Provincial differences in levels, trends, and determinants of childhood immunization in Pakistan

Background: Efforts to improve immunization rates are urgently needed in Pakistan but national statistics mask important local differences in immunization levels and determinants.

Aim: In this study we aimed to determine how similar or different are recent trends and levels of immunization coverage in Pakistan's 4 main provinces [Punjab, Sindh, Khyber Pakhtunkhwa [KPK] and Balochistan], and what factors are associated with complete childhood immunization in each province.

Method: We analysed data from the 2006–07 and 2012–13 Pakistan Demographic and Health Surveys. Trends in immunization coverage among children aged 12–23 months were calculated for each province. Bivariate and multivariate analyses were conducted to identify factors associated with complete immunization.

Results: The proportion of children completely immunized had risen significantly in Punjab but had fallen significantly in Balochistan. Complete coverage ranged from 16.4% in Balochistan to 65.8% in Punjab [2012–13]. Tetanus toxoid injection during pregnancy was a significant predictor of complete immunization everywhere. Other predictors in specific provinces were: urban residence in Balochistan, wealth in Sindh and KPK, mother's education in Punjab and KPK, and distance to the facility in Punjab.

Conclusions: Although some strategies to increase immunization coverage are relevant nationwide, programme managers need to seek solutions specific to provincial trends and predictors. This analysis demonstrates that viewing childhood immunization in Pakistan through a provincial lens can help achieve a deeper understanding of the challenges and potential strategies to boost coverage

Lifestyle related risk factors of type 2 diabetes mellitus in Saudi Arabia

To assess the impact of diet and physical activity on the risk of type 2 diabetes mellitus [T2DM] in the Kingdom of Saudi Arabia [KSA] after adjusting for family history of diabetes. We conducted a case-control study in Al Qassim, KSA to test the hypothesis that dietary practices and physical activity modify the risk of type 2 diabetes regardless of family history. Male and female Saudi citizens 30-70 years of age were eligible to participate. The sample included 283 cases [T2DM patients] and 215 non-diabetic controls randomly selected from patients visiting the primary health care centers from September to November 2009. We collected information on demographic variables, family history, dietary habits, and physical activity. Using logistic regression, we estimated adjusted odds ratios [AOR] for dietary habits and physical activity after controlling for the effects of gender, age, education, and family history of diabetes. There is strong association between diabetes and maternal history of diabetes, education, lack of exercise, and dietary habits. The AOR for regular eating of Kabsa was 5.5 [95% confidence limits [CL]: 2.3-13.5]; for vegetables an AOR of 0.4 [95% CL: 0.2-0.7]; for dates an AOR of 1.8 [95% CL: 1.0-3.3] ;and the AOR for sedentary lifestyle was 2.5 [95% CL: 1.2-5.0]. Healthy diet and active lifestyle may significantly decrease the risk of T2DM in spite of having a family history of diabetes. Effective health education programs promoting healthy diet and regular exercise are needed to reduce the burden of diabetes in Saudi Arabia

Validating the verbal autopsy questionnaire for maternal mortality in Pakistan

Maternal mortality represents the largest and the most persistent gap between developed and developing countries. The maternal mortality ratio [MMR], which measures the risk of death at each pregnancy, is up to 40 times higher in some African countries than the countries of Northern Europe. MMR is believed to be the most sensitive indicator of women's status in the society and of the quality and accessibility of maternal health services available to women. The primary purpose of the study was to determine the level of agreement in the cause and the category of death assigned by the hospital and the obstetrician who reviewed the completed VA questionnaire. The validation study was conducted during July-September 2006 by the National Institute of Population Studies [NIPS], which is also the executing agency for PDHS 2007. The primary objective of the study was to test the sensitivity and specificity of the VA questionnaire developed for PDHS 2007. An important lesson learned from this study is that the sensitivity of the VA technique can be further enhanced by rigorous training of the review panelists in the utilization of the information contained in the coded parts of the questionnaire

Prevalence and determinants of self-reported morbidity among pregnant women in rural areas of Pakistan

Background: The maternal mortality ratio [MMR] in Pakistan is estimated at 400 maternal deaths per 100,000 live births. Prevalence of minor and major illnesses related with pregnancy and childbirth is much higher. However, most births in the rural areas take place at home, conducted by untrained traditional birth attendants. Data on the prevalence of maternal morbidity is, therefore, limited. Self-reporting of illnesses related with pregnancy and childbirth is generally considered as unreliable, as women's perception of the seriousness of the health problems is inadequate

Method: The data were collected in a baseline survey that was conducted for an operations research project of the Ministry of Health, Government of Pakistan. The baseline survey comprised interviews with the ever-married women in the reproductive ages [15-49 years]. For the selection of eligible women for the interview, a two-staged cluster random sampling procedure was applied. The response rate was 94.4% and interviews with 9,118 of the identified 9,655 females were successfully completed. The interviews were conducted by female interviewers having graduate degree or above. Completed questionnaires were edited and coded by a team of professional data editors

Results: The prevalence of maternal morbidity in this study was 20%, which is considered to be high, although can be expected in this population. Nearly half of the women reported some kind of illness during pregnancy, which is also expected. This study also estimated that the unmet obstetric need among rural women was very high; this finding has policy implication, as the need for alternative and more operational indicators of maternal health is increasingly felt

Conclusion: It is recommended that population-based studies and national surveys routinely incorporate well designed questions to elicit information on self-reported maternal morbidity; the same studies can also be used to identify the determinants of common obstetric problems and to estimate the unmet need of obstetric care

Prevalence and determinants of self-reported morbidity among pregnant women in rural areas of Pakistan

The maternal mortality ratio [MMR] in Pakistan is estimated at 400 maternal deaths per 100,000 live births. Prevalence of minor and major illnesses related with pregnancy and childbirth is much higher. However, most births in the rural areas take place at home, conducted by untrained traditional birth attendants. Data on the prevalence of maternal morbidity is, therefore, limited. Self-reporting of illnesses related with pregnancy and childbirth is generally considered as unreliable, as women's perception of the seriousness of the health problems is inadequate. The data were collected in a baseline survey that was conducted for an operations research project of the Ministry of Health, Government of Pakistan. The baseline survey comprised interviews with the ever-married women in the reproductive ages [15-49 years]. For the selection of eligible women for the interview, a two-staged cluster random sampling procedure was applied. The response rate was 94.4% and interviews with 9,118 of the identified 9,655 females were successfully completed. The interviews were conducted by female interviewers having graduate degree or above. Completed questionnaires were edited and coded by a team of professional data editors. The prevalence of maternal morbidity in this study was 20%, which is considered to be high, although can be expected in this population. Nearly half of the women reported some kind of illness during pregnancy, which is also expected. This study also estimated that the unmet obstetric need among rural women was very high; this finding has policy implication, as the need for alternative and more operational indicators of maternal health is increasingly felt. It is recommended that population-based studies and national surveys routinely incorporate well designed questions to elicit information on self-reported maternal morbidity; the same studies can also be used to identify the determinants of common obstetric problems and to estimate the unmet need of obstetric care

value of intermittent growth monitoring in primary health care programmes

The objective of growth monitoring is to detect early growth faltering before the child becomes severely malnourished. It has been found in many large projects in the private sector and in Government run Primary Health Care [PHC] programmes that monthly weighing is not feasible which makes it impossible to develop a functional outreach programme on a sustainable basis. This study is an attempt to propose an intermittent growth monitoring which is operationally feasible for large scale PHC programmes in the public sector. A historical prospective study was conducted to find out the correlation of weights of children at different ages with weights at subsequent months. Two hundred and ninety-two growth cards of children were selected from two squatter settlements of Karachi which are having a PHC programme through the Aga Khan University. At six months, about 71% of children were within the normal range, with increasing age from 10% to 39% of these children shifted to grade I Protein Energy Malnutrition [PEM]. When weights of children for each month were correlated with weights at all other months uptil 24 months, it was found that correlation coefficient at 6th and 9th month were significant [P value < 0.001]. Probability of developing malnutrition at different weights and ages were also calculated. The results indicate that malnutrition starts appearing at 6 months and weights at 6 months and to a lesser extent at 9 months are better prognostic indices of future malnutrition. Intermittent weighing of children can help in early identification of "high risk" children who can then be managed and even be prevented from developing future malnutrition