7^th Annual Congress on Primary Healthcare, Nursing and Neonatal Screening July 27-28,2018 Vancouver, British Columbia, Canada

Chair

Natasha Iyer

Better: A medical centre for complete living

Co-Chair

Muhammad Ajmal Zahid

Kuwait University

Session Introduction

Bhaskar Chakravorti

Amipharma Laboratories Ltd

Title: Patient centric healthcare industry: Pharmaceutical companies can do more to put patients first

Biography:

Bhaskar Chakravorti has Pharmaceutical Marketing background which spans over 30 years in India and Sudan. His expertise is in formulating business strategies, developing new products & markets, launching new products and strengthening territorial markets. He has built people and brands in his career. Having worked with both multinational and regional companies, he has experienced the evolution of production-oriented marketing, sales-oriented marketing, doctor-centric marketing and finally to Patient-centric Marketing in Healthcare industry. He is a blogger, active in social media, photographer, TEDx speaker, Trainer, Speaker and a Social Entrepreneur.

 

Abstract:

Pharmaceutical companies must keep the patients at the top of their minds. On one hand pharma companies don’t want

to upset doctors by bypassing them and on the other hand, they have to function under stringent guidelines that regulate

direct to consumer (DTC) marketing. The best way to do this is to focus on creating trust rather than building brands. With

the increasing number of patients suffering from chronic illnesses such as diabetes and hypertension, noncompliance and

nonadherence is a big problem which further increases the suffering of the patients. Patient Information Leaflets (PIL) are now

being printed in local language e.g. Arabic in Sudan or Hindi in India. Patients can read about the several questions they have

in mind about their medication, especially the side effects. Codes in the PIL can link to the company’s website. The patient can

communicate directly with the company for various queries. The patients when they register themselves can receive online

medication reminder service. Pharma companies also provide health information so that patients can manage their illness

better. Pharma companies can create advocacy groups from the patients who are opinion leaders. These patients have a lot of

clouts both online and offline and these patients can be engaged periodically under the supervision of physicians who are Key

Opinion Leaders. Some of the patients in the advocacy group are frequent bloggers and active in social media and thus can

engage in chats with others interested in the specific disorder either hypertension or diabetes. This can benefit the patients to

modify lifestyles and reduce risk factors to prolong life with less suffering.

Margaret Kababu

LVCT Health

Title: Assessment of the uptake of intimate partner violence interventions among women accessing HIV testing services in Kenya: A quasi-experimental study

Biography:

Margaret Kababu is a research scientist with ten years’ experience in multi-disciplinary research. She has been involved in operational research in HIV and Gender-

Based Violence for the last four years. Margaret was previously a research scientist in an Integrated Pest Management and Malaria vector control program. She

has experience in the design and development of research protocols; development of research IEC materials and data collection tools; training and coordination of

field teams; qualitative and quantitative data management; analysis and documentation of research findings.

Abstract:

Background: Globally, about a third of women have experienced Intimate Partner Violence (IPV). IPV is linked to increased

HIV risk and is a key barrier to uptake of HIV prevention and treatment services among women. LVCT Health integrated IPV

counseling and support group interventions in HIV Testing Service (HTS) sites in Kenya. We conducted a study to measure

the uptake of IPV interventions in HTS settings.

Methods: In this study, we recruited 146 women who screened positive for experiencing IPV in four HTS sites in rural and

urban settings. Women accessing HTS were screened by HTS providers using the validated IPV screening tool. These women

were enrolled in the IPV interventions. The IPV intervention comprised monthly one-on-one IPV counseling and support

group sessions that ran for a period of six months. Baseline and end line surveys were conducted at the beginning and after 6

months using semi-structured questionnaires. We collected quantitative data on socio-demographics, willingness to take up

IPV services, uptake of IPV interventions and reasons for non-uptake of IPV services. Descriptive analysis was done using

SPSS version 22.

Results: Enrolled women had a median age of 28 years and 89% were married. At baseline, 55% and 42% of the participants

expressed a willingness to take up one-on-one counseling and support group interventions, respectively. However, 7% and 5%

of the participants took up one-on-one IPV counseling and support group interventions, respectively over the 6 month period.

Reasons for low uptake of the integrated IPV intervention included: lack of follow up after the sessions by HTS providers, busy

with home chores, lack of childcare support and fear that spouse would find out which would, in turn, escalate the experience

of violence.

Conclusion and recommendations: Low uptake of IPV interventions in HTS settings demonstrates the need for enhanced

follow up of women taking up IPV services in HTS settings. Integration of IPV in HTS settings requires additional investment

in human resources to manage the workload that comes with integration and communications to facilitate follow up.

ANOUA Adou Serge

Alassane Ouattara University

Title: Obstetric culture in the development of reproductive health

Biography:

ANOUA Adou Serge is a Doctor in socio-anthropology and Assistant in the Department of Anthropology and Sociology at the Alassane Ouattara University since July 2015. His domain of speciality is the socio-anthropology of health. The general problem that occupies its scientific reflection is the issue of Reproductive Health in rural Africa. He is particularly interested in the aspects of maternal and child health in Ivory. He is a member of the Laboratory of Studies and Research in Reproductive Health care Transition. He has published several articles in journals.

Abstract:

Maternal and child health remains a current challenge in Ivory Coast because of high maternal and child mortality rates

in that country. This failure raises the limits of the biomedical sciences in reproductive health. In this field of health,

there is undeniably a life quality problem. This concern is shared by socio-anthropology. As a matter of fact, how can we

explain and understand the evolution of reproductive health problems in mothers and children? All the work carried out

revolves around the issue of "Obstetric culture and reproductive health". In other words, how can we explain and understand

obstetric culture as a major determinant in the development of reproductive health in Côte d'Ivoire? In this context, reflections

oriented through socio-anthropological research are constantly supported by the same precise thesis: "Taking into account

socio-cultural determinants specific to the communities in question, impeding the health of the mother-child couple, could

contribute to opening the communities studied to a safer motherhood". Starting from this fundamental aim, strategies for

reducing dramas by taking into account the cultural markers of communities can be identified as well as actions for behavioral

change can be planned. This orientation seems to us a hypothesis of possible solution to circumvent the epidemiological

monopoly underlying the approach in public health.

Gwen van Servellen

University of California School of Nursing

Title: Quality care: Communication skills work...if we use them

Biography:

Professor van Servellen is a noted author, consultant, and educator. Her book: Communication Skills for the Health Professional: Context, Concepts, Practice,

and Evidence is in its 3rd edition and will be available September 2018. She completed her BS and MS in Nursing at the University of California, San Francisco

and her PhD from Stanford University, Palo Alto, California. She has published extensively on issues of quality care, treatment adherence, and patient satisfaction

and obtained research funding on these topics. She is a reviewer for several journals including those in Nursing, Psychology, Public Health, and Social Science

in Medicine. She is an editorial board member for Nursing and Health Sciences. After retiring from UCLA (2007) she held positions in research and administration

at three additional major universities. Her passion about communications and quality care are quite obvious from her widely read publications and invitations to

consult in the US and aboard.

Abstract:

There is ample evidence that health professionals do not always communicate as well as they should. Nursing is not alone;

this can be said about most health professionals having direct encounters with patients and their families Noted scholars

and professional organizations emphasized that communication skills are critical to providing patient- and family-centered

care and warn that health professionals lack adequate training and education in using communication skills to provide highquality

patient-centered care. The deficit in communication skill training is important across the board, but particularly in

health promotion and chronic illness, two concerns driving the direction of healthcare worldwide. Quality communications

promote high-quality patient-centered care, accurate identification of patients’ problems, health care utilization, adherence

to treatment, shared decision-making, and satisfaction with care. Core competencies; include active listening, empathy

and compassion, and appropriate use of questions. There is some evidence that lower work stress is associated with strong

communication skills. In any case, the greater part of specialists doesn’t feel sure about their relational abilities or maybe have

had no formal preparing by any means. If their skills were improved, it follows that quality of care could improve, and costs

of this care might be reduced. Educational preparation is foundational, but supportive work environments are also extremely

important. This presentation will focus on the role of communication skills in primary care practice and evidence to support

the link between communication skills, quality care outcomes, and patient satisfaction. Samples of dialogue will be offered

to illustrate points made. The role of informational technology in shaping healthcare communications, good and bad, will be

highlighted.

Ameneh Safarzadeh

University of Medical Sciences, Iran

Title: The effect of sexual counseling based on assertiveness on sexual function of married female students

Biography:

Ameneh Safarzadeh is working as faculty midwifery in pregnancy health research center, Zahedan university of medical sciences, Zahedan, Iran. She has 12 years

experience in teaching and researching midwifery and have published more than 20 articles in English language journal.

Abstract:

Objective: Sexual tolerability is one of the false convictions among ladies about sexual capacity, and ladies who have this

conviction pick a dormant and aloof sexual part. The present examination was led intended to research the impact of

conclusiveness construct sexuality mentoring with respect to the sexual capacity of wedded female understudies of University

of Sistan and Baluchistan.

Materials and Methods: This semi exploratory examination was a pretest-posttest configuration led on 80 female wedded

female understudies who were chosen and haphazardly doled out into two interventions(n=40) and control (n=40) gatherings.

The data collection tool was a questionnaire of Rosen's Sexual Function. The mediation aggregate after pretest participated in

four sessions under emphatics based sexual directing week after week in 2 sessions of 90 to 120 minutes. Both two groups filled

out the questionnaires after the end of the waiting period (2 months) (post-test). Chi-square, covariance and independent, pair

t-test was used to examine the mean of quantitative variables in the two groups.

Findings: The outcomes demonstrated that the mean score of sexual capacity list expanded in the meditation gathering and

after sexual guiding and diminished in the control gathering. Independent T-test also showed that the mean score of sexual

function index after sexual counseling in two intervention and control groups was not significant. But the mean change in total

index score was significant in both groups (P=0.0001).

Conclusion: Counseling method based on sexual assertiveness has been able to influence sexual function, expressing sexual

rights, and reducing the shame and contempt of women under study and cause significant results. It is safe to admit that this

method can be used as a way to promote sexuality and to establish a more intimate relationship in marital life.

Rita Giri

Tribhuwan University

Title: Knowledge regarding cervical cancer among undergraduate female student at selected college of lalitpur, Nepal

Biography:

Rita Giri has completed her Master in Nursing from Tribhuwan University. She has worked as staff nurse in different hospitals in Nepal and worked as lecturer and

clinical supervisor in different Nursing College of Nepal.

Abstract:

Cervical cancer is the second most common cancer in women living in less developed regions. In Nepal, Little is known about

the knowledge regarding cervical cancer in a female young adult. A descriptive cross-sectional study was conducted to find

out the knowledge regarding cervical cancer among undergraduate female students. Non-probability purposive sampling with

the self-administered structured questionnaire was used to collect the information among 150 female students of Little Angels

College of Management, Lalitpur, Nepal. The obtained data were analyzed using descriptive and inferential statistics. Among

the respondents, the mean age was 19.3 ± 1.1 years. Almost all (95%) of the respondents had inadequate knowledge regarding

cervical cancer. The respondents who knew the meaning of cervical cancer were 56%. Similarly, 35% of the respondents on an

average had knowledge about the risk factor. Almost two-thirds of students knew that cervical cancer is preventable. Regarding

the preventive measures, good hygiene was told by 68.5% of respondents followed by HPV vaccine 38.3%, using condom 19.5%

and Pap smear test 8.7%. The knowledge about the HPV vaccine was only on 11.8% of respondents. There was no statistically

significant association between knowledge with selected variables (age, religion, ethnicity, family income, smoking and sexual

practice) in the study. Based on findings it is concluded that female students had inadequate knowledge regarding cervical

cancer. This result reflects the need for health awareness campaigns to the students and community people regarding cervical

cancer including the symptoms, causes, risk factors and preventive measures.

Jason Wheatley

University of Pittsburgh Medical Center

Title: Fibular aplasia, tibial campomelia, oligosyndactyly (FATCO) syndrome: A rare disease with an evolving definition

Time : 17:05-17:30

Biography:

Jason Wheatley being educated in CPR and first aid in addition to lifesaving techniques from his days as a lifeguard to helping customers learn about their medications and insurance options as a pharmacy clerk. Dr Wheatley has his roots firmly in the science of healing. He is currently under training as a Maternal Fetal

Medicine Fellow.

Abstract:

Fibular aplasia, tibial campomelia, and oligosyndactyly (FATCO syndrome) is a rare disorder (estimated incidence of 5.7 to 20 cases/1 million births). Genetic basis and inheritance are unknown. Each case should be reported due to the paucity of reports and lack of a standardized treatment approach. To date, 15 cases of FATCO syndrome have been reported. We report two cases which match the radiological description of a FATCO syndrome variant and are the third and fourth reports on this variant. A 32-year-old female, G5/P2022 presented for her fetal anatomic survey at 20 2/7 weeks which showed a short

left femur, short bowed left tibia, fibular hypoplasia and a left foot shorter than the right, leading to a diagnosis of FATCO (Fibular aplasia, tibial campomelia, oligosyndactyly) syndrome. She met with Pediatric Orthopedic surgery prior to delivery as a result of this finding. She will be followed throughout the rest of the pregnancy with serial growth ultrasounds. A 34-yearold female, G1/P0 was seen for the routine fetal anatomic survey at 21 3/7 weeks which showed a shortened/bowed right tibia and shortened right fibula. This led to the diagnosis of FATCO syndrome. She met with Pediatric Orthopedic surgery prior to

delivery as a result of this finding and the rest of her pregnancy was uneventful with the spontaneous vaginal delivery of a baby boy at 40 weeks 1/7 days. FATCO syndrome ultimately requires corrective surgery after delivery. Prenatal identification of this syndrome allows for informed family planning. A detailed discussion with the pediatric orthopedic surgery as to the surgical timeline allows the mother and family to make informed decisions and plan for the necessary adjustments to their home life.

Nigussie Tadesse Sharew

Debre Berhan University, Ethiopia

Title: Occupational exposures to sharp injury among health care providers in Ethiopia regional hospitals

Biography:

Nigussie Tadesse sharew is an expert nurse practitioner (MSc Adult health Nursing holder) who is currently working as a lecturer at Debre Berhan University.

Nigussie is currently serving as a dean of college of Health science, Debre Berhan University. He is providing a free community service on live broadcasts about

numerous nursing issues. Moreover, he has been pursuing various research projects which could possibly improve the quality of nursing care in Ethiopia. Some of

the articles which are being considered for publication include a systematic review and meta-analysis of Infant and young child feeding practice in Ethiopia, A systematic

review, and meta-analysis of predictors of cervical cancer screening in sub-Saharan Africa and adherence to dietary and physical activity recommendation

among diabetic patients in Ethiopia. Nigussie is highly motivated to take apart at any international stage which could improve his research experience and expertise.

Abstract:

Background: According to World Health Organization pooled estimate, the annual incidence of sharps injury in Africa was

ranged from 2.10 to 4.68 per person per year, but research data in Ethiopia is limited. The point of the examination was to

research sharps damage pervasiveness and related hazard factors.

Methods: Institution based cross-sectional study was conducted with 200 healthcare providers (HCP) in Northeast Ethiopia.

Proportionate stratified sampling was used to select HCP. Sharps injury during the last 12 months was an outcome variable.

Data was collected adapting the World Health Organization best practices for injections and related procedures toolkit.

Bivariate and multivariate logistic regression analysis was carried out to identify sharps injury associated risk factors.

Results: In total, 195 HCP participated with a response rate of 97.5%. The prevalence of sharps injury was 32.8%. Following

adjustment for covariates health care workers who had no in-service job training (p < 0.001, OR = 4.7, 95% CI = 2. 05–10.56)

and HCP who had previous exposure to sharps injury (p-value = 0.002, OR = 3.7, 95% CI = 1.62–8.27) were more likely to

experience sharp injuries.

Conclusions: This study revealed 32.8% or at least three out of ten HCP exposed to sharps injury. This was found statistically

significant among HCP who had no in-service job training and who had previous exposure to sharps injury. Thus, training

HCP perhaps increases their skill and curiosity to reduce exposure to sharps injury.

Chair

Natasha Iyer

Better: A medical centre for complete living, Canada

Co-Chair

Muhammad Ajmal Zahid

Kuwait University

Session Introduction

Fatemeh Oskouie

Iran University of Medical Sciences (IUMS)

Title: Attrition among Iranian nursing students: A qualitative study

Biography:

Fatemeh Oskouie, BScN, MScOH and DrPH, is a Professor of School of Nursing and Midwifery, Iran University of Medical Sciences (IUMS) Tehran, Iran. She is

currently the head of Nursing Care Research Center (since 2007). She established WHO Collaborating Center for Education and Research in Nursing and Midwifery

in 2014. She also established the National Nursing Research Network in 2016. She works as a member of Nursing Board and is research advisor to the Nursing

Deputy of Ministry of Health of Iran. Her research interests are Public Health, Nursing Education, Quality of life, Non-communicable Diseases.

Abstract:

Statement of the Problem: Attrition is a major challenge facing nursing students that results in substantial costs on the

education, health, and treatment systems across countries and can have an unwanted effect on the quality and quantity of health

services provided as well as on the health of citizens. The purpose of this study is to describe nursing students' perceptions

toward factors influencing attrition.

Methodology & Theoretical Orientation: A qualitative study conducted using a content analysis approach. Nineteen

undergraduate nursing students enrolled in the nursing bachelor program were recruited using purposive and snowball

sampling. In-depth face-to-face focus and group interviews and participant observation were used for data production.

Conventional content analysis approach utilized for analyzing.

Findings: In this study nursing students’ attrition factors were categorized into two themes: ‘before admission’ and ‘after

admission’. The obligation to choose to nurse in the National Entrance Exam, poor management in workforce provision and

improper supervision, the discrepancy between expectations and experiences, and being work abused in clinical training were

the main factors of attrition.

Conclusion & Significance: Authorities in education and practice sectors can use these findings to improve the quality of

clinical and theoretical education and to avoid nursing student attrition. This can be accomplished through an expansion in

network consciousness of the character of nursing, proficient administration of workforce arrangement and clear and succinct

supervision of exercises in both hypothetical and clinical fields.

Rafiqul Islam

Kyushu University Hospital

Title: The portable health clinic: An innovative tele-healthcare system for unreached communities

Biography:

Dr Rafiqul Islam is working as an Associate Professor at Medical Information Center of Kyushu University Hospital under Kyushu University, Fukuoka, Japan.

Before joining here, he has been working as a Director of Global Communication Center, the ICT based R&D center of Grameen Communications, Bangladesh

for about 8 years. Earlier Dr Islam worked in Japanese IT industries for 12 years after completing his PhD in Information Engineering in 1993 from Hokkaido University,

Japan. Dr Islam has been associated with various Internet standardization organizations, government bodies and business communities. He has attended

many International Conference, Seminars and events of ICT around the world and spoke on ICT for development with a special focus on the healthcare sector. His

interest also covers in the areas including ICT for agriculture, education, energy, and environment.

Abstract:

Statement of the Problem: Two main obstacles to ensuring basic healthcare service in remote areas of developing countries

are the poor doctor-patient ratio and insufficient medical facilities. The Portable Health Clinic (PHC) system made it possible

to provide primary healthcare services to the doorstep of the rural communities in affordable price by providing telemedicine

service in a preventive healthcare way. The PHC system introduces a triage process based on the concept of “Bangladesh

Logic” for the people of Bangladesh and it classifies the subjects under investigation into four categories, namely, (1) green

or healthy (2) yellow or alarming (3) orange or sick and (4) red or emergent, based on the gradual higher risk status of

their health. The subjects under orange and red are primarily diagnosed as in the risky zone who need doctor`s consultancy.

However, the major part of the subjects who are diagnosed in the safe and alarming zone (yellow) can be served by the trained

health workers without medication and they can be mostly prevented not to shift into the risky zone being under the guided

lifestyle. This reduces the pressure on the doctors enabling them to focus on the risky patients who deserve better attention.

The Tele-Pathology module of the PHC system enables the rural diagnostic centers operated by the laboratory technologist

for producing a quality pathological report with the support of the qualified remote pathologist. Thus, the PHC telehealth

care system offers a unique opportunity for ensuring better healthcare service to the unreached rural communities of the

developing countries. Although it was developed aiming to the low-income rural communities, it is found equality useful for

the urban rich aged community for home delivery service due to its portability and easy operation.

Dale M Hilty

Mount Carmel College of Nursing

Title: Innovative method to improve nursing student nutrition knowledge

Biography:

Dale M Hilty, Associate Professor, received his PhD in counseling psychology from Department of Psychology at the Ohio State University. He has published

studies in the areas of psychology, sociology, and religion. Between April 2017 and April 2018, his ten research teams published 55 posters at local, state, regional, national, and international nursing conferences. His colleague sharing the author line of this poster is Aimee Shea, MPH, RDN, CSO, LD.

Abstract:

Unique Innovation: The goal of this project was to improve student knowledge regarding how different diet choices hinder an

individual’s ability to meet the Dietary Guidelines for Americans. A 30-minute presentation included a nutrient analysis per

meal for four diets: Omni Heart, Fancy Fast Foods (Panera), Fast Foods (McDonald's), and Snack Diets (Vending Machine).

Undergraduate nursing students observed how choosing two Omni Heart meals per day plus one meal from any of the other

three diets resulted in positive energy balance and the potential for significant weight gain.

Method: Independent variable: 30-minute presentation. The dependent variables were student completion of (1) cognitive

nutrition pre/post-test questions (2pre/post-test Nutrition Assessment Questionnaire (NAQ). Fiber, added sugars, fats, protein,

and sodium subscale scores are available for the NAQ. Subjects: Undergraduate students (66, 3rd year; 64, 1st year students).

Hypothesis: The 30-minute presentation will cause a statistically significant improvement on the pre- and post-test cognitive

questions and the overall NAQ score as well as on the fiber, added sugars, fats, protein, and sodium subscales.

Favorable Outcomes: Statistically significant differences (p<003, dependent t-test) were found on each of the dependent

variable measures (cognitive knowledge questions, overall NAQ total score, NAQ subscales: fiber, added sugars, fats, protein,

and sodium).

Application Relevance: In this educational intervention, student nutrition knowledge increased significantly from the pre to

the post-test measures based on the independent variable (30-minute classroom presentation). These findings could facilitate

health promotion efforts by increasing nursing student self-knowledge and their ability to educate patients.

Babita Saxena

Government Homeopathic Medical College and Hospital

Title: Dysfunctional uterine bleeding in premenopausal female

Biography:

Babita Saxena is currently professor in gynec and obstetrics department at Government homeopathic medical college and hospital in Bhopal since last 15 years. During her journey of practicing, she had encountered and treated many cases of DUB successfully of which approximately 15% need surgical intervention. Presently she is working for autistic children and a common pubertal problem i.e. polycystic ovarian disease. They have specific geriatric unit in which they manage menopausal complaints of females through proper counseling and medication. She is fond of reading, writing, and cooking she also likes to join job as freelancer in other countries. She has completed her Post Graduation from Mumbai University in Materia Medica.

Abstract:

Statement of the Problem: Menopause, the term in itself brings many thoughts in a female’s life. Especially if, it is related to

the excessive hemorrhage during menstrual periods. Dysfunctional uterine bleeding (DUB) is a variety of manifestations of

the anovulatory cycle (in the absence of pathology or medical illness).

(a) DUB in menarche i.e. puberty menorrhagia

(b) DUB in middle age female as metropathia hemorrhagic

(c) DUB in premenopausal female i.e. heavy bleeding in a woman approaching menopause.

Of these, the third point affects women the most as they are in troubles related to menopause itself.

Cause: As approaching menopause time ovaries start devoid of mature follicles. So, FSH start increasing as a result initially

proliferative endometrium grows up to 5-6 mm size which is very fragile, only estrogenic primed endometrium. So, as soon as

estrogen level decreases, tissues undergo spontaneous breakage and bleeding as one site heals another, yet another new site of

breakdown will appear. Endometrial control mechanism is missing. So, excess blood loss is due to disorderly, abrupt, random

breakage of tissue- with opening of multiple vascular channels. (a) No vasoconstriction (b) No tight coiling of spiral vessel (c)

No collapse to induce stasis. As a result, a most common treatment program for such cases is: (i) Hormones OCP (ii) Estrogen

therapy (iii) Maintenance of hemoglobin (iv) Use of antiprostaglandins (v) GnRH (gonadotropin-releasing hormone) agonists

(vi) Ablation of the endometrium (vii) Surgical removal of uterus i.e. hysterectomy

An agent from this entire homeopathy -an alternative science is a better choice where without hormonal side effects bleeding

and the cycle can be controlled satisfactorily. Few things to take care like: (a) Proper case taking (b) Selection of similimum

(c) Selection of good potency (d) Selection of intercurrent remedy (e) Selection of mother tinctures for acute conditions (f)

Re-case taking- taking miasm behind into consideration (g) Give mental symptoms top priority (h) Reassurance to patient (i)

Spending some extra time with patient alone then with husband and children counseling them (j) See the response of cases.

So, managing DUB in the premenopausal female is time taking with best results.