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Wahlström, Rolf
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Publications (10 of 24) Show all publications
Daivadanam, M., Wahlström, R., Ravindran, T. K., Sarma, P. S., Sivasankaran, S. & Thankappan, K. R. (2018). Changing household dietary behaviours through community-based networks: A pragmatic cluster randomized controlled trial in rural Kerala, India. PLOS ONE, 13(8), Article ID e0201877.
Open this publication in new window or tab >>Changing household dietary behaviours through community-based networks: A pragmatic cluster randomized controlled trial in rural Kerala, India
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2018 (English)In: PLOS ONE, E-ISSN 1932-6203, Vol. 13, no 8, article id e0201877Article in journal (Refereed) Published
Abstract [en]

Trial design: With the rise in prevalence of non-communicable diseases in India and Kerala in particular, efforts to develop lifestyle interventions have increased. However, contextualised interventions are limited. We developed and implemented contextualised behavioural intervention strategies focusing on household dietary behaviours in selected rural areas in Kerala and conducted a community-based pragmatic cluster randomized controlled trial to assess its effectiveness to increase the intake of fruits and vegetables at individual level, and the procurement of fruits and vegetables at the household level and reduce the consumption of salt, sugar and oil at the household level.

Methods: Six out of 22 administrative units in the northern part of Thiruvananthapuram district of Kerala state were selected as geographic boundaries and randomized to either intervention or control arms. Stratified sampling was carried out and 30 clusters comprising 6-11 households were selected in each arm. A cluster was defined as a neighbourhood group functioning in rural areas under a state-sponsored community-based network (Kudumbasree). We screened 1237 households and recruited 479 (intervention: 240; control: 239) households and individuals (male or female aged 25-45 years) across the 60 clusters. 471 households and individuals completed the intervention and end-line survey and one was excluded due to pregnancy. Interventions were delivered for a period of one-year at household level at 0, 6, and 12 months, including counselling sessions, telephonic reminders, home visits and general awareness sessions through the respective neighbourhood groups in the intervention arm. Households in the control arm received general dietary information leaflets. Data from 478 households (239 in each arm) were included in the intention-to-treat analysis, with the household as the unit of analysis.

Results: There was significant, modest increase in fruit intake from baseline in the intervention arm (12.5%); but no significant impact of the intervention on vegetable intake over the control arm. There was a significant increase in vegetable procurement in the intervention arm compared to the control arm with the actual effect size showing an overall increase by 19%; 34% of all households in the intervention arm had increased their procurement by at least 20%, compared to 17% in the control arm. Monthly household consumption of salt, sugar and oil was greatly reduced in the intervention arm compared to the control arm with the actual effect sizes showing an overall reduction by 45%, 40% and 48% respectively.

Conclusions: The intervention enabled significant reduction in salt, sugar and oil consumption and improvement in fruit and vegetable procurement at the household level in the intervention arm. However, there was a disconnect between the demonstrated increase in FV procurement and the lack of increase in FV intake. We need to explore fruit and vegetable intake behaviour further to identify strategies or components that would have made a difference. We can take forward the lessons learned from this study to improve our understanding of human dietary behaviour and how that can be changed to improve health within this context.

National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:uu:diva-365027 (URN)10.1371/journal.pone.0201877 (DOI)000442500400044 ()
Available from: 2018-11-08 Created: 2018-11-08 Last updated: 2022-01-29Bibliographically approved
Daivadanam, M., Ravindran, T. K., Thankappan, K. R., Sarma, P. S. & Wahlström, R. (2016). Development of a Tool to Stage Households' Readiness to Change Dietary Behaviours in Kerala, India. PLOS ONE, 11(11), Article ID e0165599.
Open this publication in new window or tab >>Development of a Tool to Stage Households' Readiness to Change Dietary Behaviours in Kerala, India
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2016 (English)In: PLOS ONE, E-ISSN 1932-6203, Vol. 11, no 11, article id e0165599Article in journal (Refereed) Published
Abstract [en]

Dietary interventions and existing health behaviour theories are centred on individuals; therefore, none of the available tools are applicable to households for changing dietary behaviour. The objective of this pilot study was to develop a practical tool that could be administered by community volunteers to stage households in rural Kerala based on readiness to change dietary behaviour. Such a staging tool, comprising a questionnaire and its algorithm, focusing five dietary components (fruits, vegetables, salt, sugar and oil) and households (rather than individuals), was finalised through three consecutive pilot validation sessions, conducted over a four-month period. Each revised version was tested with a total of 80 households (n = 30, 35 and 15 respectively in the three sessions). The tool and its comparator, Motivational Interviewing (MI), assessed the stage-of-change for a household pertaining to their: 1) fruit and vegetable consumption behaviour; 2) salt, sugar and oil consumption behaviour; 3) overall readiness to change. The level of agreement between the two was tested using Kappa statistics to assess concurrent validity. A value of 0.7 or above was considered as good agreement. The final version was found to have good face and content validity, and also a high level of agreement with MI (87%; weighted kappa statistic: 0.85). Internal consistency testing was performed using Cronbach's Alpha, with a value between 0.80 and 0.90 considered to be good. The instrument had good correlation between the items in each section (Cronbach's Alpha: 0.84 (fruit and vegetables), 0.85 (salt, sugar and oil) and 0.83 (Overall)). Pre-contemplation was the most difficult stage to identify; for which efficacy and perceived cooperation at the household level were important. To the best of our knowledge, this is the first staging tool for households. This tool represents a new concept in community-based dietary interventions. The tool can be easily administered by lay community workers and can therefore be used in large population-based studies. A more robust validation process with a larger sample is needed before it can be widely used.

National Category
Nutrition and Dietetics Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Nutrition
Identifiers
urn:nbn:se:uu:diva-311190 (URN)10.1371/journal.pone.0165599 (DOI)000388350300010 ()27861500 (PubMedID)
Projects
BID study
Available from: 2016-12-22 Created: 2016-12-22 Last updated: 2021-06-14Bibliographically approved
Daivadanam, M., Wahlström, R., Thankappan, K. R. & Ravindran, T. K. (2015). Balancing expectations amidst limitations: the dynamics of food decision-making in rural Kerala. BMC Public Health, 15, Article ID 644.
Open this publication in new window or tab >>Balancing expectations amidst limitations: the dynamics of food decision-making in rural Kerala
2015 (English)In: BMC Public Health, E-ISSN 1471-2458, Vol. 15, article id 644Article in journal (Refereed) Published
Abstract [en]

Background: Food decision-making is a complex process and varies according to the setting, based on cultural and contextual factors. The study aimed to understand the process of food decision-making in households in rural Kerala, India, to inform the design of a dietary behaviour change intervention. Methods: Three focus group discussions (FGDs) and 17 individual interviews were conducted from September 2010 to January 2011 among 13 men and 40 women, between 23 and 75 years of age. An interview guide facilitated the process to understand: 1) food choices and decision-making in households, with particular reference to access; and 2) beliefs about foods, particularly fruits, vegetables, salt, sugar and oil. The interviews and FGDs were transcribed verbatim and analysed using qualitative content analysis. Results: The analysis revealed one main theme: 'Balancing expectations amidst limitations' with two sub-themes: 'Counting and meeting the costs'; and 'Finding the balance'. Food decisions were made at the household level, with money, time and effort costs weighed against the benefits, estimated in terms of household needs, satisfaction and expectations. The most crucial decisional point was affordability in terms of money costs, followed by food preferences of husband and children. Health and the risk of acquiring chronic diseases was not a major consideration in the decision-making process. Foods perceived as essential for children were purchased irrespective of cost, reportedly owing to the influence of food advertisements. The role of the woman as the homemaker has gendered implications, as the women disproportionately bore the burden of balancing the needs and expectations of all the household members within the available means. Conclusions: The food decision-making process occurred at household level, and within the household, by the preferences of spouse and children, and cost considerations. The socio-economic status of households was identified as limiting their ability to manoeuvre this fine balance. The study has important policy implications in terms of the need to raise public awareness of the strong link between diet and chronic non-communicable diseases.

Keywords
Food decision-making, Household, Non-communicable diseases, Behavioural intervention, Focus groups, Content analysis, Kerala, India
National Category
Nutrition and Dietetics Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:uu:diva-260298 (URN)10.1186/s12889-015-1880-5 (DOI)000357781100002 ()26164527 (PubMedID)
Projects
BID study
Available from: 2015-08-20 Created: 2015-08-18 Last updated: 2023-08-28Bibliographically approved
Taha, H., Nyström, L., Al-Qutob, R., Berggren, V., Esmaily, H. & Wahlström, R. (2014). Home visits to improve breast health knowledge and screening practices in a less privileged area in Jordan. BMC Public Health, 14, Article ID 428.
Open this publication in new window or tab >>Home visits to improve breast health knowledge and screening practices in a less privileged area in Jordan
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2014 (English)In: BMC Public Health, E-ISSN 1471-2458, Vol. 14, article id 428Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Breast cancer is the most common cancer afflicting women in Jordan. This study aimed to assess the effects of an educational intervention through home visits, including offering free mammography screening vouchers, on changing women's breast health knowledge and screening practices for early detection of breast cancer in a less privileged area in Jordan.

METHODS: Two thousand four hundred breast health awareness home visits were conducted and 2363 women aged 20-79 years (median: 41) answered a pre-test interview-administrated questionnaire to assess their breast health knowledge and practices at the baseline. After a home-based educational session, 625 women aged 40 years or older were referred to free mammography screening. Five hundred and ninety six homes were revisited six months later and out of these 593 women participated in a post-test. The women's retained breast health knowledge, the changes in their reported breast health practices and their usage of the free mammography voucher, were assessed.

RESULTS: The mean knowledge score increased significantly (p < 0.001) from 11.4 in the pre-test to 15.7 in the post-test (maximum score: 16). At the six month follow-up the post-test showed significant (p < 0.001) improvement in women's perceived breast self-examination (BSE) knowledge, reported BSE practice and mammography screening. Out of 625 women that received a voucher for free mammography screening 73% attended the mammography unit, while only two women without a voucher went for mammography screening at the assigned unit. Women who received a follow-up visit were more likely to use the free mammography voucher compared to those who were not followed-up (83% vs. 67%; p < 0.001).

CONCLUSIONS: Home visits by local community outreach workers that incorporated education about breast cancer and breast health in addition to offering free mammography screening vouchers were effective in improving women's breast health knowledge and practices in a less privileged area in Jordan.

National Category
General Practice
Identifiers
urn:nbn:se:uu:diva-245305 (URN)10.1186/1471-2458-14-428 (DOI)24885063 (PubMedID)
Available from: 2015-02-26 Created: 2015-02-26 Last updated: 2023-08-28Bibliographically approved
Shirazi, M., Lonka, K., Parikh, S. V., Ristner, G., Alaeddini, F., Sadeghi, M. & Wahlstrom, R. (2013). A tailored educational intervention improves doctor's performance in managing depression: a randomized controlled trial. Journal of Evaluation In Clinical Practice, 19(1), 16-24
Open this publication in new window or tab >>A tailored educational intervention improves doctor's performance in managing depression: a randomized controlled trial
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2013 (English)In: Journal of Evaluation In Clinical Practice, ISSN 1356-1294, E-ISSN 1365-2753, Vol. 19, no 1, p. 16-24Article in journal (Refereed) Published
Abstract [en]

Rational and objectives To assess the effects of a tailored and activating educational intervention, based on a three-stage modified Prochaska model of readiness-to-change, on the performance of general physicians in primary care (GPs) regarding management of depressive disorders. Methods Parallel group, randomized control trial. Primary hypothesis was that performance would improve by 20 percentage units in the intervention arm. The setting was primary care in southern Tehran. The participants were 192 GPs stratified on stage of readiness-to-change, sex, age and work experience. The intervention was a 2-day interactive workshop for a small group of GPs' at a higher stage of readiness-to-change (intention) and a 2-day interactive large group meeting for those with lower propensity to change (attitude) at the pre-assessment. GPs in the control arm participated in a standard educational programme on the same topic. The main outcome measures were validated tools to assess GPs' performance by unannounced standardized patients, regarding diagnosis and treatment of depressive disorders. The assessments were made 2 months before and 2 months after the intervention. Results GPs in the intervention arm significantly improved their overall mean scores for performance regarding both diagnosis, with an intervention effect of 14 percentage units (P = 0.007), and treatment and referral, with an intervention effect of 20 percentage units (P < 0.0001). The largest improvement after the intervention appeared in the small group: 30 percentage units for diagnosis (P = 0.027) and 29 percentage units for treatment and referral (P < 0.0001). Conclusions Activating learning methods, tailored according to the participants' readiness to change, improved clinical performance of GPs in continuing medical education and can be recommended for continuing professional development.

Keywords
assessing performance, depression, randomized control trial and doctors, stages of change, unannounced standardized patient
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-196022 (URN)10.1111/j.1365-2753.2011.01761.x (DOI)000314114400003 ()
Available from: 2013-03-04 Created: 2013-03-04 Last updated: 2017-12-06Bibliographically approved
Sparring, V., Nystrom, L., Wahlström, R., Jonsson, P. M., Ostman, J. & Burstrom, K. (2013). Diabetes duration and health-related quality of life in individuals with onset of diabetes in the age group 15-34 years - a Swedish population-based study using EQ-5D. BMC Public Health, 13, 377
Open this publication in new window or tab >>Diabetes duration and health-related quality of life in individuals with onset of diabetes in the age group 15-34 years - a Swedish population-based study using EQ-5D
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2013 (English)In: BMC Public Health, E-ISSN 1471-2458, Vol. 13, p. 377-Article in journal (Refereed) Published
Abstract [en]

Background: Diabetes with onset in younger ages affects both length of life and health status due to debilitating and life-threatening long-term complications. In addition, episodes and fear of hypoglycaemia and of long-term consequences may have a substantial impact on health status. This study aims to describe and analyse health-related quality of life (HRQoL) in individuals with onset of diabetes at the age of 15-34 years and with a disease duration of 1, 8, 15 and 24 years compared with control individuals matched for age, sex and county of residence. Methods: Cross-sectional study of 839 individuals with diabetes and 1564 control individuals. Data on socioeconomic status and HRQoL using EQ-5D were collected by a postal questionnaire. Insulin treatment was self-reported by 94% of the patients, the majority most likely being type 1. Results: Individuals with diabetes reported lower HRQoL, with a significantly lower mean EQ VAS score in all cohorts of disease duration compared with control individuals for both men and women, and with a significantly lower EQ-5D(index) for women, but not for men, 15 years (0.76, p = 0.022) and 24 years (0.77, p = 0.016) after diagnosis compared with corresponding control individuals. Newly diagnosed individuals with diabetes reported significantly more problems compared with the control individuals in the dimension usual activities (women: 13.2% vs. 4.0%, p = 0.048; men: 11.4% vs. 4.1%, p = 0.033). In the other dimensions, differences between individuals with diabetes and control individuals were found 15 and 24 years after diagnosis: for women in the dimensions mobility, self-care, usual activities and pain/discomfort and for men in the dimension mobility. Multivariable regression analysis showed that diabetes duration, being a woman, having a lower education and not being married or cohabiting had a negative impact on HRQoL. Conclusions: Our study confirms the negative impact of diabetes on HRQoL and that the difference to control individuals increased by disease duration for women with diabetes. The small difference one year after diagnosis could imply a good management of diabetes care and a relatively quick adaptation. Our results also indicate that gender differences still exist in Sweden, despite modern diabetes treatment and management in Sweden.

Keywords
Diabetes mellitus, Disease duration, EQ-5D, Health-related quality of life, Sweden
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-201819 (URN)10.1186/1471-2458-13-377 (DOI)000318636300001 ()
Available from: 2013-06-17 Created: 2013-06-17 Last updated: 2023-08-28Bibliographically approved
Elliott, J. A., Abdulhadi, N. N., Al-Maniri, A. A., Al-Shafaee, M. A. & Wahlström, R. (2013). Diabetes Self-Management and Education of People Living with Diabetes: A Survey in Primary Health Care in Muscat Oman. PLOS ONE, 8(2), e57400
Open this publication in new window or tab >>Diabetes Self-Management and Education of People Living with Diabetes: A Survey in Primary Health Care in Muscat Oman
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2013 (English)In: PLOS ONE, E-ISSN 1932-6203, Vol. 8, no 2, p. e57400-Article in journal (Refereed) Published
Abstract [en]

Background: Although the prevalence of type 2 diabetes in Oman is high and rising, information on how people were self-managing their disease has been lacking. The objective of this study was therefore to assess diabetes self-management and education (DSME) among people living with type 2 diabetes in Oman. Methods: A questionnaire survey was conducted in public primary health care centres in Muscat. Diabetes self-management and education was assessed by asking how patients recognized and responded to hypo- and hyperglycaemia, and if they had developed strategies to maintain stable blood glucose levels. Patients' demographic information, self-treatment behaviours, awareness of potential long-term complications, and attitudes concerning diabetes management were also recorded. Associations between these factors and diabetes self-management and education were analysed. Results: In total, 309 patients were surveyed. A quarter (26%, n = 83) were unaware how to recognize hypoglycaemia or respond to it (26%, n = 81). Around half (49%, n = 151), could not recognize hyperglycaemia and more than half could not respond to it (60%, n = 184). Twelve percent (n = 37) of the patients did not have any strategies to stabilize their blood glucose levels. Patients with formal education generally had more diabetes self-management and education than those without (p<0.001), as had patients with longer durations of diabetes (p<0.01). Self-monitoring of blood glucose was practiced by 38% (n = 117) of the patients, and insulin was used by 22% (n = 67), of which about one third independently adjusted dosages. Patients were most often aware of complications concerning loss of vision, renal failure and cardiac problems. Many patients desired further health education. Conclusions: Many patients displayed dangerous diabetes self-management and education knowledge gaps. The findings suggest a need for improving knowledge transfer to people living with diabetes in the Omani clinical setting.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-198934 (URN)10.1371/journal.pone.0057400 (DOI)000316658800104 ()
Available from: 2013-04-29 Created: 2013-04-29 Last updated: 2021-06-14Bibliographically approved
Noor Abdulhadi, N. M., Al-Shafaee, M. A., Wahlström, R. & Hjelm, K. (2013). Doctors' and nurses' views on patient care for type 2 diabetes: an interview study in primary health care in Oman.. Primary Health Care Research and Development, 14(3), 258-69
Open this publication in new window or tab >>Doctors' and nurses' views on patient care for type 2 diabetes: an interview study in primary health care in Oman.
2013 (English)In: Primary Health Care Research and Development, ISSN 1463-4236, E-ISSN 1477-1128, Vol. 14, no 3, p. 258-69Article in journal (Refereed) Published
Abstract [en]

AIM: This study aimed at exploring the experiences of primary health-care providers of their encounters with patients with type 2 diabetes, and their preferences and suggestions for future improvement of diabetes care.

BACKGROUND: Barriers to good diabetes care could be related to problems from health-care providers' side, patients' side or the health-care system of the country. Treatment of patients with type 2 diabetes has become a huge challenge in Oman, where the prevalence has increased to high levels.

METHOD: Semi-structured interviews were conducted with 26 health-care professionals, 19 doctors and seven nurses, who worked in primary health care in Oman. Qualitative content analysis was applied. Findings Organizational barriers and barriers related to patients and health-care providers were identified. These included workload and lack of teamwork approach. Poor patients' management adherence and influence of culture on their attitudes towards illness were identified. From the providers' side, language barriers, providers' frustration and aggressive attitudes towards the patients were reflected. Decreasing the workload, availability of competent teams with diabetes specialist nurses and continuity of care were suggested. Furthermore, changing professional behaviours towards a more patient-centred approach and need for health education to the patients, especially on self-management, were addressed. Appropriate training for health-care providers in communication skills with emphasis on self-care education and individualization of care according to each patient's needs are important for improvement of diabetes care in Oman.

National Category
General Practice
Identifiers
urn:nbn:se:uu:diva-245302 (URN)10.1017/S146342361200062X (DOI)000209619100006 ()23259934 (PubMedID)
Available from: 2015-02-26 Created: 2015-02-26 Last updated: 2018-01-11Bibliographically approved
Manithip, C., Edin, K., Sihavong, A., Wahlström, R. & Wessel, H. (2013). Poor quality of antenatal care services-Is lack of competence and support the reason?: An observational and interview study in rural areas of Lao PDR. Midwifery, 29(3), 195-202
Open this publication in new window or tab >>Poor quality of antenatal care services-Is lack of competence and support the reason?: An observational and interview study in rural areas of Lao PDR
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2013 (English)In: Midwifery, ISSN 0266-6138, E-ISSN 1532-3099, Vol. 29, no 3, p. 195-202Article in journal (Refereed) Published
Abstract [en]

Objective: to explore the health-care providers' performance and their own perceptions of the ANC services they provide. Design, setting and participants: this cross-sectional exploratory survey was carried out in 2009 at four district hospitals and 18 health centres in Khammouane and Champasack provinces in rural areas of Laos. Measurements and findings: combinations of quantitative and qualitative methods were used: (i) 59 observations of ANC sessions (components performed and equipment used); (ii) 26 semi-structured interviews with health-care providers engaged in ANC services, interpreted through content analysis. The findings indicated an overall poor quality and performance of ANC services in rural health facilities with lack of routines, scarce or insufficient equipment and limited skills among providers. The health-care providers gave an often pessimistic picture of their competence and motivation to work with ANC. Some articulated a resignation due to lack of feedback from the patients and they expressed a need for support from health-care superiors. Compared to the district hospitals, the health centres were less well-equipped and supplied, and the providers had a heavier workload, because all activities including ANC were carried out by the same provider. The average consultation time for each woman was 5 mins. Conclusions: the quality of ANC services in rural health facilities in Laos was poor due to lack of resources, the providers' limited skills concurrent with inadequate routines and insufficient backup from superiors. Implications for practice: to comply with national and international recommendations for ANC services, our suggestion is to improve the quality of the rural health facilities in Laos by providing basic equipment, support from experienced superiors and in-service training.

Keywords
Antenatal care, Performance, Health-care providers, Rural Lao PDR
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-197385 (URN)10.1016/j.midw.2011.12.010 (DOI)000315160100003 ()
Available from: 2013-04-01 Created: 2013-03-25 Last updated: 2017-12-06Bibliographically approved
Taha, H., Al-Qutob, R., Nystorm, L., Wahlström, R. & Berggren, V. (2013). "Would a man smell a rose then throw it away?" Jordanian men's perspectives on women's breast cancer and breast health. BMC Women's Health, 13, 41
Open this publication in new window or tab >>"Would a man smell a rose then throw it away?" Jordanian men's perspectives on women's breast cancer and breast health
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2013 (English)In: BMC Women's Health, E-ISSN 1472-6874, Vol. 13, p. 41-Article in journal (Refereed) Published
Abstract [en]

Background: Breast cancer is the most common malignancy afflicting women, and the most common cancer overall in Jordan. A woman's decision to go for screening is influenced by her social support network. This study aims to explore Jordanian men's individual and contextual perspectives on women's breast cancer and their own role in the breast health of the females within their families. Methods: An explorative qualitative design was used to purposively recruit 24 married men aged 27 to 65 years (median 43 years) from four governorates in Jordan. Data in the form of interviews transcriptions was subjected to qualitative content analysis. Results: Three themes were identified: a) Supporting one's wife; b) Marital needs and obligations; c) Constrained by a culture of destiny and shame. The first theme was built on men's feelings of responsibility for the family's health and well-being, their experiences of encouraging their wives to seek health care and their providing counselling and instrumental support. The second theme emerged from men's views about other men's rejection of a wife inflicted by breast cancer, their own perceptions of diminished femininity due to mastectomy and their own concerns about protecting the family from the hereditary risk of breast cancer. The third theme was seen in men's perception of breast cancer as an inevitable act of God that is far away from one's own family, in associating breast cancer with improper behaviour and in their readiness to face the culture of Eib (shame). Conclusions: Jordanian men perceive themselves as having a vital role in supporting, guiding and encouraging their wives to follow breast cancer early detection recommendations. Breast health awareness campaigns could involve husbands to capitalize on family support.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-211794 (URN)10.1186/1472-6874-13-41 (DOI)000326395500001 ()
Available from: 2013-12-02 Created: 2013-12-02 Last updated: 2023-08-28Bibliographically approved
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