Perspectives of healthcare workers on integrated management of childhood illness in Pakistan: A phenomenological approach.

In 2019, an estimated 5.2 million deaths were reported among children less than 5 years of age. At primary healthcare level, healthcare workers (HCWs) mostly rely on history and clinical findings and less on inadequate diagnostic facilities. To enhance case management skills of HCWs, World Health Organization devised an integrated management of childhood illnesses (IMCI) strategy in 1995, modified to distance learning IMCI in 2014. A qualitative phenomenological study was conducted to explore perceptions of HCWs about standard and distance IMCI. Four focus group discussions were conducted with purposively selected 26 HCWs (IMCI trained) from 26 basic health units of Abbottabad district in Pakistan. Gadamer's philosophical hermeneutics were adopted during the inductive thematic analysis. Five themes that emerged are inexorable health seeking behaviors, IMCI being a comprehensive algorithm for consultation, a tedious protocol, scaling up protocol to specialists and private practitioners, and administrative insufficiency by the department of health. Improvement in case management skills of HCWs was reported as a result of IMCI trainings. It needs administrative support, regulations to control poly-pharmacy and provision of drugs without prescription, and a curb on political and bureaucratic interference.

Non-Participatory Observation Of Integrated Management Of Childhood Illness Practices At Selected Basic Health Units Of District Abbottabad, Kp, Pakistan: A Qualitative Hermeneutic Study.

BACKGROUND: It was in 1995 when a strategy was devised to reduce under-five mortality in countries with a prevalence of child mortality above 40/1000 live births. This strategy is called "Integrated Management of Childhood Illness" (IMCI). Improvement in the skills of healthcare workers (HCWs) depends on the IMCI training received by them. To make IMCI training more effective and scale up, a global technical consultation committee in Geneva recommended implementing an innovative training approach in 2014: the distance learning IMCI (dIMCI). This study was conducted to observe qualitatively the practices of IMCI-trained HCWs at their respective workplaces. METHODS: This qualitative hermeneutic study was conducted through non-probability criterion sampling in the district Abbottabad of Pakistan on all 26 basic health units trained in IMCI (either standard or distance learning) from December 9, 2019, to March 9, 2020. Data collection was done by qualitatively observing consultations and interactions of caretakers of under-five children at basic health units. Inductive thematic analysis was used. This qualitative exploration was underpinned by Hans Georg Gadamer's philosophy of hermeneutics. RESULTS: Four themes emerged from the observation notes. These themes are gratification after consultation, altercation for medication, non-observance of protocol, and methodical consultation. CONCLUSIONS: Improvement in the skills of HCWs in the form of IMCI training, either through distance learning or the common eleven-day standard method, can improve caretakers' satisfaction. However, awareness at the community level is needed for better compliance.

Gender Difference In Awareness And Behaviours Of Medical And Dental Students About Corona Virus Disease (Covid-19) In Pakistan.

BACKGROUND: Medical and dental students are the future of health workforce and a potential volunteer pool in the COVID-19 crises. This study aimed to assess the level and gender differences in the awareness, attitude and behaviours of medical and dentals students about COVID-19 in Pakistan. METHODS: An online cross-sectional survey was conducted among medical and dental undergraduate students in Khyber Pakhtunkhwa province. Data was collected using a structured questionnaire having four sections: socio-demographics, knowledge, attitude and practices. RESULTS: A total of 1770 medical and dental students participated and completed the questionnaire. About 1239 (70%) of the respondents were female and 1526 (87%) were MBBS students. We found that 1685 (95%) of the students had adequate knowledge. Majority, 1565 (89%) of the students was concerned about COVID-19 and 1480 (84%) believed that disease will ultimately be controlled. Only about 1129 (64%) of the participants in our study had adequate practices. Male gender was associated with higher risk of inadequate practices. CONCLUSIONS: There were good knowledge and attitudes about COVID-19 among medical and dental students. However, one third of the participants did not have adequate practices and female had better practices than male students. This gap in the knowledge and practice calls for urgent interventions to improve practices.

Know thyself: Development and validation of self-awareness of teaching skills (SATS) measuring instrument for medical teachers.

BACKGROUND: Self-awareness is measured previously in the higher education however not specifically in relation to 'effectiveness of teaching' thus leaving a gap in the literature. AIM: To develop and validate an instrument for medical teachers to measure the self-awareness of their teaching. METHODS: This was an instrument development multiphase mixed-method study design, based on Brookfield's four lenses theory. The instrument was validated after administering content validity, cognitive pretesting, confirmatory factor analysis and reliability analysis. Contrasting groups' method of standard setting was used to determine the cut-off scores for the levels of self-awareness of medical teachers. RESULTS: A 26-item preliminary draft instrument was reduced to a 19-item final instrument having four themes, that is; self-reflection, communication with students, student feedback, and peer review. Content Validity Scale was 0.92. Confirmatory factor analysis yielded a model with a good-to-excellent fit and an internal consistency of 0.85. The cut-off values were calculated to be 79%, 70%, 59%, and 53% for excellent, good, average and poor self-awareness of teaching skills respectively. CONCLUSION: The Self-awareness of the teaching skills instrument has excellent validity and good reliability in measuring the self-awareness of teaching skills of medical teachers.

Effectiveness Of DIMCI Training In District Abbottabad, Khyber Pakhtunkhwa: An External Pilot Study.

BACKGROUND: Five million deaths per year in under-five children are reported to be due to preventable and treatable causes. IMCI strategy targets these causes through improvement in the case management skills of health care workers. The objectives of this study were to identify eligible clusters and identify & rectify any process, resources, and management-related issues for the main trial. METHODS: This study was conducted in two phases. Phase 1 was conducted for eligibility of Basic Health Units from which sample can be drawn for the main cluster randomized control trial. A single-page proforma was sent to all 54 BHUs of Abbottabad through registered mail service and replies received were analysed through SPSS-V25 and MS Excel-2016. Afterward a sample of 26 BHUs was drawn for the definitive trial. In phase 2, four BHUs were conveniently selected from the remaining sampling frame; one in the control arm while three in the intervention arm. From each BHU, a health care worker responsible for under-five consultations was trained; control arm in standard IMCI while intervention arm on distance learning IMCI. Ten observations in the form of cases managed were assessed at each BHU by a gold standard IMCI master trainer after a specific period. Descriptive summary measures and 95% CI were calculated using SPSS-V25. RESULTS: Out of 54 BHUs, 3 were nonrespondents while 36 were identified as an eligible sampling frame. The mean index of integrated assessment was found to be 0.90 and 0.89 for the control and intervention arm respectively. Discrepancies in filled forms were noted as 60% in control while 63.3% in intervention arm. CONCLUSIONS: Modifications in the plan for the main trial based on the findings of pilot study can ensure credibility and rigor in the definitive trial.

Impact of Coronavirus Disease (COVID-19) Pandemic on Psychological Well-Being of the Pakistani General Population.

Background and Objectives: In order to curb the spread of coronavirus disease 2019 (COVID-19), the countries took preventive measures such as lockdown and restrictions of movements. This can lead to effects on mental health of the population. We studied the impact of COVID-19 on psychological well-being and associated factors among the Pakistani general population. Methods: An online cross-sectional survey was conducted between 26th April and 15th May and included participants from all over the Pakistan. Attitudes and worriedness about COVID-19 pandemic were assessed using a structured questionnaire. A validated English and Urdu version of the World Health Organization Well-Being Index (WHO-5) was used to assess the well-being. Factor analysis was done to extract the attitude item domains. Logistic regression was used to assess the factors associated with poor well-being. Results: A total of 1,756 people participated in the survey. Almost half 50% of the participants were male, and a similar proportion was employed. About 41% of the participants were dependent on financial sources other than salary. News was considered a source of fear as 72% assumed that avoiding such news may reduce the fear. About 68% of the population was worried about contracting the disease. The most common coping strategies used during lockdown were spending quality time with family, eating healthy food, adequate sleep, and talking to friends on phone. Prevalence of poor well-being was found to be 41.2%. Female gender, being unemployed, living in Sindh and Islamabad Capital Territory (ICT), fear of COVID-19, and having chronic illness were significantly associated with poor well-being. Similarly, coping strategies during lockdown (doing exercise; spending time with family; eating healthy food; having good sleep; contributing in social welfare work and spending time on hobbies) were also significantly associated with mental well-being. Conclusion: We found a high prevalence 41.2% of poor well-being among the Pakistani general population. We also investigated risk factors of poor well-being which included female gender, unemployment, being resident of ICT and Sindh, fear, chronic illness, and absence of coping strategies. This calls for immediate action at population level in the form of targeted mass psychological support programs to improve the mental health of population during the COVID-19 crises.

Variation In Haematological Profile Of Pregnant Women Attending Combined Military Hospital Quetta.

BACKGROUND: World Health Organization recommends eight antenatal visits throughout pregnancy. Along with full blood count and fasting blood sugar tests, thirty-nine recommendations are given. The objective of this study was to find out significance of difference in haematological profile of pregnant women. METHODS: This cross-sectional study on 384 pregnant women attending outpatient department of combined military hospital Quetta, Pakistan, was conducted from 1st November 2017 to 28th February 2018. Simple random sampling technique through random number table was used. Data collected through structured questionnaire from participants and their laboratory reports was grouped trimester wise. Apart from descriptive statistics, one-way ANOVA with post hoc Tukey test was used to find out significant difference at p≤0.05. SPSS Version 20 and MS Excel 2007 were used for data analysis and plotting graphs. Principles of research ethics were exercised. RESULTS: Mean age (±SD) of the study participants was 27.5 (±4.8) years. Statistically significant difference was found for variables like haemoglobin, haematocrit and MCHC in different trimesters. Only 2 (0.5%) of the total participants had gestational diabetes mellitus. CONCLUSIONS: For getting normal reference ranges in our setting, large population-based studies are needed.

Pregnancy Outcomes Of Consanguinity Among Antenatal Patients Attending Combined Military Hospital Quetta, Pakistan.

BACKGROUND: All definitions of consanguinity encompass the basic concept of close blood relation. Highest rates of consanguineous unions are observed for North and Sub Saharan Africa, Middle East, and west, central and south Asia, where 20-50% marriages are consanguineous. In Pakistan, we can hardly find any rigorous research on the pregnancy outcomes of consanguinity except those conducted by Allan Bittles. This study was conducted with the objective to measure statistically if there existed any association of consanguinity with pregnancy outcomes in the form of stillbirths, abortion and Rh-incompatibility. METHODS: This cross sectional analytical study was conducted at the Obstetrics department of Combined Military Hospital Quetta, Pakistan from 1st November 2017 to 28th February 2018. All pregnant women visiting Out Patient Department were included. Women unwilling to participate or needing emergency intervention were excluded. Sample size, i.e., 384 was calculated using online OpenEpi calculator and simple random sampling technique was applied. A structured interviewer administered questionnaire was used to extract retrospective information. Descriptive statistics, 95% Confidence Intervals, Chi-Square test and Contingency Coefficient were calculated using SPSS Version 20. Results were regarded significant at p<0.05. RESULTS: Out of 384 study participants, 188 (48.9% with 95% CI:43.9- 53.9%) were married to first cousins. Mean±SD age of the study participants was 27.5±4.8 years. Difference between stillbirth, and abortion among consanguineous unions and nonconsanguineous unions was significant while that of Rh-incompatibility was non-significant.. CONCLUSIONS: Large population based studies are needed before declaring consanguinity as a health problem in our setting.

ASSOCIATION BETWEEN PLACENTAL ABRUPTION AND CAESAREAN SECTION AMONG PATIENTS AT KHYBER TEACHING HOSPITAL PESHAWAR.

BACKGROUND: Ante partum haemorrhage remains to be a major cause of morbidity and mortality.30% of this haemorrhage is attributed to placental abruption. Along with other adverse maternal outcomes, it increases the risk of Caesarean sections in patients, which is a public health concern. This study was conducted to find out whether any significant association exists between placental abruption and C-section in our set up. METHODS: A cross-sectional study was conducted from July 26th, 2011 to May 1st, 2013 (i.e., 21 months) in the Department of Obstetrics and Gynaecology, Khyber Teaching Hospital Peshawar on a sample of 334 patients who presented with antepartum haemorrhage after 28 weeks of gestation. All those patients with and without placental abruption were followed throughout pregnancy and labour to detect the risk of caesarean section. RESULTS: Among study participants, parity had the highest dispersion while gestational age had the lowest. Caesarean section was performed on 26.3% (95% CI) of the study participants. Proportion of placental abruption among patients presenting with ante partum haemorrhage was 20.6%, (95% CI) out of which 7.5% underwent C-section. Association between placental abruption and C-section was found significant at α = 0.05 (p = 0.03). CONCLUSION: Risk of caesarean section is increased in pregnancies complicated by placental abruption as compared to pregnancies complicated by other causes of ante partum haemorrhage.

STATUS OF ETHICAL REVIEW BOARDS IN MEDICAL COLLEGES OF KHYBER PAKHTUNKHWA.

BACKGROUND: Ethics means custom, character, habit or disposition and as a discipline is frequently called Moral Philosophy. Ethics cannot be regulated until it is incorporated in Law. With the advent of research in life sciences, the need of ethical review boards was felt to protect individual and public interests. The objective of this study was to know the status of ethical review boards at all medical colleges of Khyber Pakhtunkhwa in terms of its existence, membership and activities. METHODS: This province wise cross-sectional survey was conducted over a period of three months. All the sixteen medical colleges of the province registered with Pakistan Medical and Dental Council Islamabad were included. A structured questionnaire was used as data collection tool. Single respondent from each medical college was identified by the respective chief executive officer or principal. Data was analysed through SPSS V-20 and MS Excel 2007. Descriptive statistics were calculated for quantitative data. RESULTS: Out of sixteen medical colleges, one had no ethical review board and another neither refused nor returned filled questionnaire. Eleven medical colleges reported combined boards with their teaching hospitals, while 3 had separate boards. Highest number of members noted was 14 and lowest being 4. Mode was 8. None of the boards had a medical doctor with degree or diploma in bioethics, as its member. Six medical colleges had medical doctors who had attended workshops on bioethics. Majority of medical colleges had no track of record about its review boards. CONCLUSION: Overall situation of ethical review boards at the medical colleges of Khyber Pakhtunkhwa is not satisfactory and needs proper regulatory measures.