were re-randomised into four new teams; each was randomly assigned to a post-course simulation. All simulations were videoed. The footage was reviewed by two independent CRM-trained assessors, who were blinded to the before/after the status of the simulations. Assessors used the internationally validated team emergency assessment measure (TEAM) to evaluate key areas of team performance, as well as a global outcome rating. Prior to the study, assessors had scored two unrelated scenarios using the same assessment tool, demonstrating 89% concordance. Participants also completed pre- and post-course questionnaires. Likert scales were used to rate individuals’ perceived NTS ability and their confidence to work in a team in time-critical, high-stress situations. Results: Following participation in the course, a significant improvement in CRM was observed in all areas of team performance. Furthermore, the global outcome rating for team performance was markedly improved (40-70%; mean 55%), thus demonstrating an impact at Level 4 of Kirkpatrick’s hierarchy. At an individual level, participants’ self-perceived CRM improved markedly after the course (35-70% absolute improvement; mean 55%), as did their confidence to work in a team in high-stress situations. Conclusion: Our study demonstrates that with a short, cost-effective course, using easily reproducible teaching sessions, it is possible to significantly improve participants’ CRM skills, both at an individual and, perhaps more importantly, at a teams level. The successful functioning of multi-disciplinary teams is vital in a healthcare setting, particularly in high-stress, time-critical situations. Good CRM is of paramount importance in these scenarios. The authors believe that these concepts should be introduced from the earliest stages of medical education, thus promoting a culture of effective CRM and embedding an early appreciation of the importance of these skills in enabling safe and effective healthcare.

Keywords: crew resource management, non-technical skills, training, simulation

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Authors: Shomaila Sadaf, Margarethe Olbertz-Siitonen

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This study looks at identity and othering in discourses around sensitive issues in social media. More specifically, the study explores the multimodal resources and narratives through which the other is formed, and identities are ascribed in online spaces. As an integral part of social life, media spaces have become an important site for negotiating and ascribing identities. In line with recent research, identity is seen hereas constructions of belonging which go hand in hand with processes of in- and out-group formations that in some cases may lead to othering. Previous findings underline that identities are neither fixed nor limited but rather contextual, intersectional, and interactively achieved. The goal of this study is to explore and develop an understanding of how people co-construct the ‘other’ and ascribe certain identities in social media using multiple modes. In the beginning of the year 2018, the British government decided to include relationships, sexual orientation, and sex education into the curriculum of state funded primary schools. However, the addition of information related to LGBTQ+in the curriculum has been met with resistance, particularly from religious parents.For example, the British Muslim community has voiced their concerns and protested against the actions taken by the British government. YouTube has been used by news companies to air video stories covering the protest and narratives of the protestors along with the position ofschool officials. The analysis centers on a YouTube video dealing with the protest ofa local group of parents against the addition of information about LGBTQ+ in the curriculum in the UK. The video was posted in 2019. By the time of this study, the videos had approximately 169,000 views andaround 6000 comments. In deference to multimodal nature of YouTube videos, this study utilizes multimodal discourse analysis as a method of choice. The study is still ongoing and therefore has not yet yielded any final results. However, the initial analysis indicates a hierarchy of ascribing identities in the data. Drawing on multimodal resources, the media works with social categorizations throughout the documentary, presenting and classifying involved conflicting parties in the light of their own visible and audible identifications. The protesters can be seen to construct a strong group identity as Muslim parents (e.g., clothing and reference to shared values). While the video appears to be designed as a documentary that puts forward facts, the media does not seem to succeed in taking a neutral position consistently throughout the video. At times, the use of images, soundsand language contributes to the formation of “us” vs. “them”, where the audience is implicitly encouraged to pick a side. Only towards the end of the documentary this problematic opposition is addressed and critically reflected through an expert interview that is – interestingly – visually located outside the previously presented ‘battlefield’. This study contributes to the growing understanding of the discursive construction of the ‘other’ in social media. Videos available online are a rich source for examining how the different social actors ascribe multiple identities and form the other.

Keywords: identity, multimodal discourse analysis, othering, youtube

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Authors: Ferzat Anka

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Many types of problems can be solved using traditional analytical methods. However, these methods take a long time and cause inefficient use of resources. In particular, different approaches may be required in solving complex and global engineering problems that we frequently encounter in real life. The bigger and more complex a problem, the harder it is to solve. Such problems are called Nondeterministic Polynomial time (NP-hard) in the literature. The main reasons for recommending different metaheuristic algorithms for various problems are the use of simple concepts, the use of simple mathematical equations and structures, the use of non-derivative mechanisms, the avoidance of local optima, and their fast convergence. They are also flexible, as they can be applied to different problems without very specific modifications. Thanks to these features, it can be easily embedded even in many hardware devices. Accordingly, this approach can also be used in trend application areas such as IoT, big data, and parallel structures. Indeed, the metaheuristic approaches are algorithms that return near-optimal results for solving large-scale optimization problems. This study is focused on the new metaheuristic method that has been merged with the chaotic approach. It is based on the chaos theorem and helps relevant algorithms to improve the diversity of the population and fast convergence. This approach is based on Chimp Optimization Algorithm (ChOA), that is a recently introduced metaheuristic algorithm inspired by nature. This algorithm identified four types of chimpanzee groups: attacker, barrier, chaser, and driver, and proposed a suitable mathematical model for them based on the various intelligence and sexual motivations of chimpanzees. However, this algorithm is not more successful in the convergence rate and escaping of the local optimum trap in solving high-dimensional problems. Although it and some of its variants use some strategies to overcome these problems, it is observed that it is not sufficient. Therefore, in this study, a newly expanded variant is described. In the algorithm called Ex-ChOA, hybrid models are proposed for position updates of search agents, and a dynamic switching mechanism is provided for transition phases. This flexible structure solves the slow convergence problem of ChOA and improves its accuracy in multidimensional problems. Therefore, it tries to achieve success in solving global, complex, and constrained problems. The main contribution of this study is 1) It improves the accuracy and solves the slow convergence problem of the ChOA. 2) It proposes new hybrid movement strategy models for position updates of search agents. 3) It provides success in solving global, complex, and constrained problems. 4) It provides a dynamic switching mechanism between phases. The performance of the Ex-ChOA algorithm is analyzed on a total of 8 benchmark functions, as well as a total of 2 classical and constrained engineering problems. The proposed algorithm is compared with the ChoA, and several well-known variants (Weighted-ChoA, Enhanced-ChoA) are used. In addition, an Improved algorithm from the Grey Wolf Optimizer (I-GWO) method is chosen for comparison since the working model is similar. The obtained results depict that the proposed algorithm performs better or equivalently to the compared algorithms.

Keywords: optimization, metaheuristic, chimp optimization algorithm, engineering constrained problems

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Authors: Priyajeet Kaur Kaleka

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Introduction: A dentist is often the first responder in the battle for a patient’s healthy body and maybe the first health professional to observe signs of child abuse, be it physical, emotional, and/or sexual mistreatment. Therefore, it is an ethical responsibility for the dental clinician to detect and report suspected cases of child abuse and neglect (CAN). The main reasons for not reporting suspected cases of CAN, with special emphasis on the third: 1) Uncertainty of the diagnosis, 2) Lack of knowledge of the reporting procedure, and 3) Child abuse and neglect somewhat remained the subject of ignorance among dental professionals because of a lack of advance clinical training. Given these epidemic proportions, there is a scope of further research about dental school curriculum design. Purpose: This study aimed to assess the knowledge and attitude of dentists in Canada regarding signs and symptoms of child abuse and neglect (CAN), reporting procedures, and whether educational strategies followed by dental schools address this sensitive issue. In pursuit of that aim, this abstract summarizes the evidence related to this question. Materials and Methods: Data was collected through a specially designed questionnaire adapted and modified from the author’s previous cross-sectional study on (CAN), which was conducted in Pune, India, in 2016 and is available on the database of PubMed. Design: A random sample was drawn from the targeted population of registered dentists and dental students in Canada regarding their knowledge, professional responsibilities, and behavior concerning child abuse. Questionnaire data were distributed to 200 members. Out of which, a total number of 157 subjects were in the final sample for statistical analysis, yielding response of 78.5%. Results: Despite having theoretical information on signs and symptoms, 55% of the participants indicated they are not confident to detect child physical abuse cases. 90% of respondents believed that recognition and handling the CAN cases should be a part of undergraduate training. Only 4.5% of the participants have correctly identified all signs of abuse due to inadequate formal training in dental schools and workplaces. Although nearly 96.3% agreed that it is a dentist’s legal responsibility to report CAN, only a small percentage of the participants reported an abuse case in the past. While 72% stated that the most common factor that might prevent a dentist from reporting a case was doubt over the diagnosis. Conclusion: The goal is to motivate dental schools to deal with this critical issue and provide their students with consummate training to strengthen their capability to care for and protect children. The educational institutions should make efforts to spread awareness among dental students regarding the management and tackling of CAN. Clinical Significance: There should be modifications in the dental school curriculum focusing on problem-based learning models to assist graduates to fulfill their legal and professional responsibilities. CAN literacy should be incorporated into the dental curriculum, which will eventually benefit future dentists to break this intergenerational cycle of violence.

Keywords: abuse, child abuse and neglect, dentist knowledge, dental school curriculum, problem-based learning

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Authors: Maria M. Calheiros, Carla Silva, Eunice Magalhães

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Professionals working in child protection services (CPS) need to have common and clear criteria to identify cases of maltreatment and to differentiate levels of severity in order to determine when CPS intervention is required, its nature and urgency, and, in most countries, the service that will be in charge of the case (community or specialized CPS). Actually, decision-making process is complex in CPS, and, for that reason, such criteria are particularly important for who significantly contribute to that decision-making in child maltreatment cases. The main objective of this presentation is to describe the Maltreatment Severity Assessment Questionnaire (MSQ), specifically designed to be used by professionals in the CPS, which adopts a multidimensional approach and uses a scale of severity within subtypes. Specifically, we aim to provide evidence of validity and reliability of this tool, in order to improve the quality and validity of assessment processes and, consequently, the decision making in CPS. The total sample was composed of 1000 children and/or adolescents (51.1% boys), aged between 0 and 18 years old (M = 9.47; DP = 4.51). All the participants were referred to official institutions of the children and youth protective system. Children and adolescents maltreatment (abuse, neglect experiences and sexual abuse) were assessed with 21 items of the Maltreatment Severity Questionnaire (MSQ), by professionals of CPS. Each item (sub-type) was composed of four descriptors of increasing severity. Professionals rated the level of severity, using a 4-point scale (1= minimally severe; 2= moderately severe; 3= highly severe; 4= extremely severe). The construct validity of the Maltreatment Severity Questionnaire was assessed with a holdout method, performing an Exploratory Factor Analysis (EFA) followed by a Confirmatory Factor Analysis (CFA). The final solution comprised 18 items organized in three factors 47.3% of variance explained. ‘Physical neglect’ (eight items) was defined by parental omissions concerning the insurance and monitoring of the child’s physical well-being and health, namely in terms of clothing, hygiene, housing conditions and contextual environmental security. ‘Physical and Psychological Abuse’ (four items) described abusive physical and psychological actions, namely, coercive/punitive disciplinary methods, physically violent methods or verbal interactions that offend and denigrate the child, with the potential to disrupt psychological attributes (e.g., self-esteem). ‘Psychological neglect’ (six items) involved omissions related to children emotional development, mental health monitoring, school attendance, development needs, as well as inappropriate relationship patterns with attachment figures. Results indicated a good reliability of all the factors. The assessment of child maltreatment cases with MSQ could have a set of practical and research implications: a) It is a valid and reliable multidimensional instrument to measure child maltreatment, b) It is an instrument integrating the co-occurrence of various types of maltreatment and a within-subtypes scale of severity; c) Specifically designed for professionals, it may assist them in decision-making processes; d) More than using case file reports to evaluate maltreatment experiences, researchers could guide more appropriately their research about determinants and consequences of maltreatment.

Keywords: assessment, maltreatment, children and youth, decision-making

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Authors: Brian Bacia, Esther Githaiga, Teresia Kabucho, Paul Moses Ndegwa, Lucy Gichohi

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Purpose: The aim of the study is to ensure an appropriate mix of evidence-based prevention strategies geared towards the reduction of new HIV infections and the incidence of Sexually transmitted Illnesses Background: In Nakuru County, more than 90% of all HIV-infected patients are adults and on a single-dose medication-one pill that contains a combination of several different HIV drugs. Nakuru town has been identified as the hardest hit by HIV/Aids in the County according to the latest statistics from the County Aids and STI group, with a prevalence rate of 5.7 percent attributed to the high population and an active urban center. Method: 2 key studies were carried out to provide evidence for the effectiveness of antiretroviral therapy (ART) when used optimally on preventing sexual transmission of HIV. Discussions based on an examination, assessments of successes in planning, program implementation, and ultimate impact of prevention and treatment were undertaken involving health managers, health workers, community health workers, and people living with HIV/AIDS between February -August 2021. Questionnaires were carried out by a trained duo on ethical procedures at 15 HIV treatment clinics targeting patients on ARVs and caregivers on ARV prevention and treatment of pediatric HIV infection. Findings: Levels of AIDS awareness are extremely high. Advances in HIV treatment have led to an enhanced understanding of the virus, improved care of patients, and control of the spread of drug-resistant HIV. There has been a tremendous increase in the number of people living with HIV having access to life-long antiretroviral drugs (ARV), mostly on generic medicines. Healthcare facilities providing treatment are stressed challenging the administration of the drugs, which require a clinical setting. Women find it difficult to take a daily pill which reduces the effectiveness of the medicine. ART adherence can be strengthened largely through the use of innovative digital technology. The case management approach is useful in resource-limited settings. The county has made tremendous progress in mother-to-child transmission reduction through enhanced early antenatal care (ANC) attendance and mapping of pregnant women Recommendations: Treatment reduces the risk of transmission to the child during pregnancy, labor, and delivery. Promote research of medicines through patients and community engagement. Reduce the risk of transmission through breastfeeding. Enhance testing strategies and strengthen health systems for sustainable HIV service delivery. Need exists for improved antenatal care and delivery by skilled birth attendants. Develop a comprehensive maternal reproductive health policy covering equitability, efficient and effective delivery of services. Put in place referral systems.

Keywords: evidence-based prevention strategies, service delivery, human management, integrated approach

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Authors: Jasna Milošević Đorđević, Jelisaveta Blagojević, Jovana Timotijević, Alison Mckinley

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Young people in Serbia, have grown up in turbulent times during the Balkan wars, in a cultural and economic isolation without adequate education on (ethnic, gender, social,..) equality. They often have very strong patriarchal gender stereotypes. The perception of gender in Serbia is still heavily influenced by traditional worldview and young people have little opportunity in traditional educational system to challenge it, receiving no formal sex education. Educational policies have addressed achieving gender equality as one of the goals, supporting all young people to gain better educational opportunities, but there are obvious shortcomings of the official education system in implementation of those goals. Therefore new approaches should be implemented. We evaluate the impact of non traditional approach, such as participatory theatre performance with strong transformative potential, especially in relation to gender issues. Theatre based intervention (TBI) was created to provoke the young people to become aware of their gender constructs. Engaging young people in modern form of education such as transformative gender intervention through participatory theatre could have positive impact on their sex knowledge and understanding gender roles. The transformative process in TBI happens on two levels – the affective and the cognitive. The founding agency of the project and evaluation is IPPF. The most important aim of this survey is evaluation of the transformative TBI, as a new educational approach related to better understanding gender as social construct. To reach this goal, we have measured attitude change in three indicators: a) gender identity/ perception of feminine identity, perception of masculine identity, importance of gender for personal identity, b) gender roles on the labor market, c) Gender equality in partnership & sexual behavior. Our main hypothesis is that participatory theatre-based intervention can have a transformational potential in challenging traditional gender knowledge and attitudes among youth in Serbia. To evaluate the impact of TB intervention, we implement: online baseline and end-line survey with nonparticipants of the TBI on the representative sample in targeted towns (control group). Additionally we conducted testing the experimental group twice: pretest at the beginning of each TBI and post testing of participants after the play. A sample of 500 respondents aged 18-30 years, from 9 towns in Serbia responded to online questionnaire in September 2017, in a baseline research. Pre and post measurement of all tested variables among participants in nine towns would be performed. End-line survey with 500 respondents would be conducted at the end of the project (early year 2018). After the first TBI (60 participants) no impact was detected on measured indicators: perception of desirable characteristics of man F(1,59)= 1.291, p=.260; perception of desirable characteristics of women F(1,55)=1.386, p= .244; gender identity importance F(1,63)= .050, p=.824; sex related behavior F(1,61)=1,145, p=.289; gender equality on labor market F(1,63)=.076, p=.783; gender equality in partnership F(1,61)=.201, p=.656; However, we hope that following intervention would bring more data showing that participatory theatre intervention explaining gender as a social construct could have additional positive impact in traditional educational system.

Keywords: educational impact, gender identity, gender role, participatory theatre based intervention

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Authors: Sara Parker, Kay Standing

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This paper will share insights into how menstruators bodies in Nepal are viewed and controlled in Nepal due to the deeply held stigmas and taboos that exist that frame menstrual blood as impure and polluting. It draws on a British Academy Global Challenges Research (BA/GCRF) funded project, ‘Dignity Without Danger,’ that ran from December 2019 to 2022. In Nepal, beliefs and myths around menstrual related practices prevail and vary in accordance to time, generation, caste and class. Physical seclusion and/or restrictions include the consumption of certain foods, the ability to touch certain people and objects, and restricted access to water sources. These restrictions not only put women at risk of poor health outcomes, but they also promote discrimination and challenge fundamental human rights. Despite the pandemic, a wealth of field research and creative outputs have been generated to help break the silence that surrounds menstruation and also highlights the complexity of addressing the harms associated with the exclusion from sacred and profane spaces that menstruators face. Working with locally recruited female research assistants, NGOS and brining together academics from the UK and Nepal, we explore the intersecting factors that impact on menstrual experiences and how they vary throughout Nepal. WE concur with Tamang that there is no such thing as a ‘Nepali Woman’, and there is no one narrative that captures the experiences of menstruators in Nepal. These deeply held beliefs and practices mean that menstruators are denied their right to a dignified menstruation. By being excluded from public and private spaces, such as temples and religious sites, as well as from kitchens and your own bedroom in your own home, these beliefs impact on individuals in complex and interesting ways. Existing research in Nepal by academics and activists demonstrates current programmes and initiatives do not fully address the misconceptions that underpin the exclusionary practices impacting on sexual and reproductive health, a sense of well being and highlight more work is needed in this area. Research has been conducted in all 7 provinces and through exploring and connecting disparate stories, artefacts and narratives, we will deepen understanding of the complexity of menstrual practices enabling local stakeholders to challenge exclusionary practices. By using creative methods to engage with stakeholders and share our research findings as well as highlighting the wealth of activism in Nepal. We highlight the importance of working with local communities, leaders and cutting across disciplines and agencies to promote menstrual justice and dignity. Our research findings and creative outputs that we share on social media channels such as Dignity Without Danger Facebook, Instagram and you tube stress the value of employing a collaborative action research approach to generate material which helps local people take control of their own narrative and change social relations that lead to harmful practices.

Keywords: menstruation, Nepal, stigma, social norms

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Authors: Iryna Teslenko

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According to the provisions of the current criminal procedural legislation of Ukraine, the issue of admissibility of evidence is closely related to both the right to a fair trial and the presumption of innocence. The general rule is that evidence obtained improperly or illegally cannot be taken into account in a court case. Therefore, the evidence base of the prosecution, collected at the stage of the pre-trial investigation, compliance with the requirements of the law during the collection of evidence, is of crucial importance for the criminal process, the violation of which entails the recognition of the relevant evidence as inadmissible, which can nullify all the efforts of the pre-trial investigation body and the prosecution. Therefore, the issue of admissibility of evidence in criminal proceedings is fundamentally important and decisive for the entire process. Research on this issue began in December 2021. At that time, there was still no clear understanding of what needed to be conveyed to the scientific community. In February 2022, the lives of all citizens of Ukraine have totally changed. A war broke out in the country. At a time when the entire world community is on the path of humanizing society, respecting the rights and freedoms of man and citizen, a military conflict has arisen in the middle of Europe - one country attacked another, war crimes are being committed. The world still cannot believe it, but it is happening here and now, people are dying, infrastructure is being destroyed, war crimes are being committed, contrary to the signed and ratified international conventions, and contrary to all the acquisitions and development of world law. At this time, the life of the world has divided into before and after February 24, 2022, the world cannot be the same as it was before, and the approach to solving legal issues in the criminal process, in particular, issues of proving the commission of crimes and the involvement of certain persons in their commission. An international criminal has appeared in the humane European world, who disregards all norms of law and morality, and does not adhere to any principles. Until now, the practice of the European Court of Human Rights and domestic courts of Ukraine treated with certain formalism, such a property of evidence in criminal proceedings as the admissibility of evidence. Currently, we have information that the Office of the Prosecutor of the International Criminal Court in The Hague has started an investigation into war crimes in Ukraine and is documenting them. In our opinion, the world cannot allow formalism in bringing a war criminal to justice. There is a war going on in Ukraine, the cities are under round-the-clock missile fire from the aggressor country, which makes it impossible to carry out certain investigative actions. If due to formal deficiencies, the collected evidence is declared inadmissible, it may lead to the fact that the guilty people will not be punished. And this, in turn, sends a message to other terrorists in the world about the impunity of their actions, the system of deterring criminals from committing criminal offenses (crimes) will collapse due to the understanding of the inevitability of punishment, and this will affect the entire world security and European security in particular. Therefore, we believe that the world cannot allow chaos in the issue of general security, there should be a transformation of the approach in general to such a property of evidence in the criminal process as admissibility in order to ensure the inevitability of the punishment of criminals. We believe that the scientific and legal community should not allow criminals to avoid responsibility. The evil that is destroying Ukraine should be punished. We must all together prove that legal norms are not just words written on paper but rules of behavior of all members of society, their non-observance leads to mandatory responsibility. Everybody who commits crimes will be punished, which is inevitable, and this principle is the guarantor of world security in the future.

Keywords: admissibility of evidence, criminal process, war, Ukraine

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Authors: Iliana Georganta, Clare Deehan, Marysia Thomson, Miriam McDonald, Kerrie McNulty, Anna Strachan, Elizabeth Anderson, Alyaa Mostafa

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Context: A meta-analysis of randomized controlled trials (RCTs) comparing hysterectomy versus endometrial ablation and resection in the management of heavy menstrual bleeding. Objective: To evaluate the clinical efficacy, satisfaction rates and adverse events of hysterectomy compared to more minimally invasive techniques in the treatment of HMB. Evidence Acquisition: A literature search was performed for all RCTs and quasi-RCTs comparing hysterectomy with either endometrial ablation endometrial resection of both. The search had no language restrictions and was last updated in June 2020 using MEDLINE, EMBASE, Cochrane Central Register of Clinical Trials, PubMed, Google Scholar, PsycINFO, Clinicaltrials.gov and Clinical trials. EU. In addition, a manual search of the abstract databases of the European Haemophilia Conference on women's health was performed and further studies were identified from references of acquired papers. The primary outcomes were patient-reported and objective reduction in heavy menstrual bleeding up to 2 years and after 2 years. Secondary outcomes included satisfaction rates, pain, adverse events short and long term, quality of life and sexual function, further surgery, duration of surgery and hospital stay and time to return to work and normal activities. Data were analysed using RevMan software. Evidence synthesis: 12 studies and a total of 2028 women were included (hysterectomy: n = 977 women vs endometrial ablation or resection: n = 1051 women). Hysterectomy was compared with endometrial ablation only in five studies (Lin, Dickersin, Sesti, Jain, Cooper) and endometrial resection only in five studies (Gannon, Schulpher, O’Connor, Crosignani, Zupi) and a mixture of the Ablation and Resection in two studies (Elmantwe, Pinion). Of the 1² studies, 10 reported women’s perception of bleeding symptoms as improved. Meta-analysis showed that women in the hysterectomy group were more likely to show improvement in bleeding symptoms when compared with endometrial ablation or resection up to 2-year follow-up (RR 0.75, 95% CI 0.71 to 0.79, I² = 95%). Objective outcomes of improvement in bleeding also favored hysterectomy. Patient satisfaction was higher after hysterectomy within the 2 years follow-up (RR: 0.90, 95%CI: 0.86 to 0.94, I²:58%), however, there was no significant difference between the two groups at more than 2 years follow up. Sepsis (RR: 0.03, 95% CI 0.002 to 0.56; 1 study), wound infection (RR: 0.05, 95% CI: 0.01 to 0.28, I²: 0%, 3 studies) and Urinary tract infection (UTI) (RR: 0.20, 95% CI: 0.10 to 0.42, I²: 0%, 4 studies) all favoured hysteroscopic techniques. Fluid overload (RR: 7.80, 95% CI: 2.16 to 28.16, I² :0%, 4 studies) and perforation (RR: 5.42, 95% CI: 1.25 to 23.45, I²: 0%, 4 studies) however favoured hysterectomy in the short term. Conclusions: This meta-analysis has demonstrated that endometrial ablation and endometrial resection are both viable options when compared with hysterectomy for the treatment of heavy menstrual bleeding. Hysteroscopic procedures had better outcomes in the short term with fewer adverse events including wound infection, UTI and sepsis. The hysterectomy performed better when measuring more long-term impacts such as recurrence of symptoms, overall satisfaction at two years and the need for further treatment or surgery.

Keywords: menorrhagia, hysterectomy, ablation, resection

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