In a General Practitioner (GP) setting, preventative medicine is reported as the predominant source of health care for the well-child. However, the role of the GP in well-child health care is not well understood in Australia. The aim of this study was to describe the role of the GP in providing services for well-children and families in Australia.This was a qualitative descriptive study. Face-to-face interviews were held with 23 GPs to identify their role in the provision of well-child health care. Participants worked in a variety of general practice settings and 21 of the 23 GPs worked in the Greater Western Sydney area.Five main themes were identified in the analysis: ‘prevention is better than cure’, ‘health promotion: the key messages’, ‘working with families’, ‘working with other health professionals’, and ‘barriers to the delivery of well-child health services’.Participating GPs had a predominantly preventative focus, but in the main well-child care was opportunistic rather than proactive. The capacity to take a primary preventative approach to the health of children and families by GPs is limited by the increasing demands to manage chronic disease. Serious consideration should be given to developing collaborative models of care where GPs are joined up with services funded by State and Territory governments in Australia, such as the universal maternal child and family health nursing services that have well children and families as their prime focus. The early years of a child’s life are crucial for optimising growth and development . DespiteThe Royal Australian College of General Practitioners (RACGP) states that children should be screened opportunistically, to assess hearing, vision, language and social skills, as well as growth and development . FurtherGeneral practitioners therefore, have the potential to play a key role in preventative health care for children and families , yet verFor the purpose of this study, we have defined early childhood as the period between birth and eight years of age.This was a qualitative descriptive study. Participating GPs were interviewed to explore their role in the provision of well-child care. Data were analysed using thematic analysis. Ethics approval for the study was obtained from the University of Western Sydney Human Research Ethics Committee. Each GP provided informed consent prior to the individual interviews.The study was conducted in Sydney, NSW with 23 GPs who worked in a variety of general practice settings including solo practices and medical centres with up to 15 GPs. From the 25 GPs originally invited, two chose not to participate due to time constraints. Participants were approached based on the location of their practice, with many having an affiliation with University of Western Sydney. Twenty one participants worked in Sydney’s western suburbs. Equal numbers of male and female GPs participated , with 23 GPs, either in the GPs’ practices or a location of their convenience. Key prompts were used to explore the role of the GP in child and family health , another prioritised preventative health stating “first of all, we provide preventative medicine for the children…” (GP5) and a third participant described that GPs “…deal with normal GP things like immunisation, preventative medicine, growing and all the usual paediatric things” (GP10). Another participant emphasised that a preventative approach “…also covers not just the child, but the parents” (GP9).The majority of GPs highlighted the importance of prevention; one stated “catch things early” (GP6). They achieved this through organising routine health checks to identify problems with development, as well as applying recall systems for immunisation to “…make sure you get them back if they don’t come in time” (GP7).Some reported that they take a proactive approach to health promotion, wanting to “The majority however, described their role in child health as ‘opportunistic’, with consultations seen as an opportunity to conduct routine health checks and ensure normal development,…so I don’t just give them a needle, I also talk about development and what to expect as well (GP1),""We see them at four years old for their vaccinations, and then we do the health check then as well (GP20).""“We normally see unwell children” (GP6) and “With well-children, they hardly come to the surgery. They normally come with a problem” (GP11).A small number of participants were more focussed on children with an acute illness. When asked about their role in health care for children, they immediately reflected on the sick child rather than the well-child, some responding with, While the participants spoke broadly about their role in health promotion, it appeared that this was focused on three areas, namely immunisation, breastfeeding and parent-infant relationships,Well, in the well-child, it would basically be, number one to keep them well – that is prevention, meaning immunisation, and preferably full immunisation (GP21).""You counsel the mother to see if they are breastfeeding or bottle feeding and how they are going with it, and if they are developmentally consistent (GP2).""The participants demonstrated some familiarity with anticipatory guidance but provided limited illustrations of putting this into practice other than relating it to the use of the ‘blue book’  in easing parental concerns about their child’s development,The parents usually read it and before they reach the age, the parents should know at what age the child should be sitting up and what age they should be talking and how many words they should be talking sentences (GP2).""would only see the child opportunistically, when the parent brings the child in…for immunisation” (GP21). In response to conducting routine health checks, one GP answered, “Normally when we do it, a motivated mother asks me, rather than doing it routinely” (GP10). Some GPs agreed that it is “Usually the parents [who] promote the issues to be checked with the children” (GP12) rather than the GPs themselves.Overall the approach to health promotion tended to be reactive, as the GP “…“I think in the early years of parenting it is more important to give them support” (GP2). Providing information in a reassuring way was necessary to ensure that families were not distressed,Participants were also asked to describe how they worked with families. GPs identified their role as being educators and providers of support, We need to educate, we need to enhance, we need to give more information in a compassionate, empathetic way, but not to scare them (GP5).""developing a strong rapport and relationship with the family is the most important thing” (GP14). Difficulty in maintaining continuity of care was considered a barrier for working effectively with families. Participants believed that lack of continuity occurred due to both GP and family factors,The importance of developing a relationship with parents was also emphasised, with one GP commenting that “…I work 3 days a week in my practice so sometimes I’d like to follow up a child, but it’ll be a day that I’m not there and they end up seeing a different GP so sometimes you tend to lose that follow up (GP3).""This fragmented care was thought to result from switching doctors frequently,Here the family chooses the GP whenever they want, whoever they want. So they can move from GP to GP. So there can be a problem in the continuity of care (GP7).""“It’s easy with shared care, because most of them like it and they are more comfortable with us, because they have known us for a long time” (GP13) and “…the role of this for a GP is absolutely vital because it is the interface between the hospital and primary care” (GP14).Those who were involved in shared antenatal care believed that they had the best opportunity for forming relationships with families from the outset. According to one GP, “providing medical information in lay person terms is of paramount importance” (GP5). They also reported that GPs need to help interpret information available from other sources, “…a lot of the time, parents do their own research and ask us about that service” (GP1). At times, however, this proved to be a challenge,Participants described the educational role of GPs including assisting families to interpret health information, as The revolution of knowledge through the internet in one way its good but in another way it puts a lot of strain on us, because whenever we make a recommendation, they just Google it or research it and come back with a lot of queries or questions (GP10).""“If there is a problem then we’ll refer them to the appropriate services” (GP11). These services included paediatricians, child psychologists and allied health services such as speech therapy, occupational therapy, social work, and audiologists. Some GPs also liaised with non-referral based local government services such as community and childcare groups to support children and families. In the main, GPs would work in collaboration with either a practice nurse or a community-based child and family health nurse in providing care for the well-child, through anticipatory guidance and support as well as health promotion services such as immunisation and information on feeding issues,All participants had some understanding of the services available for the well-child and families. However, only 15 out of the 23 GPs described some form of interaction with other services, which usually only amounted to referrals, A practice nurse is actually a big help…[they] give vaccinations, weigh the child and take measurements…as well as provide advice to parents (GP20)""In our practice, the nurses do the routine health checks. (GP4)""If both the child and family are well there isn’t much need to work with other services” (GP14) and commented on logistical issues such as waiting times and poor communication, “Really the problem is the lack of communication between the [specialist] services and the GPs” (GP17).Of the eight GPs who did not have any involvement with other services, the majority cited the redundancy of these services in well-child care, ““In my practice I don’t think time can be an excuse. You can always find the time” (GP11).The major limitation that GPs identified was finding the time to spend in consultations to provide optimal well-child care. Despite this, one participant added, “…some people can’t afford to even cover that [Medicare] gap, in the lower socioeconomic groups” (GP8). Furthermore, some GPs identified the lack of knowledge of, and access to, services available for children under their care, “Part of the problem is actually knowing what’s around, you can’t access them” (GP9).Another issue faced by GPs in providing optimal well-child care was the financial status of families, especially in practices that did not bulk bill, “Better information interflow between hospital and GPs is necessary…awareness of what services are available rather than duplicating some and lacking others” (GP16). Participants also suggested increasing the number of health services in the community, “…more community based services, especially community based nursing. Also easier access to allied health services, like speech pathologists” (GP1).Nonetheless, the GPs recommended possible improvements to facilitate optimal well-child management. Improvements in communication between GPs and other health services were identified as important, both to increase quality of care as well as efficiency, The purpose of this study was to describe GPs’ perceptions of their role in the provision of well-child health care. As reported in the literature , most pa“catch things early” demonstrated a proactive approach to well-child health care. As reported in the literature [The majority of participants prioritised prevention however their approach to this varied. GPs who wanted to terature , having “motivated mother”. Arguably this is the most common approach in general practice [Most participants took an opportunistic approach to preventative health care, providing child health surveillance focused on growth, hearing, vision and speech when a child was brought in for a scheduled immunisation visit, an episodic illness or when brought in by a practice  and is spractice .The introduction of the Medicare item number for the four year old ‘Healthy Kids Check’ has provided another opportunity for GPs to undertake developmental assessment of children. It was introduced by the Australian government in July 2008 to “promote early detection of lifestyle risk factors, delayed development and illness, and introduce guidance for healthy lifestyles and early intervention strategies” .Despite the weak evidence on the Healthy Kids Check, refinements could be made to better address current shortfalls in well-child healthcare. Therefore, more emphasis should be placed on screening for issues with a strong evidence base, including oral health and fluoride exposure, as opposed to issues not supported by evidence such as questioning toilet habits . FurtherAs reported by others, ,19, whilWhile the participants also reported having an educative role, this was often described as ‘teaching’ and interpreting information for parents. The preventative care guidelines for general practice in Australia advocate the provision of parent education, including accident and injury prevention, nutrition advice and child health surveillance . HoweverSeveral GPs identified developing a rapport or building a relationship as essential in providing continuity of care to well-children and their families. This is considered to be the core of general practice and is well supported in the literature . HoweverCollaboration is important to achieve the goal of effective health care for children and families and requires health professionals from different disciplines and sectors to provide services in new ways. Collaboration exists on a continuum; with no communication between professionals at one end, moving to referrals with limited communication and ultimately to service integration at the other ,28. EvidThe participating GPs indicated that they would prefer more feedback from services they referred their patients to. A proposed initiative by Nicolson et al. in resolving this barrier to well-child care is to implement a liaison position to be accountable for the communication outcomes . Case coFurthermore, Gardner argued that while effective communication is pertinent in delivering services, it is equally important to have access to and awareness of a variety of available services .crowding out” of non-acute and preventive care visits by the primary care needs of Australia’s ageing population [The key limitation in GP provision of care for the well-child is lack of time . GPs finpulation . This mapulation ,35,36Finally, it is evident that may GPs defer the healthy kids check and other child health activities to practice nurses ,38. PracThis is a small qualitative study conducted in a specific metropolitan location and the findings cannot be generalised. In addition, interviews were limited by availability of GPs due to time constraints in busy practices.Further research is needed with a larger sample of GPs to understand the role of GPs and how these services interact with the role of other health services, including Non Government Organisations, across universal and targeted services. Looking at parents’ perspectives in delivery of health services may also prove useful in identifying shortfalls and areas for future improvement.This study contributes to our understanding of GP perspective of their role in well-child care and is timely given the current health reforms in Australia such as Medicare Locals. Participating GPs had a predominantly preventative focus, but in the main well-child care was opportunistic rather than proactive. The findings suggest that GPs may require some professional development to support their role in working effectively with families and children to address missed opportunities in preventative care. Looking at parents’ perspectives in the delivery of health services would be useful in identifying shortfalls and areas for future improvement.None identified. We confirm that the content of this paper is currently not submitted or published in full or in part elsewhere.AJ, JR, JC, AT, RB and SN carried out interviews with General Practitioners, thematically analysed the data and collaboratively wrote the manuscript. AJ and JR edited the manuscript for submission. VS conceived the study, and supervised its design and data analysis. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2296/14/2/prepub


Gennari and MacDonald  presentePDC is usually discussed as a “view” or “perspective.” But when the author suggests it's mechanistic, it sounds more like an empirical claim. If it is an empirical claim, then one might want to know how distributional patterns are discovered in the input, how general they are, how they are stored, and how they are utilized. After all, on the PDC model, that's where all the action is, at least for the comprehension system. It might also be germane to figure out whether the statistics are gathered separately for different speakers, different dialects, different registers. Also, it might be good to provide evidence that it IS the statistics themselves that guide expectations in comprehension, and not implicit knowledge of how the production system works.As for the PDC perspective, let's endorse it. Let's look for production-based explanations, and any other explanations we can construct, if they are precise enough to make predictions.Does the PDC make predictions? It might if speakers can say what they please. But in fact the grammar of the language will dictate what constitutes a phrase, what order is permitted or required, whether ellipsis is possible, and so forth. And the grammar demonstrably is NOT just the summation of past favored production choices but, in addition to whatever constraints acquisition or comprehension may impose, convention and historical accident also come into play, and these various factors interact in complex ways. So, at best, PDC applies when the grammar offers more than one option for the same message. To take a well-known example, in sentences containing a dative verb, Double Object structures (DO) and Prepositional Object structures (PO) are largely synonymous. Maybe in such cases principles like Easy First apply. Although Easy First is not well-defined, clearly on any tenable version of it, phrases already “given” in discourse will count as “easy.” So the prediction is that given should appear before new, listeners should store these statistics, and comprehenders should find these structures easier when given appears before new. So there is a prediction. The problem in this case, however, concerns the facts. For DO, the prediction appears to be correct. But for PO, it is not  and from object (2b). Apparently we could explain the ease of (1b) with “Easy First”—the most important of the three core production planning principles since “Plan reuse/priming” will depend on context, and Reduce interference will depend on lexical choices. But “Easy First” would seem to predict no advantage for extraposition from object (2b) since the object is last regardless of whether the object is extraposed, as in (2b), or not extraposed (2a). Nevertheless, intuitively, and in pilot data of Emily Westland , (2b) isThat Max left early bothered me.It bothered me that Max left early. (Extraposition from subject)I hated that Max left early.I hated it that Max left early. (Extraposition from object)Let's consider another example. Take the repeatedly demonstrated finding that speakers will include optional constituents  at points of high complexity in production  is not of the form the speaker would have been most likely to choose so perhaps the PDC predicts comprehension difficulty.Hear what I say? Hear what who say? (agreement error intended), or worse Hear what I say, hear what I say, hear what I say….Turning to the second major production claim “Plan reuse/frequency/priming,” it is important to recall that empirical evidence supports the existence of abstract syntactic representations . In terms of distribution, it is not clear what is counted, why, nor are the implied mechanisms spelled out. As for the claim that comprehension ease is determined by production ease (mediated by distribution), only one case study has been presented that shows a production-based explanation is best, rather than merely possible. Against this there are several apparently incorrect predictions of PDC about comprehension difficulty in datives, argument extraposition, and complementizer use.Is there a productive way forward that goes beyond simply tallying up the columns of the scoreboard? In my view, yes. MacDonald's thoughtful paper could be the first step toward an explanatory theory of sub-categorization of lexical items, i.e., sub-classification of items based on the type of argument and the actual arguments with which a lexical head of phrase co-occurs. All theories of comprehension rely on stored sub-categorization information without much concern for precisely what information is encoded, where it came from, or even the basic question of whether the lexical-syntactic interface in comprehension extends beyond what's captured by sub-categorization.


Despite rising breast cancer incidence and mortality rates, breast cancer screening (BCS) rates among women in Qatar remain low. Previous studies indicate the need to better understand the many complex beliefs, values, and attitudes that influence Arab women’s health seeking behavior for the development of culturally appropriate and effective intervention strategies to address breast cancer in the Middle East. This study investigates beliefs, attitudes, and BCS practices of Arabic-speaking women in Qatar.A multicenter, cross-sectional quantitative survey of 1,063 (87.5% response rate) Arabic-speaking female Qatari citizens and non-Qatari residents, 35 years of age or older, was conducted in Qatar from March 2011 to July 2011. Associations between beliefs and BCS practice were estimated using chi-square tests and multivariate logistic regression analyses. Participants who adhered to BCS guidelines (BCS practice = Yes) were compared to those who did not (BCS practice = No).In addition to low levels of awareness and low participation rates in BCS, one quarter of the participants stated their doctors talked to them about breast cancer, and less than half of the women interviewed believed breast cancer can be prevented. Women who engaged in BCS practice were more likely to have a doctor who talked to them about breast cancer, to believe they were in good–excellent health, that cancer can be prevented, or that cancer might be hereditary. The majority wanted to know if they had cancer and felt their health care needs were being met. The main reasons given for not planning BCS were lack of a doctor’s recommendation, fear, and embarrassment.These findings indicate that a variety of channels  should be utilized to create culturally appropriate breast cancer intervention programs and increased awareness of breast cancer, BCS, and the benefits of early detection of breast cancer. Employment of these measures will reduce breast cancer mortality rates among Arabic-speaking women living in the State of Qatar. Qatar, like many other Middle Eastern countries, comprises a traditional, collectivist society. H.H. Sheikha Moza bint Nasser, the most respected and celebrated woman of Qatar, once described Qatar as “a rising homeland that confidently embraces modernization and proudly observes tradition” . Thus, Qatar has the potential to offer the best of the West and the East by offering state-of-the-art medical technology while incorporating social, cultural, and religious principles to address the health care concerns of its two million people. The government of Qatar has made health care research as one of national research priorities; close to 3% of its annual GDP  is allocated to funding research in Qatar. Therefore, health care programs and research aimed at addressing cancer in Qatar can significantly impact the Middle East region and Muslim and Arab women worldwide.Breast cancer is one of the most commonly diagnosed and leading causes of cancer-related deaths among women just after lung cancer ,2. A 201When combined with appropriate treatment, early detection through breast cancer screening (BCS) activities that include breast self examination (BSE), clinical breast examination (CBE), and mammography, has been shown to decrease cancer mortality rates by 25–30% ,13. StudA cancer diagnosis is often accompanied by social stigma in the Middle East, and limited physician disclosures of cancer diagnoses often coincide with social and cultural norms . BecauseStudies indicate that a BCS recommendation from a physician, family member, or friend; awareness of breast cancer and the importance of BCS; a family history of breast cancer; and a higher education level, residence in an urban area, employment, and higher socioeconomic status are important facilitators of BCS behavior -17,25,26Lack of a physician’s recommendation, fear of the BCS procedure and fear of finding cancer, low perceived risk of cancer or effectiveness of BCS, time, cost, preference for a female health professional, accessibility of the health care system, and embarrassment related to the BCS procedure are barriers to clinical breast examination and mammogram practice among Arab women ,14,15,17Despite fear of cancer and low levels of BCS participation, Arab women are eager to learn more about breast cancer and its screening activities -31. To dAccording to Kleinman’s Explanatory Model, “beliefs about sickness … including treatment expectations … affect the way individuals think about and react to sickness and choose among and evaluate the effectiveness of the health care practices available to them” . Thus, iThis paper reports (a) BCS participation rates of Arabic women living in Qatar, and (b) relationships between Arabic women’s BCS practice, their beliefs, values, and attitudes toward BCS, and selected sociodemographic factors. We hypothesize that there is a relationship between Arabic women’s beliefs, values, and attitudes toward BCS and their participation in BCS activities in Qatar.Participant inclusion criteria included being 35 years or older , abilitEthics approval for this research study was obtained from the Hamad Medical Corporation Research Committee , the Qatar Supreme Council of Health (Ethics Assurance No: SCH-A-UCQ-050), and the University of Calgary’s Conjoint Health Research Ethics Board (Ethics ID: E-23551). Consent to participate in this study was obtained from each participant. Prior to conducting an interview, each participant was given an explanation of the study and informed of her rights according to the standard interview guideline. Participants were assured that all information would remain confidential and interview questionnaires were stripped of identifying information to preserve confidentiality. No incentive was given to participants of the survey.Data collection was obtained from interviews using a structured survey questionnaire. Interviews were conducted in Arabic by seven female nurses fluent in Arabic and English. Survey questionnaire items were incorporated from previous peer-reviewed surveys on breast cancer research in the United States and Australia with permission from authors, and further refined after a pilot study field-tested the questionnaire in Qatar -39. ForwDescriptive statistics  and chi-squared tests were performed to determine associations between categorical dependents and categorical predictors. Simultaneous multivariate logistic regression analyses using the “Enter” method was used to further assess the association of preselected factors related to beliefs, values, attitudes, and sociodemographics with binary dependent variables . Multicolinearity for all covariates significant after bivariate analyses was tested before using them in the multivariate logistic regression analyses. Participants assessed with appropriate adherence to BCS recommendations (BCS Practice = Yes) were compared to those who were not (BCS Practice = No). Statistical significance levels were established at alpha = 0.05 , 52% were Qatari nationals, and 47.9% were non-Qatari residents , two-thirds had lived in Qatar for 30+ years, 33.3% had a university education, 36.6% of the married participants’ husbands had a university education, and 65.9% of the participants were unemployed (89.3% of whom were homemakers). Additional analyses found that younger participants were more likely to be university educated than older participants, and the eldest age group (50+ years) was made up of more Qatari nationals than non-Qataris (p < 0.05) , religion 98.2% Muslim), and living area (88.7% in urban areas). Participants’ ages ranged from 35–82 years  Figure .The majority of participants stated that their health status was “good” or “excellent” (76.2%). When asked why people get cancer, participants responded “fate,” “having an unhealthy lifestyle,” “not breastfeeding one’s baby,” or “hereditary factors.” Less than half believed that cancer is preventable (42.8%), and less than one fifth reported that cancer was a punishment from God, bad luck, or that cancer was contagious.The majority of participants reported that they trusted and understood their health care provider (HCP), they felt their health care providers respected them, and that their health care needs were being met. Although only 24.4% of the participants reported that their doctors had talked to them about breast cancer, most said they would make a mammogram appointment if they received a recommendation from their HCP. Most participants said they would want to know if they were diagnosed with cancer (86.6%), and preferred to consult doctors (72.4%) and other HCPs (90.8%) who were female; only 2.1% preferred that a nurse examine them rather than a doctor. Approximately half of the participants had no preference for their HCPs’ language (48.6%) Table .Of the participants who were planning to have a CBE n = 525) or a mammogram , over three quarters reported the following reasons: their own health, their doctor recommended it, or fear of getting cancer. Approximately two thirds said their plan to have a CBE or a mammogram was due to a recommendation from a family member/friend or nurse or from seeing information about breast cancer and its screening in the media or hearing about it in a community health clinic lecture  was because their doctor did not recommend it. Approximately one fifth to one quarter of all participants said their failure to plan a CBE or a mammogram was due to embarrassment related to the procedure, not knowing where to go for a CBE or mammogram, possible pain involved in the mammogram procedure, or fear of cancer being discovered. Fewer participants reported reasons such as it would not do any good, a male might examine them, or fear of gossip. Less than 2% said their avoidance of CBE and mammography was due to their husbands’/male relatives’ disapproval of breast examinations  than younger or older participants. Participants were more likely to practice BCS if they reported their health status to be good or excellent, if they thought that cancer is preventable, or if they thought that cancer is hereditary than participants who did not subscribe to these beliefs. Participants who stated they would want to know if they have cancer were more likely to have had or were planning to have a mammogram. Participants were significantly A higher education level of the participant or the participant’s husband was significantly related to a perceived good-excellent health status, the belief that cancer can be prevented, or the desire to know if cancer was present (p < 0.05). Participants with higher education levels were also more likely to believe that cancer can be hereditary or can arise from an unhealthy lifestyle, whereas less educated participants were more likely to believe that cancer is God’s punishment, bad luck, or contagious (p < 0.05).Participants whose doctors had talked to them about breast cancer and who understood the doctor’s message were significantly more likely to practice BCS. Participants who trusted their doctors and had no gender preference for their HCP were more likely to have had a CBE. Those who preferred to have a doctor rather than a nurse examine them were more likely to have a mammogram than those who preferred a nurse examine them or who had no preference. Language preference for one’s HCP (Arabic or English) was not significantly related to BCS practice Table .Further analyses on age and education differences indicated that older participants (50+ years) and those with lower education levels were more likely to have no preference for the status of HCP (doctor or nurse) that examined them, did not want to know if they had cancer, and believed cancer result from not breastfeeding (p < 0.05).Participants who were planning to have a CBE “for health” were significantly more likely to have had a CBE. Participants were less likely to have had a CBE and less likely to plan to have a future CBE if they perceived a CBE might be painful/ uncomfortable, if they were afraid cancer might be discovered, or they felt the procedure would embarrass them (p < 0.05) Table .Participants with lower education levels were more likely than those with higher education levels (p < 0.05) to give the following reasons for not planning a CBE: fear of finding cancer, and the belief that a CBE would not be beneficial.Participants 40 years of age or older were significantly less likely to have had a mammogram if they stated the following reasons for not planning a future mammogram: a mammogram might be painful/uncomfortable, fear of knowing they might have cancer, fear of gossip, or embarrassment (p < 0.05) Table .Mammogram practice was not significantly related to participants’ perceptions that a mammogram would not have benefits. However, older participants were more likely to state that their doctors did not recommend having a mammogram, that a mammogram would not do any good, or that they were afraid that cancer might be discovered (p < 0.05). It is important to note that nonsupport of husband or male relatives was not significantly related to participants’ intention to avoid mammography.Table Participants who believed their health status was good–excellent , that cancer could be prevented , or that cancer is hereditary  were twice as likely to practice BSE than those who did not subscribe to these beliefs. Participants who preferred female rather than male HCPs to examine them were half as likely to practice BSE  as those who did not care whether the examining HCP was male or female.Participants who believed cancer could be prevented , who understood their doctor’ message , and believed cancer is hereditary  were more likely to have had a CBE than those who did not. Participants who believed that cancer is God’s punishment  or preferred a female HCP rather than a male HCP to examine them  were approximately half as likely to have had a CBE than those who did not believe cancer is God’s punishment or did not care whether the examining HCP was male or female.Predictors for not planning a CBE included participants’ fear of knowing they might have cancer  and participants’ embarrassment regarding the CBE procedure .Participants (40+ years of age) were more likely to have had a mammogram if they understood their doctor’s message , if they believed cancer could be prevented , or if they believed cancer is hereditary . Participants were half as likely to have had a mammogram if they believed that cancer is God’s punishment  than those who did not have this belief.Fear of knowing one might have cancer  was a significant predictor for not planning to have a mammogram.These findings provide a partial answer to the question of why, despite the availability of health care services and gender-appropriate health care providers in Qatar, less than one third of the women interviewed practiced BCS according to national guidelines. Consistent with Kleinman’s explanatory model of health, illness and disease, this study found that several complex beliefs and attitudes toward breast cancer screening influence BCS uptake among Arabic-speaking women in Qatar. As with Arab or Muslim women living in the West, the women interviewed had low BCS awareness and low screening rates, they overwhelmingly preferred female physicians, and they gave fear or embarrassment as reasons for why they did not plan to have a CBE or mammogram ,41. HoweIt is important to note that fear of cancer is apparently both a facilitator and a barrier to BCS participation, a finding congruent with previous studies in the region ,15,17,30Previous studies indicate that low perceived risk and pessimistic views related to cancer among Arab women can act as barriers to cancer treatment or BCS ,15,43,44Arab patients greatly respect their physicians as experts whose advice is followed . While oMost Qatari women are Muslim and report having a strong faith in God . ModestyIt is difficult to generalize the results of this study to all women living in Qatar because of the non-probability convenience sampling. An attempt to increase generalizability and to reduce potential bias was made by randomly-selecting times to reach every potential participant who met study’s inclusion criteria at all research sites, resulting in a high response rate of 87.5%. Also, data were collected from self-reported interviews, which might be affected by recall or social-desirability response bias. However, the results of this study give insights into breast cancer screening practices of Qatari women that can be applied to women with similar sociocultural backgrounds throughout the Middle East and globally.This study’s findings indicate low levels of awareness of BCS and low participation rates in BCS among women in Qatar. Women who engaged in BCS practice were more likely to have a doctor who talked to them about breast cancer, to believe they were in good–excellent health, to believe that cancer can be prevented, or to believe that cancer might be hereditary. While the majority of participants stated they would want to know if they had cancer and felt their health care needs were being met, their main reasons for not planning BCS were lack of a doctor’s recommendation, fear of being diagnosed with cancer, fear of possible discomfort in the BCS procedures, and embarrassment in undergoing BCS.As women in Qatar become more educated and aware of health and disease, health care providers and policy makers must facilitate Arab women’s desire to know more about the benefits of cancer screening for early detection of this disease. Similar to the findings of a qualitative study of Iraqi women living in the U.S. , the majIf female and male health care professionals would make breast cancer and its screening a mandatory topic of discussion with all gender and age-appropriate women and men, awareness could be raised of culturally-appropriate services available in Qatar. Public health awareness campaigns that highlight these services and regular physician-patient discussions about BCS can be cost-effective and efficient strategies to integrate BCS into the public consciousness while effort is being made to advance national cancer registries and national population based screening programs in Qatar.Ensuring ongoing screening practices requires culturally appropriate community support from respected elders, religious leaders, and breast cancer survivors. Collaboration between researchers, community leaders, health care professionals, and policy makers is important to ensure the appropriateness and success of educational and outreach campaigns aimed at increasing screening uptake and reducing morbidity and mortality related to breast cancer among women in Qatar.BCS: Breast cancer screening; BSE: Breast self examination; CBE: Clinical breast examination; HCP: Health care provider.The authors declare that they do not have any competing interests.DT: Contributed to the conception and design of the study and the acquisition, analysis, and interpretation of data, drafted the manuscript, and gave final approval of the manuscript version submitted for publication. AKA: Contributed to the conception and design of the study and the acquisition of data, revised the manuscript, and gave final approval of the manuscript version submitted for publication. BAS: Contributed to the conception and design of the study and the acquisition of data, revised the manuscript, and gave final approval of the manuscript version submitted for publication. AKM: Contributed to the conception and design of the study and the acquisition of data, reviewed the manuscript critically for content, and gave final approval of the manuscript version submitted for publication. AMN: Contributed to the conception and design of the study and the acquisition of data, revised the manuscript, and gave final approval of the manuscript version submitted for publication. MM: Contributed to the conception and design of the study and the acquisition of data, reviewed the manuscript critically for content, and gave final approval of the manuscript version submitted for publication. SR: Contributed to the conception and design of the study and the acquisition, analysis, and interpretation of data, revised the manuscript, and gave final approval of the manuscript version submitted for publication. CS: Contributed to the analysis and interpretation of data, drafted the manuscript, and gave final approval of the manuscript version submitted for publication. FT: Contributed to the analysis and interpretation of data, revised the manuscript, and gave final approval of the manuscript version submitted for publication. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6874/13/49/prepub


More knowledge is needed about structural factors in society that affect risky sexual behaviors. Educational institutions such as universities provide an opportune arena for interventions among young people. The aim of this study was to investigate the relationship between sociodemographic and religious factors and their impact on sexual behavior among university students in Uganda.In 2005, 980 university students (response rate 80%) were assessed by a self-administered questionnaire. Validated instruments were used to assess socio-demographic and religious factors and sexual behavior. Logistic regression analyses were applied.Our findings indicated that 37% of the male and 49% of the female students had not previously had sex. Of those with sexual experience, 46% of the males and 23% of the females had had three or more sexual partners, and 32% of the males and 38% of the females did not consistently use condoms. For those who rated religion as less important in their family, the probability of early sexual activity and having had a high number of lifetime partners increased by a statistically significant amount . However, the role of religion seemed to have no impact on condom use. Being of Protestant faith interacted with gender: among those who had debuted sexually, Protestant female students were more likely to have had three or more lifetime partners; the opposite was true for Protestant male students.Religion emerged as an important determinant of sexual behavior among Ugandan university students. Our findings correlate with the increasing number of conservative religious injunctions against premarital sex directed at young people in many countries with a high burden. of HIV/AIDS. Such influence of religion must be taken into account in order to gain a deeper understanding of the forces that shape sexual behavior in Uganda. The early phase of the HIV/AIDS pandemic struck Uganda with great severity. In 1995 the estimated prevalence of HIV infection in the adult population was 15% Such efforts reduced the prevalence of HIV/AIDS in the adult population to about 5% In a global perspective, there are several studies of the relation between sexual behaviors and the financial and educational level of the household, and the influence of urban or rural setting elements The importance of socioeconomic factors was demonstrated in a study on the estimated median age at first sex (AFS) among men and women born from the 1950 s through the 1980 s in Uganda. The findings showed an increase of AFS among women born after 1970, but not men. However, since results varied in comparing the neighboring districts of Masaka and Rakai, the authors suggest this might be explained by socioeconomic differences between those areas A cross-sectional study carried out among young people in Zimbabwe found religion to be a protective factor in sexual abstinence Our knowledge of whether urbanization and a growing middle class, together with an increasing conservative religious movement, has changed the ABC pattern among university students in sub-Saharan Africa in general, or in Uganda in particular, is uncertain and even contradictory. Therefore, we lack the information to assess the implications these societal changes may have on the HIV/AIDS situation in this group and, consequently, on the prerequisites for successful intervention. Accordingly, the aim of this study was to investigate the relationship between sociodemographic and religious factors and their impact on sexual behavior among university students in Uganda.The research project was approved by the Institutional Ethical Review Committee at MUST.The study was performed at Mbarara University of Science and Technology (MUST), a public university in the town of Mbarara in southwestern Uganda. Founded in 1988, the school emphasizes community involvement in its teaching, fieldwork, and research. Our sample was drawn from the university's three faculties: medicine, science, and development studies, which at the time had a combined enrolment of 1220 undergraduate students, most of whom came from the surrounding area.Data was collected by means of an 11 page self-administered instrument consisting of 132 questions. The development of the questionnaire was based on valid instruments used in other studies of a similar nature, and on the outcomes of focus group discussions with youth, including students in Mbarara district The questionnaire assessed lifestyle factors ; relationships, love, and sexuality; social relations, participation, and trust ; self-rated health, including mental health; and social and demographic factors .Area of origin was dichotomized into “rural” and “urban/peri-urban or small town”.The educational level of the head of household during childhood was dichotomized, so that “did not finish primary school” and “completed primary school” were coded as “low”, and “completed secondary school” and any education above that was classified as “high”.The primary family religion during childhood was reported by selecting one of the following alternatives: “Protestant”, “Catholic”, “Moslem”, “Pentecostal”, “Seventh-day Adventist”, “Orthodox”, and “other”. In the final analysis only individuals reporting “Protestant” or “Catholic” denomination were used, since they make up the two major religions in our sample.The role of religion in the family when growing up was dichotomized, so that “religion played a big role” and “religion was relatively important” were coded as “big role”; and “religion was not so important” and “religion was not important at all” were coded as “not big role”.Faculty of study was reported and categorized as “medicine”, “development studies”, or “science”.Two age groups were established for our analysis: “younger” (≤23 years old), and “older” (>23 years old).Self-related health was defined on the basis of responses to the question: “How do you classify your current health in general?” There were five alternative answers: “very bad”, “bad”, “fair”, “good”, and “very good”. In the following analyses, the variable was dichotomized into less good  and good .The variable for having previously had sexual intercourse was defined as “yes” or “no”, based on responses to the question: “Have you ever had sexual intercourse?”Age at sexual debut was dichotomized, so that having sexual intercourse for the first time before age 19 was coded as “low”, and at or above age 19 as “high”.Number of lifetime sexual partners was defined by responses to the question: “How many sexual partners have you had altogether?” The variable was then dichotomized, so that ≥3 was coded as “high”, and <3 was coded as “low”.Condom use with new partner was measured by responses to the question: “How often do you use a condom with a new sexual partner?” Respondents could answer by choosing any of five alternatives: “always”, “often”, “sometimes”, or “never”. This was then dichotomized by keeping the first alternative as “always” and the latter three as “not always”.Condom use on latest occasion of sexual intercourse was assessed through responses to the question: “Did you use any method for avoiding STDs on your latest occasion of sexual intercourse?” There were three alternative answers: “no”, “yes, condom”, and “yes, other”. The variable was then dichotomized, so that “no” and “yes, other” were coded as “inconsistent”, and “yes, condom” was coded as “consistent”.Sample size was given since we assessed all the students at the university, but a formal check revealed that in most analyses a 75% increase of risk could be ascertained at 80% probability. This did not exclude the risk of not being able to detect some true effects of moderate size.p-values shown in The statistical analyses were done with SPSS Version 16.0. Logistic regressions were performed to calculate the crude odds ratios (OR) and 95% confidence intervals (CI) for the effect on age at sexual debut, having previously had sex, number of lifetime sexual partners, and consistent condom use. Differences between men and women in the prevalence of the variables used were calculated by means of Chi-square values upon which the In order to estimate the mean age of sexual debut, we performed a survival analysis with our data by making age at first sex right-censored since some people had not yet had sex.Multivariate logistic regression stratified by sex was used to investigate the association between role of religion, religious affiliation, and sexual behavior. The effect of these variables on behavioral factors  was adjusted for age and area of origin. OR and 95% CI were used as measures of association.An additional analytical step was taken to determine whether there was effect modification between the variables chosen. Effect modification is present when a certain factor has a greater impact on an outcome in the presence or absence of a third variable .The test for effect modification was made as a test for “more than additivity”, according to Rothman SI = OR(AB)−1/(OR(Ab)−1)+(OR(aB)−1) OR = odds ratio; AB = exposed to both factors; Ab = exposed to one of the factors, and aB = exposed to the other factor. In the absence of effect modification, SI = 1, i.e., there is a pure additive effect when both exposures are present. In case of synergy, SI is greater than 1 ; in case of antagonism, SI is less than 1.A total of 980 students responded to the questionnaire, representing 80% of all (n = 1220) registered students. Thirty-five percent (n = 347) of the respondents were female and 65% (n = 633) were male.In the group that stated they had previously had sex, 45.9% of the males and 23.1% of the females reported having had three or more sexual partners. More females (37.8%) than males (31.5%) stated that they do not always use a condom with a new partner.Based on these findings, two variables (role of religion and religious affiliation) were chosen as the main determinants of sexual behaviors for further investigation. We adjusted for potential confounding due to age and rural origin by employing multi-variate logistic regression.Since the aim of the study was to analyze the pattern of associations between sociodemographic and religious factors that correlate with previously had sex, age of sexual debut, number of sexual partners, and condom use, we next, in Effect modification between gender and role of religion was demonstrated regarding having previously had sex: males reporting that religion did not play a big role had a higher probability of having previously had sex than males for whom religion was rated as important, a pattern not visible found among females. Effect modification between gender and type of religion, i.e. Protestant vs. Catholic, was also demonstrated with regard to previously having had sex. We found that type of religion had opposite outcomes among men and women. In Protestant male students, the likelihood of having previously had sex increased, while it decreased among women of the same denomination.Furthermore, effect modification between gender and religious affiliation was demonstrated regarding lifetime sexual partners. Being a Protestant had opposite effects for men and women. No effect modification between gender and role of religion appeared with regard to condom use, since none of the combinations of the exposure variables mentioned appeared to affect the outcome. The same was largely true concerning effect modification between gender and religious affiliation and condom use. However, Protestant male students tended to be associated with a higher risk of not using a condom, compared with female Protestant students.Our study demonstrated a statistically significant correlation between two sets of factors: importance of religion and religious denomination in relation to sexual debut and number of lifetime sexual partners.Gender tended to modify the effect of role of religion. Responses stating that religion played a big role in one's family were associated with previously having had sex among males, but not among females. Gender also seemed to modify the effect of religious affiliation. Being of Protestant faith was associated with higher risk for previously having had sex among males, but with lower risk among females. Protestant male students showed a lower probability of having many lifetime sexual partners compared with Catholic male students, while the opposite seemed to be the case among Protestant female students.The results must be interpreted in relation to its rather exclusive target group, and the generalization of our findings to all individuals of the same age should be made with care. The majority of those in the target group have most probably grown up in a more protected environment than others in their age group. More than two-thirds of the students were raised in an urban or suburban area by a head of household who had a high educational level. This is not representative of young people in Uganda in general, only 14% of whom live in urban settings, according to the 2002 National Census. Of the population ages 20 to 24 years old, 8.9% was enrolled in post-secondary (higher) education This study was performed by means of a cross-sectional design, which may present difficulties in ascertaining the direction of causality between the variables analyzed. However, the sociodemographic variables were all unlikely to be affected by the sexual behaviors that constituted the outcome variable, since the circumstances involved  chronologically preceded the outcome.As noted, more than 80% of all students at the university completed the questionnaire. Most of the remaining 20% could not be contacted by the research team because they were not on campus for various reasons. The “true” rate of non-responders was, therefore, less than 20% (and probably below 5%). Although we did not have access to information on how many students were off-campus, we know that 66% of the total number of students were males and 34% were females. The distribution of males and females in the remaining 20% (240 students) was 72% (n = 172) for males and 28% (n = 68) for females. Under these circumstances, it seems unlikely that systematic factors should have caused any selection bias of importance for the results. Internal missing was on the order of 5% to 10% regarding questions concerning sexual behavior. This could lead one to infer a moderate selection bias in an unknown direction, although the likelihood that this would have dramatically biased the risk is low.The issue of misclassification should also be considered. We could not rule out the possibility that some of the respondents underreported sexual behavior that would be viewed as socially undesirable. If this were done in association with the background factors , it could represent dependent misclassification and, in such a case, would most likely exaggerate the findings. Thus, an alternative explanation to the suggested effect modification by gender would be that there may have been differential reporting of sexual behavior by the men and women in our sample, i.e., stronger moral rules might have made women underreport “unacceptable” sexual behavior to a greater extent than men did. However, upon scrutinizing our findings, this does not seem to be a very systematic pattern, although it cannot be ruled out. Moreover, respondents were guaranteed anonymity, and when the outcome of the questionnaire was discussed with student representatives, they stated that this guarantee was taken seriously. In their judgment the results gave a realistic picture of the true circumstances.Among possible confounders the most obvious one was age. All final risk estimates were, therefore, controlled for this factor. Since being of rural origin was also a predictor of sexual behavior, this variable was included as a potential confounder in the final multivariate model. However, one might object that this could result in a measure of overadjustment, since the variable could be a determinant of religious engagement, thus representing a single possible pathway. Because the other sociodemographic factors did not appear significantly related to the outcome variables, they were not considered potential confounders. In summary, even though the most plausible confounders were controlled for, this did not change the risk estimates.Age was used as a dichotomous variable in the analyses. We made supplementary analyses which very clearly showed that age and sexual debut/number of sexual partners were not related in a linear way as a simple function of time . Rather, there is evidence for both a period and cohort effect. Therefore, we found it justifiable to group all individuals into two age groups. The results of our study indicated a relatively low level of risky sexual behavior among the majority of students. Religious influences and denominational networks might partly explain this.Our findings are in agreement with those of previous research performed mainly in settings outside Africa, where it was concluded that religious engagement was a protective factor for risky sexual behavior present religious practices are directly related to the religion with which one grew up. As a result, hence an association may be drawn between past and present religious affiliation and current sexual behavior.Religious affiliation in Uganda is a lifetime commitment whose practices and rituals becomes part of an individual's daily experience. If one is born Catholic, she or he will be baptized Catholic, will go to Catholic schools, is expected to marry someone from a Catholic family, and will vote for Catholic-leaning politicians. Since it is uncommon to change one's religious affiliation , it is highly likely that a person's Although the Protestant Church only represents the second largest religion in Uganda, the western region of the country in which Mbarara University is located is predominately Protestant. That denomination exerts a strong political and social influence on many aspects of public and private life in Uganda. Religion among conservative Protestants in Uganda has increasingly become an exclusive “club” in which membership is obtained through strict Christian indoctrination. For example, students at Makerere University in Kampala, the capital of Uganda, are invited to join both a Christian Union and a care group  when they enter the university. These two organizations distribute cards for students to sign pledging themselves to “abstinence until marriage”. Students are also invited to attend “virginity rallies” According to informants in Mbarara, “subgroups” or networks of conservative Protestant students at MUST stage similar activities and recruit new members during the first few days of each semester. The groups have the financial resources to mount attractive networking activities. In order for students to join, they are obligated to follow certain rules of conduct . Whoever does not abide by the rules is reported to the group leaders.In our judgment, the Protestant group at MUST seems most akin to Kindler's category “participation in a religious community” cited above. Institutional conservatism may also be implied because of the character of the Protestant Church in Uganda.Our survey showed a similar pattern of behavior among Protestant female students regarding condom use as identified in Miller & Gur's study as their institutional conservative group, i.e., neither differed from other individuals. However, most sexual relationships involving a Protestant female student in Uganda take place in secrecy, according to informants, which differs from the findings reported by Miller & Gur. Moreover, the impact of religion may depend on the specific cultural context. A Ugandan Protestant young woman involved in a sexual relationship may be more likely to use condoms for fear of pregnancy, which would expose her clandestine behavior and subject her to condemnation by her family and coreligionists.Our findings also showed a lower risk for having had sexual intercourse among Protestant female students. In Uganda, this might be because Protestant girls are brought up in a closed system of rigid institutionalized choices, less exposed to the “outside” world, and thus less likely to engage in early sexual activities. In previous research conservative Protestantism has been described as both a cultural phenomenon and a religious subculture that protects or insulates the individual from external secularizing trends We found that importance of religion and religious affiliation was associated with abstinence. In a recent study Muslim men were less likely to practice abstinence than Protestants, Pentecostals, and Catholic male youth Not only is, premarital sex is unacceptable to religious individuals in Uganda: it is believed that becoming pregnant stigmatizes not only the individual, but the church as well. Thus, the demand that members practice abstinence before marriage is not debatable, regardless of whether an individual is planning to marry in the near future. According to interviews with 15 to 24-year-old young people in the Mityana and Mubende districts of Uganda, their society expects that a person abstain from sex before marriage, i.e., remain a virgin. Moreover, the prevailing norms do not support the use of condoms or any other method of contraception The increasing impact of religion and religious affiliation is very obvious in Ugandan society, and impacts most young people's daily lives in Uganda. Religious beliefs and attitudes on sexual matters appear to have considerable influence on the sexual conduct of Ugandan young men and women. However, the causal pathway between religion and sexual behaviors among university students is likely to be complex. Interaction between such factors as social capital, social norms, and influence of peers may play a role. This was illustrated in a recent study in which students from a university in Uganda described themselves as being in the middle of an emerging clash of sexual ideologies The results of the same study showed that 11 out of 20 students who are members of the Pentecostal Church had been involved in sexual activities. This indicates that even a fundamentalist religious commitment does not rule out sexual activity among young people, despite the church proclaiming the opposite.It is unclear if the control mechanisms of religion generate behavior modification through fear or through conviction. However, one may conjecture that fear of consequences plays a significant role in explaining why religious affiliation has had a more conservative effect on females. The gender imbalance rooted in the social culture and property relations in Uganda influences the power of decision making in sexual relationships. Uganda is predominately a masculine society in which men also control matters of sex Religious factors appear to be important determinants of sexual behavior among Ugandan university students. Our findings should be viewed against the background of the increasing role of conservative religious injunctions against premarital sex among young people that is evident in many countries with a high burden of HIV/AIDS. Thus, the influence of religion must be taken into account in order to gain a deeper understanding of the forces that shape sexual behavior in Uganda. With such knowledge, one may design and implement more effective interventions to prevent the spread of sexually transmitted infections. However, the interplay between religion and gender is very complex and only some facets can be captured by means of quantitative methods. Additional light might, therefore, be shed on those issues by means of complementary studies using qualitative methods. Therefore, further research is needed to fully comprehend the mechanisms by which conservative religious beliefs and the social attitudes that result from them inadvertently promote risky sexual behavior.


The Internet’s potential impact on suicide is of major public health interest as easy online access to pro-suicide information or specific suicide methods may increase suicide risk among vulnerable Internet users. Little is known, however, about users’ actual searching and browsing behaviors of online suicide-related information.To investigate what webpages people actually clicked on after searching with suicide-related queries on a search engine and to examine what queries people used to get access to pro-suicide websites.A retrospective observational study was done. We used a web search dataset released by America Online (AOL). The dataset was randomly sampled from all AOL subscribers’ web queries between March and May 2006 and generated by 657,000 service subscribers.We found 5526 search queries  that included the keyword "suicide". The 5526 search queries included 1586 different search terms and were generated by 1625 unique subscribers . Of these queries, 61.38% (3392/5526) were followed by users clicking on a search result. Of these 3392 queries, 1344 (39.62%) webpages were clicked on by 930 unique users but only 1314 of those webpages were accessible during the study period. Each clicked-through webpage was classified into 11 categories. The categories of the most visited webpages were: entertainment , scientific information , and community resources . Among the 1314 accessed webpages, we could identify only two pro-suicide websites. We found that the search terms used to access these sites included “commiting suicide with a gas oven”, “hairless goat”, “pictures of murder by strangulation”, and “photo of a severe burn”. A limitation of our study is that the database may be dated and confined to mainly English webpages.Searching or browsing suicide-related or pro-suicide webpages was uncommon, although a small group of users did access websites that contain detailed suicide method information. Internet usage is growing exponentially with one third of the world population having Internet access as of 2011, of which 45% were users below the age of 25. The number of Internet users from developing countries has increased from 44% in 2006 to 62% in 2011 .Infodemiology is a new area of research described as “the science of distribution and determinants of information in an electronic medium,”  specificIn the area of suicide prevention, Dobson  has estiSearch engines on the Internet are often assumed to be an efficient, if not the preferred, gateway for access to suicide-related information ,20. A haAlthough prior research has shown that pro-suicide information on methods of suicide are easily accessible through search engines, the findings invited the criticism that the keywords and phrases used were pre-selected by researchers and thus had poor generalizability since the studies were not grounded in the naturalistic search behavior of non-researchers, web-savvy, or suicidal people . AnecdotA web search dataset released by the AOL is publicly accessible for data analysis (see similar research in ). This dEach entry contained an anonymous service subscriber identity code (ID), time of submission, the rank position, and domain of the clicked-through webpage. A single search query represents one individual click on the “search” button as initiated by a user, regardless of whether the user clicked on any of the webpages in the results page(s). A unique set of one or more keywords used in a search query constitutes the search term(s). A click-through is where a webpage in the returned search results was accessed by an individual click following a single instance of a search query and consequently that webpage is referred to as a clicked-through webpage. The number of click-throughs can also be referred to as traffic.In response to concerns about privacy, additional measures were taken to replace all possible personal identifiable information from the dataset before undertaking analysis. Each unique subscriber was assigned a random identifier number. The Human Research Ethics Committee for Nonclinical Faculties of the University of Hong Kong approved the ethical aspect of the study protocol.suicide in the search term(s) was retrieved from the dataset, and the contents of all clicked-through webpages following these search queries were then content analyzed to derive categories for analysis. Researchers PW and RY independently categorized all of the identified webpages, and each created an initial coding frame. The two coding frames were then compared and refined to develop a consensus coding frame. All of the clicked-through webpages were subsequently individually re-categorized by researchers PW and RY to form the final coding frame. Using the final coding frame, coding disagreements between PW and RY that could not be resolved were referred to the third researcher KWF, who analyzed those blinded to the codes assigned by researchers PW and RY. In most cases, this approach resolved the disagreements but when a decision still could not be made, researchers PW, RY, and KWF jointly visited the clicked-through webpage and discussed the rationale for their coding until agreement was reached.To address our first research question, any search query containing the keyword To address our second research question, web domains from the webpages in the above 11 categories that appeared to encourage suicide or promote the individual right of dying by suicide regardless of medical grounds  were ideWe found 5526 search queries  that included the keyword suicide. The 5526 search queries were generated by 1586 unique search terms and 1625 unique users . The three most frequently used search terms were “suicide” , “suicide girls” , and “how to commit suicide” . Of the 5526 search queries, 3392 (61.38% of 5526) clicked through to a resulting webpage.Of 3392 search queries with a click-through, 1344 unique webpages were clicked through by 930 unique users using 908 unique search terms. Of the 1344 webpages, 30 webpages were found to be inaccessible during the study period (October to November 2011) and returned error messages such as “page could not be found”, “forbidden access”, or “unable to display page” resulting in 1314 accessible clicked-through webpages. The three most frequently used search terms were also “suicide” , “suicide girls” , and “how to commit suicide” .Each clicked-through webpage was classified into 11 categories:Entertainment : Webpages of original writing, pictures, music, or other content that may contain the keyword “suicide” for the purpose of amusement but not necessarily related to the conscious act of killing oneself.Scientific Information: Webpages containing general educational materials, suicide statistics, and research studies.Community Resources: Peer support or non-governmental organization webpages related to suicide prevention.Specific Case/Incident: Webpages related to specific cases of highly publicized suicides.Specific Means: Webpages that explicitly provide details on the methods of suicide, except drug overdose (see below).Overdose and Suicide: There was a noticeable number of webpages that specifically addressed drug overdose or drug-related suicide information, and hence, a separate category from the Specific Means category was created.Religion and Suicide: Webpages with information on suicide from a religious perspective.Physician-Assisted Suicide: Webpages that contained information on euthanasia and physician-assisted suicide.Discussion Forum: Any webpages with an interface primarily for discussion between users.Families and Friends of Suicide/Attempt: Webpages with information about funeral arrangements and resources for family/friends of suicides.Afterlife: Webpages with information and opinions related to “life after death” from suicide as well as life after surviving a suicide attempt. This category was singled out from the “religion and suicide” category because users used search terms that specifically included “afterlife”, and these searches may or may not involve religiosity issues.Among the 1314 webpages, the proportions of the webpage categories are as follows: entertainment  , scientific information , community resources , specific case/incident , specific means , overdose and suicide , religion and suicide , physician-assisted suicide , discussion forum , families and friends of suicide/attempt , and afterlife .From the search queries, 78.01% of the traffic (2646/3392) went to a webpage link belonging to first page of the search results, 9.17% (311/3392) of the traffic went to the second page of search results, and 10.23% (347/3392) went to the third to fifth page of search results, while only 2.59% (88/3392) trickled to the sixth page or onwards in the search results. These results are generally consistent with current search engine data where links that are higher in the search engine results page, especially on the first page of the search results, tend to get majority of the traffic ,30.When suicide was used as a single keyword search term , users mostly clicked through to webpages that belong to the “community resources” (130 search queries), “scientific information” (69 search queries), and “specific means” categories (24 search queries). In contrast, when the search term “how to commit suicide” was used, the users most commonly clicked through to webpages in the “specific means” (70 queries), “overdose and suicide” (17 queries), and “religion and suicide” categories (13 queries).The search terms most commonly used to access webpages in the “entertainment” category included the keywords in the names of a specific adult website and a novel cum movie. The “specific case/incident” category top search terms involved the keywords in the names of two famous individuals and a teenager who died from suicide; of note, each of these three search queries were contributed by one single user. Webpages in the “specific means” category were most commonly clicked through when users used the search terms “how to commit suicide”, “ways to commit suicide”, and “suicide”.Among the 1314 accessed webpages, we could identify only two clicked-through websites that were considered pro-suicide. They are “http://www.suicidemethods.net” and “http://www.churchofeuthanasia.org”. The two websites not only provide information on methods of suicide but also portray a positive attitude towards the choice of using suicide as a way to ease pain. ” and investigated the types of webpages they had accessed in the search results of AOL’s search engine, one of the major search engines in the United States during the data collection period. As such, the database used in this study might be dated, confined to an English-dominated search engine, and mainly limited to North America; nonetheless, this is the most comprehensive database of its kind that is freely available in the public domain for exploration. Due to online privacy developments, no other comparable publicly available datasets exist. Although using Google’s search trend tool, Google Trends, may provide some data on searching behaviors, comparisons would be difficult on many levels, including sampling ambiguity, lack of information on absolute search numbers, normalization of search results, lack of details on scaling of search results, and inability to access fine-grained searches.This is a retrospective observational study aimed to investigate the naturalistic web searching behavior on a search engine by online users looking for content using suicide-related keywords. Specifically, we examined users’ search terms with the keyword “suicideDespite being a older dataset, especially in the context of the Internet where content and usage behavior is constantly changing, the findings still have relevance because, unlike prior studies that took a more computational perspective to suicide-related Internet searches, we used a naturalistic approach by looking at the users’ actual search behaviors. Rather than merely looking at what is available for our perusal on the Internet, which is subject to constant change, we examined the subsequent behavior with returned results, which seems relatively consistent even over time ,30. FurtUtilizing this type of dataset, however, means that although users’ search result click-throughs were logged, we do not have a record of the search results webpages they could see and potentially access. Also, users’ behavior after accessing the webpages cannot be examined. Nevertheless, it is possible to identify search trends, patterns, and popular click paths that allow us to gain insight into users’ searching goals and intent as well as pages that had high visibility based on the keywords used in the search queries.Presumably there are many existing websites that contain information about suicide, making the Internet’s role in suicides a point of concern. Our findings highlight three important findings on Internet users’ naturalistic web search behaviors that may challenge the underlying assumptions behind past studies suggesting that the Internet is intrinsically harmful because pro-suicide information can be found easily using suicide-related search terms. First, despite previous studies finding that pro-suicide and how-to-commit-suicide websites are easily accessible through search engines ,21-23, oIn traditional media, newspapers, radio, and television were the major sources for information and their consumers were perceived as passive receivers of information. Information portrayed in traditional media was mainly contributed by professional journalists, and hence, regulation of that information was relatively straightforward. In terms of suicide information in traditional media, since information about suicide cases are presented and received passively by the masses, media reporting guidelines on suicide information developed for professionals has been considered as a core prevention strategy . With thIn the Web 2.0 era, the new media is interactive. People become proactive consumers and producers of information. Not only can people search for information and contribute, messages and information can also be widely and easily shared among friends via social media and networks. The ease and low cost of creating and copying content on the Internet contributed to its exponential growth and now, the amount of information that can be found on the Internet can be considered as almost infinite. In 2004, Google’s whole data storage was approximately five petabytes, which is the quantity of data a thousand times larger than the Library of Congress’s print collection . AccordiInternet users use the Internet for various reasons. Segev and Ahituv conducted a cross-national analysis of popular search queries used in Google and Yahoo! over a 24-month period from January 2004 to December 2005 and found that there are cultural differences related to Internet usage . They foOur findings have provided a glimpse into the information consumption preferences of online users and corroborates prior studies on people’s Internet usage. Even for a domain-specific topic, suicide, our study generated consistent findings that most search engine users in the United States used suicide-related queries to search for websites that belong to the entertainment category.Although pro-suicide websites and websites that contain detailed information on suicide methods can be accessed easily, the majority of search engine users, at least in the United States, did not access them using suicide-related queries. A number of keywords used to access pro-suicide webpages were instead related to violent or bloody pictures including “gory pictures”, “gory photos”, and “homicide pictures”. With these queries, we suspect that those who accessed the websites might not have an intent to die. Westerlund  has suggIn-depth interviews with individuals with nearly lethal suicidal behavior may help to understand this phenomenon. In Biddle et al’s study , 22 indiIn our study, we found that a small group of individuals intentionally searched for information about ways to complete suicide and an even smaller group of individuals were eager to find discussion forums using suicide-related keywords. A few individuals used queries like “suicide by overdose of XX” or “suicide by XX” to get access to webpages that provide information on prescribed drugs and suicide. In contrast, websites that include information on suicide means were accessed by larger numbers of unique users. One individual used a specific discussion forum address as a query (“xxsuicide’s xanga site” as shown in the table) to get access to that particular webpage 10 times.There is a lack of research on suicide pacts arranged online, and so it is difficult to predict the major consequence of a large number of discussants getting access to this sort of discussion forum. On one hand, there have been some documented instances of completed suicide pacts in Japan , and on Current efforts to reduce the potential negative impact of the Internet on suicide include remedial actions like removing and blocking entries of harmful websites by using Internet filters, constant monitoring of potential harmful websites by “web-based police officers” as implemented in Japan and Korea, and displaying helpline resources information while users key in suicide-related queries. These strategies are in place in an attempt to either shield suicidal and vulnerable individuals from suggestive material or abort their suicidal wishes by diverting their attention to help resources. There are several challenges that these strategies face. First, these strategies do not observe the way that information is created, found, and accessed online. Accordingly then, restricting or removing potentially harmful websites is an arduous if not impossible task. Furthermore, cyber regulations are extremely difficult to enforce since the Internet is not clearly under any jurisdiction, and identification of a physical user can be elusive.Instead, it is important to further investigate the natural online behavior especially of vulnerable individuals and integrate that information with the way that search engines provide information. With the Internet inundated with information, the major search engines, ie, Google, Bing, and Yahoo!, have complex algorithms to return relevant search results to users. Consistent with the uses and gratification theory, relevance in a search engine is defined by variables such as user popularity, credible web domains, and high-quality content. As such, well-made and informative websites will tend to rank higher in search results and also be visited more often. Consequently, instead of the labor-intensive strategy of finding, sorting, and removing potentially harmful websites, more resources and effort should be spent on developing high-quality, informative, interactive, and user-friendly websites that maximize the likelihood of ranking highly in search results and therefore, being found and accessed.Also, more recent studies find that the Internet provides more positive than negative effects on the vulnerable, especially in enhancing the social support of isolated individuals though social networking sites ,42. MentOur research presented the naturalistic search behavior of search engine subscribers using any search terms with the keyword “suicide”. Currently we know that cybersuicide or Internet suicide pacts represent a small fraction of overall suicides. While those attempting suicide have searched for suicide-related information on the Internet before completing the act, we also know that the Internet can provide a unique platform to reach those individuals previously inaccessible, and web-based psychotherapies are producing promising results in helping depressed individuals, with the acknowledgment of the potential digital divide phenomenon. As such, it can be concluded that we should neither underestimate nor overestimate the potential negative impact of the Internet on suicide.Siri” (Speech Interpretation and Recognition Interface) is an intelligent personal assistant and knowledge navigator that functions as an application for Apple’s operating system and answers questions, makes recommendations, and performs actions by delegating requests to a set of web services to iPhone users. Google Images, a searching tool for images on the Internet, may help Google users to search for visual information using image or pictures. These are just a few examples. Suicide research and prevention strategies must keep up with the emerging trend and pace of ICT in order to prevent more unnecessary tragic deaths.However, the threshold between offline and online activities is quickly receding and in the near future will soon disappear. It is uncertain how much of today’s searching, and even learning, behavior will remain unchanged. There are plenty of daily examples that show how much of our learning behavior has transformed. “