Challenges and health outcomes of the exposure to soybean dust in the harbor neighborhood of Karachi, Pakistan: a wake-up call.

BACKGROUND: Chemical disasters are common worldwide and result from technological failure, war, and terrorism activities. Pakistan imports huge quantities of hazardous chemicals to meet its industrial and energy needs. Hence there is a risk of chemical disaster at the ports, during transportation of such material and processing in the chemical industry. This study aimed to review the challenges and health outcomes of cases of soybean dust exposure in Kemari district (harbor neighborhood) of Karachi, Pakistan. METHODS: A cross-sectional survey was conducted with all the affected people from a chemical incident of soybean dust which was reported in the Keamari district of Karachi, Pakistan. Included patients ≥ 18 years who visited the two major tertiary care hospitals of Karachi, Pakistan after the incident between February 17 to 23, 2020. A total of 574 patients were brought to these two major tertiary care hospitals. We collected data on basic demographics, event details, and major signs and symptoms of the affected individuals. Calculated frequencies and percentages for categorical variables. Mean ± standard deviation (SD) was calculated for continuous variables. RESULTS: The mean ± (SD) age of the victims were 32 (13.5) years. Of the 574 patients, majority of the patients (n = 319, 56%) were males. In 28 cases (41%), the onset of symptoms occurred at home, in 27 cases (39%) the onset of symptoms started in the workplace and the remaining cases (n = 14, 20%) experienced the first symptoms while roaming around the roadside. The most common reported co-morbidity was a history of asthma (56%), followed by diabetes mellitus (22%). The most common clinical manifestation was shortness of breath, reported in 94% of the cases, followed by neurological symptoms such as drowsiness, unconsciousness, or seizures experienced by 10% of the victims. A total of 9 deaths (1.5%) were recorded. CONCLUSION: A multi-sectoral systematic approach is also required to address these incidents comprehensively including the trained and equipped pre-hospital system, integrated emergency medical response, and community-wide emergency response system.

Perceptions, barriers, and strategies regarding helmet use by female pillion riders in Pakistan: A qualitative study.

INTRODUCTION: Despite the existence of a national motorcycle helmet law that applies to both riders and pillion riders, the use of helmets among female pillion riders is low in Pakistan. This study aimed to explore perceptions, barriers, and strategies related to helmet use by female pillion riders. METHODS: Data was collected from nine focus group discussions held with female pillion riders and male riders working at the Aga Khan University. Focus group discussions were transcribed verbatim and checked for accuracy before being imported into NVivo2. Transcriptions were analyzed using a thematic analysis approach. RESULTS: Four overarching themes emerged, including: (1) motorcycle as mode of transportation, (2) law on helmet use and its enforcement, (3) barriers to helmet use among female pillion riders, and (4) strategies to improve helmet use among female pillion riders. Female participants never wore a helmet or considered wearing it even though "safety" was the most important benefit of helmet usage expressed. The motorcycle is an economical mode of transportation for families, particularly those in the middle and lower socioeconomic groups. Helmet laws are not strictly enforced for pillion riders, including females. Possible barriers to helmet use among female pillion riders included discomfort in wearing a helmet, uninvited attention from others, concerns about physical appearance, and substandard quality and design of helmets. Suggested strategies for implementing helmet use among female pillion riders encompassed awareness generation through media, complementary distribution of helmets, strict law enforcement in the form of fines, and the influence of religious leaders regarding social norms and cultural barriers. CONCLUSION: Motorcycles are a risky mode of transport, and there are several social and cultural barriers regarding helmet use by female pillion riders. Enforcing helmet laws for female pillion riders, raising awareness about helmet laws, and making helmet use among pillion riders a norm are some essential steps to take to promote helmet use among female pillion riders in Pakistan.

Trends in mortality related to unintentional poisoning in the South Asian region from 1990 to 2019: analysis of data from the Global Burden of Disease Study.

OBJECTIVE: This study aimed to estimate the burden of unintentional poisoning in South Asian countries from 1999 to 2019. DESIGN: An ecological study conducted at the regional level for South Asian countries, based on data from the Global Burden of Disease Study 2019. SETTING: We extracted unintentional poisoning data from the Global Burden of Disease Study data set from 1990 to 2019 to assess trends in mortality, disability-adjusted life-years (DALYs), years of life lost, years lived with disability (YLDs) and causative agents in South Asian countries (Bangladesh, Bhutan, India, Nepal and Pakistan). OUTCOME MEASURES: We determined the per cent change and 95% CI for the period between 1990 and 2019 by age, gender and country. We also conducted Poisson regression to measure the percentage change in the rate per year. RESULTS: The absolute number of deaths due to unintentional poisoning in South Asia decreased (-32.6%) from 10 558 deaths in 1990 to 7112 deaths in 2019. The age standardised death rate from unintentional poisoning in South Asia has seen a downward trend (-55.88%), declining from 0.87 (0.67-1.01) age-standardised per 100 000 population in 1990 to 0.41 (0.34-0.47) in 2019. Among age groups, under 9 years and 10-19 years have seen downward trends for death and DALYs, accounting for -93.5% and -38.3%, respectively. YLDs have seen an upward trend (5.9%), increasing from 10 461.7 per 100 000 in 1990 to 11 084 per 100 000 in 2019. YLDs in women increased by 7.4%, from 11 558.2 per 100 000 to 12 418.3 per 100 000. The incidence rate ratios (IRRs) adjusted by all age groups and gender for DALYs in all South Asian countries has reduced significantly (IRR 0.97, 95% CI 0.96 to 0.97) from 1990 to 2019. CONCLUSION: This study showed reduction in death and DALYs due to unintentional poisoning in South Asia except YLDs which is showing an increasing trend. Public health systems should continue efforts to minimise and prevent disabilities arising from unintentional poisoning in South Asia.

Gaps in hygiene promotion at schools in Pakistan: qualitative descriptive research.

School health remains an ignored domain in Pakistan. This article presents gaps in understanding hygiene promotion efforts in school settings in urban squatter settlements by exploring perspectives of the key stakeholders and undertaking a review of the education curriculum. Using qualitative methodology, 13 in-depth interviews were held with the key informants (teachers, health and education officers) and three focus group discussions were conducted with 36 mothers. The study setting includes three schools located in a semi-urban area in the province of Sindh, Pakistan. The semi-structured guide was utilized to obtain perspectives of key stakeholders on factors constraining hygiene promotion efforts in school settings. The primary education curriculum was reviewed using the content analysis approach to assess the integration of hygiene concepts into the curriculum. Analysis of qualitative interviews and curriculum review resulted in five categories under a theme that addressed multiple factors constraining hygiene promotion in the school settings. These include (i) Gaps in the school curriculum, (ii) Poor accountability of the local administration in the upkeep of schools, (iii) Parent's negligence toward children's hygiene, (iv) Inadequate training of school teachers on hygiene concepts, and (v) Lack of interdepartmental coordination between health and education sectors. Hygiene promotion at schools has been deterred by multiple factors at the selected primary schools in Pakistan. Recommended actions include integration of health and hygiene concepts into the education curriculum, capacity building of teachers, reviving water, sanitation and hygiene infrastructure, coordination among Education and Health Departments and ownership among the local government to ensure cleanliness at schools.

Schools are not only expected to provide education to children, their mandate also includes health and hygiene promotion. Keeping in view the dearth of evidence in understanding the role of schools in hygiene promotion in the local context, this research was conducted in three semi-urban school settings in Sindh province, Pakistan. We aimed to identify factors that constrain hygiene promotion efforts at the school level. As part of this research, we interviewed multiple stakeholders. This includes (teachers, mothers, education and health officers) at the primary school level. Our findings revealed serious gaps in hygiene promotion at schools. This includes inadequate attention to hygiene concepts in the curriculum books, inconducive school environment, teachers' and parents' negligence toward children's hygiene and communication gap among them, and absence of coordination between health and education sectors. To conclude, multiple actions are needed to emphasize hygiene promotion at the school level. This ranged from revision in the education curriculum and training of teachers in hygiene promotion to instituting accountability mechanisms at the local Education Department and building strong coordination between Education and Health departments.

Follow-up household assessment for child unintentional injuries two years after the intervention: A community-based study from Karachi, Pakistan.

BACKGROUND: Unintentional childhood injuries are a growing public health concern, and the home is the most common location for non-fatal injuries in children less than 5 years of age. This study describes the long-term effects of two injury prevention educational interventions for caregivers-an educational pamphlet and an in-home tutorial guide-by comparing the change in the prevalence of home injury hazards before and after the interventions. METHODS: This was a pre- (June and July 2010) and post-study with short-term follow-up (November-December 2010) and long-term follow-up (November 2012- January 2013). Neighborhood one included households that received only educational pamphlets after completing a baseline assessment; neighborhood two included households that received an in-home tutorial guide after completing the baseline assessment and receiving the educational pamphlet. The main outcome of this study was the reduction in home injury hazards for children under 5 years of age. RESULTS: A total of 312 households participated in the long-term phase to compare the effect of the interventions. Between the short-term to long-term follow-up, injury hazards significantly reduced in neighborhood two compared to neighborhood one. These included fall hazards (walker use) (IRR 0.24 [95% CI 0.08-0.71]), drowning hazards (open bucket of water in the courtyard and uncovered water pool) (IRR 0.45 [95% CI 0.85-0.98] and IRR 0.46 [95% CI 0.76-0.94]), burn hazards (iron, water heater within reach of child) (IRR 0.56 [95% CI 0.33-0.78] and IRR 0.58 [95% CI 0.32-0.91]), poisoning hazards (shampoo/soap and medicine within reach of child) (IRR 0.53 [95% CI 0.44-0.77] and IRR 0.7 [95% CI 0.44-0.98]) and breakable objects within reach of child (IRR 0.62 [95% CI: 0.39-0.99]). CONCLUSION: An injury prevention tutorial to caretakers of children supplemented with pamphlets could significantly decrease the incidence of falls, drowning, burns, poisoning, and cut injury hazards for children under 5 years of age in their homes in a low-resource setting. This intervention has the potential to be integrated in existing public health programs, such as Lady Health Visitors (LHVs), to disseminate injury prevention information in routine home health visits.

Out of hospital cardiac arrest: experience of a bystander CPR training program in Karachi, Pakistan.

BACKGROUND: Nearly 90% of out-of-hospital cardiac arrest (OHCA) patients are witnessed, yet only 2.3% received bystander cardiopulmonary resuscitation (CPR) in Pakistan. This study aimed to determine retention of knowledge and skills of Hands-Only CPR among community participants in early recognition of OHCA and initiation of CPR in Karachi, Pakistan. METHODS: Pre and post-tests were conducted among CPR training participants from diverse non-health-related backgrounds from July 2018 to October 2019. Participants were tested for knowledge and skills of CPR before training (pre-test), immediately after training (post-test), and 6 months after training (re-test). All the participants received CPR training through video and scenario-based demonstration using manikins. Post-training CPR skills of the participants were assessed using a pre-defined performance checklist. The facilitator read out numerous case scenarios to the participants, such as drowning, poisoning, and road traffic injuries, etc., and then asked them to perform the critical steps of CPR identified in the scenario on manikins. The primary outcome was the mean difference in the knowledge score and skills of the participants related to the recognition of OHCA and initiation of CPR. RESULTS: The pre and post-tests were completed by 652 participants, whereas the retention test after 6 months was completed by 322 participants. The mean knowledge score related to the recognition of OHCA, and initiation of CPR improved significantly (p < 0.001) from pre-test [47.8/100, Standard Deviation (SD) ±13.4] to post-test (70.2/100, SD ±12.1). Mean CPR knowledge after 6 months (retention) reduced slightly from (70.2/100, ±12.1) to (66.5/100, ±10.8). CPR skill retention for various components (check for scene safety, check for response, check for breathing and correct placement of the heel of hands) deteriorated significantly (p < 0.001) from 77.9% in the post-test to 72.8% in re-test. Participants performed slightly better on achieving an adequate rate of chest compressions from 73.1% in post-test to 76.7% in re-test (p 0.27). CONCLUSION: Community members with non-health backgrounds can learn and retain CPR skills, allowing them to be effective bystander CPR providers in OHCA situations. We recommend mass population training in Pakistan for CPR to increase survival from OHCA.

Helmet Wearing Saves the Cost of Motorcycle Head Injuries: A Case Study from Karachi, Pakistan.

PURPOSE: To estimate the difference in healthcare cost of head injuries among motorcycle helmet users and non-users. METHODS: Motorcycle crash victims with head injuries that were brought to a public, tertiary care emergency room in Karachi were studied through a descriptive cross-sectional design. A standard questionnaire was used to collect data on demographics, injury pattern, helmeting practice, length of hospital stay, out-of-pocket payments (OOPs), and healthcare service utilization at the facility to estimate total healthcare and other costs applying micro-costing methods during the hospitalization period. RESULTS: A total of 323 motorcyclists involved in crash were brought to a public tertiary care ER, 112 patients had head injuries and were enrolled in the study. The helmeted motorcyclists had a significantly lower median total healthcare cost of PKR 10,796 ($69) [IQR 9851 ($63)-PKR 12,581 ($80)] compared to higher cost of PKR 12,113 ($77) [IQR 10,431 ($66)-50,545 ($322)] (p value = 0.046) in non-helmeted. Helmet users expended significantly less cost on laboratory tests, PKR 365 ($2) [IQR 365 ($2)-548 ($3)] compared to PKR 3650 ($23) [IQR 365 ($2)-5840 ($37)] (p value =0.027) among non-users. Furthermore, cost of radiological investigations was also low among helmeted patients compared to non-helmeted ones, median PKR 4096 ($26) [IQR 3166 ($20)-5678 ($36)] vs 4750 ($30) [3166 ($20)-11,358 ($72)] (p value =0.049). The out-of-pocket payments (OOPs) for healthcare services were lower among helmet users as compared to non-users, with cost of PKR 17,750 ($113) [IQR 16,650 ($106)-18,000 ($115)] vs PKR 19,800 ($126) [IQR 12,300 ($78)-30,900 ($197)] (p value =0.03), respectively. CONCLUSION: The result of this study demonstrates that helmet use among motorcyclists significantly reduced healthcare costs and healthcare resource utilizations during hospitalization for head injuries in Pakistan. Thus, it is important to implement strict helmet wearing laws to decrease head injuries and the cost burden on the healthcare facility and patients.

Heat Emergencies: Perceptions and Practices of Community Members and Emergency Department Healthcare Providers in Karachi, Pakistan: A Qualitative Study.

Heat waves are the second leading cause of weather-related morbidity and mortality affecting millions of individuals globally, every year. The aim of this study was to understand the perceptions and practices of community residents and healthcare professionals with respect to identification and treatment of heat emergencies. A qualitative study was conducted using focus group discussions and in-depth interviews, with the residents of an urban squatter settlement, community health workers, and physicians and nurses working in the emergency departments of three local hospitals in Karachi. Data was analyzed using content analysis. The themes that emerged were (1) perceptions of the community on heat emergencies; (2) recognition and early treatment at home; (3) access and quality of care in the hospital; (4) recognition and treatment at the health facility; (5) facility level plan; (6) training. Community members were able to recognize dehydration as a heat emergency. Males, elderly, and school-going children were considered at high risk for heat emergencies. The timely treatment of heat emergencies was widely linked with availability of financial resources. Limited availability of water, electricity, and open public spaces were identified as risk factors for heat emergencies. Home based remedies were reported as the preferred practice for treatment by community members. Both community members and healthcare professionals were cognizant of recognizing heat related emergencies.

Perception of the healthcare professionals towards the current trauma and emergency care system in Kabul, Afghanistan: a mixed method study.

BACKGROUND: Trauma and injury contribute to 11% of the all-cause mortality in Afghanistan. The study aimed to explore the perceptions of the healthcare providers (pre and in-hospital), hospital managers and policy makers of the public and private health sectors to identify the challenges in the provision of an effective trauma care in Kabul, Afghanistan. METHODS: A concurrent mixed method design was used, including key-informant interviews (healthcare providers, hospital managers and policy makers) of the trauma care system (N = 18) and simultaneous structured emergency care system assessment questionnaire (N = 35) from July 15 to September 25, 2019. Interviews were analyzed using content analysis approach and structured questionnaire data were descriptively analyzed. RESULTS: Four themes were identified that describe the challenges: 1) pre-hospital care, 2) cohesive trauma management system, 3) physical and human resources and 4) stewardship. Some key challenges were found related to scene and transportation care, in-hospital care and emergency preparedness within the wider trauma care system. Less than 25% of the population is covered by the pre-hospital ambulance system (n = 23, 65.7%) and there is no communication process between health care facilities to facilitate transfer (n = 28, 80%). Less than 25% of patients with an injury requiring emergent surgery have access to surgical care in a staffed operating theatre within 2 h of injury (n = 19, 54.2%) and there is no regular assessment of the ability of the emergency care system to mobilize resources (human and physical) to respond to disasters, and other large-scale emergencies (n = 28, 80%). CONCLUSION: This study highlighted major challenges in the delivery of trauma care services across Kabul, Afghanistan. Systematic improvement in the workforce training, structural organization of the trauma care system and implementing externally validated clinical guidelines for trauma management could possibly enhance the functions of the existing trauma care services. However, an integrated state-run trauma care system will address the current burden of traumatic injury more effectively within the wider healthcare system of Afghanistan.

Operability, Usefulness, and Task-Technology Fit of an mHealth App for Delivering Primary Health Care Services by Community Health Workers in Underserved Areas of Pakistan and Afghanistan: Qualitative Study.

BACKGROUND: The recent proliferation of digital health technology in low- and middle-income countries has made it possible for community health workers (CHWs) to use mobile health (mHealth) to perform tasks such as data collection and training. Although most studies focus on the prospect of digital apps to motivate and connect CHW, only a few have captured end-user experiences with mobile-based apps. We examined the experience of frontline health workers with a move towards digitalized real-time data to record maternal and childcare services in remote areas of Afghanistan and Pakistan. OBJECTIVE: Our study aimed to explore CHW perceptions on the operability of the mHealth app in a community setting, usefulness of the app in the delivery of assigned maternal and childcare functions, and the task-technology fit with monitoring information systems. METHODS: The Hayat app, designed to digitalize and facilitate electronic record keeping, was evaluated to be embedded into mainstream health systems. The app had 2 components: smartphone app for data entry and web dashboard for visualization of the maternal, newborn, and child health reports. Using a qualitative exploratory study design, we conducted a total of 8 focus group discussions with purposively selected lady health workers (LHWs) and CHWs in 3 districts of Pakistan and 3 hamlets of Afghanistan, respectively. Focus group discussions were conducted in the local language, audio recorded, and converted into expanded notes for thematic analysis. RESULTS: Although a majority of LHWs used the app with ease, some initially faced difficulties in operating it and requested a longer duration of training. Contrary to LHWs, the CHWs were able to use the app without difficulty, as they were using it only to register clients. Overall, use of the mHealth app in both countries resulted in a positive impact on health education sessions, easier communication with parents or clients, tracking of routine immunization defaulters and follow-ups, improved data validity, easily accessible vaccination schedules, and faster registration. In addition to building up their image in the community and personal development, the improved reporting and monitoring mechanisms also set the stage for the LHWs to get recognized for their hard work. CHWs in Afghanistan also reported the app provided immediate access to information when requested by their supervisor. Although the Hayat app eliminates the need to carry multiple registers and helps in recalling client information at the touch of a button, technical issues around connectivity and data inputting tabs were highlighted by the participants. CONCLUSIONS: The digitization of records not only provided CHWs support in their daily routine but also strengthened monitoring mechanisms and improved motivation. We recommend conducting end user experience studies before embedding apps into mainstream health systems as high acceptability does not always result in high uptake of digital technology.