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Awareness of dengue and practice of dengue control among the semi-urban community: a cross sectional survey

Naing C, Ren WY, Man CY, Fern KP, Qiqi C, Ning CN, et al.

J Community Health, 2011 Dec;36(6):1044-9.
PMID: 21528416 DOI: 10.1007/s10900-011-9407-1

Primary prevention is the most effective measure in dengue prevention and control. The objectives were (i) to determine the level of knowledge and practice of dengue control amongst the study community, and (ii) to explore the factors affecting practice of dengue control in the study area. A cross-sectional study was conducted in a semi-urban Town of Malaysia, using a structured questionnaire covering sociodemography, knowledge related to dengue, knowledge related to Aedes mosquito and preventive measures against the disease. For comparison of survey responses, chi-square test was applied for categorical data. To explore the factors affecting the practice of dengue control, a linear regression model was introduced. Almost all of the respondents (95%) had heard about dengue. Overall, misconceptions of dengue transmission were identified and the practice of dengue control in the study population was insufficient. About half (50.5%) had misconceptions that Aedes can breed in dirty water and the preferred biting time is dusk or sunset (45.6%). Only 44.5% of the households surveyed had covered their water containers properly. Significant associations were found between knowledge scores of dengue and age (P = 0.001), education level (P = 0.001), marital status (P = 0.012), and occupation (P = 0.007). In regression analysis, only the knowledge of dengue was significantly and positively associated with practice on dengue control. A future study with larger samples and more variables to assess the knowledge, attitudes and practices of dengue control is recommended.

Matched MeSH terms: Health Knowledge, Attitudes, Practice*
Fulltext Knowledge and attitude of colorectal cancer screening among moderate risk patients in West Malaysia

Harmy MY, Norwati D, Noor NM, Amry AR

Asian Pac J Cancer Prev, 2011;12(8):1957-60.
PMID: 22292632

Colorectal cancer is the commonest cancer among males and the third commonest cancer among women in Malaysia. However, almost 80% of patients sought treatment for cancer only when they were already in late stage due to lack of awareness. Hence, the objectives of this study were to determine the knowledge and attitude of colorectal cancer screening among moderate risk patients. A cross-sectional study was conducted between August 2009 till April 2010 in 44 health clinics with Family Medicine Specialists in West Malaysia. Stratified multistage random sampling was applied and a validated Malay version of the questionnaire with the Cronbach' alpha of 0.65 to 0.82 was used. Data were entered using SPSS 12.0 and analysed with STATA 8.0. A total of 1,905 (93.8%) patients responded. The mean (SD) knowledge and attitude score among moderate risk patients were 69.5 (6.11%) and 66.5 (7.07%), whereas, the percentages for good knowledge and attitude were 4.1% and 3.3% respectively. Less than 1% had undergone colorectal cancer screening and the main reasons were not bothered, busy and embarrassment. The majority of patients who had moderate risk for colorectal cancer had extremely low knowledge and attitude towards colorectal cancer screening. As a result, the majority did not undergo any form of colorectal cancer screening.

Matched MeSH terms: Health Knowledge, Attitudes, Practice*
Awareness of breast cancer and screening procedures among Malaysian women

Kanaga KC, Nithiya J, Shatirah MF

Asian Pac J Cancer Prev, 2011;12(8):1965-7.
PMID: 22292634

Breast cancer is the most frequently occurring cancer in women globally and early detection increases the survival rate of patients. Therefore, this study was done to determine factors which influence the awareness of breast cancer and practice of screening procedures. A cross-sectional study was performed on 125 women aged 19-60 years in urban and rural areas in Malaysia using a validated questionnaire covering knowledge of breast cancer and screening practices. A total of 99.2% respondents knew that breast cancer is the leading cancer with a mean knowledge of 67.3 ± 15.3% for urban and 50.2 ± 14.7% for rural women Mann Whitney U showed rural women had significantly less awareness compared to urban women (p< 0.05). Spearman correlation test showed a significant positive relationship between education and awareness (p< 0.05). Regarding awareness of the screening methods, 92.8%, 50.4% and 47.2% of respondents correctly answered questions on capability of BSE, CBE and mammography, respectively. In conclusion, the study showed awareness of breast cancer and practice of screening procedures increases with higher education and urban living. Therefore, there is an urgent need for an intensive breast cancer awareness campaign and availablity of screening centres prioritized in rural areas.

Matched MeSH terms: Health Knowledge, Attitudes, Practice*
Factors affecting warfarin-related knowledge and INR control of patients attending physician- and pharmacist-managed anticoagulation clinics

Hasan SS, Shamala R, Syed IA, Basariah N, Chong DW, Mei TK, et al.

J Pharm Pract, 2011 Oct;24(5):485-93.
PMID: 21844213 DOI: 10.1177/0897190011415684

OBJECTIVES: To assess the anticoagulation knowledge and international normalized ratio (INR) control among patients on warfarin.
METHODS: A cross-sectional study with 156 randomly sampled patients from physician- (non-medication therapy adherence clinic [non-MTAC]) and pharmacist (MTAC)-run anticoagulation clinics using a validated interviewer-administered questionnaire. Patients' INR readings from 2008 to 2010 were recorded.
RESULTS: Patients on warfarin scored an average of 66.5% ± 36.0% for their knowledge on how warfarin works, 42.9% ± 44.9% for interaction between warfarin and alcohol, and 49.2% ± 21.1% for adverse effects. No significant differences were found between MTAC and non-MTAC patients on their knowledge. There was a negative correlation between patients' knowledge and age (P = .001, r (s) = -.293) and a positive correlation between patients' knowledge and education level (P = .001, r (s) = .365). MTAC patients were found to have better INR control than non-MTAC when compared for mean percentage days in range (63.4% ± 18.9% vs 52.5% ± 18.2%; P = .006) and mean percentage visits in range (58.8% ± 17.9% vs 46.8% ± 18.6%; P = .001).
CONCLUSIONS: MTAC patients were found to have better INR control compared to non-MTAC patients. A joint cooperation between physicians, pharmacists, and nurses should exist to achieve desired therapeutic outcomes.

Study site: warfarin patients
attending the anticoagulation clinics

Matched MeSH terms: Health Knowledge, Attitudes, Practice*
Fulltext Perceptions and opinions towards skin cancer prevention in Malaysia: a qualitative approach

Al-Naggar RA, Al-Naggar TH, Bobryshev YV

Asian Pac J Cancer Prev, 2011;12(4):995-9.
PMID: 21790240

INTRODUCTION: Malignant melanoma in particular is one of the few remaining cancers with an increasing incidence.

OBJECTIVES: The objective of this study is to explore the perceptions and opinions of young Malaysians towards skin cancer prevention.

METHODOLOGY: Focus group discussions were conducted among 33 medical science students from Management and Science University (MSU), Shah Alam, Malaysia, using convenience sampling. Students were divided into 4 focus groups consisting of 8, 8, 9 and 8 students respectively. The facilitator wrote down the conversations and data obtained were classified into various categories and analyzed manually.

RESULTS: The majority of the participants mentioned that overexposure to ultraviolet light is the commonest cause of skin cancer but also that the most benefit we get from sun ight is vitamin D synthesis. The majority mentioned that the best prevention measure for skin cancer is using a sunscreen, followed by limit exposure to the sun.

CONCLUSION: The present study demonstrated there is a lack of knowledge regarding screening methods and prevention measures of skin cancer. Therefore, there is a need to establish health education unit in all universities to educate all university students regarding various health problems including skin cancer prevention.

Matched MeSH terms: Health Knowledge, Attitudes, Practice*
A survey on the knowledge, beliefs and behaviour of a general adult population in Malaysia with respect to the adverse effects of medicines

Jose J, Chong D, Lynn TS, Jye GE, Jimmy B

Int J Pharm Pract, 2011 Aug;19(4):246-52.
PMID: 21733012 DOI: 10.1111/j.2042-7174.2011.00113.x

The aim of the study was to explore, in the Malaysian general population: knowledge and beliefs of the characteristics in general of medication-related side effects and side effects associated with different types of medicines; behaviour related to the safe use of drugs before and after taking a medication; and behaviour in the event of a medication-related side effect.

Matched MeSH terms: Health Knowledge, Attitudes, Practice*
Perceptions and opinions regarding human papilloma virus vaccination among young women in Malaysia

Al-Naggar RA, Al-Jashamy K, Chen R

Asian Pac J Cancer Prev, 2010;11(6):1515-21.
PMID: 21338190

OBJECTIVE: The objective of this study is to explore the perceptions and opinions of young women about human papilloma virus (HPV) vaccination and associated barriers.
METHODOLOGY: This qualitative in-depth interview study was conducted in January 2010 with 30 university students from different faculties, i.e.:International Medical School (IMS), Faculty of Health and Life Sciences (FHLS), Faculty of Business Management and Professional Studies (FBMP) and Faculty of Information Sciences and Engineering (FISE) of the Management and Science University (MSU), Shah Alam, Malaysia. After consent was obtained from all participants, the interviewer wrote down the conversations during the interview sessions. The data obtained were classified into various categories and analyzed manually.
RESULTS: The majority of participants 25 (83%) had heard about cervical cancer, while 16 (53.3%) have never heard of HPV. Only five participants (17%) mentioned that HPV is the cause of cervical cancer. Ten participants (33.3%) did not know any causes. The majority 16 (53.3%) did not know the mode of HPV transmission. The majority of participants 22 (73.3%) mentioned that they had not been vaccinated against HPV. Out of 22, 16 (53.3%) agreed to be vaccinated in the future to protect themselves from cervical cancer and five (17%) participants mentioned they are not willing because of the uncertain safety of the available vaccines and their side effects.
CONCLUSION: This study showed relatively poor knowledge about HPV and its vaccines, pointing to urgency of educational campaigns aimed at students in the public and government universities to promote HPV vaccination among this highly eligible population.

Matched MeSH terms: Health Knowledge, Attitudes, Practice*
Self-reported level of and factors influencing the compliance to desferrioxamine therapy in multitransfused thalassaemias

Lee WS, Toh TH, Chai PF, Soo TL

J Paediatr Child Health, 2011 Aug;47(8):535-40.
PMID: 21392144 DOI: 10.1111/j.1440-1754.2011.02017.x

To analyse the self-reported degree of and factors influencing the compliance to desferrioxamine (DFO) therapy in children with transfusion-dependent thalassaemia major in Malaysia.

Matched MeSH terms: Health Knowledge, Attitudes, Practice*
From the ideal to the real world: a phenomenological inquiry into student sojourners' reentry adaptation

Hsiao F

J Music Ther, 2011;48(4):420-39.
PMID: 22506298

This phenomenological study examines the thematic structure of reentry transition for international music therapy graduates who have returned home after studying in the United States. Emphasis is placed upon career development. Standardized open-ended interviews were used to obtain rich and in-depth descriptions of the participants' experiences. Ten music therapists from six countries participated in the study. The themes that emerged from the data include moving from the ideal to the real world, shifting from the role of student to professional, confronting reality and working through challenges, and achieving personal growth and self-transformation. The dynamics of cross-cultural comparison, confronting the home culture, and redefining music therapy and professional identities within the local cultural context are illustrated via quotations from the participants. Implications and recommendations for music therapy education and career preparation for international graduates are discussed.

Matched MeSH terms: Health Knowledge, Attitudes, Practice*
Fulltext Negative perception in those at highest risk--potential challenges in colorectal cancer screening in an urban asian population

Hilmi I, Hartono JL, Goh KL

Asian Pac J Cancer Prev, 2010;11(3):815-22.
PMID: 21039060

INTRODUCTION: Colorectal carcinoma (CRC) is the second commonest malignancy in Malaysia, with the highest incidence seen in the Chinese. The aim of this study is to examine the knowledge of CRC and to identify potential barriers for screening, which has yet to be carried out on a nationwide scale.
METHODS: Subjects were recruited consecutively from friends and relatives accompanying patients to the general medical clinic in a tertiary hospital in Kuala Lumpur. Interviews were carried out using a standardized questionnaire for the Asia Pacific CRC working group based on the Health Belief Model (HBM).
RESULTS: 991 subjects were interviewed. From our study, 414 (41.8%), 500 (50.5%) and 646 (65.2%) could not identify any of the symptoms, risk factors and screening methods for CRC respectively. Only 384 (38.7%) were agreeable to undergo screening. Independent factors associated with willingness to undergo screening were as follows; Malay and Indian race compared to the Chinese [aOR 2.73 (1.87, 3.98) and 3.04 (2.02, 4.59) respectively], perceived susceptibility, perceived barriers to screening, doctor's recommendation and personal contact with CRC.
CONCLUSIONS: Knowledge of CRC and CRC screening is low among the Malaysian population. The majority are not willing to undergo screening, the Chinese paradoxically being the least willing despite being at greatest risk
Study site: Medical clinics, University Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia

Matched MeSH terms: Health Knowledge, Attitudes, Practice*
Predictors of adherence to clinical breast examination and mammography screening among Malaysian women

Parsa P, Kandiah M

Asian Pac J Cancer Prev, 2010;11(3):681-8.
PMID: 21039036

Breast cancer is the most common cancer among Malaysian women and early detection can play an important role in reducing cancer morbidity and mortality. The aim of this cross-sectional study was to determine the rates and factors related to clinical breast examination (CBE) and mammography among 425 female teachers in Selangor, Malaysia. A self-administered questionnaire that included questions on socio-demography, cancer-related knowledge and practice and an adapted version of Champion's revised Health Belief Model Scale was employed. The mean age of participants was 37.2 ± 7.16 years. Only 25% of the women ever had a CBE. Of women over the age 40 (n=138), 13.6% reported having had a mammography. The results showed higher susceptibility to breast cancer, higher benefits of doing CBE and regular visits with a physician to be significant predictors for undergoing CBE (p < 0.05). In addition, higher a perceived susceptibility to breast cancer and regular undergoing CBE were significant predictors for having a mammography. The findings clearly suggest a need for improving women's awareness on breast cancer screening, its importance and recommended guidelines.

Study site: Secondary school teachers in Selangor, Malaysia.

Matched MeSH terms: Health Knowledge, Attitudes, Practice*
Fulltext Awareness, knowledge and attitudes towards epilepsy among rural populations in East Coast Peninsular Malaysia: a preliminary exploration

Neni SW, Latif AZ, Wong SY, Lua PL

Seizure, 2010 Jun;19(5):280-90.
PMID: 20466567 DOI: 10.1016/j.seizure.2010.04.006

This study was carried out to gauge the preliminary insight regarding epilepsy among the rural society. The purposes of this study were: (1) to determine general level of awareness, knowledge and attitudes (AKA) towards epilepsy among rural communities, (2) to compare the AKA level based on socio-demographic characteristics and (3) to investigate rural cohort's perception of the best epilepsy treatment, preference for epilepsy information delivery and preference for mode of transportation to seek medical treatment. This prospective, cross sectional study included a sample of 615 rural residents enrolled via cluster sampling in East Coast region of Peninsular Malaysia (mean age=41.6+/-18.02, female=56.6%, married=65.5%, Malay=94.0%, monthly income < or = RM 500=56.9%). The Total AKA level was generally low (2.66+/-0.7). Gender-wise no significant difference was shown regarding AKA level (p>0.05). However, respondents with higher education significantly possessed better attitudes and higher Total AKA level compared to those with lower education level (p<0.001). Employed respondents reported significantly more favourable attitudes than unemployed respondents (p=0.011). Additionally, higher income rural cohorts possessed both significantly better attitudes and better AKA. These rural communities perceived modern medicine as the best epilepsy treatment (56.60%), preferred to obtain direct epilepsy-related information from health personnel (60.4%) and chose to use their own car to seek medical treatment in hospital (76.30%). The outcomes of this preliminary study signified the need to devise a dedicated epilepsy education program for implementation among rural residents. Increased AKA level in the society could enhance the people's acceptance, reduce stigmatisation and improve health-related quality of life (HRQoL) for epilepsy patients and their family.

Matched MeSH terms: Health Knowledge, Attitudes, Practice*
Fulltext Pattern of drug utilization in rural Malaysia

Hasamnis AA, Patil SS, Narayan KA, Khan AR, Mohanty BK

Ann Afr Med, 2010 Apr-Jun;9(2):106-7.
PMID: 20587935 DOI: 10.4103/1596-3519.64746
Matched MeSH terms: Health Knowledge, Attitudes, Practice*
Knowledge of and attitudes toward the HPV vaccine among multi-ethnic women from urban/university and rural areas

Wong LP

Int J Gynaecol Obstet, 2011 Feb;112(2):146-7.
PMID: 21130440 DOI: 10.1016/j.ijgo.2010.09.006
Matched MeSH terms: Health Knowledge, Attitudes, Practice*
Anxiety of the mothers with referred baby during Universal Newborn Hearing Screening

Mohd Khairi MD, Rafidah KN, Affizal A, Normastura AR, Suzana M, Normani ZM

Int J Pediatr Otorhinolaryngol, 2011 Apr;75(4):513-7.
PMID: 21292333 DOI: 10.1016/j.ijporl.2011.01.009

To investigate the anxiety among mothers whom their babies have failed test results in the first stage of Universal Neonatal Hearing Screening Program.

Matched MeSH terms: Health Knowledge, Attitudes, Practice*
Community knowledge, attitudes, and beliefs towards depression in the state of Penang, Malaysia

Khan TM, Sulaiman SA, Hassali MA, Anwar M, Wasif G, Khan AH

Community Ment Health J, 2010 Feb;46(1):87-92.
PMID: 20146000 DOI: 10.1007/s10597-009-9262-z

This study was intended to evaluate the mental health literacy vis-à-vis depression among inhabitants of Penang state in North Malaysia. Using a clustered random sampling method, 1,855 respondents were approached to participate in the survey. A total of 1,149 respondents actually participated, for a 61.9% response rate. Face to face interviews were then conducted using a pre-validated 21-item questionnaire. The mean age of the respondents was 30 years (SD +/-11.5). The majority (n = 884; 76.9%) could recognize three or more symptoms of depression. Chinese and/or female respondents performed the best in this domain. Respondents with a personal experience of depression displayed a significantly better knowledge of symptoms of and therapies for depression than those who did not (t = -35.745, P = <0.001). Overall, a moderate knowledge level of the symptoms of depression and a cursory knowledge towards therapy were observed among the general population in Penang. Notably, respondents were generally inclined towards the use of alternative medicine. The study suggests that strong beliefs in alternative and traditional medicines could undermine the respondents' willingness and ability to seek evidence-based mental health care.

Matched MeSH terms: Health Knowledge, Attitudes, Practice*
Ethnically diverse female university students' knowledge and attitudes toward human papillomavirus (HPV), HPV vaccination and cervical cancer

Wong LP, Sam IC

Eur J Obstet Gynecol Reprod Biol, 2010 Jan;148(1):90-5.
PMID: 19910102 DOI: 10.1016/j.ejogrb.2009.10.002

OBJECTIVE:
Cervical HPV is the most common sexually transmitted disease among college-age women. This study aimed to assess knowledge and attitudes towards HPV infection, HPV vaccination and cervical cancer among female university students, to provide insight into development of HPV educational information.

STUDY DESIGN:
A cross-sectional survey using a convenience sample. A total of 1083 ethnically diverse female students attending a public university were approached and 650 were interviewed.

RESULTS:
Knowledge regarding HPV, HPV vaccination, cervical screening and cervical cancer risk factors was remarkably poor. Across the sample, the mean total knowledge score (14-item) was only 3.25 (S.D. +/-2.41; 95% CI 3.07-3.44). Only 10.3% had heard of the newly released HPV vaccine. Approximately 48% of participants indicated an intention to receive an HPV vaccine. Intention to receive an HPV vaccine was significantly associated with knowledge of HPV and genital warts (OR 1.53; 95% CI 1.25-1.88), and knowledge of cervical screening and cervical cancer risk factors (OR 1.21; 95% CI 1.11-1.33). Of those who refused HPV vaccination, 50.9% doubted the safety and efficacy of the new vaccine, and 41.5% perceived themselves as not at risk of HPV infection.

CONCLUSION:
The findings suggest that providing education about the etiology of cervical cancer and the HPV link is an essential component to enhance HPV vaccine uptake.

Matched MeSH terms: Health Knowledge, Attitudes, Practice*
An assessment of the knowledge, attitudes, and risk perceptions of pharmacy students regarding HIV/AIDS

Ahmed SI, Hassali MA, Aziz NA

Am J Pharm Educ, 2009 Feb 19;73(1):15.
PMID: 19513153

OBJECTIVE: To evaluate the level of knowledge, attitudes, and risk perceptions of University Sains Malaysia final-year pharmacy students regarding human immunodeficiency virus (HIV) and acquired immunity deficiency syndrome (AIDS).
METHOD: A cross-sectional study among pharmacy students. Data were analyzed with Chi-square to find difference at p value < 0.05.
RESULTS: The majority of students (83.07%) responded showing a difference in gender and race. Students showed low willingness (9.2%) to assist patients and low confidence (36.1%) in their education about HIV/AIDS patients. Students recommended HIV testing for health care professionals (69.4%) and patients (75.9%) before surgical procedures. Students knew little about Post Exposure Prophylaxis (18.5%) or about the time for HIV to develop into AIDS (57.4%). About 40% of students were unaware of the inability of antivirals to treat HIV/AIDS. Students had low awareness for opportunistic infections (18.5%), and low agreement on competency to treat and counsel HIV patients (12.9%).
CONCLUSION: The study highlighted students' misconceptions, negative attitudes, and risk perceptions towards HIV/AIDS.

Matched MeSH terms: Health Knowledge, Attitudes, Practice*
Preventing cervical cancer through human papillomavirus vaccination: perspective from focus groups

Wong LP

J Low Genit Tract Dis, 2009 Apr;13(2):85-93.
PMID: 19387128 DOI: 10.1097/LGT.0b013e3181865f44

OBJECTIVE: It has been a little more than a year ago since the prophylactic vaccine against human papillomavirus (HPV) was released in Malaysia. Little is known about parental knowledge and acceptability of the vaccine. The objective of this study is to assess the mother's knowledge and attitudes toward HPV vaccination. The results are aimed to provide insights into the provision of appropriate educational and promotional program for effective immunization uptake.
MATERIALS AND METHODS: Purposive sampling method was adopted for recruitment of participants. A total of 47 mothers participated across 8 focus group discussions carried out between October and November 2007. The transcribed group discussions were analyzed using open-, axial-, and selective-coding procedures.
RESULTS: Respondents have low awareness about the newly released vaccine and the link between HPV and cervical cancer. When provided with information about HPV and cervical cancer, most mothers were in favor of protecting their daughters from cervical cancer using the vaccine. As with any new vaccine, efficacy and safety were the major concern, particularly when the vaccine is recommended to preadolescent. Many expressed concern about the high cost of the vaccine and hope that the inoculation could be at least partially subsidized by the government. A minority were concerned that the sexually transmitted disease-related vaccine would promote sexual activities, and some opposed making vaccination mandatory. For Muslim respondents, the kosher issue of HPV vaccine was an important factor for acceptance.
CONCLUSIONS: Developing public health messages that focus on the susceptibility of HPV infection and its link to cervical cancer to educate parents may have the greatest impact on improving the uptake of the vaccine. Apart from the major concern about safety and efficacy, affordability, and acceptability of vaccinating young children, religious and ethnic backgrounds were important considerations when recommending the HPV vaccine. To foster broad acceptance, these issues need to be addressed before mass vaccination is pushed forward to the Malaysian public.insights into the provision of appropriate educational and promotional program for effective immunization uptake.

Matched MeSH terms: Health Knowledge, Attitudes, Practice*
Fulltext Challenges to cervical screening in a developing country: The case of Malaysia

Othman NH, Rebolj M

Asian Pac J Cancer Prev, 2009;10(5):747-52.
PMID: 20104963

OBJECTIVES: Many developing countries, including Malaysia, will need to continue relying on cervical screening because they will not be able to cover their entire female adolescent populations with HPV vaccination. The aim of this paper was to establish the extent of the health care, informational, financial and psychosocial barriers to cervical screening in Malaysia.

METHODS: A literature search was made for reports on implementation, perceptions and reception of cervical screening in Malaysia published between January 2000 and September 2008.

RESULTS: Despite offering Pap smears for free since 1995, only 47.3% of Malaysian women have been screened. Several factors may have contributed to this. No national call-recall system has been established. Women are informed about cervical screening primarily through mass media rather than being individually invited. Smears are free of charge if taken in public hospitals and clinics, but the waiting times are often long. The health care system is unequally dense, with rural states being underserved compared to their urban counterparts. If the screening coverage was to increase, a shortage of smear-readers would become increasingly apparent.

CONCLUSIONS: Improving screening coverage will remain an important strategy for combating cervical cancer in Malaysia. The focus should be on the policy-making context, improving awareness and the screening infrastructure, and making the service better accessible to women.

Matched MeSH terms: Health Knowledge, Attitudes, Practice*

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