DRL-GAN: A Hybrid Approach for Binary and Multiclass Network Intrusion Detection.

Our increasingly connected world continues to face an ever-growing number of network-based attacks. An Intrusion Detection System (IDS) is an essential security technology used for detecting these attacks. Although numerous Machine Learning-based IDSs have been proposed for the detection of malicious network traffic, the majority have difficulty properly detecting and classifying the more uncommon attack types. In this paper, we implement a novel hybrid technique using synthetic data produced by a Generative Adversarial Network (GAN) to use as input for training a Deep Reinforcement Learning (DRL) model. Our GAN model is trained on the NSL-KDD dataset, a publicly available collection of labeled network traffic data specifically designed to support the evaluation and benchmarking of IDSs. Ultimately, our findings demonstrate that training the DRL model on synthetic datasets generated by specific GAN models can result in better performance in correctly classifying minority classes over training on the true imbalanced dataset.

Experiences of family caregivers in dealing with cases of advanced breast cancer: a qualitative study of the sociocultural context in Punjab, Pakistan.

BACKGROUND: Patients with advanced breast cancer require consistent help and support from family caregivers. These caregivers often endure financial burdens and psychological stress, with their experiences significantly influenced by sociocultural factors. This study aims to explore the experiences of family caregivers of advanced breast cancer patients in Punjab province, Pakistan. METHODS: Data was collected through in-depth interviews with fifteen family caregivers of advanced breast cancer patients in three major cities of Punjab, Pakistan. Caregivers, who had been in close contact with the patient for the last two years, were purposively sampled from five major hospitals. The data was analyzed using thematic analysis. RESULTS: The study revealed that the experiences of family caregivers are deeply rooted in the sociocultural context. Key themes identified include social responsibility and cultural reciprocity norms; limited awareness and mobility options for caregivers; financial responsibility and strain; impacts of beauty myths and shyness on caregiving attitudes and decisions; the stressful and emotional nature of caregiving; treatment perspectives influenced by social groups; challenges in consulting male physicians and associated stigma; the role of religious beliefs in caregiving; and stress management, with religion often being a coping mechanism. These factors can contribute to delayed treatment decisions for patients. CONCLUSIONS: Family caregivers are crucial in facilitating timely treatment decisions for advanced breast cancer patients in the Pakistani context. To minimize treatment delays and alleviate caregiver stress, addressing sociocultural barriers in care-seeking is essential. A tailored approach, considering sociocultural and religious factors, is imperative for the management and early diagnosis of breast cancer, necessitating appropriate policymaking and implementation.

Determinants of physical, psychological, and social well-being in older adults: a cross-sectional study in senior care facilities of Pakistan (2019/20).

BACKGROUND: Published research on senior care facilities in Pakistan is scarce and no large-scale study has been conducted to assess factors affecting well-being of older adults in these facilities. This study, therefore, investigated the effects of relocation autonomy, loneliness, and satisfaction with services along with socio-demographic characteristics on physical, psychological, and social well-being of older residents living in senior care facilities of Punjab, Pakistan. METHODS: This cross-sectional study collected data from 270 older residents living in 18 senior care facilities across 11 districts of Punjab, Pakistan from November 2019 to February 2020 using multistage random sampling. Existing reliable and valid scales were used to collect information from older adults related to relocation autonomy (Perceived Control Measure Scale), loneliness (de Jong-Gierveld Loneliness Scale), satisfaction with service quality (Service Quality Scale), physical and psychological well-being (General Well-Being Scale), and social well-being (Duke Social Support Index). A psychometric analysis of these scales was carried out followed by three separate multiple regression analyses to predict physical, psychological, and social well-being from socio-demographic variables and key independent variables (relocation autonomy, loneliness, and satisfaction with service quality). RESULTS: The results of multiple regression analyses showed that the models predicting physical (R2 = 0.579), psychological (R2 = 0.654), and social well-being (R2 = 0.615) were statistically significant (p < 0.001). Number of visitors was a significant predictor of physical (b = 0.82, p = 0.01), psychological (b = 0.80, p < 0.001), and social (b = 2.40, p < 0.001) well-being. Loneliness significantly predicted physical (b = -0.14, p = 0.005), psychological (b = -0.19, p < 0.001), and social (b = -0.36, p < 0.001) well-being. Control over relocation process significantly predicted physical (b = 0.56, p < 0.001) and psychological (b = 0.36, p < 0.001) well-being. Satisfaction with services significantly predicted physical (b = 0.07, p < 0.001) and social (b = 0.08, p < 0.001) well-being. CONCLUSION: Pragmatic, equitable and cost-effective interventions are needed to improve the wellbeing of older residents living in senior care facilities. Friendly behavior of mobilizing staff and adjusted residents to facilitate new residents, therapeutic interventions such as relocation support programs, reminiscence therapy and intergenerational support, and increasing their exposure and connection to the outside world, can raise their physical, psychological, and social well-being.

Patients' perception of the pharmacovigilance system: A pre-diagnostic and post-interventional cross-sectional survey.

Background and objective: The risk of adverse reactions necessitated the pharmacovigilance system for patient safety. A literature search documented better health literacy of patients through intervention. This investigation aims to assess the perception and the effect of an intervention on patients regarding adverse reactions caused by drugs. Methods: A pre-diagnostic and post-interventional cross-sectional investigation was designed with a sample size of 423 patients in hospitals of Islamabad. The proportion of patients was selected based on a stratified probability technique. A prevalidated tool was used to collect the response twice through a health promotion brochure with counseling, which was applied as an intervention. Results: The outcome of the investigation revealed that the prerequisite of the pharmacovigilance center in the hospital among respondents was improved significantly by 41.2% after intervention. Knowledge, communication, and practice were significantly different with respect to gender. There was a moderate Pearson correlation between diagnostic and interventional responses of patient's knowledge of adverse reactions by drugs (r = 0.66, p < 0.01) and patient's communication in pharmacovigilance (r = 0.62, p < 0.01) and a strong correlation between diagnostic and interventional responses of patient's practice in the pharmacovigilance system (r = 0.72, p < 0.01). Conclusion: The finding of the investigation provided evidence that patient awareness was significantly improved by the health promotion model. Patient participation in the reporting of adverse reactions of drugs will complement the hospital staff reporting. These reports will construct an authentic, cross-checked database for rational drug safety practices in Pakistan.

COVID-19 Vaccination Acceptance in the Context of the Health Belief Model: Comparative Cross-Sectional Study in Punjab, Pakistan.

One of the models that could be used to understand the adoption of vaccine uptake is the Health Belief Model (HBM). The aim of this study is to assess the role of HBM constructs and Perceived Health Status (PHS) on the vaccination status of individuals and to understand the role of socio-demographic variables on HBM scoring. A comparative cross-sectional telephone survey was conducted among 1325 vaccinated (60.0%) and non-vaccinated (40.0%) individuals aged 40 years and above in July 2021 in Punjab province, Pakistan. A higher level of education was the strongest predictor of positive HBM. All constructs of HBM, PHS and cues-to-action were significant predictors of COVID-19 vaccination uptake, with perceived benefits as the strongest predictor. In order to expand the vaccination coverage, double-pronged interventions utilizing both information and communication technology and human resources should be designed that address each barrier perceived by individuals and understandably communicate the benefits of COVID-19 vaccination to the broader population.

Consanguineous marriages and their association with women's reproductive health and fertility behavior in Pakistan: secondary data analysis from Demographic and Health Surveys, 1990-2018.

BACKGROUND: Pakistan has been showing consistently the highest prevalence of consanguinity. The popularity of consanguineous marriages is not declining in the country, because of social, cultural, and religious beliefs as well as economic advantages. However, couples also face various health-related implications, such as poor pregnancy outcomes or multiple reproductive and fertility consequences, having adverse effects on mothers and their children. This research investigated the trend of consanguineous marriages and their association with women's reproductive health and fertility behavior in Pakistan from 1990 to 2018. METHODS: This study is based on secondary data analysis, using all four waves of the Pakistan Demographic Health Surveys carried out from 1990 to 2018. The analysis is limited to women aged 15-49 years, who had given birth in the previous five years preceding each survey. Sampling weights were calculated and subsequently weighted analysis was conducted. Descriptive statistics, bivariable and multivariable logistic regression analysis were performed to determine the association of consanguinity with multiple characteristics related to socio-demographics, co-variates, and women's reproductive health and fertility behaviors. RESULTS: The findings revealed a high but overall stable trend of consanguinity prevalence of about 63% during the last three decades. Consanguineous marriages were more prevalent amongst young and uneducated women, living in rural areas, with poorer wealth status and having less exposure to mass media to access information. A strong association of consanguinity was observed with women's reproductive health and fertility behavior, particularly for women who gave first birth at a younger age, had multi-gravida pregnancies, multi-parity, pregnancy termination, ANC visits, and higher fertility. CONCLUSION: Consanguineous marriages are predominant in the patriarchal society of Pakistan. Findings revealed that consanguinity contributes significantly to women's reproductive health and fertility behaviors. Appropriate counseling, educational, and health promotional programs related to consanguinity should be designed and launched at the community level to raise awareness about risks towards women's reproductive health and fertility.

COVID-19 Vaccination Hesitancy or Acceptance and Its Associated Factors: Findings from Post-Vaccination Cross-Sectional Survey from Punjab Pakistan.

COVID-19 has posed massive challenges related to health, economy, and the social fabric of the entire human population. To curb the spread of the virus, the Government of Pakistan initiated a vaccination campaign against COVID-19. The objective of this research was to assess the factors associated with COVID-19 vaccine acceptance or hesitancy. The data were collected telephonically using a cross-sectional survey design through a close-ended structured questionnaire from a sample of 1325 vaccinated and non-vaccinated individuals with a response rate of 38%. SPSS v. 26 was used to analyze the data. The study revealed that 73% of the respondents were male, half in the 40-49 age group, 78% living in urban areas, and 45% had a monthly income between 20,001-50,000 Pakistani rupees. People felt reluctant to get vaccinated because of myths and misinformation related to it. The socio-demographic factors including male, age 60-69, middle or higher level of education, marital status, currently employed, from middle socio-economic status, living in urban areas, high access to mass media, history of influenza vaccination, physical activity, and perceived good health status were significantly associated with COVID-19 vaccination uptake. Concerted efforts are needed to achieve vaccine targets for the broader population through understanding and identifying barriers to vaccination.

Role of the Media in Health-Related Awareness Campaigns on Perception of COVID-19: A Pre-post Study in the General Population of Pakistan.

Medical preparedness and community education are the most valuable preventive tools for combatting the COVID-19 pandemic. This study aims to assess the role of media public health awareness campaigns on the knowledge of the general population about COVID-19 in Rawalpindi, Pakistan. A quantitative study using a pre-post design among 384 respondents was conducted. A structured questionnaire was administered to the participants twice: The first response (t 1) from participants was filled in during the 1st week in February 2020 before any confirmed cases were reported in the country, and the second response (t 2) was completed 1 month after the first case detection in Pakistan (March 2020). Media health awareness campaigns were launched just after the detection of the first case in Pakistan. Exposure to the media and knowledge relating to COVID-19 increased over time. Whereas, only a quarter of respondents judged the isolation of suspected cases in quarantine to be important to prevent the spread of infection in society at t 1, more than half did so at t 2. Socio-demographic characteristics were not significantly associated with knowledge (gains). However, more frequent use of electronic media is associated with greater knowledge gains from t 1 to t 2. The findings of this study provide evidence that awareness and knowledge related to COVID-19 symptoms and preventive measures increased significantly over time. The increased frequency of following the media indicates that health awareness campaigns are important for enhancing the knowledge of the general public regarding COVID-19.

Determinants of overall knowledge and health behaviours in relation to hepatitis B and C among ever-married women in Pakistan: evidence based on Demographic and Health Survey 2017-18.

BACKGROUND: In 2019, around 5 million and 10 million people were affected by hepatitis B virus (HBV) and hepatitis C virus (HCV) respectively in Pakistan. On World Hepatitis Day 2019, Pakistan's Government announced the Prime Minister's Plan to eliminate HBV and HCV from the country by 2030. In order to achieve this goal, adequate knowledge about HBV and HCV regarding mode of transmission, symptoms of the disease, and awareness about available treatments and vaccines is imperative. The present study aims to investigate the determinants related to overall knowledge about and behaviour in relation to HBV and HCV amongst married women in Pakistan. METHODS: Secondary data analysis was carried out using the Pakistan Demographic and Health Survey (PDHS) 2017-18. A series of questions regarding women's knowledge about how to avoid HBV and HCV and their health behaviour in relation to HBV and HCV were posed to 12,364 ever-married women of reproductive age (15-49 years). Bivariate and multivariable logistic and linear regression was applied to examine the effects of sociodemographic characteristics and covariates on women's overall knowledge and health behaviour regarding HBV and HCV. RESULTS: The findings highlight that the majority of women (88.3%) have heard of HBV and HCV. Nonetheless, only 34.8% had comprehensive knowledge about how to avoid HBV and HCV. Few women (11.3%) had been tested for HBV or HCV during the year preceding the survey. Furthermore, the results indicate that women living in urban areas, being older, and having more than 10 years of schooling, reported better knowledge and health behaviours regarding HBV and HCV. CONCLUSION: This study provides evidence that women's sociodemographic characteristics create differences in their overall knowledge about and attitudes towards HBV and HCV. This research emphasized that there is a need to create awareness about the causes and prevention of HBV and HCV in order to achieve the goal of eliminating these diseases in Pakistan by 2030.

Sociocultural Challenges in the Implementation of COVID-19 Public Health Measures: Results From a Qualitative Study in Punjab, Pakistan.

Informed public health measures are crucial to curb the COVID-19 pandemic. The sociocultural context is important to understand the success or failure of implementing public health measures. This study explores the social and behavioral response to COVID-19 and unveils challenges in the implementation of related public health measures in Pakistan. Within this qualitative study, we conducted 34 telephonic/online in-depth interviews with youths, adults, elderly people, and healthcare professionals in the Punjab province of Pakistan. Framework analysis was used for data analysis. People's poor understanding about COVID-19 and the need for preventive measures were the major challenge in implementing public health preventive strategies. Study participants reported that the lockdown strategy increased poverty and unemployment. People's poor living conditions and living environment compelled them not to follow social distancing and restricting themselves to home. Additionally, an underdeveloped healthcare system was one of the major challenges for Pakistan. The culture of denial in Pakistan related to the epidemiology of COVID-19 was an important challenge within the implementation of public health preventive measures. It is extremely important that public health experts and social scientists work together to understand the contextual sociocultural factors which shape behaviors associated with the spread of a pandemic.

The influence of social and cultural practices on maternal mortality: a qualitative study from South Punjab, Pakistan.

BACKGROUND: A disproportionately high rate of maternal deaths is reported in developing and underdeveloped regions of the world. Much of this is associated with social and cultural factors, which form barriers to women utilizing appropriate maternal healthcare. A huge body of research is available on maternal mortality in developing countries. Nevertheless, there is a lack of literature on the socio-cultural factors leading to maternal mortality within the context of the Three Delays Model. The current study aims to explore socio-cultural factors leading to a delay in seeking care in maternal healthcare in South Punjab, Pakistan. METHODS: We used a qualitative method and performed three types of data collection with different target groups: (1) 60 key informant interviews with gynaecologists, (2) four focus group discussions with Lady Health Workers (LHWs), and (3) ten case studies among family members of deceased mothers. The study was conducted in Dera Ghazi Khan, situated in South Punjab, Pakistan. The data was analysed with the help of thematic analysis. RESULTS: The study identified that delay in seeking care-and the potentially resulting maternal mortality-is more likely to occur in Pakistan due to certain social and cultural factors. Poor socioeconomic status, limited knowledge about maternal care, and financial constraints among rural people were the main barriers to seeking care. The low status of women and male domination keeps women less empowered. The preference for traditional birth attendants results in maternal deaths. In addition, early marriages and lack of family planning, which are deeply entrenched in cultural values, religion and traditions-e.g., the influence of traditional or spiritual healers-prevented young girls from obtaining maternal healthcare. CONCLUSION: The prevalence of high maternal mortality is deeply alarming in Pakistan. The uphill struggle to reduce deaths among pregnant women is firmly rooted in addressing certain socio-cultural practices, which create constraints for women seeking maternal care. The focus on poverty reduction and enhancing decision-making power is essential for supporting women's right to medical care.

Round the world, many women are dying because of complications during pregnancy or in childbirth. These deaths are more frequent in developing and underdeveloped countries. Some reasons for this are related to social and cultural factors, which form barriers to women using appropriate maternal healthcare. Therefore, this study aims to explore socio-cultural factors leading to a delay in seeking maternal healthcare in South Punjab, Pakistan. We interviewed a variety of people to get an overview of this topic: (1) 60 interviews were conducted with gynaecologists, (2) we performed four focus group discussions with eight to ten Lady Health Workers providing maternal healthcare, and (3) we talked with family members of mothers who had died.The study shows that delays in seeking care are related to poor socioeconomic status, limited knowledge about maternal care, and low incomes of rural people. The low status of women and male domination keeps women less empowered. In addition, early marriages and lack of family planning due to cultural values, religion and traditions stopped young girls from getting maternal healthcare.The number of new mothers who die is very worrying in Pakistan. One of the important tasks for reducing deaths among pregnant women is to address certain socio-cultural practices. It is very important to reduce poverty and improve decision-making power to make sure women can use their right to medical care.

Psychosocial effects of the COVID-19 pandemic and lockdown on university students: Understanding apprehensions through a phenomenographic approach.

Limited evidence exists to help understand the experiences of university students in relation to the long-term lockdown due to the COVID-19 pandemic. For that reason, we conducted a study using a phenomenographic approach in order to understand how university students perceive COVID-19 and the associated lockdown. Data were collected from 25 students in Pakistan. They were asked to demonstrate the psychological effects of the COVID-19 pandemic and lockdown in illustrations. In addition, in-depth interviews were conducted with these students, to gain further insights into their perspectives on the psychosocial effects of the COVID-19 pandemic. The analysis revealed four interlinked directions for understanding students' experiences. These themes were: 1) escape into peace, 2) hope for personal freedom, 3) fear of becoming a victim of COVID-19, and 4) concerns regarding education, future career, and opportunities. All four themes were analyzed and condensed into an outcome space, which further gathers the perceptions of students under one theme as "Hope for life while paradoxically living with fear". Studying the psychological impact of the COVID-19 pandemic and lockdown on students not only highlighted their concerns, but also emphasized the importance of starting regular psychological evaluations and stress-releasing sessions, along with online education to overcome growing depression.

COVID-19 and Health Information Seeking Behavior: Digital Health Literacy Survey amongst University Students in Pakistan.

Amid the COVID-19 pandemic, digital health literacy (DHL) has become a significant public health concern. This research aims to assess information seeking behavior, as well as the ability to find relevant information and deal with DHL among university students in Pakistan. An online-based cross-sectional survey, using a web-based interviewing technique, was conducted to collect data on DHL. Simple bivariate and multivariate linear regression was performed to assess the association of key characteristics with DHL. The results show a high DHL related to COVID-19 in 54.3% of students. Most of the Pakistani students demonstrated ~50% DHL in all dimensions, except for reliability. Multivariate findings showed that gender, sense of coherence and importance of information were found to be significantly associated with DHL. However, a negative association was observed with students' satisfaction with information. This led to the conclusion that critical operational and navigations skills are essential to achieve COVID-19 DHL and cope with stress, particularly to promote both personal and community health. Focused interventions and strategies should be designed to enhance DHL amongst university students to combat the pandemic.

Protocol for a cross-sectional study on factors affecting health-related quality of life among Afghan refugees in Pakistan.

Background: Pakistan served as a host for more than 1.4 million Afghan refugees for more than 40 years. Access to health care is the most important issue faced by refugees, because they might be at a higher risk for certain diseases. This risk can be attributed to a lack of awareness of health care facilities, health beliefs, inadequate hygiene, cultural differences, and malnutrition. Health of individuals is closely associated with their quality of life. Quality of life over the whole lifespan is pivotal to overall life satisfaction. It includes physical wellbeing, mental health, education, occupation, income, personal safety, as well as (religious) freedom. Until now, the health status of Afghan refugees has never been comprehensively investigated in Pakistan. Therefore, an assessment in this regard is needed to explore their health-related quality of life, for securing their human right to health. Methods: A cross-sectional study has been designed to describe and explain the health-related quality of life of Afghan refugees in Pakistan. Multistage cluster sampling was applied for selection of study participants. The number of respondents from two regions in Pakistan was drawn through a proportionate sampling technique. A quantitative research method using pre-validated questionnaires was used for data collection. The questionnaire included items to assess well-being, mental health, health literacy, and factors affecting health and health care. Descriptive analysis was used, whereas inferential statistical tests (binary logistic regression model) was also performed. The study received ethically permission by the Advanced Studies and Research Board of the University of the Punjab, Lahore, Pakistan. Discussion: The assessment of Afghan refugee's quality of life in Pakistan should lead to recommendations disseminated to public and health care officials. This evidence is needed for policymaking related to adequate measures for improving health conditions of Afghan refugees in Pakistan.

Trends of caesarean section deliveries in Pakistan: secondary data analysis from Demographic and Health Surveys, 1990-2018.

BACKGROUND: Pakistan is among those countries where the number of caesarean section births has increased unusually in the past two decades. Therefore, the aim of the present study is to analyse the trend of caesarean section deliveries among child-bearing women (aged 15-49 years) in Pakistan and to identify maternal socio-demographic factors and pregnancy-related variables associated with the change in caesarean deliveries from 1990 to 2018. METHODS: Secondary data from Pakistan Demographic and Health Surveys (1990-2018) were analysed. The analysis of data was confined to child-bearing mothers. Sample sizes were 4029, 5721, 7461 and 8287 for the time periods of 1990-91, 2006-07, 2012-13 and 2017-18, respectively. Socio-demographic information of the mothers and pregnancy-related variables were taken as independent variables for the present study. The association between independent variables and caesarean deliveries was measured in terms of unadjusted odds ratios (OR) and adjusted OR (AOR). RESULTS: The percentages of the mothers who had at least one delivery during the 5 years prior to each survey who had caesarean deliveries increased continuously from 3.2% in 1990-91 to 19.6% in 2017-18. Results indicate that mothers over 24 years of age, located in Punjab, from the richest socio-economic class and living in urban areas were more likely to have delivered by caesarean section. Mothers with a first child in birth order and who had five and more children, as well as mothers who had more antenatal care visits and delivered babies in private hospitals showed a higher probability of caesarean section births. CONCLUSIONS: The findings of the present study confirm the gradual upsurge in the percentage of mothers delivering by caesarean section during the past two decades in Pakistan. Against this backdrop, some measures need to be taken by health departments to regulate the number of caesarean deliveries. Awareness among women about pregnancy complications and elaborated details by gynaecologists about the medically indicated reasons for caesarean delivery are a few important steps in Pakistan that can help in reducing caesarean deliveries which are not medically indicated.

Determinants of overall knowledge of and attitudes towards HIV/AIDS transmission among ever-married women in Pakistan: evidence from the Demographic and Health Survey 2012-13.

BACKGROUND: HIV/AIDS has emerged as a serious public health issue across the globe, and particularly in developing countries. Comprehensive knowledge and positive attitudes are cornerstones for the prevention, control and treatment of HIV/AIDS. However, there are various misconceptions associated with HIV/AIDS transmission, which lead to negative attitudes towards people living with AIDS. The present study aims to explore the effects of these determinants, related to socio-demographic characteristics and autonomy, on women's overall knowledge and attitudes regarding HIV/AIDS in Pakistan. METHODS: Secondary data analysis was carried out using the national representative dataset of the 2012-13 Pakistan Demographic and Health Survey. A series of questions related to HIV/AIDS was asked of 13,558 ever-married women aged 15-49 years to assess respondents' knowledge regarding modes of HIV/AIDS transmission and preventative measures, as well as their attitudes towards people living with HIV/AIDS. Descriptive and bivariate statistics were used to identify associations with socio-demographic and autonomy-related variables. Furthermore, bivariate and multivariate logistic regression analyses were performed to assess the association between multiple factors and overall HIV/AIDS knowledge as well as attitudes towards people living with AIDS. RESULTS: The results show that only 42% of Pakistani women have heard about HIV/AIDS. Amongst these women, the majority (68%) have good overall knowledge of HIV/AIDS and more than 55% have positive attitudes towards people living with AIDS. Furthermore, women residing in urban areas, having at least secondary-level education, with high autonomy, belonging to the richest wealth quintile and having exposure to mass media had high overall knowledge and positive attitudes towards people living with AIDS. CONCLUSION: The findings of this research support the relevance of women's autonomy, education and exposure to mass media, particularly in rural areas of Pakistan, to address the lack of knowledge and eliminate various myths and stigmatisation of people living with HIV/AIDS. Furthermore, it reveals a need to increase focused and targeted interventions to enhance women's knowledge and positive attitudes towards people living with HIV/AIDS. In this regard, the media can play a proactive role to gauge wider audience in creating awareness and eradicating the myths and misconceptions regarding HIV/AIDS.

Exploring parental perceptions and knowledge regarding breastfeeding practices in Rajanpur, Punjab Province, Pakistan.

BACKGROUND: Exclusive breastfeeding is significantly associated with strong infant immunity and optimal development. The importance of breastfeeding is underestimated. Parental lack of knowledge and unhealthy practices regarding breastfeeding deprive infants of their basic right to mother's milk. In developing countries, including Pakistan, with high child mortality and malnutrition, healthy breastfeeding practices can bring positive changes in child health status. From this perspective, the present study aims to understand parents' knowledge, attitudes and practical encounters with breastfeeding practices and the factors that prevent them from adopting such practices. METHODS: A qualitative study was carried out in both rural and urban settings in Rajanpur District of Punjab Province, Pakistan. We conducted 12 focus-group discussions (FGDs) that involved 38 mothers and 40 fathers with children aged under two years who were being breastfed. A thematic content analysis of data collected through FGDs was performed manually. The themes were both inductive and deductive in nature. RESULTS: The study found that a majority of participants believed that the first thing given to an infant after birth should not be breast milk but honey, rose flower, or goat's milk from the hands of an elder in the family or a religious person. No cleanliness measures were practised in this regard. The participants had misconceptions about the benefits of colostrum, which frequently prevented it being given to newborns. Participants reported many factors, such as: insufficient milk syndrome (slow growth of infants due to insufficient daily breast milk intake), a mother's high workload, lack of social support, the influence of culturally designated advisors, and the promotion and marketing strategies of infant formula companies, that undermined exclusive breastfeeding efforts and encouraged mothers to switch to infant formula. CONCLUSIONS: Culturally acceptable and integrated public health interventions are needed to improve the breastfeeding-related health literacy and practices of parents, grandparents and communities. This will ultimately reduce the high infant mortality and malnutrition rates in Pakistan.

Underreporting of stillbirths in Pakistan: perspectives of the parents, community and healthcare providers.

BACKGROUND: Pakistan has the highest rate of stillbirths globally. Not much attention has been given so far to exploring the sociocultural factors hindering the reportage of stillbirths and the causes of death. Therefore, the aim of this study was to assess the perspectives of parents, communities and healthcare providers regarding the sociocultural practices and health system-related factors contributing to stillbirths and their underreporting. METHODS: This study used a qualitative approach including in-depth interviews and 14 focus group discussions to collect data from four districts of Pakistan. We conducted 285 in-depth interviews and 14 focus group discussions with health professionals - mainly active in the areas of maternal and child health - and parents who had experienced stillbirth. Constant comparative method and analytical induction method were performed to analyze the data. RESULTS: The results of this study show that stillbirth is frequently misclassified and, therefore, an underreported phenomenon in Pakistan. It is an outcome of sociocultural practices, such as the social meaning of stillbirth and their understanding about the conflict between cultural and medical anatomy. In addition to grief and psychological distress, it endangers the maternal identity and worth in society in contrast to the mothers of live-born children. CONCLUSION: The misclassification of stillbirth, especially by healthcare providers, is a significant impediment to designing preventive strategies for stillbirth. We recommend that the reporting system for stillbirth should be aligned with the WHO definition of stillbirth to avoid its underreporting. Reporting procedures at a more administrative level need to be made uniform and simplified.

Factors Associated with Undernutrition in Children under the Age of Two Years: Secondary Data Analysis Based on the Pakistan Demographic and Health Survey 2012⁻2013.

In Pakistan, 96% of the children under the age of two years do not receive an adequate diet. The main aim of this paper is to identify the sociodemographic, nutritional, and health-related factors associated with stunting, wasting, and underweight in children under the age of two years in Pakistan. Secondary data analysis was performed based on the Pakistan Demographic and Health Survey, 2012⁻2013. The analysis was limited to children under the age of two years (n = 984). Analysis was done using bivariate and multivariable binary logistic regression. The incidence of stunting, wasting, and underweight in children was 28.3%, 12.1%, and 27.9%, respectively. The odds of stunting, wasting, and underweight increased with the child's age. The odds of stunting and underweight increased with the mother's low body mass index, low access to information, high birth order of child, consanguineous marriages, father's low education, rural settlement, poor toilet facilities, and low vitamin A consumption. The odds of wasting increased in children who were not being breastfed, but no significant relation was seen with stunting and underweight. There is a need to improve child nutritional status in Pakistan by addressing issues such as poverty, low parental education, low micronutrient intake, and targeting provinces where undernutrition was found to be higher.

High-dose vitamin D3 in the treatment of severe acute malnutrition: a multicenter double-blind randomized controlled trial.

Background: Vitamin D deficiency is common in children with severe acute malnutrition, in whom it is associated with severe wasting. Ready-to-use therapeutic food (the standard treatment) contains modest amounts of vitamin D that do not reliably correct deficiency. Objective: The aim of this study was to determine whether high-dose oral vitamin D3 enhances weight gain and development in children with uncomplicated severe acute malnutrition. Design: We conducted a randomized placebo-controlled trial of high-dose vitamin D3 supplementation in children aged 6-58 mo with uncomplicated severe acute malnutrition in Pakistan. Participants were randomly assigned to receive 2 oral doses of 200,000 IU vitamin D3 or placebo at 2 and 4 wk after starting ready-to-use therapeutic food. The primary outcome was the proportion of participants gaining >15% of baseline weight at 8 wk after starting ready-to-use therapeutic food (the end of the study). Secondary outcomes were mean weight-for-height or -length z score and the proportion of participants with delayed development at the end of the study (assessed with the Denver Development Screening Tool II), adjusted for baseline values. Results: Of the 194 randomly assigned children who started the study, 185 completed the follow-up and were included in the analysis (93 assigned to intervention, 92 to control). High-dose vitamin D3 did not influence the proportion of children gaining >15% of baseline weight at the end of the study (RR: 1.04; 95% CI: 0.94,1.15, P = 0.47), but it did increase the weight-for-height or -length z score (adjusted mean difference: 1.07; 95% CI: 0.49,1.65, P < 0.001) and reduce the proportion of participants with delayed global development [adjusted RR (aRR): 0.49; 95% CI: 0.31, 0.77, P = 0.002], delayed gross motor development (aRR: 0.29; 95% CI: 0.13, 0.64, P = 0.002), delayed fine motor development (aRR: 0.59; 95% CI: 0.38, 0.91, P = 0.018), and delayed language development (aRR: 0.57; 95% CI: 0.34, 0.96, P = 0.036). Conclusions: High-dose vitamin D3 improved the mean weight-for-height or -length z score and developmental indexes in children receiving standard therapy for uncomplicated severe acute malnutrition in Pakistan. This trial was registered at clinicaltrials.gov as NCT03170479.