Introducing ACTFAiREST2 to implement online assessments amid COVID-19: a case study from a low resource setting.

BACKGROUND: Amid COVID-19, soon after the closure of academic institutions, academia was compelled to implement teaching and assessments virtually. The situation was not the same for all countries. This transition was much more challenging in low-resource settings like Pakistan, where the students were geographically distant with minimal connectivity. A private university in Pakistan instituted a systematic approach for ensuring quality assurance and reliability before launching online assessments amid the COVID-19. The purpose of this study was to reflect on the phased transition to online/remote assessments to facilitate continuous student learning through distance modalities during the pandemic. METHOD: To assist faculty in re-designing their assessments, a workshop was conducted which was based on the modified Walker's nine principles. The principles coded as "ACTFAiREST2" were introduced to ensure that the faculty understands and adapts these principles in designing online assessments. The faculty modified and re-designed their course assessments, from face to face to online modality and submitted their proposals to the Curriculum Committee (CC). To guide the process of approving modified and re-designed assessments, a checklist was adapted. All the pre and -post workshop assessment proposals were analyzed using a content analysis approach to ensure the alignment of course learning outcomes with the assessments. RESULTS: A total of 45 undergraduate courses' assessment proposals were approved by the CC after deliberations ensuring their applicability in a virtual environment. From the analysis of the course outlines and assessment proposals submitted to the CC, faculty made four key changes to their assessment tasks in the light of ACT FAiREST2 principles (a) alternative to performance exams; (b) alternative to knowledge exams; (c) change in the mode of assessment administration; and (d) minimizing the overall assessment load. CONCLUSION: This transition provided an impetus for the faculty from a low resource setting to build momentum towards improved and innovative ways of online teaching and assessments for future nursing education to adapt to the new normal situation. This development will serve as a resource in similar contexts with planned and evidence-based approaches for enhancing faculty readiness and preparedness for online/remote assessments.

Peer victimization and experiences of violence at school and at home among school age children with disabilities in Pakistan and Afghanistan.

Background: Children with disabilities are more likely to experience violence or injury at school and at home, but there is little evidence from Central Asia. Objective: To describe the prevalence of disability and associations with peer violence perpetration and victimization, depression, corporal punishment, school performance and school attendance, among middle school children in Pakistan and Afghanistan. Method: This is a secondary analysis of data gathered in the course of evaluations of interventions to prevent peer violence conducted in Pakistan and Afghanistan as part of the 'What Works to Prevent Violence against Women and Girls Global Programme'. In Pakistan, the research was conducted in 40 schools, and disability was assessed at midline in 1516 interviews with Grade 7s. In Afghanistan, the data were from the baseline study conducted in 11 schools with 770 children. Generalized Linear Mixed Modeling was used to assess associations with disability. Results: In Afghanistan, the prevalence of disability was much higher for girls (22.1%) than boys (12.9%), while in Pakistan 6.0% of boys and girls reported a disability. Peer violence victimization was strongly associated with disability in Afghanistan and marginally associated in Pakistan. In Pakistan, perpetration of peer violence was associated with disability. In both countries, disability was significantly associated with higher depression scores. Food insecurity was strongly associated with disability in Afghanistan. Conclusion: Disability is highly prevalent in Afghanistan and Pakistan schools and this is associated with a greater risk of experiencing and perpetrating peer violence. It is important to ensure that all children can benefit from school-based prevention interventions.

Right To Play's intervention to reduce peer violence among children in public schools in Pakistan: a cluster-randomized controlled trial.

BACKGROUND: Peer violence is common globally, but a little researched topic in low-and middle-income countries. This study presents the evaluation of a two-year randomized controlled trial of a structured play-based life-skills intervention implemented in schools in Hyderabad, Pakistan. OBJECTIVE: To determine the impact of the intervention on school-based peer violence (victimization and perpetration) and depression among school children. METHODS: 40 single-sex public schools were randomized into two study arms (20 per arm 10 of each sex). A total of 1752 grade 6 students (929 from intervention and 823 from control schools) were enrolled in the trial. The two-year intervention was a biweekly structured game led by a coach followed by critical reflection and discussion for 30 minutes. Primary outcomes (exposure to peer violence exhibited through victimization and perpetration and depression) were evaluated using generalized linear-mixed models. RESULTS: Of the enrolled children (N = 1752) 91% provided data for analysis. There were significant decreases in self-reported peer violence victimization, perpetration and depression. For peer violence victimization, the reductions in the intervention and control arms were: 33.3% versus 27.8% for boys and 58.5% versus 21.3% for girls. For peer violence perpetration, the reductions were: 25.3% versus 11.1% for boys and 55.6% versus 27.6% for girls in the intervention and control arms, respectively. There were significant drops in mean depression scores (boys 7.2% versus 4.8% intervention and control and girls 9.5% versus 5.6% intervention and control). CONCLUSION: A well-designed and implemented play-based life-skills intervention delivered in public schools in Pakistan is able to effect a significant reduction in peer violence.

Community stakeholders' perspectives regarding acceptability of a life skills building intervention to empower women in Pakistan.

Violence against women (VAW) is a major determinant in the assessment of a women's mental health. Many interventions have addressed strategies to reduce VAW, however, little information is available regarding effectiveness in the local context, particularly the role of men in women's empowerment. In Pakistan, a qualitative approach was undertaken in all four of its provinces to describe the community residents', both men and women, perceptions regarding the acceptability of a proposed life skills building (LSB) intervention involving men's engagement with regards to women's empowerment and VAW. Eighteen focus group discussions were conducted with men and women from locales within each province of Pakistan, averaging 6-10 participants per group. Fourteen key informant interviews were conducted with community stakeholders. The analysis identified three major themes: family life and male engagement, LSB training as an empowerment tool, and operationalization of the proposed LSB intervention. The proposed LSB intervention was well accepted by the participants with a strong urge to engage men in receiving the LSB training sessions. Men's engagement has been identified as an important element to facilitate women's empowerment. Participants suggested that these sessions should be held for two and a half hours per week within the community public spaces. In addition, these sessions should be based on an interactive approach. The focus of these sessions should include ideas surrounding positive relationships and economic skills building. Moreover, men's engagement will help to reduce VAW and improve the mental health of women in a patriarchal country like Pakistan.

Community stakeholders' views on reducing violence against women in Pakistan.

BACKGROUND: Nearly half of the women experience violence across their lifespan in all the provinces of Pakistan at an alarming rate. Despite knowing the prevalence, there has been meager progress in developing strategies to combat violence at individual, family, or community level. Many interventions suggested in other countries have been pilot tested but the effects of those interventions had been limited. Therefore, the aim of this study is to understand the voices of stakeholders to reduce Violence Against Women (VAW) and to explore the possible community-based strategies that could be implemented in Pakistan. METHODS: A total of 14 Key Informant Interviews (KIIs) and 18 Focus Group Discussions (FGDs) were held across all four provinces of Pakistan. Participants were purposefully recruited and all the interviews were audio-recorded. Transcriptions were open coded and content analysis was done to emerge codes, categories and themes. Ethical approval was obtained from Aga Khan University Ethics Review Committee. RESULTS: Three major themes emerged on community members and stakeholders' views on VAW: a) community's perception of VAW b) the repercussions of VAW, and c) multiple voices regarding strategies to reduce VAW. Participants voiced the need of standing against the status quo, role of awareness and education: regarding capacity building skills, promotion of women rights and women empowerment through Life Skills Based Education (LSBE) through national health works program, has been proposed as an innovative strategy to reduce VAW. CONCLUSIONS: The responsibility to bring about a substantial change in behavior and attitudes must begin with engaging men in all the interventions that aim to reduce violence. Since, VAW is very much linked with the cultural norms, so, without community stakeholder's involvement and participation it could never be reduced. Keeping the existing socio-cultural dynamics in mind, the need of time is to design and implement innovative interventions that are culturally and contextually appropriate and can be expanded across the country.

The intersection of school corporal punishment and associated factors: Baseline results from a randomized controlled trial in Pakistan.

Violence against youth is a global issue; one form of youth victimization is school corporal punishment. We use baseline assessments from a cluster randomized controlled trial to examine the prevalence of school corporal punishment, by gender, and the relationship to levels of peer violence at school, parent corporal punishment, youth food security and youth academic performance and school attendance in Pakistan. Forty homogenous public schools in the urban city of Hyderabad, Pakistan were chosen for randomization into the trial evaluating a youth violence prevention intervention. 1752 6th graders, age 11-14 years, were selected as the target population. Since schools are segregated by gender in Pakistan, data are from interviews in 20 boys' schools and 20 girls' schools. Overall, 91.4% of boys and 60.9% of girls reported corporal punishment at school in the previous 4 weeks and 60.3% of boys had been physically punished at home in the past 4 weeks compared to 37.1% of girls. Structural equation modeling revealed one direct pathway for both boys and girls from food insecurity to corporal punishment at school while indirect pathways were mediated by depression, the number of days missed from school and school performance and for boys also by engagement in peer violence. Exposure to corporal punishment in school and from parents differs by gender, but in both boys and girls poverty in the form of food insecurity was an important risk factor, with the result that poorer children are victimized more by adults.

Peer violence perpetration and victimization: Prevalence, associated factors and pathways among 1752 sixth grade boys and girls in schools in Pakistan.

BACKGROUND: Child peer violence is a global problem and seriously impacts health and education. There are few research studies available in Pakistan, or South Asia. We describe the prevalence of peer violence, associations, and pathways between socio-economic status, school performance, gender attitudes and violence at home. METHODS: 1752 children were recruited into a cluster randomized controlled trial conducted on 40 fairly homogeneous public schools (20 for girls and 20 for boys), in Hyderabad, Pakistan. This was ranging from 20-65 children per school. All children were interviewed with questionnaires at baseline. RESULTS: Few children had no experience of peer violence in the previous 4 weeks (21.7% of girls vs.7% of boys). Some were victims (28.6%, of girls vs. 17.9% of boys), some only perpetrated (3.3% of girls vs. 2.5%) but mostly they perpetrated and were victims (46.4%.of girls vs 72.6%. of boys). The girls' multivariable models showed that missing the last school day due to work, witnessing her father fight a man in the last month and having more patriarchal gender attitudes were associated with both experiencing violence and perpetration, while, hunger was associated with perpetration only. For boys, missing two or more days of school in the last month, poorer school performance and more patriarchal attitudes were associated with both victimization and perpetration. Witnessing father fight, was associated with peer violence perpetration for boys. These findings are additionally confirmed with structural models. DISCUSSION: Peer violence in Pakistan is rooted in poverty and socialization of children, especially at home. A critical question is whether a school-based intervention can empower children to reduce their violence engagement in the context of poverty and social norms supportive of violence. In the political context of Pakistan, reducing all violence is essential and understanding the potential of schools as a platform for intervention is key.

The role of micro health insurance in providing financial risk protection in developing countries--a systematic review.

BACKGROUND: Out of pocket payments are the predominant method of financing healthcare in many developing countries, which can result in impoverishment and financial catastrophe for those affected. In 2010, WHO estimated that approximately 100 million people are pushed below the poverty line each year by payments for healthcare. Micro health insurance (MHI) has been used in some countries as means of risk pooling and reducing out of pocket health expenditure. A systematic review was conducted to assess the extent to which MHI has contributed to providing financial risk protection to low-income households in developing countries, and suggest how the findings can be applied in the Pakistani setting. METHODS: We conducted a systematic search for published literature using the search terms "Community based health insurance AND developing countries", "Micro health insurance AND developing countries", "Mutual health insurance AND developing countries", "mutual OR micro OR community based health insurance" "Health insurance AND impact AND poor" "Health insurance AND financial protection" and "mutual health organizations" on three databases, Pubmed, Google Scholar and Science Direct (Elsevier). Only those records that were published in the last ten years, in English language with their full texts available free of cost, were considered for inclusion in this review. Hand searching was carried out on the reference lists of the retrieved articles and webpages of international organizations like World Bank, World Health Organization and International Labour Organization. RESULTS: Twenty-three articles were eligible for inclusion in this systematic review (14 from Asia and 9 from Africa). Our analysis shows that MHI, in the majority of cases, has been found to contribute to the financial protection of its beneficiaries, by reducing out of pocket health expenditure, catastrophic health expenditure, total health expenditure, household borrowings and poverty. MHI also had a positive safeguarding effect on household savings, assets and consumption patterns. CONCLUSION: Our review suggests that MHI, targeted at the low-income households and tailored to suit the cultural and geographical structures in the various areas of Pakistan, may contribute towards providing protection to the households from catastrophe and impoverishment resulting from health expenditures. This paper emphasizes the need for further research to fill the knowledge gap that exists about the impact of MHI, using robust study designs and impact indicators.