Qualitative adaptation of child behaviour problem instruments in a developing-country setting.

A key barrier to epidemiological research on child behaviour problems in developing countries is the lack of culturally relevant, internationally recognized psychometric instruments. This paper proposes a model for the qualitative adaptation of psychometric instruments in developing-country settings and presents a case study of the adaptation of 3 internationally recognized instruments in Pakistan: the Child Behavior Checklist, the Youth Self-Report and the Teacher's Report Form. This model encompassed a systematic procedure with 6 distinct phases to minimize bias and ensure equivalence with the original instruments: selection, deliberation, alteration, feasibility, testing and formal approval. The process was conducted in collaboration with the instruments' developer. A multidisciplinary working group of experts identified equivalence issues and suggested modifications. Focus group discussions with informants highlighted comprehension issues. Subsequently modified instruments were thoroughly tested. Finally, the instruments' developer approval further validated the qualitative adaptation. The study proposes a rigorous and systematic model to effectively achieve cultural adaptation of psychometric instruments.

Qualitative adaptation of child behaviour problem instruments in a developing-country setting

إن أحد العوائق الرئيسية للبحوث الوبائية حول مشكلات السلوك لدى الأطفال في البلدان النامية هو فقدان أدوات ملائمة ثقافيا ومعرف بها دوليا لقياس السلوك.وتقترح هذه الورقة نموذجا للمواءمة الكيفية لأدوات القياس النفسي في مواقع البلدان النامية، مع تقديم دراسة حالة لمواءمة ثلاث أدوات معترف بها دوليا في باكستان، وهي: القائمة التفقدية لسلوك الأطفال، والإبلاغ الذاتي للشباب، واستمارة تقرير المعلم. ويتضمن هذا النموذج إجراءات منهجية ذات ست مراحل متمايزة تستهدف الإقلال من التحيز وضمان التكافؤ لأقصى قدر ممكن مع الأدوات الأصلية من حيث: الاختيار، والمداولات، والتغيير، وإمكانية التطبيق، والارتياد، والموافقة الرسمية. وقد تم تنفيذ العملية بالتعاون مع القائمين على إعداد الأداة، إذ حدد فريق عمل يتكون من الخبراء المتعددي التخصصات قضايا التكافؤ والتعديات المقترحة.كما أوضحت مناقشات المجموعات البؤرية للمستجيبين للدراسة قضايا ذات أهمية استيعابية؛ ثم تلا ذلك تجريب الأدوات المعدلة تجريبا ارتياديا، وأخرا تحقق مطور الأداة من الحصول على الموافقة على المواءمة الكيفية. وتقرح الدراسة نموذجا صارما ومنهجيا لتحقيق المواءمة الثقافية لأدوات القياس النفسي بنجاح

ABSTRACT A key barrier to epidemiological research on child behaviour problems in developing countries is thelack of culturally relevant, internationally recognized psychometric instruments. This paper proposes a model for thequalitative adaptation of psychometric instruments in developing-country settings and presents a case study of theadaptation of 3 internationally recognized instruments in Pakistan: the Child Behavior Checklist, the Youth Self-Reportand the Teacher’s Report Form. This model encompassed a systematic procedure with 6 distinct phases to minimizebias and ensure equivalence with the original instruments: selection, deliberation, alteration, feasibility, testing andformal approval. The process was conducted in collaboration with the instruments’ developer. A multidisciplinaryworking group of experts identified equivalence issues and suggested modifications. Focus group discussions withinformants highlighted comprehension issues. Subsequently modified instruments were thoroughly tested. Finally,the instruments’ developer approval further validated the qualitative adaptation. The study proposes a rigorous andsystematic model to effectively achieve cultural adaptation of psychometric instruments.

RÉSUMÉ Le manque d'instruments psychométriques internationalement reconnus et culturellement adaptésreprésente un obstacle majeur à la recherche épidémiologique sur les problèmes comportementaux chez l'enfantdans les pays en développement. Le présent article propose un modèle pour l'adaptation qualitative d'instrumentspsychométriques au contexte des pays en développement et présente une étude de cas sur l'adaptation au Pakistande trois instruments internationalement reconnus : la liste de contrôle du comportement des enfants (Child BehaviorChecklist), l'auto-évaluation des jeunes (Youth Self-Report) et le rapport d'évaluation de l'enseignant (Teacher's ReportForm). Le modèle comprenait une méthode systhématique en six phases distinctes visant à réduire au minimum lesbiais et à garantir l'équivalence avec les instruments originaux : sélection, délibération, modification, faisabilité, test etapprobation formelle. La méthode a été utilisée en collaboration avec le concepteur des instruments. Un groupe detravail pluridisciplinaire composé d'experts a identifié les problèmes d'équivalence puis a suggéré des modifications.Des discussions entre les groupes thématiques et les informateurs ont permis de mettre en évidence les problèmesde compréhension. Les instruments modifiés ont ultérieurement été entièrement testés. Enfin, l'approbation duconcepteur des instruments a aussi permis de valider l'adaptation qualitative. L'étude propose un modèle rigoureuxet complet permettant d'obtenir une adaptation culturelle efficace des instruments psychométriques.

Should oral misoprostol be used to prevent postpartum haemorrhage in home-birth settings in low-resource countries? A systematic review of the evidence.

BACKGROUND: Using misoprostol to prevent postpartum haemorrhage (PPH) in home-birth settings remains controversial. OBJECTIVES: To review the safety and effectiveness of oral misoprostol in preventing PPH in home-birth settings. SEARCH STRATEGY: The Cochrane Library, PubMed, and POPLINE were searched for articles published until 31 March 2012. SELECTION CRITERIA: Studies, conducted in low-resource countries, comparing oral misoprostol with a placebo or no treatment in a home-birth setting. Studies of misoprostol administered by other routes were excluded. DATA COLLECTION AND ANALYSIS: Data were extracted by two reviewers and independently checked for accuracy by a third. The quality of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. Data were sythesised and meta-analysis was performed where appropriate. MAIN RESULTS: Ten papers describing two randomised and four non randomised trials. Administration of misoprostol was associated with a significant reduction in the incidence of PPH (RR 0.58, 95% CI 0.38-0.87), additional uterotonics (RR 0.34, 95% CI 0.16-0.73), and referral for PPH (RR 0.49, 95% CI 0.37-0.66). None of the studies was large enough to detect a difference in maternal mortality, and none reported neonatal mortality. Shivering and pyrexia were the most common side effects. AUTHOR'S CONCLUSIONS: The finding that the distribution of oral misoprostol through frontline health workers is effective in reducing the incidence of PPH could be a significant step forwards in reducing maternal deaths in low-resource countries. However, given the limited number of high-quality studies in this review, further randomised controlled trials are required to confirm the association, particularly in different implementation settings. Adverse effects have not been systematically captured, and there has been limited consideration of the potential for inappropriate or inadvertent use of misoprostol. Further evidence is needed to inform the development of implementation and safety guidelines on the routine availability of misoprostol.

Human papillomavirus infection in women with and without cervical cancer in Karachi, Pakistan.

BACKGROUND: No data exist on the population prevalence of, or risk factors for, human papillomavirus (HPV) infection in predominantly Muslim countries in Asia. METHODS: Cervical specimens were obtained from 899 married women aged 15-59 years from the general population of Karachi, Pakistan and from 91 locally diagnosed invasive cervical cancers (ICCs). HPV was detected using a GP5+/6+ PCR-based assay. RESULTS: The prevalence of HPV in the general population was 2.8%, with no evidence of higher HPV prevalence in young women. The positivity of HPV was associated with women's lifetime number of sexual partners, but particularly with the age difference between spouses and other husbands' characteristics, such as extramarital sexual relationships and regular absence from home. The HPV16/18 accounted for 24 and 88% of HPV-positive women in the general population and ICC, respectively. CONCLUSION: Cervical cancer prevention policies should take into account the low HPV prevalence and low acceptability of gynaecological examination in this population.

Review of the theoretical frameworks for the study of child development within public health and epidemiology.

BACKGROUND: Care for child development has gained international momentum in research and community-based programming. It encompasses various domains including cognitive, psychomotor, emotional, behavioural and social development, and a multitude of factors that have the potential to influence its trajectories. However, the multidisciplinary nature of child development initiatives is marred by a lack of unified perspectives across disciplines, especially basic conceptual understanding generated in the fields of education and psychology, which are not effectively exploited in public health programmes and epidemiological research. METHODS: The article suggests a four-point evaluation criteria to child development theories based on the ability to communicate in (1) Cross-disciplines, (2) an Overarching facility to address various developmental domains, (3) the capacity to link child development with Lifelong developmental potentials and, most importantly, (4) Epidemiological capability to provide supporting empirical evidence for community-based public health interventions (COLE criteria). RESULTS: Key child development theories have been reviewed by broadly grouping them into three categories on the basis of content and approach, such as descriptive theories, psychological construct-based theories, and context-based theories. The strengths and challenges of these theories have been evaluated on the basis of COLE criteria. CONCLUSION: Although most of these theories can contribute at different levels in child development initiatives, context-based theories have been particularly proposed to practitioners, researchers and policy makers for community-based programming, principally for its potential to address issues of social inequality, poverty and childcare practices, which are at the core of public health initiatives, and provide multiple level of opportunities to intervene.

The role of family configuration in early childhood intellectual development in the context of an extended family system in Pakistan.

CONTEXT: The confluence theory of intelligence by Zajonc and Markus emphasizes that individual intellectual difference of children manifests itself in the context of family configuration. Instead of assuming its generalizability, careful scientific work is required before applying the model to South Asian cultures where, predominantly, an extended family type exists. AIMS: To assess the role of extended family configuration on the child's intellectual development in a South Asian setting. SETTINGS AND DESIGN: A cross-sectional study was conducted on 4-5-year-old preschool children residing in Karachi, Pakistan. MATERIALS AND METHODS: Three hundred and forty-two child and mother dyads were assessed through a validated cognitive psychometric tool and through a structured questionnaire. Children who were registered at the main Mother and Child Health Centres (MCH) of the Aga Khan Health Services, Pakistan (AKHSP) Karachi and who were born between July 1st 1993-June 30th 1994 with traceable birth records at the maternity homes, were considered for this study. STATISTICAL ANALYSIS: Multivariate linear regression models were used to identify the individual effect of family configuration on the intellectual scores. RESULTS: Family configuration variables such as number of co-residents ( P P CONCLUSION: The findings suggest the positive role of co-residents of an extended family environment on the intellectual development in early childhood.

Residents' perceptions of work environment during their postgraduate medical training in Pakistan.

BACKGROUND: In Pakistan, there is a lack of information about the work environment of residency programs. This lack is a major impediment in their improvement. One of the approaches for improvement in these programs can be directed through the residents' own perception of their working conditions. Therefore, we collected data which would reflect working conditions of residents. AIM: To assess the perceived status of "work environment" in different specialities. MATERIALS AND METHODS: A cross-sectional survey was conducted in four teaching hospitals of Karachi from July 1999 to January 2000. Residents from selected programs were grouped into four broad groups: specialist, medical, surgical and multidisciplinary. Responses of residents were obtained on a Likert scale of 0 to 4. Indices were formed for two components of work environment: academic and mistreatment. STATISTICAL ANALYSIS: Differences between residents' groups were assessed through analysis of variance (ANOVA) at 5% significance. RESULTS: A total of 341 registered residents responded (response rate: 75%). Surgical residents were working more than 80 h/week and this was more than the other three groups. Medical residents were spending the highest actual time on research and teaching activities (10% and 14%, respectively). Academic index score was highest for surgical group (15.81, SD = 4.69) and lowest for multidisciplinary group (11.82, SD = 4.80). Medical group had the highest perceived mistreatment index score (5.56, SD = 4.57). CONCLUSIONS: In a study of work environment of residency programs, differential impact was found for the four groups on work environment perceptions. Most of the residents recognized undergraduate teaching, grand rounds, patient rounds and seminars or workshops as contributing to their academic learning. Reporting of sexual harassment was low, indicating either underreporting or cultural dynamics of our setting.

Residents' perceptions of communication skills in postgraduate medical training programs of Pakistan.

BACKGROUND: The importance of communication skills in postgraduate medical training is likely to be highlighted given the convergence of research and educational forces. Assessment of these skills in residency training is vital since it can provide basis for policy undertaking among Pakistani medical academia for improving postgraduate training programs. AIM: To assess the perceived status of communication skills of residents in different specialties. MATERIALS AND METHODS: A cross sectional survey was conducted in four teaching hospitals of Karachi between July 1999 and January 2001. A total of 455 residents in different residency programs were contacted. Residents registered both with College of Physicians and Surgeons of Pakistan and Postgraduate Medical Education office of selected hospitals were included in this study. Responses of residents were obtained on 5-point Likert scale. Indices were formed for three components of communication skills: informative, affective and professional communication. STATISTICAL ANALYSIS: Differences between residents' groups were assessed through analysis of variance. RESULTS: Total informative communication index was lowest for multi-disciplinary (12.05, SD = 4.87) and highest for surgical (15.27, SD = 2.51) residents. Total affective index was lowest for multi-disciplinary (12.58, SD = 5.68) and highest for medical (15.74, SD = 3.59) residents. The group differences for four groups of residency programs were not statistically significant for either professional attributes separately or for the total professional index. CONCLUSIONS: The residency programs must establish goals, process and outcomes to incorporate communication skills in postgraduate medical training since this can enhance residents' performance as effective health care providers. Accomplishment of better communication skills can be achieved if the importance of its teaching and training is valued by residency program coordinators.

A matched case-control study of risk factors for neonatal tetanus in Karachi, Pakistan.

BACKGROUND: Previous studies have identified various risk factors for neonatal tetanus (NNT) in rural areas of Pakistan. The present matched case control study was conducted to further evaluate these risk factors in an urban setting. AIM: The study was carried out to identify risk factors for NNT in Karachi. MATERIALS AND METHODS: Patients of NNT (n = 125) diagnosed from January 1998 to February 2001 were recruited through a surveillance system of Expanded Programme on Immunization (EPI). Two neighbourhood controls (n = 250) were matched for each case for gender and date of birth of the case. STATISTICAL ANALYSIS: Conditional logistic regression was performed to assess the independent effect of factors associated with NNT. RESULTS: The final multivariable model identified subsequent application of substances on the umbilical cord (adjusted matched odds ratio [adj. mOR] = 5.1 [2.7-9.7]), home delivery (adj. mOR = 1.8; 95% CI: 1.1- 3.1) and illiterate mother (adj. mOR = 1.6; 95% CI: 1.0- 2.0) as risk factors for NNT after adjusting for other variables in the model. Population attributable risk per cent (PAR %) for subsequent cord application was 69% and PAR % for home delivery was 31%. CONCLUSION: Health planners, while formulating control strategies through immunization programmes should also take into account the impact of post-delivery practices, such as 'subsequent cord application' along with pre-delivery practices. Health awareness regarding appropriate post-delivery practices should be promoted and counselling of pregnant women for giving preference to health care setting for delivery is also crucial.

Factors influencing the selection of surgical specialty among Pakistani medical graduates.

CONTEXT: The delineation between selection of surgery and non-surgery residency programmes could provide a pragmatic view of the influences on medical graduates' careers. This would also help coordinators and educators of residency programmes in surgery to further understand the dynamics of specialty selection. AIMS: To identify the different factors that influence the graduates to select surgical specialties in Pakistan. SETTINGS AND DESIGNS: A cross-sectional survey was conducted in 4 teaching hospitals of Karachi between July 1999 and January 2001. SUBJECTS AND METHODS: A total of 455 residents in 1-5 years of residency programmes were contacted. Three hundred and forty-one residents consented to the interview. Residents who were registered both with the College of Physicians and Surgeons of Pakistan (CPSP) and the Post Graduate Medical Education (PGME) office of the selected hospitals were included in this study. STATISTICAL METHOD USED: Logistic regression analysis. RESULTS: Final multivariate analysis identified 4 factors that remained significantly associated with the selection of surgical specialty: deriving gratification from direct patient care (adjusted odds ratio [aOR] = 5.79; 95% confidence interval [CI]: 1.24, 26.99), procedure-based medical practice (aOR = 2.85; 95% CI: 1.23, 6.61), nature of clinical problems (aOR = 3.39; 95% CI: 1.47, 7.84), and lack of consideration of stress during professional work (aOR = 2.27, 95%CI: 1.25, 4.13). CONCLUSIONS: Direct patient care is perceived to be an integral part of surgery residency and immediate patient outcome is a positive influence in selecting surgical specialty. The inclination towards surgery appeared to be determined by the type of procedures and technical skills involved in its practice. The nature of clinical problems is an important determinant of the choice of specialty. Stress was not perceived to be an important influencing factor for those who decided to select surgical specialties.

Demographic, socio-economic and environmental determinants of utilisation of antenatal care in a rural setting of Sindh, Pakistan.

OBJECTIVE: Majority of the women in the developing countries are unable receive antenatal care for a variety of reasons. This study determines the factors affecting utilisation of antenatal care by women of a rural area in Sindh, Pakistan. METHODS: A cross-sectional study was conducted during August 1997, in Union Council Jhangara, Sindh, Pakistan. Married women, who had delivered at least one child, were included in the study from each household and systematically 222 eligible women were selected. The effects of demographic, socio-economic and environmental factors on the utilisation of antenatal care, by women during their most recent pregnancy were also studied. Multivariate logistic regression analysis was used to assess independent effect of individual factors. RESULTS: Among the study subjects, 29.3% (65) of the women utilised antenatal care during the last (most recent) pregnancy and out of them 72.3% (47) received it from the government health care provider. Presence of electricity in the house was strongly associated with the utilisation of antenatal care (AOR = 5.3; 95% CI 2.2-12.7). Women whose husbands were in white-collar occupation, were utilizing the antenatal care significantly more (AOR = 2.4; 95% CI 1.2-4.6) compared to women whose husbands were in blue-collar occupations. CONCLUSION: The study shows that social status and economic condition of a woman is an important determinant of utilisation of antenatal care. Therefore, improvement of socioeconomic status is required to increase utilization of antenatal and perinatal care.

Why a research study needs a design?

Medical research requires as much attention to management as it does to science. Effective research depends first upon the thoughtful statements of purpose and objectives, and related research questions. These important initial steps in turn drive key decisions regarding study type, plans for analyses and competent implementation within bounded timeframes and budgets. The research endeavour materializes by selecting appropriate study types based on coherent research questions, appropriate data collection, and ultimately concludes by drawing inferences on the basis of properly planned analyses. This article reviews these principles and inter-relationships.

Perspective on variables in medical research.

Research concepts cannot be materialized until and unless study variables are carefully selected and clearly defined. However, emphasis on variables is not limited to data collection. It should be envisioned from the start that the contents of the variables recorded are congruent with the statistical analysis suggested. These two processes require a comprehensive understanding of variables in epidemiology and biostatistics disciplines. In this article classifications are discussed keeping in view their utility in medical research.

The proposition: an insight into research.

Propositions form the basis for scientific research. The validity of a research study is, to a large extent, evaluated on the criteria of its propositions. For internal validity, study propositions provide information regarding precision of definitions, measurements, associations, confounding factors etc. that are considered in research. While for external validity, propositions form the premise for the deduction of inferences. The aim of this article is to help readers understand the propositions that are made in research. This article discusses those propositions, which are relevant to medical research.

Moving from concepts to study types approaches to classifying scientific inquiry.

There is no such concept as "the ideal research method". Most study types are understood and taught in a relative vacuum without appreciating their philosophical context. However, to achieve an optimal approach is more a matter of resolving the congruence between research purpose and method. Proper location of research methods within a theoretical framework is therefore important, otherwise the resulting over-simplification will eventually lead to inappropriate use of study types. Designing any type of study encompasses the process of identification, exploration and explanation, and utilizes concepts such as manipulation, sampling, replication and time dimensions. Medical research has borrowed study types both from Epidemiology and Social Sciences and practiced as observational and experimental inquiries, and we offer in the present review a framework within which these various types may be understood.

Comparison of clinical and laparascopic features of infertile women suffering from genital tuberculosis (TB) or pelvic inflammatory disease (PID) or endometriosis.

OBJECTIVE: The objective of the study was to analyze the clinical and laparoscopic features, which may help to differentiate between infertility in females due to Genital Tuberculosis from Pelvic Inflammatory Disease (PID) and Endometriosis. METHODS: This case control study was carried out in a teaching tertiary care hospital. Medical records were searched from 1st January 1987 to 31st December 2000 and 43 infertile women with biopsy proven genital tract tuberculosis were found. Equal number of infertile females with diagnosed PID and Endometriosis were randomly selected. Comparisons were done between features of Genital Tuberculosis with PID and Endometriosis separately and also genital tuberculosis with combined controls of PID and Endometriosis. RESULTS: Patients with genital tuberculosis commonly had primary infertility. PID and Endometriosis patients had early menarche and increased duration of menstruation. On physical examination, patients with Genital Tuberculosis were found to have short heights. No significant findings were observes in the pelvic examination and menstruation history between the comparison groups. Laparascopic examination revealed that fallopian tubes were abnormal, tortuous, bilaterally blocked and thickly adherent more commonly in Genital Tuberculosis when compared to other groups. CONCLUSION: The primary infertility patients with chronic malnutrition and massive adhesive fallopian tubes on laproscopic examination should be evaluated for genital tuberculosis.

Place research problem in theory--a theory research symbiosis.

Theory gives a specific perspective to research by providing systematic guidance for the identification and investigation of the logical relationship in the phenomenon of interest. To critically appraise the theoretical bases of a research, it is important first to familiarize with the language of theory, which mainly comprises of concepts and propositions. Furthermore, models are developed to act as a springboard for theory generation and theory practice. To organise the research findings in order to develop a body of knowledge, the connection between theory and research should be explicit in the study.

Point of entry into research--problem orientation.

A prerequisite for scientific research is the possession of a well-developed body of knowledge. Knowledge can be obtained from either traditional wisdom or scientific disciplines. Traditional sources of information usually lack any standardized authenticity checks. The main magical point about scientific facts is that they demand empiric evidence: even if traditional wisdom has empirical evidence it is a part of scientific knowledge. The scientific acquisition of knowledge follows certain predetermined steps of research with a starting point of identification and definition of the problem statement. From this article onwards we will try to gradually build up a thorough understanding of those steps.