Listening to Caregivers: Narratives of Health Seeking for Children Under Five with Pneumonia and Diarrhea: Insights from the NIGRAAN Trial in Pakistan.

Background: Understanding health-seeking behaviors of caregivers is important to reduce child mortality. Several factors influence decision-making related to childhood illnesses. Objective: The objective of this study was to gather caretaker narratives to develop a comprehensive understanding of the context and process of caregiving at household level during all stages of an episode of diarrhea and pneumonia in children <5. Methods: Using a narrative interview approach, stories from caregivers of children <5 were collected from a rural district in Sindh Pakistan. Eleven households with children <5 were randomly selected and purposive sampling was done to interview 20 caregivers. All data collection was conducted privately in participants' homes and informed consent taken. Manual content analysis was carried out by three independent researchers and emerging themes drawn. Results: The role of joint family system is integral in making decisions and the child's paternal grandmother, is an important and trusted source of information regarding child sickness in the household. They often promote home remedies with considerable authority prior to formal consultation with the health care system. Caregivers were generally dissatisfied with doctors in the public sector who were perceived to be providing free consultation with a poor quality of care and long waiting time as compared to private doctors. Financial considerations and child support were favorably addressed in households with a joint family system. Conclusion: The joint family system provides a strong support system, but also tends to reduce parental autonomy in decision-making and delay first contact with formal health providers. Prevalent home remedies, and authority of elders in the family influence management practices. Interventions for reducing improving child mortality should be cognizant of the context of decision-making and social influences at the household level.

Violence and abuse among working children in urban and suburban areas of lower Sindh, Pakistan.

BACKGROUND: Child labourers are exposed to an insecure environment and higher risk of violence. Violence among child labourers is an under-studied phenomenon which requires contextual assessment. AIMS: We applied Bronfenbrenner's ecological model (micro-, exo- and macro-system) to understand the interplay of individual, community, societal and policy context fuelling violence. METHODS: Focus group discussions and family ethnographies of child-labourers working in common occupational sectors of suburban areas of Sindh were carried out to gain in-depth understanding of their immediate environment and abuse (micro-system). Frequency of emotional, physical and sexual violence (5-14 years; n = 634) was also determined. Indepth interviews with employers (exo-system, n = 4) and key-informant-interviews of prominent stakeholders in Pakistan (macro-system, n = 4) working against labour/violence were carried out Thematic-content analysis was performed using MAXQDA, version 8.0. RESULTS: We estimated that 21%, 19% and 9% of children suffered from emotional, physical and sexual violence respectively. Child labourers' interviews indicated the existence of all forms of abuse at home and in the workplace; sexual violence by grandfathers was highlighted (micro-system). Children reported frequent scolding and insults in the workplace along with physical violence that could be fatal (exo-system). The legal environment of violence in Pakistan was considered deficient as it did not address the hidden forms (touching, kissing, etc.; macro-system). CONCLUSION: We documented that all forms of violence were rampant among the child labourers, and improved efforts and comprehensive legislation is direly needed to alleviate the situation.

Applying Public Health Principles to Better Manage the COVID-19 Pandemic: "Community Participation," "Equity," and "Cultural Sensitivity".

Although coronavirus vaccine roll-out is beginning, standard public health practices will, for most people, remain their first line of protection for some time. Three principles guiding the pandemic control process, namely community participation, promotion of equity, and cultural sensitivity, can help people adhere to public health advice. These three principles can enhance intervention effectiveness, decreasing the rate of infection and protecting human rights, promoting social harmony and preventing unrest.

Malnutrition and food insecurity in child labourers in Sindh, Pakistan: a cross-sectional study.

BACKGROUND: Child labour is common in low- and middle-income countries. Although child labour is widespread in Pakistan, no data are available on the health of child labourers. AIMS: This study aimed to assess the food security, food intake and nutritional status of child labourers aged 5-14 years working in lower Sindh, Pakistan. METHODS: Child labourers aged 5-14 years working in agriculture, manufacturing industry, hotels and restaurants, domestic work and migrant child labourers working in vegetable markets were recruited using a respondent-driven sampling technique. Sociodemographic and nutrition information was obtained by an interviewer questionnaire. The children's height and weight were measured to assess stunting (height-for-age z scores less than -2) and wasting (weightfor- height z scores less than -2). RESULTS: A total of 634 child labourers were included: 184 worked in agriculture, 120 in industry, 67 in hotels and restaurants, 63 in domestic work and 200 were migrant child labourers. Overall, 15.5% of the children were stunted and 30.0% were wasted. The prevalence of stunting was highest in children working in agriculture (27.2%) and the prevalence of wasting was highest in migrant child workers (35.0%). About half the children (51.1%) were suffering from food insecurity. Food inadequacy was mainly in consumption of vegetables/potatoes (98% of the children had inadequate intake), legumes (97%), fruits (96%), meat/ poultry (95%) and milk/dairy products (82%). CONCLUSION: The nutritional status and food insecurity of the child labourers of Pakistan are comparable with the general population, highlighting the grave situation of the country with regard to food security.

Impact of humanities and social sciences curriculum in an undergraduate medical education programme.

OBJECTIVE: To evaluate the impact of humanities and social sciences curriculum in an undergraduate medical education programme. METHODS: The qualitative study was conducted from May 2016 to May 2017 at a private medical college in Karachi where humanities and social sciences subject is an art of the undergraduate curriculum as a 6-week module at the start of Year 1 of the five-year programme. Focus group discussions were held with students from all the five years as well as with faculty related to humanities and social sciences, basic sciences and their clinical counterparts. The views of alumni of the undergraduate programme who are now members of the faculty at the institution were also explored and semi-structured interviews were conducted with institutional academic leaders. MAXQDA software was used to identify the themes for analysis. RESULTS: Of the 50 participants, 27(54%) were students, 21(42%) were faculty members and 2(4%) were academic leaders. From the 11 sub-themes, 5 themes were identified: Expectations, Strengths, Challenges, Way forward, and Institutional role and responsibility. Faculty members perceived humanities and social sciences as encouraging creative and critical thinking, boosting students' confidence and positively impacting their behaviour. Student perception seemed to change as they progressed through the years and they appreciated its impact at different stages. CONCLUSIONS: The existing humanities and social sciences curriculum can be further strengthened by integrating contents throughout the five-year programme and continuing it as a longitudinal theme rather than limiting it to a one-time exposure at the start of the programme.

Recommendations: putting an end to child labour in Pakistan!

Child labour is rampant in Pakistan since ages. Laws, policies, programmes and strategies to eliminate child labour have been in place with little gain. Implementation of laws and sustainability of programmes offer barriers to eliminate the menace. We recommend a new approach of regulating child labour as a strategy to eliminate it in the longer run. Model districts with drop-in-centres offering free education to the working children should be constructed. The key stakeholders should unite on a common platform to formulate guidelines defining the nature and duration of work for children in various sectors such that they have sufficient time to visit the drop-incentres. Once a generation of children is educated, the cycle will start to break itself and gradually we will overcome child labour.

Exploring women and traditional birth attendants' perceptions and experiences of stillbirths in district Thatta, Sindh, Pakistan: a qualitative study.

BACKGROUND: Pakistan reports the highest stillbirth rate in the world at 43 per thousand births with more than three-quarters occurring in rural areas. The Global Network for Women's and Children's Health maintains a Maternal and Newborn Health Registry (MNHR) in 14 study clusters of district Thatta, Sindh Pakistan. For the last 10 years, the MNHR has recorded a high stillbirths rate with a slow decline. This exploratory study was designed to understand the perspectives of women and traditional birth attendants regarding the high occurrence of stillbirth in Thatta district. METHODS: We used an exploratory qualitative study design by conducting in-depth interviews (IDIs) and focus group discussions (FGDs) using semi-structured interview guide with rural women (FGDs = 4; n = 29) and traditional birth attendants (FGDs = 4; n = 14) who were permanent residents of Thatta. In addition, in-depth interviews were conducted with women who had experienced a stillbirth (IDIs = 4). This study presents perceptions and experiences of women and TBAs regarding high rate of stillbirth in Thatta district, Karachi. RESULTS: Women showed reluctance to receive skilled/ standard care when in need due to apprehensions towards operative delivery, poor attitude of skilled health care providers, and poor quality of care as service delivery factors. High cost of care, far distance to facility, lack of transport and need of an escort from the family or village to visit a health facility were additional important factors for not seeking care resulting in stillbirth. The easy availability of unskilled provider in the form of traditional birth attendant is then preferred over a skilled health care provider. TBAs shared their husband or family members restrict them to visit or consult a doctor during pregnancy. According to TBAs after delivering a macerated fetus, women are given herbs to remove infection from woman's body and uterus. Further women are advised to conceive soon so that they get rid of infections. CONCLUSION: Women of this rural community carry lots of apprehension against skilled medical care and as a result follow traditional practices. Conscious efforts are required to increase the awareness of women to develop positive health seeking behavior during pregnancy, delivery and the post-partum period. Alongside, provision of respectful maternity care needs to be emphasized especially at public health facilities.

Insight into Mechanistic Action of Thymoquinone Induced Melanogenesis in Cultured Melanocytes.

BACKGROUND: Melanin plays a crucial role in camouflage, social communication and protection against harmful ultraviolet radiations. Melanin is synthesized by melanocytes through melanogenesis and several intrinsic and extrinsic factors are involved during the process. Any change occuring in the normal melanogenesis process can cause severe pigmentation problems of hypopigmentation or hyperpigmentation. OBJECTIVE: The present study is based on the evaluation of the effect of thymoquinone on melanogenesis and their possible mechanism of action using the B16F10 melanoma cell line for the production via blocking signaling pathways. METHODS: Phase contrast microscopy, cell viability, tyrosinase activity, melanin content and western blot analysis were used in the present study. RESULTS: In the present investigation, cultured melanocytes exhibit that the stimulation of melanin synthesis when treated with thymoquinone. Tyrosinase activity and melanin production in B16F10 melanoma cell line was increased in doze-dependent manner. In western blot, we investigated the involvement of the cAMP/PKA pathway in thymoquinone induced melanogenesis. It was observed protein kinase inhibitors PKA, PKC, PKB and MEK1 decreased the stimulatory effects of thymoquinone from 11.45- fold value to 8.312, 6.631, 4.51, and 7.211-fold value, respectively. However, the results also prove that thymoquinone may partially induce tyrosinase expression via PKA, PKB, PKC and MEK1 signaling pathways. CONCLUSION: The present finding proposed that thymoquinone is a protective challenger for melanogenesis and it might be useful for the treatment of hypopigmentary disorders.

Stretching the boundaries of medical education A case of medical college embracing humanities and social sciences in medical education.

OBJECTIVE: Aga Khan University, a private medical college, had a vision of producing physicians who are not only scientifically competent, but also socially sensitive, the latter by exposure of medical students to a broad-based curriculum. The objective of this study was to identify the genesis of broad-based education and its integration into the undergraduate medical education program as the Humanities and Social Sciences (HASS) course. METHODS: A qualitative methodology was used for this study. Sources of data included document review and in-depth key informant interviews. Nvivo software was utilized to extract themes. RESULTS: The study revealed the process of operationalization of the institutional vision to produce competent and culturally sensitive physicians. The delay in the establishment of the Faculty of Arts and Sciences, which was expected to take a lead role in the delivery of a broad-based education, led to the development of an innovative HASS course in the medical curriculum. The study also identified availability of faculty and resistance from students as challenges faced in the implementation and evolution of HASS. CONCLUSIONS: The description of the journey and viability of integration of HASS into the medical curriculum offers a model to medical colleges seeking ways to produce socially sensitive physicians.

Schools of public health in low and middle-income countries: an imperative investment for improving the health of populations?

BACKGROUND: Public health has multicultural origins. By the close of the nineteenth century, Schools of Public Health (SPHs) began to emerge in western countries in response to major contemporary public health challenges. The Flexner Report (1910) emphasized the centrality of preventive medicine, sanitation, and public health measures in health professional education. The Alma Ata Declaration on Primary Health Care (PHC) in 1978 was a critical milestone, especially for low and middle-income countries (LMICs), conceptualizing a close working relationship between PHC and public health measures. The Commission on Social Determinants of Health (2005-2008) strengthened the case for SPHs in LMICs as key stakeholders in efforts to reduce global health inequities. This scoping review groups text into public health challenges faced by LMICs and the role of SPHs in addressing these challenges. MAIN TEXT: The challenges faced by LMICs include rapid urbanization, environmental degradation, unfair terms of global trade, limited capacity for equitable growth, mass displacements associated with conflicts and natural disasters, and universal health coverage. Poor governance and externally imposed donor policies and agendas, further strain the fragile health systems of LMICs faced with epidemiological transition. Moreover barriers to education and research imposed by limited resources, political and economic instability, and unbalanced partnerships additionally aggravate the crisis. To address these contextual challenges effectively, SPHs are offering broad based health professional education, conducting multidisciplinary population based research and fostering collaborative partnerships. SPHs are also looked upon as the key drivers to achieve sustainable development goals (SDGs). CONCLUSION: SPHs in LMICs can contribute to overcoming several public health challenges being faced by LMICs, including achieving SDGs. Most importantly they can develop cadres of competent and well-motivated public health professionals: educators, practitioners and researchers who ask questions that address fundamental health determinants, seek solutions as agents of change within their mandates, provide specific services and serve as advocates for multilevel partnerships. Funding support, human resources, and agency are unfortunately often limited or curtailed in LMICs, and this requires constructive collaboration between LMICs and counterpart institutions from high income countries.

Gender: shaping personality, lives and health of women in Pakistan.

BACKGROUND: Gender norms determine the status of Pakistani women that influence their life including health. In Pakistan, the relationship between gender norms and health of women is crucial yet complex demanding further analysis. This paper: determines the reasons for reiteration of gender roles; describes the societal processes and mechanisms that reproduce and reinforce them; and identifies their repercussions on women's personality, lives and health especially reproductive health. METHODS: As part of a six-country study titled 'Women's Empowerment in Muslim Contexts', semi-structured group discussions (n = 30) were conducted with women (n = 250) who were selected through snowballing from different age, ethnic and socio-economic categories. Discussion guidelines were used to collect participant's perceptions about Pakistani women's: characteristics, powers, aspirations, needs and responsibilities; circumstances these women live in such as opportunities, constraints and risks; and influence of these circumstances on their personality, lifestyle and health. RESULTS: The society studied has constructed a 'Model' for women that consider them 'Objects' without rights and autonomy. Women's subordination, a prerequisite to ensure compliance to the constructed model, is maintained through allocation of lesser resources, restrictions on mobility, seclusion norms and even violence in cases of resistance. The model determines women's traits and responsibilities, and establishes parameters for what is legitimate for women, and these have implications for their personality, lifestyle and health, including their reproductive behaviours. CONCLUSION: There is a strong link between women's autonomy, rights, and health. This demands a gender sensitive and a, right-based approach towards health. In addition to service delivery interventions, strategies are required to counter factors influencing health status and restricting access to and utilization of services. Improvement in women's health is bound to have positive influences on their children and wider family's health, education and livelihood; and in turn on a society's health and economy.

Situation analysis of child labour in Karachi, Pakistan: a qualitative study.

In Karachi, large employment opportunities, burgeoning population and the availability of cheap labour might be the contributing factors for the increasing prevalence of child labour. A literature review was conducted in 2007 that included published and unpublished literature since 2000. Various organizations working in the field were also covered, while the perception of the child labourers was covered through three focus group discussions. Common health issues among the child labourers in Karachi included respiratory illnesses, fever and generalised pains, as well as drug and sexual abuse. Organisations working for child labour could be broadly categorised into those working for legal advice and advocacy; those generating statistics; and those that are providing interventions. Discussion with children showed that irrespective of the immediate cause, the underlying determinant for child labour was poverty. The best practices identified included evening schools and drop-in centers for working children with provision for skill-based education and basic health facilities. There is need to have more such centres.

Women's empowerment in Pakistan-definitions and enabling and disenabling factors: a secondary data analysis.

PURPOSE: The purpose of the study was to explore Pakistani women's definition of women's empowerment, including its enabling and disenabling factors. Through understanding empowerment, interventions may be developed for women to be empowered. DESIGN: Transcriptions of 35 interviews from a previous study were reanalyzed through secondary data analysis. FINDINGS/RESULTS: The themes of economic stability, social acceptability, educational achievement, and family harmony emerged for the concept of definition of empowerment. Themes for enabling factors were strength of personality and openness of mind. Disenabling factors had sociocultural influences, religious misinterpretations, and dominant ideology as themes. DISCUSSION/CONCLUSIONS: Pakistani women hold on to their customs, traditions, and religion tenaciously. The views of empowerment leading to the themes were expressed as true for their lives.

A source of strength and empowerment? An exploration of the influence of disabled children on the lives of their mothers in Karachi, Pakistan.

PURPOSE: Previous literature has highlighted marginalisation and stigma of children with disabilities in developing countries, but few studies have explored the central care-giving environment and the relationship of the mother and her child with disabilities in this context. A group of women caring for children with disabilities in a low income community in Karachi, Pakistan was identified for the study. The aims were: (1) to explore the influence children with disabilities have on the daily lives of their mothers, (2) to describe the factors which influence the care-giving capacity of mothers. METHOD: A participatory qualitative research design was implemented. A women's group of caregivers of children with disabilities was formed. Several different tools were used during the course of the group meetings to facilitate discussion including social mapping. A thematic analysis of issues around care-giving and the relationship between the mother and her child with disabilities was conducted. RESULTS: In a society where women may experience restrictions in freedom of movement and decision making, caring for a child with disabilities enabled women to move beyond traditional boundaries in seeking health and education services for their children. However, the gain in empowerment was counter-acted by a lack of care-giving support, a lack of appropriate services for health, rehabilitation and education of children with disabilities and stigma creating anxiety and stress for women. CONCLUSION: While children with disabilities do have some positive effects on the lives of their mothers, there are many more factors which create anxiety for this group of mothers (including a lack of care-giving support and stigma). Community-based rehabilitation strategies should consider the care-giving environment of children with disabilities and shift from a child only to family focus. Interventions which support, empower and strengthen the capacity of mothers are essential for the well being of their children with disabilities.

How we developed a bioethics theme in an undergraduate medical curriculum.

The 5-year undergraduate medical curriculum at Aga Khan University integrates basic sciences with clinical and community health sciences. Multimodal strategies of teaching and learning, with an emphasis on problem-based learning, are utilized to equip students with knowledge, skills, behaviours, attitudes and values necessary for a high-calibre medical graduate. Bioethics teaching was introduced in the medical curriculum in 1988 and has since undergone several changes. In 2009, a multidisciplinary voluntary group began review of undergraduate bioethics teaching and invested over 350 man-hours in curricular revision. This involved formulating terminal objectives, delineating specific objectives and identifying instructional methodologies and assessment strategies appropriate for the contents of each objective. Innovative strategies were specially devised to work within the time constraints of the existing medical curriculum and importantly, to increase student interest and engagement. The new bioethics curriculum is designed to be comprehensive and robust, and strives to develop graduates who, in addition to being technically skilled and competent, are well-versed in the history and philosophy of ethics and bioethics and are ethical in their thinking and practice, especially in the context of a developing country like Pakistan where health indicators are among the worst in the region, and clinical practices are not effectively regulated to ensure quality of care.

Tawana project-school nutrition program in Pakistan--its success, bottlenecks and lessons learned.

Tawana Pakistan Project, a multifaceted pilot project (Sept. 2002 to June 2005) was funded by the Government of Pakistan to address poor nutritional status and school enrollment of primary school age girls. The core strategy was to create safe environment empowering village women to take collective decisions. Through reflective learning process women learnt to plan balanced menus, purchase food, prepare and serve a noon meal at school from locally available foods at nominal costs (USD 0.12/child). Aga Khan University partnered the government for the design, management, monitoring and evaluation of the project, 11 NGO's facilitated implementation in 4035 rural government girls' schools. Training was provided to 663 field workers, 4383 community organizers, 4336 school teachers and around 95 thousand rural women. Height and weight were recorded at baseline and every 6 months thereafter. Wasting, underweight and stunting decreased by 45%, 22% and 6% respectively. Enrollment increased by 40%. Women's' ability to plan balanced meals improved and >76% of all meals provided the basic three food groups by end of project. Government bureaucracy issues, especially at the district level proved to be the most challenging bottlenecks. Success can be attributed to synergies gained by dealing with nutrition, education and empowerment issues simultaneously.

Medical education and training: responding to community needs.

At its inception in 1987, the Aga Khan University introduced the idea of community-based medical education in Pakistan, at a time when this model was being introduced and adapted internationally. Human resource development has been a major objective in the Department of Community Health Sciences (CHS). CHS has contributed to developing a medical curriculum that addresses the health needs of the community at large. This paper narrates the department's experience in working directly with under-served communities, leading to the development of specialized courses and degree programs. CHS emphasizes operational research and development of managerial skills among front-line public health professionals, in both the public and private sectors. Training is provided by people from diverse backgrounds, such as public health, community development, social sciences, law, epidemiology, economy, biostatistics, demography, theater, and film. The lessons we have learned show that the mode of training depends on the overall objectives of the program, the clients and the setting. However, in the spirit of the participatory approach, the recipients of the training must be involved during all stages so as to ensure the sustainability of the training program. Training must focus on the communities at the grass roots level or community based organizations, where the communities identify their own capacity and needs. Wide dissemination of training materials, courses and manuals is also useful to replicate successful experience.