Thursday, February 18, 2016

BREAST SELF EXAMINATION: RELIABILITY QUESTIONED??

Breast Self Examination (BSE) is the process of self screening of breast cancer. That we all know!!
However, while there are numerous research going on at student/faculty level about knowledge and attitude of BSE, interesting is the fact that BSE has long been discarded as the screening process. 

According to World Health Organization (2012), there is minimal evidence supporting the efficacy of BSE as a screening method. Kosters and Gotzchse (2003) conducted a meta-analysis in order to explore the efficacy of BSE. Two studies which included 3,88,535 women were included in the review. The analysis revealed that BSE led to unwanted distress, anxiety and greater number of invasive procedures. The false positive results were also greater in population of women who had undergone BSE as compared to the women who had not undergone BSE. 

However, it is still promoted!! What could be the reason?

Although WHO (2012) recommends against its use as screening method, it states that it can be used as the method of raising awareness and empowering women. Thus, nurses should be aware of the Evidence Based Practice that follows. While suggesting the patient about BSE, it is necessary to help them understand the possibility of false positive results and undue stress that it may bring along with it.

The student nurses who are searching for a research topic could use this one, i.e. the Changing practice of Breast Self Examination (BSE) or The knowledge/attitude of changing practice of BSE??

Hence, Breast Self Examination is the method of raising awareness and empowering women by helping them to understand and take control of their body,  NOT A RELIABLE SCREENING METHOD. 

References:
World Health Organization. (2012) Breast Cancer: Prevention and Control [Online]. Available from: https://www.blogger.com/blogger.g?blogID=3036035428696811962#editor/target=post;postID=1369389078637849683 [Accessed 18 February 2016].

Koster, J.P and Gotzsche, P.C. (2003) Regular Self Examination or Clinical Examination for Early Detection of Breast Cancer. Cochrane Database Systematic Review. 

Saturday, January 16, 2016

Challenge: Are women in developed societies facing less domestic violence than the women in developing societies?

Domestic violence towards women in Nepal is currently at its heights. The figures from data and statistics are self explanatory of the burden of this social problem in Nepal. Domestic violence is the act of actual or potential harm inflicted in the form of physical or verbal act that affect the physical, mental and social health of the victim. The perpetrators of domestic violence against women have been identified as the male partner, mother-in-law, father-in-law and other members of the male partner's family. These facts are not what interests me and there are plenty of articles that have been published to elucidate these facts. Why does the woman hesitate to speak against the violence is the question that I have been searching the answer to.

The most important answer that I have found is self-esteem or wish to maintain their reputation intact. The woman chooses not to make the formal complaint or not to share these incidences with the family as she does not want the family members/society members/friends to show the pity or make sarcastic comments to her. The study by Poudel et al (2014) revealed many cases of violence are unrecorded and the prevalence of psychological violence is greater than other forms of violence in Nepal. The dilemma in complaining is further fuelled by the inability of the government to criminalize the act of violence. The most significant problem is bore by the women themselves. If they were strong enough to stand against these acts with their head held high, the situation could have been different. After all, it is not her mistake that she has been exposed to such acts of violence. What could be the remedy in these situations? The first thought in our mind could be education?? policies?? laws?? but all these interventions will go in vain until and unless women overcome their so called perception about the intact reputation. This is very difficult to achieve.

 A family that she has accepted as her own, inflicting acts of violence beyond her expectations is set to traumatize her emotionally. In my view, the acts of domestic violence that occurs in developed societies have higher chances of not being reported. Several researches around the world show that the undeveloped countries are at higher risk of domestic violence, they bear greater risk of domestic violence etc, but the question is whether the incidences of violences in the developed countries are reported. The women from these societies are educated and bold but are they bold enough to let down their intact reputation and report that the persons whom they fell in love with are the ones hurting them now? The mysterious nature of human behavior, the veracity of self-reported incidences and the trajectory of the violence are all too tedious but not impossible to understand.

Friday, November 13, 2015

Social Inequality: Maslow's Hierarchy of Needs

In this post, I will further discuss about social inequality in Nepal with reference to my last post, "Social Inequality in Nepal: Kanxi". This is my view irrespective of what is mentioned in the books.

Social inequality, the literal meaning of this word as perceived by many is "lack of equal opportunity to all" which is undeniable. However, in addition to lack of opportunity, there are many dimensions to defining this term. "Kanxi" was just a meager demonstration of this term. 

Let's discuss the answer to the first question: In your view, why did Kanxi elope??

The lack of education, improper upbringing, inadequate parenting and lack of emotional support system could be some of the reasons. Let's remember the Maslow's Hierarchy of needs and plug in  Kanxi's action in the hierarchy which apparently fits in the third step in the hierarchy that suggests "Love and belonging needs". However, Maslow states that the first two needs (Physoloical need and safety. security need) should be fulfilled before the third can be demanded for. The story reveals that Kanxi had no proper food to eat, she was compelled to sleep outside the safety of her home which definitely breaches some portions of the first two needs. Still, Kanxi asks for the third need to be fulfilled. Why?? Apparently, the first two needs did not seem to be fulfilled but if we analyze thoroughly, she had all the components of the physiological needs and safety/security as well. So, the main issue here is she was not allowed to access the facilities provided to her by her stepmother which means that she was short of love and belonging. Thus, when she met a young man willing to give up everything for her (we know the talks of teenagers in love), she surrendered herself to the basic need of human being, love. 

Maslow's Hierarchy of Needs


Now, the question arises if Maslow hierarchy is related to social inequality? My view is, "Yes". Since, social inequality means that all the people in the society do not have equal access to the resources whether be it related to health, education, employment, household, living environment or quality of life, it relates to the hierarchy which also corresponds to these domains of the society. For some of you who think, "NO, it's not related", that can be true too. I have used Maslow hierarchy just to simplify the understanding of social inequality while this does not represent it's broad dimensions. 

So, the problem identified here is the lack of intimacy, friendship and care. Can this contribute to social inequality?? It may not borne the inequality directly, it surely predisposes a person to the state of inequality. Kanxi married an immature that led to all the other consecutive problems in her life. She ran away because her family was not able to provide the love she wanted.



Monday, October 26, 2015

Social inequality in Nepal: "Kanxi"

"Kanxi", an alias for a young girl in Nepal. She was brought up in eastern rural area of Nepal in a joint family. Her mother died when she was young. Her father remarried soon after. The days of her bad fortune began then. Her bacchanalian father initiated fights with her stepmother every night. Her elder brothers left the village with a hope for a better life in the coveted city, Kathmandu. She witnessed numerous family violence between her step-mother and father every night. She herself became victim of acerbity, coercion and unceasing hatred from her step mother. She slept through the cold winter in sheds, suffered for hours deprived of food not because her family had no good shelter or enough food but her stepmother could not tolerate her. Her father never advocated for her rights. School, the right of every girl was a strange word for her. She felt its not her thing. She did not even know that she is supposed to be educated. She never realized the importance of education. Despite all her sufferings, she blossomed into a young, beautiful and charming young girl. Soon,  the violence of her step-mother and the fights between her parents became intolerable to her. "I will show her what I can do", Kanxi thought. She came to live with her elder brother in Kathmandu. But, Kathmandu is no gold. It's a polluted city overcrowded with people where people struggle to feed everyday. The emotions of 17 year old girl are complex. As Freud suggests she is in genital stage, focused on sexuality and independence from parents. Inevitable may be, she eloped with a guy from her village who was in Kathmandu for a while. Her elder brother was furious, "This is what I fed her for, so she could run away with an immature". Her callow step was despised by everyone. Her father was furious too. 

As, I dig deep into this matter. I do not feel that Kanxi committed something wrong. She must have felt loved by someone, for the first time in her life. She must have felt coddled and warm. Given her innocence and ignorance, what happened was inevitable. 

In your view, why did Kanxi elope?

However, Kanxi's happiness was not for long. Her husband went abroad with the hope of good earning and good life. After all, money is the key to materials and materials bring happiness and sustain life. After being a month apart from her husband, Kanxi eloped again with another man, 15 years older to her. Again, her family outburst into anger and hatred. Everyone claimed she was an immature young girl, which she was. Her family members tried to bring her back. She was "in love", I suppose, she did not come back. Her sorrows were to become endless in next few months. 

In your view, why did Kanxi elope second time?

The man she eloped with had no stable job or shelter. They rented a room near her elder brother's place. The rent in Kathmandu was soaring. Their income was around 1$-3$ per day. She got pregnant. In any other circumstance, that could have been a blessing. This was not the case for Kanxi. Her poverty would not let her pregnancy end in a good way. However, abortion was not her option, not because she did not opt for it, but because her husband would not let it happen. Thus, Kanxi succumbed to the male dominant society. Months passed by, she did not visit any prenatal care services. After all, a single visit to prenatal care services would cost her at least 40$ which was beyond her ability. She was 18 years old at the time of pregnancy. According to WHO (World Health Organization), this is a case of adolescent pregnancy and thus the risks were high. Everyone in the community encouraged her to visit the hospital but unfortunately encouragement does not pay the hospital bills. There should have been free community prenatal care services for girls like her. 

What can be done to prevent these situations?

Her family members including her elder brother did not have any enough resources to help her. Luckily during her 9th month of pregnancy, her husband was able to make greater earnings. Thus, she visited the hospital with her brother's wife. After hours of waiting time at Paropkar maternity and Women's Hospital, the affordable maternity government hospital of Nepal, her turn came. It was her first visit to a hospital after her own birth. Natural herbs and shaman were the preferred methods of treatment in her village. The nurse asked her to lay on the bed. Nobody cared about how shy or uncomfortable she was. When she hesitated, she was literally shouted at by the nurse. Tears started to roll from her eyes. The doctor approached her. The doctor did not bother to look at her patient's face. She started scolding the nurse for not getting the patient ready. She was then pushed to the examination table by the nurse and the examination began. The furious doctor began to shout at her for not coming earlier. Why did not the doctor ask about her inability to approach the hospital earlier? The doctor performed the abdominal examination without any consent. Innocent Kanxi did not perceive the manners of the doctor and nurse as obnoxious. Her brother's wife told her that doctors and nurses are always right and this is how they behave usually. This scenario does not apply to the situation of Kanxi only. Thus is the case in most government hospitals where doctors and nurses run the show. The doctor ordered several expensive tests like blood tests and Ultrasonography which costs around 30$ ignoring the situation of her patient. The medical education does emphasize on these aspects but it would be a miracle when these learning will be practiced in government hospitals. Kanxi's sister in law helped her select few tests and they performed it. Kanxi never went for follow up because she was too scared to show incomplete reports to the doctor. 

How do you perceive these behaviors of health personnel? Has it ever happened to you?

Labor pain started and Kanxi remained quite because she did not want to go back to the hospital.  She was scared of what the nurses and doctors might do. She had tolerated too many sufferings in her life that tolerating labor pain was not difficult for her. She was helping her sister in law wash the cloth when her water broke. It was then that everybody knew about her labor pain. She was an adolescent primipara and everyone around her was appalled by her tolerance of the pain. She was rushed to the hospital. She gave birth after 4 hours. Despite the lack of nutritious food, rest, medical check up and any other preparations, she gave birth to a healthy son. She was lucky but not every adolescent pregnancy has the similar outcome. WHO (2014) states that a child born to a teenage mother has greater risk of dying rather than a child born to a woman greater than 19 years of age. 

Kanxi's son was in the oral stage as suggested by Freud. He cried for milk, cried when he was uncomfortable, cried when he peed. The crying was his only way to convey his feelings to his mother. She was unable to breastfeed because of the inverted nipple. She had not prepared her nipple during her pregnancy. Her baby was unable to suck the milk. Thus, she was forced to pump the milk every time her baby cried. With time, she was too tired to do so. Her husband was not at home to care for her. She had to prepare meals, take care of herself as well as her baby in her postnatal period when she required maximum rest. With time, she was too tired to milk the breast, thus she started feeding the DDC milk that we get in the Kathmandu market. She added around 200 milliliters of water to 250 milliliters of DDC milk to increase the quantity of milk as she could not afford more. The dilution was heavy and decreased the nutritional value of milk. So, the child got hungry more frequently than normal child would. He was fed from a spoon because Kanxi could not afford a feeding bottle. She started working as a housemaid in a house nearby, thus leaving little time to care for her child. 

What impact could this have on child's development?

Her life took a more miserable turn when her husband started thrashing her after he got drunk every night. He returned home drunk and alleged Kanxi of infidelity. She was beaten till she bled. One morning, she went to work, with swollen lips and blue eyes. When she was asked regarding her condition, she could not stop her tears. She cried sharing how her husband thrashed her with fists, kicked her and swirled her around anchoring her hair and even strangled her. Women in the community gathered, they pledged to help her if she was ready to go against her husband. But, Kanxi was silent. She did not utter a word. It was clear that she did not want to speak against her husband. The fear was apparent in her eyes. How can others help her when she is not willing to help herself? But, can Kanxi be blamed for not being able to overcome her fear? Only if there had been a social worker in each ward who could address these problems or a community nurse where Kanxi could have been referred to, this would not have been the case, may be. 

Why is Kanxi hesitant to complain against her husband?

Contrary to everyone's expectation, Kanxi's son grew without any problems. She never took the boy hospital for minor coughs or fever. The child started babbling only at 15 months which is very late. He started standing at the same time. However, for a child he was very protective. When anyone raised his voice at him or stared at him with wide eyes, he would immediately understand the negative gesture and raise his hand in defense. He bit adults or his other friends when they were close enough. even when they meant no harm to the child. Kanxi shared that after 3 months of age, he did not cry even when he peed in his pants. She could not afford a diaper for sure. So, why would a child tolerate the discomfort? What could account for his behavior? My assumption is that he remained quiet because his needs that he expressed by crying earlier were not fulfilled. So, later he stopped crying for such reasons. Others said that the child is patient and lucky for the mother but was that the case? After he was a year older, he witnessed his father beating his mother every night . His sleep was disturbed and he cried the whole time his parents fought. This could be reason for his increased protective instincts or hostile behavior.

What could be the reasons for child's behavior?

The list goes on. This is a true story. The name of the person has been changed but I have witnessed the girl from the time she arrived in Kathmandu. She is 21 years now and her son is 2 years old. These problems were faced by a single girl. 

What do you think the reason could be? 

In my thought, the main reason is social inequality. The lack of education is the major contributing factor. Had Kanxi been educated, had the circumstances been the same? Go back to each problem that Kanxi faced and ultimately it relates to social inequality. 

I will continue this post next time with more emphasis on social inequality and its impact on development of children. 

Comment regarding what you feel the reasons for the above situations are and what could be done for it? Which part touched you the most?