Patients' experiences with tele-mental health services during COVID-19 in Pakistan.

Background: Although the concept of telehealth is of great interest globally, its potential has not yet been realized in Pakistan. It is therefore essential to explore the perspectives of stakeholders on the technology, particularly for mental health, to be able to increase and improve its use. Aim: To assess the perceptions and experiences of patients receiving tele-mental health services, including telepsychiatry and tele-psychotherapy, in Pakistan. Methods: For this qualitative exploratory study, we conducted in-depth interviews with 49 individuals at a tertiary care hospital in Karachi, Pakistan. Using the Cresswell framework for content analysis, we identified 3 major themes that focused on the positive and negative aspects of tele-mental health services and made suggestions for enhancing them. Results: Twenty-six of the participants received telepsychiatry, while the remaining 23 received tele-psychotherapy services. Technical literacy, cost of consultation, privacy, and therapeutic alliance were the major challenges identified by the patients, while convenience and the absence of stigma were highlighted as key facilitators for tele-mental health. Tele-consultations reduced travel and waiting time, thus improving access to healthcare. Participants suggested that the processes for booking appointments and making payments should be streamlined and the cost of tele-consultation reduced. Conclusion: This study provides insightful findings on tele-mental health services from the perspectives of patients living in an Asian culture. The major benefits highlighted were destigmatization of mental health and elimination of commuting costs and travel time. There were concerns about privacy, therapeutic alliance and availability and affordability of the technology.

Adolopment of clinical practice guidelines and creation of referral pathways for psychiatric conditions in Pakistan.

Psychiatric disorders are highly prevalent in Pakistan and burdens the scarce number of psychiatrists present in the country. The establishment of evidence-based clinical practice guidelines (EBCPGs) and primary-care referral pathways within the local context is imperative to make the process efficient. In this Health Policy, we aimed to develop EBCPGs and primary-care referral pathways that are specific to Pakistan's primary-care setting, with the aim of facilitating the management of psychiatric conditions. Ten EBCPGs were created through the GRADE-ADOLOPMENT process; two recommendations were adopted with minor changes, 43 were excluded, and all others were adopted without any changes. Ten primary-care referral pathways for managing ten psychiatric disorders were created and 23 recommendations were added which will help to bridge the gap in care provision. These psychiatric referral pathways and EBCPGs will bring Pakistan's healthcare system a step closer to achieving optimal health outcomes for patients.

Covid-19 related isolation and risk of post-traumatic stress disorder in patients presenting to tele-clinics at a private tertiary care hospital in Karachi.

The objective of this study was to assess the psychological impact of isolation on individuals with Covid-19 and determine the experiences of people in isolation. All adults with Covid-19 who reported to the infectious disease tele-clinic were included in the study; participants were sent the survey form via email. The email was sent to 146 people and 47 responses were received. IES-R questionnaire was submitted to all individuals on Day 7 of quarantine, along with a qualitative questionnaire. The mean score on IES-R for all the respondents was 18.77. Out of 47 participants, for 6 (12.8%) PTSD was a clinical concern, 3 (6.4%) participants had a probable diagnosis of PTSD, and 6 (12.8%) participants scored high enough to suppress immune function. The majority of participants reported stress due to confinement in an isolated space and interruption in daily routine, specifically work-related routine. Praying, meditation, and having social support helped the participants cope with the isolation.

Testing an educational intervention to enhance resilience and self-efficacy among schoolteachers in Karachi Pakistan.

OBJECTIVE: A pilot study using a pre-post interventional design, was carried out to evaluate the effectiveness of a resilience-based training workshop on the self-efficacy and resilience of schoolteachers in a peri-urban area of Karachi, Pakistan. Four in person workshops were held at the school's location during January to June 2022. RESULTS: A total of 14 teachers participated in the workshop. The effectiveness of interventions was evaluated by assessing self-efficacy and resilience in pre- and post-teaching modules. The Wilcoxon Signed Rank Test determined a significant difference between the pre- to post-module scores of Self Efficacy (p = 0.016) and resilience (p = 0.006). The pre-median scores with IQR of Self-Efficacy were 28 (10), and Resilience scores 76 (12); and post-scores for Self-Efficacy and Resilience scores increased to 35 (5.5) and 88 (14) respectively. This indicated significant improvement in general self-efficacy and resilience skills after four weeks of training. This pilot study showed that building knowledge regarding mental health struggles in students and oneself, learning ways to cope with stress and manage student behavior, and forming a peer support system are crucial in building self-efficacy and resilience in teachers.

Evaluating knowledge about HIV and discriminatory attitudes among Pakistani women of reproductive age using 2017-18 Demographic Health Survey data.

A prominent issue associated with HIV is the stigma around it owing to a lack of awareness. This study aimed to find the association between HIV and AIDS-related knowledge and discriminatory attitudes amongst Pakistani women of reproductive age using the 2017-18 Pakistani Demographic Health Survey (PDHS) data. We analyzed a sample of 3381 Pakistani women of reproductive age using ordinal logistic regression for complex survey data. Two composite variables were created using the HIV module to denote the respondents' HIV-related knowledge and their attitude toward people living with HIV (PLHIV) and calculated using a scoring method. Additional variables included the respondents' age, education level, socioeconomic status, residential setting, and HIV testing history. More than half (58.8%) of the respondents presented with a negative attitude toward PLHIV and 64.3% of the respondents had poor knowledge regarding the illness. In the multivariable analysis, knowledge about HIV and level of education reported significant associations with discriminatory attitudes. We concluded that the odds of individuals living in a rural setting and hailing from a low socioeconomic background presenting with a negative attitude towards PLHIV were 2.52 times (95% CI 1.07-5.89) higher as compared to those living in an urban setting from a high socioeconomic background.

Clinical and psychosocial factors associated with quality of life in patients with head and neck cancer: an analytical cross-sectional study from a lower-middle-income country.

INTRODUCTION: The disease course of head and neck (H&N) cancer can severely impair patients' quality of life (QoL). In Pakistan, a South Asian lower-middle-income country (LMIC), psychosocial factors may impact QoL. We aimed to assess QoL and associated factors amongst patients with H&N cancer in Pakistan. METHODS: An analytical cross-sectional study was conducted amongst adult (≥ 18 years) patients with H&N cancer who were ≥ 4 weeks post-initiation of treatment. The survey assessed QoL (European Organization for Research and Treatment of Cancer Quality of Life Questionnaires), anxiety and depression (Hospital Anxiety and Depression Scale), and social support (Enriched Social Support Instrument). Multivariable linear regression was performed for analysis. RESULTS: A total of 250 patients (mean age: 51.6 years) were included. The majority of patients were married (87%) and living with multigenerational/extended family households (53%). On multivariable linear regression, ongoing cancer treatment (beta coefficient: -13.93), having a tracheostomy (-10.02), and receiving adjuvant chemoradiotherapy (-8.17) were significantly associated with poorer global QoL. Additionally, poorer QoL was associated with depression (-24.37) and anxiety (-13.34). However, having more household family members was associated with better global QoL (0.34). CONCLUSION: The QoL of patients with H&N cancer in Pakistan is affected by both the nature of cancer treatment as well as sociocultural factors such the number of household family members. Given that poorer QoL is associated with worse mental health outcomes, there is a need to develop and implement psychosocial interventions to improve the QoL of patients with H&N cancer in Pakistan, particularly during active treatment.

Enhancing a Willingness to Respond to Disasters and Public Health Emergencies Among Health Care Workers, Using mHealth Intervention: A Multidisciplinary Approach.

Health care workers (HCWs) are increasingly faced with the continuous threat of confronting acute disasters, extreme weather-related events, and protracted public health emergencies. One of the major factors that determines emergency-department-based HCWs' willingness to respond during public health emergencies and disasters is self-efficacy. Despite increased public awareness of the threat of disasters and heightened possibility of future public health emergencies, the emphasis on preparing the health care workforce for such disasters is inadequate in low-and-middle-income countries (LMICs). Interventions for boosting self-efficacy and response willingness in public health emergencies and disasters have yet to be implemented or examined among emergency HCWs in LMICs. Mobile health (mHealth) technology seems to be a promising platform for such interventions, especially in a resource-constrained setting. This paper introduces an mHealth-focused project that demonstrates a model of multi-institutional and multidisciplinary collaboration for research and training to enhance disaster response willingness among emergency department workers in Pakistan.

The Role of Self-Efficacy and Risk Perception in the Willingness to Respond to Weather Disasters Among Emergency Medicine Health Care Workers in Pakistan.

OBJECTIVE: Optimizing health care workers' (HCWs) willingness to respond (WTR) is critical in low-and-middle-income countries (LMICs) for proper health system functioning during extreme weather events. Pakistan frequently experiences weather-related disasters, but limited evidence is available to examine HCW willingness. Our study examined the association between WTR and behavioral factors among emergency department HCWs. METHODS: A cross-sectional survey was conducted from August to September 2022 among HCWs from 2 hospitals in Karachi, Pakistan. Non-probability purposive sampling was used to recruit participants. A survey tool was informed by Witte's Extended Parallel Process Model (EPPM). Multivariate logistic regression analyses were performed to examine the association between WTR and attitudes/beliefs as well as EPPM profiles. RESULTS: Twenty-nine percent of HCWs indicated a low WTR. HCWs using public transportation had a higher WTR. Perceived knowledge and skills, self-efficacy, and perceived impact of one's response showed positive associations with WTR if required. Perception that one's colleagues would report to work positively predicted WTR if asked. Consistent with the EPPM, HCWs with high efficacy and perceived threat were willing to respond to weather disasters. CONCLUSIONS: Our findings highlight the need of strengthening WTR by promoting self-efficacy and enhancing accurate risk perception as a response motivator, among emergency department HCWs in Pakistan.

Association of depressive symptoms and quality of life in Pakistani youth (15-24 years) with polycystic ovarian syndrome: a web-based analytical cross-sectional study.

Introduction: Polycystic ovarian syndrome (PCOS) is associated with impaired quality of life (QOL) of individuals, predominantly in youth, who are most vulnerable to its impact. Psychological morbidity could be one of the factors influencing QOL. The study investigated the association between depressive symptoms and QOL in Pakistani youth (15-24 years) with PCOS and determined other factors associated with QOL. Methods: We conducted an analytical-cross-sectional survey on 213 single Pakistani females aged 15-24 years recruited via a web-based approach. Depression and QOL were assessed through Center-of-Epidemiological-Studies-Depression tool and Polycystic-ovarian-syndrome-quality-of-life-scale. Multiple-linear-regression was used to determine factors associated with QOL, and adjusted regression-coefficients along with a 95% confidence interval were reported. Results: The mean QOL score: 2.9 ± 1.1. The domain of obesity had the lowest mean score (2.5 ± 1.6) whereas domain of hirsutism had the highest (3.2 ± 1.9). 172/213 (80%) participants were screened positive for depressive symptoms. Participants with depressive symptoms reported reduced mean QOL scores than respondents with no such symptoms (2.8 ± 1.0 vs. 3.4 ± 1.3, p < 0.001). No differences were found in overall QOL and individual domains between participants 15-19 years (n = 36, 17%) and participants >19-24 years (n = 177, 83%) (2.9 ± 1.1 vs. 2.9 ± 1.1) (p > 0.05). We found a significant interaction between depressive symptoms and PCOS duration, indicating that the estimated mean overall QOL score decreases by 25.1 (-36.6, -13.6) for every year increase in PCOS duration among participants screened positive for depressive symptoms. Furthermore, for those respondents who had family history of PCOS and were not satisfied with their healthcare provider treating PCOS, the estimated mean QOL score was 17.47 (-26.1, -8.8) lower than participants who had no family history of PCOS and were satisfied with their healthcare provider. Other factors associated with reduced quality of life included societal pressure to improve appearance affected by PCOS, parental criticism related to PCOS, education, socioeconomic status, working status and BMI. Conclusion: Depressive symptoms with increasing duration of PCOS were significantly associated with reduced QOL. Therefore, to improve the overall QOL of PCOS youth, screening and timely addressing of psychological morbidities should be considered.

Eating Disorders in Medical and Nursing Students of a Private University: Relationship with Depression, Anxiety, and Stress.

The study aimed to identify the relationship between Avoidant/Restrictive Food Intake Disorder (ARFID), Anorexia and Bulimia nervosa with stress, depression, and anxiety, among undergraduate students at Aga Khan University (AKU) in Pakistan. The data collection was done online using Eating Attitude Test-26 (EAT-26), Nine Item ARFID Screen (NIAS), and Depression Anxiety Stress Scale (DASS-21). A total of 79 responses were received. Among them, 83.5% (n=66) were females and 16.5% (n=13) were males. On the NIAS screen, 16.5% participants tested positive and 15.2% indicated high risk of eating disorders on EAT-26. There were 26% participants who were underweight while 20% were overweight. Anxiety was significantly associated with all eating disorders while depression and stress were significantly associated with positive EAT-26 results too. Females and early- year students were at higher risk. We recommend regular monitoring for eating changes which may improve psychological and physical wellbeing of medical and nursing students. Key Words: Eating disorders, Stress, Dysfunctional eating behaviours, Students, Pakistan.

A pilot study of offering a positive disciplining module for public school teachers in Hyderabad, Pakistan: A quasi-experimental study.

A pilot quasi-experimental study was conducted in which participants in the intervention group (n = 31) received positive learning environment through Positive Disciplining (PLEPD) module, while those in the control group (n = 29) received routine training. Teachers' knowledge and attitude regarding corporal punishment (CP) and Beck Depression Inventory-II (BDI-II) were measured before (T0), immediately after (T1) and 3 months after the intervention (T2). Descriptive analysis and analysis of variance (ANOVA) were used to describe participants' characteristics and mean scores for knowledge and attitude among teachers. A total of 60 teachers completed the 16 hours training module. The overall response rate was >90%. Most participants recommended increasing the overall duration of the programme by reducing 4 to 2 hours per day, thus, increasing the period from 4 to 8 days of training. There were no differences between control and intervention groups at baseline regarding participant characteristics (p= > .05). The difference in depression (F = .0863, p = .357) and knowledge and attitude (F = 1.589, p = .213) scores among groups were not statistically significant. However, the mean score for knowledge and attitude followed a positive trend, increasing depression mean scores at T1 and T2. A positive disciplining programme is a feasible school intervention for public schools and may effectively reduce depression to ensure overall well-being.

Psychosocial factors influencing quality of life in patients with primary brain tumors in Pakistan: an analytical cross-sectional study.

OBJECTIVE: Despite quality of life (QoL) being recognized as an important outcome in neuro-oncology, there is a lack of research from Pakistan where sociocultural differences may influence QoL. This study aimed to measure the QoL in patients with primary brain tumors (PBTs) and assess its association with mental health outcomes and social support. RESULTS: Our study included a total of 250 patients, with a median age of 42 years (range 33-54 years). The commonest brain tumors were glioma (46.8%) and meningioma (21.2). The mean global QoL of the sample was 75.73 ± 14.9. The majority of patients had high social support (97.6%) and were not depressed (90%) or anxious (91.6%). On multivariable linear regression, global QoL was inversely associated with no or low income (beta coefficients: -8.75 to -11.84), having hypertension (-5.53), currently using a urine catheter (-13.55), having low social support (-28.16) suffering from mild (-15.31) or symptomatic (-23.84) depression, or mild anxiety (-13.22).

Factors affecting well-being in brain tumor patients: An LMIC perspective.

Introduction: Brain tumor is a devastating and often fatal diagnosis; quality of life and patient well-being are important goals of treatment. This study addresses the gap in culture-specific literature exploring the needs and coping strategies of brain tumor patients within an LMIC setting. Methodology: A qualitative approach was undertaken using an exploratory descriptive study design. In-depth interviews were conducted to capture the perspective of 250 brain tumor patients at a private tertiary center followed by extensive content analysis to identify major themes and sub-themes across responses. Results: The analysis identified three major themes: (i) Factors affecting the lives of brain tumor survivors (BTSs) and their impact (ii) What works to improve QoL according to the survivors' perspectives, and (iii) Coping tactics & fostering healthy relationships. The need for financial navigation strategies improved patient-physician relationships, and reinforcing positive coping strategies were emphasized. Conclusion: In our population, family support and spiritual connection played an important role in helping patients mitigate the psychosocial burden of illness. However, financial concerns were pervasive and need to be addressed for better overall well-being.

Resilience and prenatal mental health in Pakistan: a qualitative inquiry.

BACKGROUND: Women in Pakistan suffer from a high rate of depression. The stress of low-income, illiteracy, exposure to violence and living in a patriarchal society are predisposing vulnerabilities for depression, particularly during and following pregnancy. The resilience of an individual plays a significant role in promoting prenatal mental health, but this has yet to be thoroughly researched. In this article, our objective is to identify the core characteristics of resilience among pregnant women, which will then help us in developing an intervention. METHODS: The exploratory-descriptive study was conducted over 6 months in five different antenatal hospitals in Sindh, Pakistan. A total of 17 semi-structured interviews were conducted with pregnant women, purposefully selected with heterogeneous characteristics to explore diverse perspectives, while symptoms of depression were quantified by the Edinburgh Postnatal Depression Scale before the interview. Verbatim transcriptions were coded openly and merged into categories and themes. RESULT: A total of six themes emerged from in-depth thematic analysis: 1) purpose of life, 2) dealing with emotions, 3) believing in yourself, 4) optimistic approach, 5) strengthening support and relationship and 6) spirituality and humanity. Women agreed that these characteristics could help them improve their mental health. CONCLUSION: In conclusion, these themes were the core components of pregnant women's resilience which ultimately could help to promote prenatal mental health. These pave a pathway towards developing culturally and contextually resilience interventions aimed at enhancing mental health of pregnant women which then may improve neonatal and family mental wellbeing.

Patterns of suicide and self-harm in Pakistan: a retrospective descriptive study protocol.

INTRODUCTION: Suicide is a major global public health problem. Low-income and middle-income countries contribute 78% of all suicidal deaths. Pakistan, a South Asian country, lacks official statistics on suicides at national level. Statistics on suicide are neither collected nationally nor published in the annual national morbidity and mortality surveys. Medicolegal reports on suicides and self-harm are extremely rich and important source of information but greatly underused in Pakistan. We aim to examine the patterns of suicides and self-harm retrospectively in patients who were registered with medicolegal centres (MLCs) in Karachi, during the period January 2017 to December 2021. METHODS AND ANALYSIS: Using retrospective descriptive design, the data will be collected from the medical records maintained at the main office of the Karachi police surgeon. Data from all nine MLCs of Karachi are collated and stored at the main office of Police surgeon. Information on suicide and self-harm cases will be extracted from records of all MLCs. The data will be collected using structured proforma and it will be analysed using descriptive and inferential analysis. ETHICS AND DISSEMINATION: The study was approved for exemption from Aga Khan University, Ethical Review Committee. The findings of the study will be disseminated by conducting seminars for healthcare professionals and stakeholders including psychiatrists, psychologists, counsellors, medicolegal officers, police surgeons, mental health nurses, general and public health physicians and policy makers. Findings will be published in local and international peer-reviewed scientific journals.

Psychometric properties of the Urdu version of the EORTC QLQ-H&N35 (European organization for research and treatment of cancer head and neck module) quality of life tool.

BACKGROUND: We translated and validated the Urdu version of the European Organization for Research and Treatment of Cancer Quality of Life (QoL) Questionnaire's Head and Neck (H&N) Cancer Module (EORTC QLQ-H&N35) and assessed its convergent and discriminant validity by examining correlations of QoL with depression, anxiety, and resilience. METHODS: We translated the EORTC QLQ-H&N35 according to EORTC instructions. Patients at a tertiary care hospital in Pakistan completed a survey consisting of Urdu versions of EORTC QLQ-C30 (core QoL tool), QLQ-H&N35, Hospital Anxiety and Depression Scale, and Wagnild and Young Resilience Scale (RS-14). Content validity, convergent validity, discriminant validity, and reliability (using Cronbach's alpha) of the EORTC QLQ-H&N35 were assessed. RESULTS: Our sample comprised 250 patients with H&N cancer, most commonly oral (82%). The Urdu translations were comprehensible for all patients. The Cronbach alpha for QLQ-H&N35 multi-item domains ranged from 0.75 to 0.98 (acceptable to excellent), barring "Senses Problems", which was less than the generally acceptable level (0.50). The patient-reported content validity index (CVI) scores for relevance and clarity of the Urdu version of the QLQ-H&N35 were 0.93 and 0.92, respectively (both excellent). Our results revealed weak bidirectional correlations of the QLQ-H&N35 with resilience, depression, and anxiety, showing good discriminant validity. A weak-to-moderate but significant negative correlation (r: - 0.185 to - 0.613; p < 0.01) was seen between the QLQ-H&N35 and the global QoL measure of the QLQ-30. CONCLUSION: Our Urdu translation of the EORTC QLQ-H&N35 demonstrated validity comparable to previous studies, with good discriminant construct validity when measured against resilience, depression, and anxiety. An issue of concern is the poor internal consistency of the "Senses Problems" domain. Nevertheless, the Urdu translation produced in this study serves as a valid and reliable measure to measure QoL in H&N cancer in clinical or research settings in Pakistan.

A dyadic approach to depression, resilience and quality of life on marital adjustment among infertile couples in Karachi, Pakistan: A cross-sectional study.

BACKGROUND: Infertility is a major reproductive health problem in Pakistan. It has the potential to cause serious negative impact on a couple's marital life and psychological health. AIM: This study aimed to assess the factors associated with maladjustment among infertile couples. METHOD: An analytical cross-sectional design was employed. Validated scales were used to assess marital adjustment, depression, resilience and quality of life among infertile couples. Purposive sampling was employed to enrol 334 infertile couples from a private infertility medical centre, of Karachi, Pakistan. RESULTS: Among couples, marital adjustment scores were comparable, but resilience and quality of life were significantly low among wives whereas depression was significantly high among wives compared with husbands. Wives' marital adjustment was positively correlated with husband's resilience and quality of life and negatively related with his depression. After employing adjusted actor-partner interdependence modelling, wives' own depression and resilience had significant effect on their marital adjustment and their partner's resilience, depression and quality of life did not have any impact on their outcome. On the contrary, wives' resilience had a significant effect in increasing the marital adjustment of their husband. CONCLUSION: This study highlights the need to promote psychological support (resilience building skills) or couples' therapy to all those couples undergoing infertility treatment.

Are Nonfatal Suicide Attempts Instrumental in Achieving Personal and Interpersonal Goals?

This study focused on the well-being of the survivors of suicide attempts and the well-being of their interpersonal relationships after the attempt. The data came from a sample of 392 college students from 10 Muslim majority countries who reported having attempted suicide in the last 4 years. Suicide was conceptualized as a goal-directed behavior embedded in a sociocultural context and motivated by personal or interpersonal goals. We tested a process that linked culturally shaped self-construal to the postsuicidal personal and interpersonal well-being. We posited that this process would operate through the attitudes towards suicide, motives for suicide, the strength of the intention to die. Our model indicated that the acceptability of suicide was positively associated with escape motives, and this association was even stronger for the individuals with interdependent self-construals. Escape motives were negatively associated with postsuicidal personal and interpersonal well-being, but communication motives were not associated with these outcomes. We also found evidence that having an interdependent self-construal might be beneficial for postsuicidal personal and interpersonal well-being. Our results further suggested that the postsuicidal personal and interpersonal well-being of highly interdependent individuals may depend on the interpretation of their act of suicide by their close others.

Burden and factors associated with perceived stress amidst COVID-19: a population web-based study in Pakistan.

OBJECTIVE: This study aims to determine the burden and factors associated with perceived stress in the Pakistani population amidst the COVID-19 pandemic. SETTING: A web-based cross-sectional survey was conducted from April to August 2020. POPULATION: This survey was broadcasted on the web using a Google form link and 1654 Pakistani residents had completed this survey. Individuals belonging to any province, city, village, or district of Pakistan irrespective of any age, having internet access and a link of Google form, with English/Urdu competency, consent to participate, and currently residing in Pakistan were eligible to participate. OUTCOME MEASURE: Perceived stress was measured using a validated tool of perceived stress scale-10. Multiple ordinal regression was used, and an adjusted OR along with a 95% CI are reported. RESULTS: The mean score of perceived stress was 19.32 (SD ±6.67). Most of the participants screened positive for moderate (69%) and high levels (14%) of stress, respectively. The odds of high-perceived stress among severely anxious participants were 44.67 (95% CI: 21.33 to 93.53) times than participants with no/minimal generalised anxiety during the complete lockdown. However, the odds of high levels of perceived stress among moderately anxious respondents were 15.79 (95% CI: 10.19 to 24.28) times compared with participants with no/minimal anxiety during the smart lockdown. CONCLUSION: This study evidence that the pandemic was highly distressing for the Pakistani population causing the maximum level of perceived stress in more than half of the population. Adequate and timely interventions are needed before high-stress levels culminate into psychological disorders.