Exploring the phenomenon of suicidal behaviour (SB): An explanatory, mixed-method study in rural Pakistan.

BACKGROUND: Despite scientific literature and media reports of rising cases of suicide and attempted suicide in different parts of Pakistan, the extent of this problem remains unknown, particularly from outside the main urban centres of the country. AIMS: To report data on Suicidal Behaviour (SB) from Malakand Division, a rural and marginalised part of Khyber Pakhtunkhwa (KPK) province, explore aetiological factors and propose preventive strategies. METHODS: This study followed an explanatory, mixed-method study design. The first part quantitative [QUANT] comprised of police reports on suicidal behaviour, from 2001 till first 8 months of 2018. Detailed analysis of only data from 2013 was undertaken, as data prior to 2013 contained insufficient information. The second part that is, qualitative (QUAL) consisted of in-depth interviews with relevant stakeholders. A mixed method of inductive and deductive analytical approach was used. RESULTS: From 2013 until the first quarter of 2018, the police recorded 1,645 attempts of both males and females of which 144 (8.75%) resulted in fatalities. Suicide attempts rose by 83.4% over the 5 years and 8 months. Approximately, 43.3% of the attempts were attributed to 'depression'. Domestic abuse was reported in 49.6% of cases. Of the total victims, 1,049 (63.7%) were females, whereas 60.1% were married. Ingestion of the organophosphates poison (pesticide) was reported in 53.2% (n = 999) of suicide attempts. In more than 90% of the non-fatal suicide attempts, victims were booked under punitive laws. Poor socio-economic status, inter-personal stressors, violence against women and mental illnesses were the major causes of suicidal behaviour in Malakand [QUAL]. Investment in human development, strengthening of the healthcare system, de-stigmatisation of mental illnesses and women empowerment could possibly prevent suicidal behaviour in Malakand [QUAL]. CONCLUSION: SB in Malakand Division is steadily increasing. The increase is more evident in vulnerable populations such as women and the younger population. 'Psychosocial stressors' and 'depression' were the main causes of suicidal behaviour. A broad-based, proactive, multi-sectorial approach is needed to prevent SB in the region.

Developing a three-dimensional narrative to counter polio vaccine refusal in Charsadda.

BACKGROUND: Endemic polio in Pakistan is threatening the Global Polio Eradication Initiative (PEI). In recent years, vaccine refusals have surged, spiking polio cases. The current study was conducted to understand the ethnic, religious and cultural roots of vaccine refusals in Charsadda District and explore the remedial options. METHODS: We conducted 43 in-depth interviews with parents who had refused polio vaccines for their children and the PEI staff. Interviews were audio-recorded, written in verbatim and analysed with Atlis.ti. We conducted a thematic analysis of our data. RESULTS: The fear of American and Jewish conspiracies was the primary cause of vaccine refusals. Militant groups like Tehrek-i-Taliban Pakistan capitalised on this fear, through social media. The Pashtun ethnic group considers itself at the centre of conspiracies. They are suspicious of mass investment and mobilisation behind the polio campaign. Our respondents feared that polio vaccines were making children vulgar. They also feared a reduction in the male to female ratio in childbirth. In Pashtun communities, the iconic conventional community gatherings ["Hujras"] are being replaced by provocative digital Hujra [social media], which the PEI and the Government of Pakistan (GOP) are failing to influence or regulate. The PEI uses the misleading term 'religious refusal'. Some factions in the clergy are maligning people from vaccinations, but not through religious dictum. The anti-state elements have stirred sentiments to weaken the state initiative. Fear of adverse effects, attitudinal barriers of health care providers, unmet basic needs and alleged haram composition of the vaccine were among the reasons for vaccine refusals. The PEI needs to revise its misleading nomenclature and ensue open discussion to dispel the myths of infertility, vulgarity and gender ratio related to the vaccines. Simultaneously, the GOP should stop disinformation on social media and rebrand polio vaccination with popular initiatives like the government-sponsored health insurance schemes. CONCLUSIONS: The ethnic, cultural and religious dispositions of community members shape polio vaccine refusals in Charsadda District, in different ways. In synch with existing conspiracy theories and medical misconceptions, these three factors make refusals harder to counter. Awareness campaigns with content addressing these three dimensions can improve the situation.

Political Architecture And Legal Framework Related To Social Health Protection Schemes In Pakistan: Qualitative Inquiry Of Policy Makers' Viewpoint.

BACKGROUND: Pakistan is a federal state with three tiers of government. Following contentious general elections in 2013, ever first democratic transition took place in Pakistan. Subsequently, two social health protection schemes were launched. Current paper's objective is to understand the political context in which these schemes were launched and to explore the constitutional position of access to healthcare in Pakistan. This paper also explores the legal protection/ sustainability with regards to these schemes. METHODS: We used qualitative research techniques with interpretivist paradigm and case-study approach. In-depth interviews were conducted, followed by content analysis. Triangulation and data saturation were observed to guide our sample size. Officials involved with these schemes at policy and implementation level were interviewed. Ethical approval was taken from ethics board of Khyber Medical University. Based on purposive sampling, in-depth interviews were conducted and thematic analysis was performed. RESULTS: We identified two themes in response to question-1 of our interview, asking about the cause of action behind starting these schemes and their legal protection. These themes were: (i) [initiation of] Social Health Protection as democratization of healthcare, and (ii) [initiation of] Social health protection in legal void. Implicitly, these schemes are a product of grass root political activism and health found berth in election manifestos recently. Also, we deduce that health is not a constitutional right in Pakistan. These schemes lack constitutional guarantee and ensued in absence of overarching legal framework. CONCLUSIONS: These social health protection schemes are high on political agenda but lack constitutional and legal protection.

Progress Of Khyber Pakhtunkhwa (Pakistan) Towards Universal Health Coverage.

BACKGROUND: Khyber Pakhtunkhwa (KP) launched its flagship Social health protection initiative (SHPI), named Sehat Sahulat Program (SSP). SSP envisions to improve access to healthcare for poorest of the poor and contribute towards achieving Universal Health Coverage (UHC). Current study was undertaken to analyze SSP in context of UHC framework i.e. to see as to (i) who is covered, (ii) what services are covered, and (iii) what extent of financial protection is conferred. METHODS: We conducted thorough archival research. Official documents studied were concept paper(s), approved planning commission documents (PC-1 forms) and signed agreement(s) between government of KP and the insurance firm. RESULTS: SSP enrolled poorest 51% of province' population i.e. 14.4 million people. It covers for all secondary and limited tertiary services. Maximum expenditure limit per family per year is Rs.540, 000/-. Government pays a premium of Rs.1549/- per year per household to 3rd party (insurance firm) which ensures services through a mix of public-private providers. CONCLUSIONS: The breadth, depth and height of SSP are significant. It is a phenomenal progress towards achieving UHC.