Gender roles and their influence on life prospects for women in urban Karachi, Pakistan: a qualitative study

"You are a child and this is not your business": Decision-making on child marriage in Sindh, Pakistan

Young people in Pakistan face challenges such as child marriage, which have adverse consequences on their education, employment, health and overall well-being. We conducted interviews (26) and focus group discussions (12) with young people (15 to 24 years) and community stakeholders to understand how child marriage is perceived by them and to gain insight into the decision-making regarding marriage of youth in Sindh, Pakistan. Study findings show that many young people wish to marry later, but recognize that child marriage is used as a protective strategy to cope with poverty and prevent sexual activity prior to marriage. Young people are expected to obey elders and young women are relegated to domestic roles which limit their decision-making about marriage. Young people and parents who are educated seem to have more negotiating power in delaying marriage than those with little or no education. Our results suggest that interventions should focus on expanding education and livelihood opportunities for young women while changing social norms through parental engagement and youth empowerment.

The impact of partner's behaviour on pregnancy related outcomes and safe child-birth in Pakistan

BACKGROUND

Pakistan is one of the nations with the worst statistics for pregnancy-related outcomes. Health programmes in underdeveloped nations frequently ignore the role of partners in maternal health, which is a crucial contributing factor in these worst situations. This research study aims to explore the role of husbands in maternity care and safe childbirth in Pakistan.

METHODS

The data for this study comes from the Pakistan Maternal Mortality Survey 2019. The k-Modes clustering algorithm was implemented to generate clusters from the dataset. Cluster profiling was used to identify the problems in pregnancy-related outcomes in cases where women live away from their partners. The chi-square test and logistic regression model were fitted to identify the significant factors associated with women's health and safe childbirth.

RESULTS

The finding of the study reveals that the partner's support during and after pregnancy plays a vital role in maternal health and safe child-birth. It was revealed that the women living away from their partners have certain health problems during pregnancy. These problems include Vaginal bleeding, Excessive vomiting, Chest pain, Cough, High B.P, Excessive weight gain, Body aches, Swelling of feet, and Swelling of the face. This also leads to complications and health problems in the postpartum period. Due to a lack of antenatal care from the spouse during pregnancy, the women who lived away from their partners lost their pregnancies.

CONCLUSION

The study concludes that the husband's emotional and financial support substantially impacts the overall health of expecting mothers and the safety of delivery in Pakistan. Given its potential advantages for mother and child health outcomes, male engagement in health education must be acknowledged and addressed. The finding of the study is of immense importance, as it guides the policymakers to arrange various awareness programs for the male partners to support their pregnant spouse and provide proper antenatal care.

Association of Maternal Preferred Language with Breastfeeding Attitudes, Intentions, and Knowledge

INTRODUCTION

Assessing intentions, attitudes, and knowledge about breastfeeding among different language groups is important because the languages reflect cultural differences. We compared attitudes, subjective norms, perceived behavioural control, intentions, and knowledge of breastfeeding among mothers with the five most common preferred languages spoken at a New York City hospital.

MATERIALS AND METHODS

This cross-sectional study surveyed women (n = 448) in the prenatal clinic and the post-partum unit of a New York City hospital. The survey questions were about breastfeeding attitudes, subjective norms, perceived behavioural control, and intentions, based on the Theory of Planned Behavior. We also administered the Iowa Infant Feeding and Attitude Scale and measured the knowledge of the mothers about breastfeeding. The preferred language spoken by the mother was the main predictor variable. English, Russian, Spanish, Urdu, and Uzbek were the languages studied.

RESULTS

Multivariate linear regression analyses showed that Russian (B = 2.24, SE = 1.09, p = 0.04), Urdu (B = 2.90, SE = 1.45, p = 0.046), and Uzbek (B = 4.21, SE = 1.35, p = 0.002) speakers all had significantly more positive attitudes toward breastfeeding than did English speakers. Spanish and English language speakers did not differ from each other in their attitudes towards breastfeeding. The language groups did not differ significantly for subjective norms, perceived behavioural control, intention to breastfeed, the Iowa Infant Feeding and Attitude Scale, nor in knowledge regarding breastfeeding.

CONCLUSIONS

Urdu, Uzbek, and Russian speakers had significantly more positive attitudes towards breastfeeding than did English speakers. To the extent that preferred language is a proxy for culture, clinicians can use this parameter as a basis for directing approaches toward lactation education.

Determinants of Adherence to Antihypertension Medications Among Patients at a Tertiary Care Hospital in Islamabad, Pakistan, 2019

INTRODUCTION

Medication nonadherence leads to poor health outcomes, frequent complications, and high economic impact. Our objective was to assess the determinants of adherence to medication regimens among patients with hypertension.

METHODS

We conducted a cross-sectional study of patients with hypertension attending the cardiology clinic of a tertiary care hospital in Islamabad, Pakistan. Data were collected by using semistructured questionnaires. A score of 7 or 8 on the 8-item Morisky Medication Adherence Scale was classified as good adherence, 6 as moderate, and less than 6 as nonadherence. Logistic regression was performed to determine covariates associated with medication adherence.

RESULTS

We enrolled 450 patients with hypertension (mean age, 54.5 y; SD, 10.6). Medication adherence was good among 115 (25.6%) patients and moderate among 165 (36.7%); 170 (37.8%) patients were nonadherent. Most patients (72.7%) had uncontrolled hypertension. Nearly half (49.6%) were unable to afford monthly medication. In bivariate analysis, nonadherence was associated with female sex (odds ratio [OR], 1.44; P = .003) and long waiting times in the health care facility (OR, 2.93; P = .005); the presence of comorbidities (OR, 0.62; P = .01) was associated with good adherence. In multivariate analysis, nonadherence was associated with unaffordability of treatment (OR, 2.25; P = .002) and uncontrolled hypertension (OR, 3.16; P < .001). Good adherence determinants included adequate counseling (OR, 0.29; P < .001) and education (OR, 0.61; P = .02).

CONCLUSION

Addressing identified barriers, including medication affordability and patient counseling, should be included in Pakistan's national policy on noncommunicable disease.

Relationship of Gender With Laser Retinopexy for Retinal Breaks

PURPOSE

To explore the relationship of gender with laser retinopexy for retinal breaks in the Pakistani population.

MATERIALS AND METHODS

This was a 10-year retrospective observational study conducted at Aga Khan University Hospital, Karachi, Pakistan. All consecutive patients who underwent laser retinopexy between January 2009 and December 2018 for a retinal tear or high-risk retinal degeneration (such as lattice degeneration) were included in this study. Data were collected from patients' files. Index eyes with a history of or treatment for retinal detachment were excluded. A structured pro forma was used to collect information. Descriptive statistics were used to explore the relationship between gender and laser retinopexy.

RESULTS

We identified 12,457 patients through the coding system of our hospital who underwent various laser procedures from January 2009 to December 2018. Yttrium aluminium garnet (YAG) laser, laser peripheral iridotomy (PI), and laser trabeculoplasty procedures were all excluded. A total of 3,472 patients' files were reviewed for this study, out of which 958 patients met the inclusion criteria. Males accounted for a higher number (n=515, 53.87%). The mean age was 43.99±15.37 years. For exploratory analysis, participants were divided into five age groups: <30 years (24.16%); 31-40 years (16.59%); 41-50 years (19.45%); 51-60 years (26.40%); and >60 years (13.49%). Bilateral laser retinopexy was performed in 48.12% of patients; 24.79% and 27.13% of patients underwent unilateral laser retinopexy for the right and left eyes, respectively.

CONCLUSION

In our cohort study, laser retinopexy was more commonly performed in men than in women. The ratio was not significantly different from the prevalence of retinal tears and retinal detachment in the general population, which has a slightly higher male preponderance. We did not find evidence of significant gender bias among patients who underwent laser retinopexy in our study.

Immunization Gender Inequity in Pakistan: An Analysis of 6.2 Million Children Born from 2019 to 2022 and Enrolled in the Sindh Electronic Immunization Registry

Gender-based inequities in immunization impede the universal coverage of childhood vaccines. Leveraging data from the Government of Sindh’s Electronic Immunization Registry (SEIR), we estimated inequalities in immunization for males and females from the 2019–2022 birth cohorts in Pakistan. We computed male-to-female (M:F) and gender inequality ratios (GIR) Tfor enrollment, vaccine coverage, and timeliness. We also explored the inequities by maternal literacy, geographic location, mode of vaccination delivery, and gender of vaccinators. Between 1 January 2019, and 31 December 2022, 6,235,305 children were enrolled in the SEIR, 52.2% males and 47.8% females. We observed a median M:F ratio of 1.03 at enrollment and at Penta-1, Penta-3, and Measles-1 vaccinations, indicating more males were enrolled in the immunization system than females. Once enrolled, a median GIR of 1.00 indicated similar coverage for females and males over time; however, females experienced a delay in their vaccination timeliness. Low maternal education; residing in remote-rural, rural, and slum regions; and receiving vaccines at fixed sites, as compared to outreach, were associated with fewer females being vaccinated, as compared to males. Our findings suggeste the need to tailor and implement gender-sensitive policies and strategies for improving equity in immunization, especially in vulnerable geographies with persistently high inequalities.

Using mixed models to examine the factors associated with intimate partner violence among married women in Pakistan

Currently, the rate of intimate partner violence (IPV) in Pakistan is 29%, which is likely an underestimate. This study used mixed models to examine the effects of women empowerment, women and husband's education, number of adult women in a household, number of children 5 or under in a household, and place of residence on physical violence and controlling behavior, controlling for women's current age and wealth status. Nationally representative data collected from 3,545 currently married women in the Pakistan Demographic and Health Survey (2012-2013) was used for the current study. Mixed models were estimated separately for physical violence and controlling behavior. Logistic regression was also used to conduct additional analyses. Results indicated that women and their husband's education, and number of adult women in a household were associated with a decrease in physical violence, whereas women's empowerment, and women and their husband's education were associated with a decrease in controlling behavior. The implications and limitations of the study are discussed.

Analysis of adolescents' perception and awareness level for Sexual and Reproductive Health Rights in Pakistan

Background

Awareness of rights is a precondition to establishing rule of law in society. Sexual and Reproductive Health and Rights (SRHR) are closely knitted in the human rights framework as they overlap with other human rights such as the right to health and life. However, awareness about these rights remains a challenge. Considering the importance of these rights this study has measured the awareness of adolescents about SRHR in Bahawalpur (Division) of Pakistan.

Methodology

We conducted a cross-sectional study in the Divison of Bahawalpur, Pakistan from October 2019 to December 2019. The study included a sample size of 500 respondents which included 250 young females of age 15-19 and 250 their parents (mother). The reasoning behind including only females in this study was the increased vulnerability and greater impact of SRHR in their life compared to males. The age range 15-19 was primarily selected as females this age will better understand and respond to the questionnaire compared to females in their early adolescent years. The quantitative research was conducted using two-stage cluster sampling. Detailed structured questionnaires were distributed among the respondents to obtain their points of view on the awareness of SRHR. The population was divided into multi-clusters with 25 households comprising 250 households for the division of Bahawalpur. The information was also gathered from the doctors and the teachers through interviews. The data were analyzed using SPSS version 21.

Results

The study explored the knowledge and understanding of adolescent SRHR thereby highlighting the key restrictions in Bahawalpur, Pakistan, which prohibit adolescents from gaining access to SRHR and exercising it. There is a significant portion of adolescents who strongly agreed with the importance and awareness level and think they should be more aware of information regarding SRHR. However, they are of the view that they are less independent in practicing them.

Conclusion

The study found a low level of awareness about SRHR among young female and their parents in Bahawalpur, Pakistan. It is a need of time and responsibility of the local government of the Bahawalpur region to devise clear and proper policies which give access to these rights. This can be done by including the information on these rights in the course curriculum and teachers keeping in view the cultural and regional restrictions that guide the young female about SRHR.

Intimate-partner violence and its association with symptoms of depression, perceived health, and quality of life in the Himalayan Mountain Villages of Gilgit Baltistan

Study objectives

We aimed to estimate the prevalence of intimate partner violence (IPV) and associated risk factors in married women in rural villages of Gilgit Baltistan in Pakistan.

Methods

A cross-sectional design to assess the magnitude and factors associated with IPV in a random sample of 789 married women aged 18–49 years. A World Health Organization screening instrument was used to assess the presence of IPV in the previous 12 months. A locally validated instrument was adopted to identify self-reported symptoms of major depression according to the DSM IV. Trained nurses obtained socio-demographic and reproductive history through structured interviews. Bivariate and multivariable logistic regression analyses were used to estimate prevalence and identify significant predictors of IPV.

Results

The mean age of the participants was 38.3 years (SD: ±12.8). The prevalence of IPV in women was 22.8% (95% Confidence Interval: 20.0–25.9), 18.5% in pregnant women (95% CI: 11.7–27.9) and significantly associated with depression in 55.1% of IPV cases. Husband education level (college/higher) (Adjusted Odds Ratio: 0.40; 95%CI: 0.22–0.70) and high household income (AOR: 0.44; 95% CI: 0.29–0.68) were protective against IPV. Increase in age (AOR;1.02; 95% CI: 1.01–1.02) and poor relationship with mother-in-law increased the risk of IPV (AOR = 2.85; 95% CI: 1.90–4.28). IPV was positively associated with symptoms of depression (AOR = 1.97; 95% CI:1.39–2.77), poor perceived quality of life (AOR = 3.54; 95% CI: 1.90–6.58) and poor health (AOR = 2.74; 95% CI: 1.92–3.92).

Conclusion

IPV is substantial public health burden significantly associated with depressive symptoms, poor perceived health and the quality of life.

A comic-based body image intervention for adolescents in semi-rural Indian schools: Study protocol for a randomized controlled trial

Adolescents in India experience body dissatisfaction, however, empirically supported interventions are lacking. This paper describes the protocol for the development, acceptability testing, and cluster randomized controlled trial (RCT) of a six-session comic-based intervention, which aims to improve body image and related outcomes among adolescents in semi-rural Indian schools. If found to be acceptable and effective, UNICEF will disseminate the intervention across schools in eight states of India. The acceptability study will be conducted with 24 students in Classes 6-8 (age 11-14) and nine teachers from Hindi-medium government schools using interviews and focus groups. The subsequent RCT will be conducted with 2400 students, with schools randomized to either the comic-based intervention or lessons-as-usual (control) groups. The primary outcome is body esteem, and secondary outcomes are disordered eating, appearance ideal internalization, body-image-related life disengagement, self-esteem, negative affect, and positive affect. Additional exploratory outcome measures are skin colour dissatisfaction, body hair dissatisfaction, appearance-based teasing, and endorsement of traditional gender roles. These outcomes will be examined at three timepoints: baseline (T1), 1 week-post-intervention (T2), and 12-weeks follow-up (T3). Analyses will compare outcomes in the intervention with the control group. This will be the first study to evaluate a body image intervention for adolescents in semi-rural Indian schools.

Experiences of living with type 2 diabetes in Pakistan: the role of culture and family in physical activity

Background

Diabetes-related guidelines recommend lifestyle changes for people living with type 2 diabetes (PLwD). In South Asian (SA) families, cultural and contextual expectations often influence people’s decisions. However, broad explanations provided in the existing literature and theories concerning family involvement can increase the chance of health professionals overlooking the complexities of family roles within SA communities. Previous literature has identified the need to examine the perspectives of PLwD and their family members in Pakistan to shed light on factors perceived to support and hinder recommended physical activity (PA) to manage type 2 diabetes. This study explored (1) the enablers of and barriers to PA in the context of PLwD in Pakistan and (2) family involvement regarding PLwD’s engagement with PA.

Methods

Semi-structured interviews were conducted with 30 PLwD and 17 family members of PLwD who were recruited in metropolitan Lahore (Pakistan) and primarily used state health services available to relatively disadvantaged populations. Interviews were transcribed and analysed using thematic analysis.

Results

Three themes were identified: (1) Going for a walk as a feasible PA; (2) the role of family members in influencing PA; and (3) gender differences and cultural acceptability of an activity. PA enablers for PLwD consist of gender-specific opportunities for activity facilitated by peers and family members. Culturally acceptable opportunities for PA in Pakistan for specific genders and age groups within the socio-cultural context constituted an essential factor. In this study, all women with diabetes described walking as the only acceptable form of PA, whereas some men mentioned other activities such as running, playing cricket, and cycling.

Conclusions

Medical guidelines must consider patients’ daily routines, account for cultural and familial expectations of different genders and age groups, and address social and physical barriers encountered by these different groups to encourage PA among PLwD in SA cultures.

Child Marriage, Reproductive Outcomes, and Service Utilization among Young Afghan Women: Findings from a Nationally Representative Survey in Afghanistan

This study explored the prevalence of child marriage and its association with reproductive outcomes and service utilization among young women in Afghanistan. We conducted a secondary analysis of data from the 2015 Afghanistan Demographic and Health Survey (DHS), focusing on women aged 20-24 years old based on the United Nations' recommendation on child marriage study. Multivariate logistic models examined the association between child marriage, reproductive outcomes, and service utilization. An estimated 52% of the Afghan women aged 20-24 married at ages less than 18 years. Poverty and illiteracy were associated with the higher likelihood of early marriage. There was a significant negative relationship between child marriage and history of rapid repeat childbirth, delivery by skilled personnel, and institutional delivery. In both adjusted and unadjusted models, women married at age ≤14 were more likely to experience terminated or unintended pregnancy, inadequate ANC, unmet need for family planning, and fistula; while, for those married at age 15-17 years, only terminated or unintended pregnancy remained significant. Strict international law enforcement and advocacy are needed in the current situation of Afghanistan to increase young women's education, promote their civil rights, and improve their autonomy and role in decision-making concerning their fertility preferences and reproductive health.

Social Dominance, Sexual Double Standards, and Violence Against Women in Tight and Loose Cultures

Sexual double standards are associated with adverse consequences for women, including violence. However, little research examines sexual double standards across cultures that vary in tight or loose sexuality norms. Therefore, using social dominance theory, this study examined sexual double standards and violence against women in the United States of America (U.S., a loose culture) and Pakistan (a tight culture). We hypothesized that social dominance orientation is associated with violence against women via endorsement of sexual double standards for both the U.S. and Pakistan. We recruited 315 people in total from the U.S. ( N = 169; women = 56.3%; Mage = 29 ± 5.6 years) and Pakistan ( N = 138; women = 73%; Mage = 26 ± 5.3 years). After establishing measurement invariance for our measures, we used structural equation modeling to analyze our theoretical model in two cultural settings. Multigroup path models found support for social dominance theory’s proposition that people higher on social dominance orientation justify violence against women through their endorsement of sexual double standards in both countries, above and beyond more general attitudes toward women (i.e., ambivalent sexism). We also found that the processes (i.e., social dominance and sexual double standards) supporting violence against women are similar in the two countries. A sexual double standard is found to be strong predictor of justification of violence even after controlling for gender, ambivalent sexism, and cultural tightness/looseness for both countries. Discussion focusses on a sexual double standard may be a risk factor for violence against women in different parts of the world.

Bereavement in Pakistan during the COVID-19 pandemic: Psychometric analysis of the Pandemic Grief Scale-Urdu Version (PGS-UV)

With nearly 4 million deaths worldwide, COVID-19 has resulted in a great loss of life. For many of the bereaved, the grieving process has been especially difficult due to COVID-19 spatial distancing procedures and the traumatic circumstances of this particular form of loss. Consequently, a large number of the world's bereaved are experiencing dysfunctional levels of grief. To assess such grief, the Pandemic Grief Scale (PGS) was created to identify those affected who may benefit from professional support. This study aimed to psychometrically analyze the properties of the Urdu version of the scale, among a sample of 272 Pakistanis who lost a loved one to COVID-19 from March to June 2021. Results revealed that the scale was found to be a reliable and valid tool for assessing dysfunctional pandemic grief for both men and women. However, unique gender differences were found. Additional research should further confirm the psychometric properties of the PGS on other culturally diverse samples.

Experiences of Mothers Who Relinquished Their Child for Adoption in Pakistan: A Qualitative Study

The literature suggests long-term consequences and lack of support for birthmothers following relinquishment of their child for adoption (Memarnia in Listening to the experience of birth mothers whose children have been taken into care or adopted, 2014). But there was not any work done to study in-depth experiences of birthmothers after giving away their child in Pakistan. So, the purpose of the present study was to explore the experiences of mothers who relinquished their child for adoption. As the present study was intended to explore lived experiences of a particular group, the phenomenological research design was used to conduct this qualitative study. An interview protocol was devised to explore the experiences of birthmothers. The sample was comprised of five birthmothers who relinquished their child for adoption and fulfilled the criteria. Semi-structured interviews were conducted with the birthmothers, and all the interviews were audio-recorded and transcribed before analysis. Interpretive Phenomenological Analysis (IPA) was used to interpret the transcripts of interviews. Further, data verification was done through peer scrutiny, by debriefing sessions with the supervisor, and enriches the description of the phenomenon. Four main themes were emerged: Reasons to Relinquish, Psychological Distress, Coping Strategies, and Disenfranchised Grief. The study present that the experience of relinquishment has a negative impact on birthmother and highlights the need for proper measures to regulate the process of adoption and involvement of psychologists during the process of adoption. Moreover, it stresses the need for acknowledgment of the experience and psychological services for birthmothers who relinquish their child.

Time for themselves: Perceptions of physical activity among first and second-generation Pakistani women living in the Raval, Barcelona

Objectives:

Pakistani women experience higher-than-average rates of certain chronic diseases, including diseases related to sedentary lifestyles. The aim of this study is to explore how first and second-generation Pakistani women living in the Raval, Barcelona, conceive of physical activity, and their barriers and facilitators around participating in physical activity, with the goal of increasing physical activity in this group.

Methods:

Qualitative research with an intersectional approach. Nine informal interviews with key community informants were conducted from November 2018 to January 2019 to gain background on the topic, using snowball sampling. Eleven individual interviews were conducted from February to June 2019. Seven were with Pakistani women having lived, or currently living, in the neighborhood of the Raval, Barcelona. Four additional interviews were conducted with non-Pakistani women key community informants who have worked extensively with this community. Thematic content analysis was carried out using ATLAS.ti.

Results:

First-generation Pakistani women generally did not have physical activity present in their daily lives, but by most accounts wished to. Areas that shed light on this included the following: limited economic opportunities and associated living conditions, barriers to social integration, health concepts and access to information, and cultural norms and related gender roles. For the first-generation, gender-related divisions of labor as well as the absence of the concept of self-care were particularly relevant barriers to their participation in physical activity. The experience of immigration-related grief emerged as a transversal theme which overlapped with multiple areas. While both generations expressed a need for the separation of genders during physical activity—as per their cultural interpretation of Islam—the lack of such spaces was highlighted as a principal barrier in physical activity among the second generation.

Conclusion:

These findings shed light on distinct elements that exert influence in Pakistani women immigrants’ participation in physical activity—among them: social and living conditions, access to public space, and gender-related work distribution and cultural norms—which are in turn influenced by first or second-generation immigration status. Considering the specific needs of both groups when proposing politics and health programs to encourage physical activity is paramount in order to successfully partner with these populations.

Community Attitudes Towards Violence Against Women, and Lived Experiences of Family Violence and Abuse During Childhood in Rural Eastern Nigeria: Implications for Policy and Programming

Background

Violence against women (VAW) has remained an increasingly significant public health problem globally. This study explored childhood experiences of abuse and attitude towards violence against women among adults in a rural community in South-east Nigeria.

Methods

This was a cross-sectional study conducted in a rural community in Ebonyi, Nigeria. Data were collected from 280 respondents using interviewer-administered questionnaires. Data analysis was performed using SPSS version 25.

Results

The mean age of the male participants was 46.5±16.8, while that for the female participants was 43.3±16.9. Most were females (203/280, 72.5%), out of which (83/203, 40.9%) had secondary school as the highest level of education attained. Most participants were females (203/280, 72.5%), married (225/280, 80.4%) with secondary school education (124/280, 44.3%). More than one-tenth (33/280, 11.8%) had ever witnessed parental violence, while 46.4% had been physically abused in childhood. Forced touching and penetrative sex was experienced sometimes by 11.4% (32/280) and 21.8% (61/289), respectively. Overall, the majority (258/280, 92.8%) had a disapproving attitude towards gender-based violence. Most participants disagreed that hitting or insulting woman was not wrong (246/280, 87.9%). The majority of the respondents agreed that women were inferior to men from a cultural perspective (175/280, 62.5%). Almost half strongly agreed (125/2280, 44.6%) and agreed (118/280, 42.1%) that a woman is a man’s possession. The predictors of attitude were secondary school education (AOR = 7.74, 95% CI = 1.69–35.54) and monogamous marital setting (AOR = 2.83, 95% CI = 1.08–7.42).

Conclusion

This study showed that Nigerian adults had high levels of childhood exposures to family violence, physical and sexual abuse. Overall, the majority disapproved of VAW; however, there were gaps that endorsed patriarchal ideologies. Interventions to address VAW should include components targeted at children exposed to violence and de-bunking patriarchal ideologies that encourage VAW.

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 (t₁) 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 (t₂) 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 t₁, more than half did so at t₂. Socio-demographic characteristics were not significantly associated with knowledge (gains). However, more frequent use of electronic media is associated with greater knowledge gains from t₁ to t₂. 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.

Spatial accessibility to health care services among children with cerebral palsy in Johor, Peninsular Malaysia

Cerebral palsy (CP) is one of the most common causes of disability in childhood, leading to functional limitations and poor nutritional status. Families with CP children face challenges in providing proper care. Thus, accessibility of CP patients to health facilities is important to ensure that they can maintain regular visits to health facilities for proper treatment and care. The current study aimed to map the spatial distribution of CP in Johor, Malaysia and measure the accessibility of CP patients to nearby hospitals, health clinics and community-based rehabilitation centres. The study is based on CP cases in 2017 obtained from the Department of Social Welfare, Malaysia and analysed using the average nearest neighbour, buffer analysis and Kernel Density Estimation. Results indicate that there is generally good access to health care services for many of the CP children in Johor, but for 25% of those living more than 10 km away from the health clinics or community-based rehabilitation centres, regular visits can be a problem. This information should be used for targeted intervention and planning for health care strategies. Furthermore, information on hospital accessibility of CP children would allow for planning of proper and regular treatment for these patients. The study has shown that it is possible to improve the understanding of the distribution of CP cases by integrating spatial analysis using geographical information systems without relying on official information about the density of populations.

Suicide by poisoning in Pakistan: review of regional trends, toxicity and management of commonly used agents in the past three decades

BACKGROUND

Suicide is one of the leading mental health crises and takes one life every 40 seconds. Four out of every five suicides occur in low- and middle-income countries. Despite religion being a protective factor against suicide, the estimated number of suicides is rapidly increasing in Pakistan.

AIMS

Our review focuses on the trends of suicide and means of self-poisoning in the past three decades, and the management of commonly used poisons.

METHOD

We searched two electronic databases (PubMed and PakMediNet) for published English-language studies describing agents used for suicide in different regions of Pakistan. A total of 46 out of 85 papers (N = 54 747 cases) met our inclusion criteria.

RESULTS

Suicidal behaviour was more common among individuals younger than 30 years. Females comprised 60% of those who attempted suicide in our study sample, although the ratio of completed suicides favoured males. There were regional trends in the choice of agent for overdose. Organophosphate poisoning was reported across the nation, with a predominance of cases from the agricultural belt of South Punjab and interior Sindh. Aluminium phosphide ('wheat pills') was a preferred agent in North Punjab, whereas paraphenylenediamine ('kala pathar') was implicated in deaths by suicide from South Punjab. Urban areas had other means for suicide, including household chemicals, benzodiazepines, kerosene oil and rat poison.

CONCLUSIONS

Urgent steps are needed, including psychoeducational campaigns on mental health and suicide, staff training, medical resources for prompt treatment of self-poisoning and updated governmental policy to regulate pesticide sales.

Gynaecological morbidities among married women and husband's behaviour: Evidence from a community-based study

AIM

To determine the association between gynaecological morbidities and IPV among married women specifically, with attention to the attitudes of the husband and the degree of satisfaction in a marital relationship.

DESIGN

Cross-sectional study design.

METHODS

Data were collected using face-to-face interviews with married women aged 15-49 years, living in selected communities. Information was collected on demographic characteristics, gynaecological morbidities and IPV using a self-developed tool. Descriptive and inferential statistics were used to analyse the data.

RESULTS

Logistic Regression showed a significant association between physical violence and burning micturition, increased urinary frequency, constant dribbling of urine, genital ulcers, lower abdominal pain, vaginal discharge and painful coitus (OR: 1.41-1.84). A significant association between sexual and psychological abuse was also found with burning micturition (OR: 1.41) and dribbling of urine (OR: 0.12). Since gynaecological morbidities can have a serious effect on the psychological, physical well-being, and the social status of women in Pakistan; effective interventions are imperative in dealing with their symptoms and decreasing their emergence.

The Role of Orgasmic Difficulty in Attributing Cause for Positive and Negative Sexual Outcomes in Women: The Importance of Cross-Cultural Analyses

Studies investigating women's attributions for positive and negative sexual experiences have been slow to adopt a cross-cultural perspective, resulting in a perspective defined by Western experiences. This cross-cultural analysis examined such attribution processes in 88 Pakistani and 187 USA women, and identified differences related to orgasmic difficulty and country-of-origin. Pakistani and USA women differed on both self-blame and relationship blame related to negative sexual outcomes, an effect intensified in Pakistani women who reported orgasmic difficulty during partnered sex. Differences are interpreted within a cultural context and underscore the importance of addressing women's sexual experiences in a more global context.

Cross-Cultural Analysis of Sexual Response and Relationship Satisfaction in Women With and Without Orgasmic Difficulty During Partnered Sex

Objective To investigate how orgasmic difficulty may impact women's sexual/relationship quality depending upon their cultural origin. Method: We used a cross-sectional, multinational survey designed to assess orgasmic difficulty during partnered sex and other sexual/relationship factors in 88 Pakistani and 188 U.S. women. Results: Pakistani women reported less orgasmic difficulty than U.S. women, but those Pakistani women having orgasmic difficulty reported lower relationship satisfaction, less interest in sex, and greater difficulty becoming sexually aroused compared to U.S. respondents with orgasmic difficulty. Conclusions: The presence of orgasmic difficulty affected sexual and relationship factors more in Pakistani women than U.S. women.

Emotion regulation difficulties and psychopathology among Pakistani adolescents

The main aim of this study was to examine the associations between emotion dysregulation and psychopathology in adolescence. A representative sample of 1,500 adolescent students (50% female) aged 12 to 19 years (M = 15.08, SD = 1.44) was recruited from schools and colleges located in the province of district Punjab, Pakistan, using a stratified sampling technique. Structural equation modeling (SEM) was used to test associations between five dimensions of emotion regulation difficulties and five forms of psychopathology by gender (male/female). The model provided an adequate fit to the data among girls and boys. In the model tested among boys, seven positive associations between emotion regulation difficulties and psychopathology variables were found. The model tested with girls included one negative and 13 positive associations between the study variables. Findings can be used for designing universal prevention programs to prevent the development of psychopathology.

Psychometric properties and validity of dyadic coping inventory-urdu version for use in Pakistan

For married individuals living in Pakistan, stress within their relationship has emerged as a major source of marital conflicts and even relationship dissolution. However, research based on the systemic transactional model of dyadic coping (DC) suggests partners’ use of coping strategies may help in buffering these devastating effects of stress. The original German version of the Dyadic Coping Inventory (DCI) is a widely used self-report measure that has been translated in various languages, however, has not been validated for use with individuals living in Pakistan who speak Urdu. The purpose of the present study was to translate and validate the DCI into Urdu for use with married individuals living in Pakistan. Data were collected from 538 Pakistani married adults. Findings supported the original factor structure of the German and English version of the DCI. As such, results supported the 33-items DCI-Urdu as a valid and reliable measure to assess DC behaviors in Pakistani married individuals. Further, convergent and discriminant validity and measurement invariance (MI) across gender for the DCI-Urdu were consistent with that of DCI-English. A validated measure of the DCI in Urdu provides new directions for researchers and clinicians working with couples in Pakistan.

An Ethno-phenomenological Study of Pregnant Women's Experiences regarding Household Roles

Background

Household labor has been indicated as a feminine role even in the present millennium, in which gender role orientations have been changed. As pregnancy is an important time for studying the division of household labor, this study aimed to discover the meaning of the pregnant women's experiences of household roles.

Methods

An ethno-phenomenological study, in which van Manen approach to phenomenology was its core and focused ethnographic approach was its supplementary component, was used to conduct this study. 25 pregnant women with maximum variation were recruited via the purposeful sampling during 2016-2017 in Mashhad, Iran. In-depth semi-structured interviews, vignette interviews as well as observations were used for data collection. Six-step van Manen's descriptive-interpretive phenomenological approach was used for concurrent data collection and analysis. MAXQDA, version 10, was used for data organization.

Results

Data analysis led to the emergence of an overarching theme entitled: "couples' preservation, keeping up and protection of the household roles". This was derived from two subthemes including the mother's efforts to play the household roles and spouse confrontation with the household chores.

Conclusion

The consequence of all endeavors of pregnant women along with their husbands develops the experience of preserving and maintaining the importance of household roles. As pregnancy is an important period for considering division of household responsibilities, it is necessary to design and implement gender sensitive programs to empower pregnant women and their families as well.

Mass Media Exposure and Women's Household Decision-Making Capacity in 30 Sub-Saharan African Countries: Analysis of Demographic and Health Surveys

Background

Women’s household decision-making capacity is an essential component of their empowerment which include decisions related to personal health care, large household purchase and family visitations. Despite research evidence acknowledging mass media’s influences on women’s empowerment, including their ability to take household decisions, empirical data through multi-country comparison on mass media exposure and women’s decision making capacity are sparse. This study sought to assess the association between exposure to mass media (television, radio and newspaper/magazine) and women’s household decision-making capacity in 30 countries in sub-Saharan Africa (SSA).

Materials and Methods

Data from current Demographic and Health Surveys (DHS) conducted in 30 countries in SSA from January 1, 2010 to December 31, 2016 were used. Binary Logistic Regression analysis was used to assess the association between mass media exposure and women’s household decision-making capacity in SSA. Results were presented using crude odds ratios (COR) and adjusted odds ratios (AOR).

Results

Women who watched television almost every day had higher capacity to take household decisions, compared to those who did not watch television at all. Women who read newspaper/magazine less than once a week were less likely to take household decisions compared to those who never read newspaper/magazine. However, there was no association between exposure to radio and household decision-making capacity. Regarding the covariates, age, level of education, wealth index, occupation, and parity showed significant associations with women’s household decision-making capacity.

Conclusion

Findings stressed the positive contribution of mass media in enhancing women’s household decision-making capacity in SSA. Viewing television, a model of mass media, is a very powerful conduit to enhance the household decision-making capacity of women. The use of mass media, especially television in communicating the relevance and ways of achieving household decision-making capacity for all women in SSA is paramount and perhaps, in other low and middle-income countries of the world. Interest groups that require greater attention are women with less exposure to television as well as women in their early reproductive age, the poor, women who are not working and rural residents.

Attribution patterns related to positive and negative sexual experiences in married Pakistani women with differing levels of orgasmic difficulty

Studies using Western samples have found that people with sexual problems attribute negative sexual experiences more to themselves whereas those without sexual problems attribute negative sexual experiences more to external factors such as the particular situation or even the partner. While attribution patterns vary across sex, age, dysfunction status, and generations, to date no studies have investigated how they might vary across cultures. We compared attribution patterns of (presumed) heterosexual/cisgender Pakistani women with varying levels of orgasmic difficulty (OD) on hypothetical scenarios presenting either positive or negative partnered sexual outcomes, with attributions to four possible targets: self, husband, situation, and relationship. Similar to previous research using Western samples, Pakistani women with greater OD were more likely than non-OD counterparts to blame themselves and their partners for negative sexual experiences. In contrast with prior research, for Pakistani women, attributions were distributed widely across all targets, including relationship factors (e.g., compatibility and communication). Specifically, Pakistani women tied their explanations for both positive and negative sexual outcomes more strongly to assessment of their relationship with their husband. The way in which women with sexual difficulties in non-Western cultures interpret their sexual experiences suggests the need for remediation strategies sensitive to socio-sexual scripts of the culture.

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

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

Understanding individual, family and community perspectives on delaying early birth among adolescent girls: findings from a formative evaluation in rural Bangladesh

BACKGROUND

Pregnancy among adolescent girls in Bangladesh is high, with 66% of women under the age of 18 reporting a first birth; this issue is particularly acute in the northern region of Bangladesh, an area that is especially impoverished and where girls are at heightened risk. Using formative research, CARE USA examined the underlying social, individual and structural factors influencing married girls' early first birth and participation in alternative opportunities (such as education or economic pursuits) in Bangladesh.

METHODS

In July of 2017, researchers conducted in-depth interviews of community members in two sub-districts of northern Bangladesh (Kurigram Sadar and Rajarhat). Participants (n = 127) included adolescent girls (both married and unmarredi), husbands of adolescent girls, influential adults in the girls' lives, community leaders, and health providers. All interviews were transcribed, coded and organized using Dedoose software.

RESULTS

Participants recognize the health benefits of delaying first birth, but stigma around infertility and contraceptive use, pressure from mothers-in-law and health provider bias interfere with a girl's ability to delay childbearing. Girls' social isolation, lack of mobility or autonomy, and inability to envision alternatives to early motherhood compound the issue; provider bias may also prevent access to methods. While participants agree that pursuit of education and economic opportunities are important, better futures for girls do not necessarily supersede their marital obligations of childrearing and domestic chores.

CONCLUSIONS

Findings indicate the need for a multi-level approach to delaying early birth and stimulating girls' participation in economic and educational pursuits. Interventions must mitigate barriers to reproductive health care; train adolescent girls on viable economic activities; and provide educational opportunities for girls. Effective programs should also address contextual issues by including immediate members of the girls' families, particularly the husband and mother-in-law.

Psychometric development and validation of attitude rating scale towards women empowerment: across male and female university population in Pakistan

Purpose

Attaining equality between women and men and eliminating all forms of discrimination are fundamental human rights and United Nations values. Nevertheless, women globally suffer violations of their human rights throughout their lives. This necessitates investigation of the attitude that people hold towards women empowerment, which is defined as their ability to practice their rights, freedom and attain resources within a framework of gender inequality. The purpose of this study is to develop an instrument to measure attitudes regarding women’s empowerment, which can develop better understanding and future interventions to counter these negative attitudes for better social and health care, including mental and physical health.

Design/methodology/approach

The factorial structure, reliability, content validity and impact of gender on factor structure of scale were examined among university students (N = 500) in study with male (n = 180) and female (n = 320) population.

Findings

Exploratory factor analysis using direct oblimin method based on principal component analysis indicated a three-factor, 16-item scale including subscales of personal freedom; equal rights and women empowerment-related fears. Instrument exhibited decent reliability (0.80) and content validity in both male and female university students with a t = −7.64, p = 0.00, suggesting a highly significant difference between the two genders on the developed scale.

Research limitations/implications

The major limitation was that the sample was obtained from student population; therefore, it will not be entirely correct to generalize it to the whole population of Pakistan. Similarly, there are issues regarding the availability of students because of a busy schedule or not having interest to take part in the study that led to variance in the sample. Lastly, the current scale is developed based on exploratory factor analysis (EFA) and it should be further enhanced using item response theory in future. Future studies need to include samples from different populations in Pakistan to bring out a more generalized view and try to minimize the variances in sample as much as possible for better results.

Practical implications

The scale is constructed using the basic features of women empowerment at its core and is applicable in various settings to measure the attitude towards women empowerment. It will be a helpful tool to be used in various health, employment and educational settings. Moreover, this instrument can be applied for research purpose of measuring attitude as a predictor in combination with other variables such as domestic violence and harassment.

Social implications

Empowering of women is one of the main agendas of 2019 of United Nations for Asian countries where women are not given equal rights, because of which suffer socially and economically from various problems along with issues regarding physical and mental health. By identifying the attitudes of general population, their causes for their attitudes can help in betterment of the women empowerment process.

Originality/value

This paper in discussion is an original work and has been performed with the purpose of assessing attitudes of males and females regarding women empowerment as the previous measures are either not psychometric valid or are in interview or survey form. The current developed scale is an attempt to develop an instrument that can be globally used.

Ethiopian Health Care Workers' Insights into and Responses to Intimate Partner Violence in Pregnancy-A Qualitative Study

Violence against women is a global pandemic, with the potential to spread through generations. Intimate partner violence has impacts on women’s sexual, reproductive, and psycho-social health. It can occur during pregnancy and adversely affect the health of both mother and child. Health care workers involved in antenatal care can have a unique role in identifying intimate partner violence and in intervening, preventing, and mitigating its consequences. In this study, the objective was to explore Ethiopian health care workers’ insights of and responses to intimate partner violence in pregnancy. Using an exploratory design, this qualitative study includes ten semi-structured interviews of health care workers representing different antenatal care centers in Jimma, Ethiopia. The content analyses of translated interview notes were conducted with Atlas.ti7 software, (Atlas.ti Scientific Software Development Gmbh, Berlin). The health care workers shared their insights of the consequences of intimate partner violence during pregnancy in addition to their experience with and responses to the victims. There was a limited understanding of the extent of the adverse impacts of intimate partner violence on pregnancy outcomes, as well as the potential long-term health implications. The informants described how they only gave medical treatment for obstetric complications or visible trauma during pregnancy. There was no formal referral to or linkages with other resources. Women’s empowerment and systemic changes in the health care, including training and capacity building, clear guidelines addressing management of intimate partner violence in pregnancy, and inclusion of intimate partner violence screening tools in the Ethiopian antenatal care chart/card, were recommended by the informants. The adverse impacts of intimate partner violence on pregnancy outcomes were poorly understood by the Ethiopian health care workers in this study. They offered limited assistance to the victims and recommended changes in the routine antenatal care (ANC) and health care systems. They identified various policy initiatives focusing on women’s empowerment to reduce intimate partner violence and its complications especially during pregnancy.

Potential for Long-Term Benefit of Cognitive Behavioral Therapy as an Adjunct Treatment for Men with Erectile Dysfunction

INTRODUCTION

Psychosexual counseling may enhance sexual performance outcomes in men with erectile dysfunction (ED) treated with a phosphodiesterase type 5 (PDE5) inhibitor.

AIM

To determine the potential long-term effects of cognitive behavioral therapy (CBT) on Pakistani men with ED who had undergone treatment with a PDE5 inhibitor (PDE5i).

METHODS

In a 15-18-month follow-up, we reassessed a subsample of 20 men who had been treated with either PDE5is (monotherapy group) or CBT + PDE5i (combined group) on 2 dimensions: sexual functioning and mental health functioning.

MAIN OUTCOME MEASURE

International Index of Erectile Function was used to assess sexual function, and 2 Mental Health Inventory subscales were used to assess anxiety and depression. A brief semi-structured interview assessed men's current sexual status and evaluation of their CBT experience.

RESULTS

Men in the combined group continued to show improvement on erectile function and several other sexual parameters, whereas men in the monotherapy group showed either no further improvement or a decrement in sexual response parameters. The results did not appear to be related to changes in relationship satisfaction or mental health indices.

CLINICAL IMPLICATIONS

Adjunctive CBT shows long-term benefits in men with ED treated with a PDE5i.

STRENGTH & LIMITATIONS

Effect sizes were strong, overcoming the small sample size, but attrition may affect the generalizability of the findings.

CONCLUSION

In the first long-term follow-up study of its kind, CBT proved an effective and supportive adjunctive treatment for Pakistani men with ED taking a PDE5i, with benefits extending long after the end of treatment. Khan S, Amjad A, Rowland D. Potential for Long-Term Benefit of Cognitive Behavioral Therapy as an Adjunct Treatment for Men with Erectile Dysfunction. J Sex Med 2019;16:300-306.

Psychosocial predictors of antenatal stress in Pakistan: perspectives from a developing country

Objective

Antenatal stress is highly prevalent globally and is associated with adverse physical and psychiatric morbidities and adverse neonatal outcomes. However, the burden of antenatal stress and its psychosocial predicators have not been explored in context of the Pakistani sociocultural environment. The present study explores the prevalence of antenatal stress and its association with gender of offspring, socioeconomic background, cultural beliefs, and access to healthcare in the province of Punjab, Pakistan.

Results

There was a total of 516 pregnant women. Antenatal stress was measured by the Perceived Stress Scale (PSS). The mean score of the respondents on the Perceived Stress Scale was 7.55 (3.43). A total of 218 (42.2%) respondents reported higher stress levels. Logistic regression analysis (backward method) yielded a significant model predicting high stress levels. According to it, low family income, unplanned pregnancy, increasing number of children, less autonomy in decision making, marital problems, harassment, desire to have a male offspring, and the history of birth complications, attended by midwives were associated with high stress levels.

Community Stakeholders' Perspectives on Intimate Partner Violence during Pregnancy-A Qualitative Study from Ethiopia

Intimate partner violence (IPV) in pregnancy adversely affects the health of women and unborn children. To prevent this, the community responses, societal systems, and structures to support victims of IPV in pregnancy are vital. Objectives: to explore community stakeholders’ perspectives related to IPV in pregnancy in Jimma, Ethiopia, and if needed, create the knowledge base for interventions. Methods: using an exploratory design, this qualitative study had a maximum-variation (multiple spectrum sources) sampling strategy with 16 semi-structured interviews of purposively selected key informants representing different community institutions. Guided by Connell’s theory of gender and power, a content analysis of the translated interviews was conducted using Atlas.ti 7 software. Results: reconciliation between IPV victims and their abusers was the solution promoted by almost all the respondents. There was limited awareness of the adverse impacts IPV in pregnancy has on the health of the woman and the foetus. Despite regular encounters with victims, there is no organized or structured operational response to support IPV victims between the participating institutions. Conclusion: the potential danger of IPV for the mother or the unborn child was not well understood by the members of the studied Ethiopian community. Neither coordinated efforts to support IPV victims nor links among relevant agencies existed. The study demonstrated the dire need of coordinated practical action, changes in current socio-cultural norms, formal training and capacity building, awareness creation, clear intervention guidelines, and facilitation of support networks among relevant institutions in Ethiopian communities.

Care and social support from family and community in patients with pulmonary tuberculosis in Pakistan

Objectives

This study aimed to validate the Medical Outcome Study-Social Support Survey (MOS-SSS) instrument in Pakistan and to quantify the nature of care and social support currently extended to patients with pulmonary tuberculosis (TB) in Pakistan.

Design

This is a cross-sectional study design conducted within a period of 3 months from 1 November 2016 to 31 January 2017.

Participants

A total of 269 patients, registered at 11 TB centres and private clinics, were interviewed through an interviewer-administered questionnaire.

Main outcome measures

Cronbach's alpha was used to measure the internal consistency and reliability of the MOS-SSS survey instrument. Univariate and multivariable logistic regressions have been used to explore the association between care and social support, and socioeconomic factors.

Result

This study validated the use of the MOS-SSS among patients with TB in Pakistan. Findings of the study revealed significant differences among the socioeconomic groups of patients in each subscale of social support. Additionally, results of logistic regressions showed that patients who were older (adjusted OR=6.17, 95% CI 1.55 to 24.59, p≤0.01), male (adjusted OR=2.73, 95% CI 1.49 to 4.98, p≤0.01), widow (adjusted OR=0.17, 95% CI 0.04 to 0.80, p≤0.05), and had a larger household size (adjusted OR=5.69, 95% CI 1.32 to 24.65, p≤0.05), higher monthly income (adjusted OR=2.00, 95% CI 1.11 to 3.60, p≤0.05) and house ownership (adjusted OR=1.99, 95% CI 1.10 to 3.60, p≤0.05) were significant factors associated with the extent of care and social support that the participants received.

Conclusion

To cure TB, this study suggests a coordinated approach that includes not only clinical services to address this issue but also a strong social support system based on family and community necessary throughout the treatment process.

Agreement between Fathers' and Mothers' Reported Stimulation and Associations with Observed Responsive Parenting in Pakistan

Parental stimulation and responsiveness are associated with improved early child development outcomes. However, the majority of studies have relied on maternal-reported measures of only mothers’ parenting practices. The purpose of this study was to assess the agreement between fathers’ and mothers’ reports of their own and their partner’s engagement in stimulation and assess the degree to which parents’ reported stimulation correlated with their observed responsive caregiving behaviors. Data were collected from 33 couples (33 fathers and 32 mothers) who had a child under 5 years of age in rural Pakistan. Paternal and maternal stimulation were measured based on reports of their own and their partner’s practices in play and learning activities with the child. Paternal and maternal responsiveness were observed in a subsample of 18 families. Moderate agreement was found between paternal and maternal reports of their own and their partner’s practices. Moderate associations were also found between self-reported measures of stimulation and observed responsive caregiving for both fathers and mothers. The strengths of agreement and associations were greater among couples who had higher quality coparenting relationships. Findings highlight the feasibility, reliability, and promise of assessing fathers’ parenting in a low-resource setting, using similar methods as for mothers’ parenting, to triangulate measures between reported and observed parenting and gain a deeper understanding of fathers’ and mothers’ unique caregiving contributions.

An assessment of awareness of mental health conditions and its association with socio-demographic characteristics: a cross-sectional study in a rural district in Bangladesh

Background

To assess the level of awareness, knowledge and help-seeking attitudes and behaviours in relation to mental health conditions (MHCs) and associations with socio-demographic characteristics of a rural district of Bangladesh.

Methods

We recruited 2425 adult samples (18–90 years) from a Cross-sectional study in Narial district of Bangladesh. Data on awareness, knowledge, help-seeking attitudes and practice in relation to six MHCs were collected. The MHCs were classified as common (depression, anxiety and drug addiction), and severe (psychosis, dementia and bipolar disorder). Associations of MHCs with socio-demographic characteristics were assessed using Chi-square tests. Rasch analysis was performed to transform the latent attribute (awareness) of MHCs from ordinal to interval scale. Multiple regression analysis was performed to determine how the socio-demographic characteristics contribute to the combined awareness score of MHCs.

Results

Of 2425 participants, 17 (0.7%) were cognizant of all the awareness construct of MHCs, and 1365 (56.28%) were not aware of any of MHCs. The prevalence of awareness of MHCs such as depression (8.5%), anxiety (6.2%), psychosis (3.5%), and bipolar disorder (3.3%), was found to be very low. Awareness was significantly lower in older adults, and in women. Higher levels of education (β 1.77, 95% confidence interval (CI): 1.58–1.97) associated with common MHCs and (β 0.81, 95% CI: 0.67–0.95) those associated with severe MHCs contributed significantly to increased awareness as opposed to having no or primary level of education. Availability of sufficient funds when applied to common MHCs (β 0.43, 95% CI: 0.26–0.61) and severe MHCs (β 0.25, 95% CI: 0.13–0.38) appeared to be more effective in boosting awareness compared to unstable financial situations. Almost 100% of the participants who were aware of the MHCs demonstrated positive attitudes towards seeking medical or psychological counselling.

Conclusions

Awareness of MHCs appeared to be very limited. However, knowledgeable participants were found to be very receptive to medical or psychological counselling. For improving awareness of MHCs need to conduct various intervention programs in particular those campaigns that focus on women, older adults, low SES and people up to the primary levels of education.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4385-6) contains supplementary material, which is available to authorized users.

Child abuse in Pakistan: A qualitative study of knowledge, attitudes and practice amongst health professionals

Child abuse is a global problem and pervades all cultures and socio-economic strata. The effects can be profound and life altering for victims. There is substantial literature from high income countries about signs of abuse, but a dearth of data from low and middle income countries like Pakistan. Healthcare professionals (HCP) are ideally placed to detect abuse, but, to inform interventions, an understanding of their experiences, training needs and cultural beliefs is needed. This study aimed to: (1) Explore the challenges that HCP face when managing cases of abuse; (2) Explore cultural beliefs and understand how these shape practice and (3) Identify training needs. A qualitative study using a phenomenological design was conducted. In-depth interviews were conducted with doctors, nurses and security staff in the emergency department of a large private hospital in Pakistan (n = 15). Interviews were undertaken in Urdu, translated into English and analysed using an inductive thematic approach. Multiple challenges were identified. The process of referral to legal services was poorly understood and further training and guidelines was suggested by participants. As the legal system in Pakistan does not allow HCP to keep potentially abused patients in their custody, they felt restricted in their ability to advocate and concerned about the safety of both the identified children and themselves. HCP have potential to detect abuse early; however, in Pakistan there are numerous challenges. HCP require support through training, as well as clear institutional frameworks and legal support to undertake this role.

"His mind will work better with both of us": a qualitative study on fathers' roles and coparenting of young children in rural Pakistan

Background

Parents are the primary providers of nurturing care for young children’s healthy early development. However, the literature on parenting in early childhood, especially in low- and middle-income countries, has primarily focused on mothers. In this study, we investigate how parents make meaning of fathers’ parenting roles with regards to their young children’s early health and development in rural Pakistan.

Methods

Data were collected between January and March 2017 through in-depth interviews with fathers (N = 33) and their partners (N = 32); as well as separate focus group discussions with fathers (N = 7) and mothers (N = 7). Data were analyzed using thematic content analysis.

Results

Parents described a distinct division of roles between fathers and mothers; and also several shared caregiving roles of fathers and mothers. Specifically, parents highlighted aspects of fathers’ coparenting and several common ways by which fathers supported their partners. We found that these gendered divisions in parenting roles were strongly embedded within a complex network of interacting factors across the individual, family, and sociocultural contexts of the study community.

Conclusions

Our findings suggest a more family-centered conceptualization of fatherhood during early childhood that encompasses both fathers’ direct engagement with their young children and their indirect contributions through coparenting, while recognizing a variety of contextual systems that shape paternal parenting. Future parenting interventions that reflect the lived experiences of both fathers and mothers as parents and partners may further enhance the nurturing care environments that are critical for promoting healthy early child development.

Short-Term Association between Black Carbon Exposure and Cardiovascular Diseases in Pakistan’s Largest Megacity

This study investigated the association between black carbon (BC) exposure and hospital admissions (HAs) and outpatient department/emergency room (OPD/ER) visits for cardiovascular diseases (CVD) among residents of Karachi, the largest city in Pakistan. We measured daily concentrations of BC in fine particulate matter (PM2.5) and collected records of HAs and OPD/ER visits for CVD from 2 major tertiary care hospitals serving Karachi for 6 weeks continuously during each quarter over 1 year (August 2008–August 2009). We subsequently analyzed daily counts of hospital and BC data over 0–3 lag days. Daily mean BC concentrations varied from 1 to 32 µg/m3. Results suggest that BC concentrations are associated with CVD HAs and OPD/ER visits. However, associations were generally only observed when modeled with BC from Tibet Center, the commercial-residential site, as compared to Korangi, the industrial-residential site. Overall, low statistical significance suggests that while BC may be a valuable indicator for CVD health risks from combustion-derived particles, further evaluation of the constituents of PM2.5 and their relative contributions to CVD health impacts is necessary.

Violence against women in different stages of the life cycle in Brazil: an exploratory study

Objective:

The aim of this study was to describe the profile of violence against women in different life cycles, according to the sociodemographic characteristics of the victims and offenders.

Methods:

A cross-sectional and exploratory study was performed based on 1,388 police reports during a four-year period, in a metropolitan area of Northeast Brazil. The dependent variable was the type of aggression suffered by the victims. The independent variables were sociodemographic characteristics of the victims and offenders. Statistical analysis included the χ2 test (p < 0.05) and the decision tree analysis, through the Chi-squared Automatic Interaction Detector (CHAID) algorithm.

Results:

Cases of physical abuse (n = 644) were the most common, followed by threat (n = 415) and verbal aggression (n = 285). The violence profiles could be explained by the relationship between victims and offenders (p < 0.001) and age of the victims (p = 0.026 in Node 1; p = 0.019 in Node 3).

Conclusion:

It was observed that women in different stages of life are more exposed to different types of violence.

Attitude towards gender roles and violence against women and girls (VAWG): baseline findings from an RCT of 1752 youths in Pakistan

BACKGROUND

Violence against women is driven by gender norms that normalize and justify gender inequality and violence. Gender norms are substantially shaped during adolescence. Programs offered through schools offer an opportunity to influence gender attitudes toward gender equity if we understand these to be partly shaped by peers and the school environment.

OBJECTIVE

We present an analysis of the baseline research conducted for a randomized controlled trial with 1752 grade 6 boys and girls and their attitudes toward gender roles, VAWG, and associated factors.

METHODS

We used baseline data from a  cluster randomised control study. Interviews were conducted in 40 public schools in Hyderabad, with 25-65 children per school. Questions were asked about attitudes toward gender roles, peer-to-peer perpetration, and victimization experiences, and family life, including father- or in-law-to- mother violence and food security. Multiple regression models were built of factors associated with gender attitudes for boys and girls.

RESULTS

Our result have shown youth attitudes endorsing patriarchal gender beliefs were higher for boys, compared to girls. The multiple regression model showed that for boys, patriarchal gender attitudes were positively associated with hunger, depression, being promised already in marriage, and being a victim and/or perpetrator of peer violence. For girls gender attitudes were associated with hunger, experiencing corporal punishment at home, and being a perpetrator (for some, and victim) of peer violence.

CONCLUSION

Youth patriarchal attitudes are closely related to their experience of violence at school and for girl's physical punishment, at home and for boys being promised in early marriage. We suggest that these variables are indicators of gender norms among peers and in the family. The significance of peer norms is that it provides the possibility that school-based interventions which work with school peers have the potential to positively impact youth patriarchal gender attitudes and foster attitudes of gender equality and respect, and potentially to decrease youth victimization and perpetration.

Meckel-Gruber Syndrome: An Update on Diagnosis, Clinical Management, and Research Advances

Meckel-Gruber syndrome (MKS) is a lethal autosomal recessive congenital anomaly syndrome caused by mutations in genes encoding proteins that are structural or functional components of the primary cilium. Conditions that are caused by mutations in ciliary genes are collectively termed the ciliopathies, and MKS represents the most severe condition in this group of disorders. The primary cilium is a microtubule-based organelle, projecting from the apical surface of vertebrate cells. It acts as an "antenna" that receives and transduces chemosensory and mechanosensory signals, but also regulates diverse signaling pathways, such as Wnt and Shh, that have important roles during embryonic development. Most MKS proteins localize to a distinct ciliary compartment called the transition zone (TZ) that regulates the trafficking of cargo proteins or lipids. In this review, we provide an up-to-date summary of MKS clinical features, molecular genetics, and clinical diagnosis. MKS has a highly variable phenotype, extreme genetic heterogeneity, and displays allelism with other related ciliopathies such as Joubert syndrome, presenting significant challenges to diagnosis. Recent advances in genetic technology, with the widespread use of multi-gene panels for molecular testing, have significantly improved diagnosis, genetic counseling, and the clinical management of MKS families. These include the description of some limited genotype-phenotype correlations. We discuss recent insights into the molecular basis of disease in MKS, since the functions of some of the relevant ciliary proteins have now been determined. A common molecular etiology appears to be disruption of ciliary TZ structure and function, affecting essential developmental signaling and the regulation of secondary messengers.

Quality of life after stroke in Pakistan

Background

There is very little information about the quality of life (QOL) of stroke survivors in LMIC countries with underdeveloped non communicable health infrastructures, who bear two thirds of the global stroke burden.

Methodology

We used a sequential mix methods approach. First, a quantitative analytical cross-sectional study was conducted on 700 participants, who constituted 350 stroke survivor and their caregiver dyads. QOL of stroke survivor was assessed via Stroke Specific Quality of Life Scale (SSQOLS) whereas QOL of caregivers was assessed through RAND-36. In addition; we assessed complications, psychosocial and functional disability of stroke survivors. Following this quantitative survey, caregivers were qualitatively interviewed to uncover contextually relevant themes that would evade quantitative surveys. Multiple linear regression technique was applied to report adjusted β-coefficients with 95% C.I.

Results

The QOL study was conducted from January 2014 till June 2014, in two large private and public centers. At each center, 175 dyads were interviewed to ensure representativeness. Median age of stroke survivors was 59(17) years, 68% were male, 60% reported depression and 70% suffered post-stroke complications. The mean SSQOLS score was 164.18 ± 32.30. In the final model severe functional disability [adjβ -33.77(-52.44, -15.22)], depression [adjβ-23.74(-30.61,-16.82)], hospital admissions [adjβ-5.51(-9.23,-1.92)] and severe neurologic pain [adjβ -12.41(-20.10,-4.77)] negatively impacted QOL of stroke survivors (P < 0.01).

For caregivers, mean age was 39.18 ± 13.44 years, 51% were female and 34% reported high stress levels. Complementary qualitative study revealed that primary caregivers were depressed, frustrated, isolated and also disappointed by health services.

Conclusion

The QOL of Stroke survivors as reported by SSQOLS score was better than compared to those reported from other LMIC settings. However, Qualitative triangulation revealed that younger caregivers felt isolated, depressed, overwhelmed and were providing care at great personal cost. There is a need to develop cost effective holistic home support interventions to improve lives of the survivor dyad as a unit.

Trial registration

NCT02351778 (Registered as Observational Study).

Electronic supplementary material

The online version of this article (doi:10.1186/s12883-016-0774-1) contains supplementary material, which is available to authorized users.

Culturally Relevant Protective and Risk Factors of Youth Risk Behaviors Among Pakistani and Indian Students in Hong Kong: A Focus Group Study

PURPOSE

The risk behaviors of Hong Kong ethnic minority students are understudied. This exploratory qualitative study aimed to explore culturally nuanced factors for the development and prevention of risk behaviors among Pakistani and Indian students in Hong Kong.

METHOD

Twenty-three students participated in four focus groups. All interviews were transcribed verbatim and analyzed using thematic analysis.

RESULTS

The participants reported bullying, delinquency, gambling, alcohol, cigarette, and drug uses as risk behaviors. Four themes emerged in the development and prevention of risk behaviors: (a) Parental and peer influence, (b) An unsafe community environment were perceived by the participants as essential factors for the development of risk behaviors, (c) Parental monitoring, and (d) Strong religious beliefs were believed as protective factors for the prevention of risk behaviors.

CONCLUSION

Further research and practice may investigate and focus on the factors embedded in the Hong Kong ethnic minorities' sociocultural contexts to prevent risk behaviors.

The dilemma of arranged marriages in people with epilepsy. An expert group appraisal

INTRODUCTION

Matrimony remains a challenging psychosocial problem confronting people with epilepsy (PWE). People with epilepsy are less likely to marry; however, their marital prospects are most seriously compromised in arranged marriages.

AIMS

The aim of this study was to document marital prospects and outcomes in PWE going through arranged marriage and to propose optimal practices for counseling PWE contemplating arranged marriage.

METHODS

A MEDLINE search and literature review were conducted, followed by a cross-disciplinary meeting of experts to generate consensus.

RESULTS

People with epilepsy experience high levels of felt and enacted stigma in arranged marriages, but the repercussions are heavily biased against women. Hiding epilepsy is common during marital negotiations but may be associated with poor medication adherence, reduced physician visits, and poor marital outcome. Although divorce rates are generally insubstantial in PWE, divorce rates appear to be higher in PWE undergoing arranged marriages. In these marriages, hiding epilepsy during marital negotiations is a risk factor for divorce.

CONCLUSIONS

In communities in which arranged marriages are common, physicians caring for PWE are best-equipped to counsel them about their marital prospects. Marital plans and aspirations should be discussed with the family of the person with epilepsy in a timely and proactive manner. The benefits of disclosing epilepsy during marital negotiations should be underscored.

Facilitators and barriers to NCD prevention in Pakistanis-invincibility or inevitability: a qualitative research study

BACKGROUND

Non-communicable diseases (NCD) are the leading causes of death globally. In Pakistan, they are among the top ten causes of mortality, especially in the productive age group (30-69 years). Evidence suggests that health perceptions and beliefs strongly influence the health behavior of an individual. We performed focus group interviews to delineate the same so as to design the user interface of a non-invasive stroke risk monitoring device.

METHODS

It was a qualitative study, designed to explore how health perceptions and beliefs influence behavior for NCD prevention. Four focus group discussions (FGD) were conducted with 30 stable participants who had diabetes mellitus, ischemic heart disease, blood pressure, and stroke. The data was collected using a semi-structured interview guide designed to explore participants' perceptions of their illnesses, self-management behaviors and factors affecting them. The interviews were transcribed and content analysis was done using steps of content analysis by Morse and Niehaus [10].

RESULTS

Medication adherence, self-monitoring of blood sugars and blood pressures, and medical help seeking were the commonly performed self-management behaviors by the participants. Personal experience of illness, familial inheritance of disease, education and fear of premature death when life responsibilities were unfulfilled, emerged as strong facilitators of self-management behaviors. A sense of personal invincibility, Fatalism or inevitability, lack of personal threat realization, limited knowledge, inadequate health education, health care and financial constraints appeared as key barriers to the self-management of chronic disease in participants.

CONCLUSIONS

Behavioural interventional messaging will have to engender a sense of personal vulnerability and yet empower self-efficacy solutions at the individual level to deal with both invincibility and inevitability barriers to adoption of healthy behavior.