Recognized by Pakistan Medical and Dental Council (PMDC)

Vol. 7, No. 1March 2017

Recognized by Pakistan Medical and Dental Council (PMDC)Registered at Index Copernicus ICI Journals Master list

Vol. 7, No. 1March 2017

Recognized by Pakistan Medical and Dental Council (PMDC)Registered at Index Copernicus ICI Journals Master list

Health Services Academy

2016

www.pjph.hsa.edu.pk

developing human resource for public health and contribute

Pakistan Journal of Public Health, 2017 (March)

Vol 7, No.1 (March) 2017

01

11

19

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49

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38

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Assessment of knowledge, attitude and practices regarding Vitamin D among students of saidu medical college, SwatFazal e Haq, Rukhsana Khan, Zille Huma Mustehsan......................................................................

Role of socio-demographic and cultural factors in knowledge, attitude and practice of users about family planning methods and services, rendering from rural primary health care centre of BangladeshMuhammad Shamsal Islam, Kourosh Holakouie Naieni, Hassan Eftekhar Ardebili, Abbas Rahimi Foroushani and Amjad Mirani........................................................................................

Challenges and opportunities to access health care in urban slums of lagos-state in Nigeria

Bolaji Samson Aregbeshola, Olanrewaju Olusola Onigbogi and Samina Mohsin Khan.......................

Spectrum of Hepatitis C virus (HCV) genotypes among diagnosed cases of HCV in Rawalpindi and Islamabad region over the period of six yearsHamna Javed, Tehreem Arif, Saba Arshad, Saadia Khan Baloch, Bushra Anwar, Muhammad Aleem Khan and Muhammad Faheem Shahzad...........................................................................................

Awareness of problems due to menstruation in school going girls-hyderabad Sindh Shama Nawaz Rozina Khalidand Nandlal Serani...............................................................................

Challenges of hospital preparedness in disasters in BalochistanSaleem ullah, Noureen Latif, Ali Nasre Alam, Tabinda Zaman.......................................................... Physical violence and its associated factors among married women in Multan, Southern Punjab, PakistanShafquat Inayat, Shahina Pirani, Tazeen Saeed Ali, Uzma Rahim Khan and Josefin Särnholm ...........

Assessment of skilled birth attendants regarding helping babies breath intervention to improve newborn care in rural district of SindhSheh Mureed, Muhammad Hassan Gandro and Walid Hassan...........................................................

Stunting among children of 18 to 36 months of age in Bhawalghar village, district Lodhran: a cross-sectional studyHaider Ali Younas, Siham Sikander, Mudassar Mushtaq Jawad Abbasi...............................................

Self-medication practices and perceptions among undergraduate medical students of Multan Medical & Dental College, MultanAsif Noor, Ejaz Hussain Sahu, Muhammad Umer Abdullah and Aftab Yousaf ....................................

Nutritional status among primary school going children living in urban area of Sindh PakistanMuhammad Faisal Qureshi, Aneeta Rathore, Nandlal Seerani, Sumera Qureshi, Dr. Bisharat Faisal and Ramesh Kumar...............................................................................................................

7th annual public health conference 2016 at health services academy: experiences in the field of public health and way forwardNeelam A Khan, Saima Hamid, Katrina Ronis.....................................................................................

Original Articles

59

63

Report

Dr. Saima Hamid,

Managing Editors

Pakistan Journal of Public Health

Associate Professor, Health Services Academy, Islamabad

Dr Babar Tasneem Shaikh

Dr Ejaz Ahmad Khan, Associate Professor, Health Services Academy, Islamabad

Dr Shahzad Ali Khan, Associate Professor, Health Services Academy, Islamabad

Organization Representative, Iran

Dr Zafar Ullah Mirza, Director, Division of Health System Development, WHO, EMRO, CAIRO




Managing Editors


ASSESSMENT OF KNOWLEDGE, ATTITUDE AND PRACTICES REGARDING VITAMIN D AMONG STUDENTS OF SAIDU MEDICAL COLLEGE, SWAT

1 2MSPH fellow, Health Services Academy, Islamabad, Associate Professor, Department of Community Medicine Fazaia Medical College, IslamabadCorrespondence: Fazale Haq. Email: [email protected]

1 2 2Fazal e Haq , Rukhsana Khan , Zille Huma Mustehsan

Original Article

Abstract

Background: Vitamin D is also known as the “Vitamin of Sun”. More than one billion people are suffering from Vitamin D deficiency globally; it is an epidemic and a very serious global public health problem. In South Asia, Vitamin D deficiency is quite prevalent. Many recent studies have shown that vitamin D helps in preventing cancer, cardiovascular diseases and diabetes.Objectives: To assess the knowledge, attitude, dietary and sunshine practices regarding Vitamin D among students of Saidu Medical College, Swat.Methods: A cross sectional study was carried out among 106 students of Saidu Medical College, Swat. Self- administered questionnaire was distributed to all students and data was analyzed on SPSS 20.Results: Majority of the students 72% had good knowledge of Vitamin D and its synthesis in the body. 91% of the students were aware of the source of Vitamin D and 87.5% knew about sources of vitamin D. However, the attitude of students towards sunlight exposure was poor as 65.2% students disliked being in the sun, 62.5% thought that sunlight exposure was harmful for skin, and 65.4% of the students thought that their Vitamin D levels were sufficient without getting their laboratory tests done.59.6% students used sunscreen in summer. Conclusion: The student's knowledge about Vitamin D was good but their attitude towards sun exposure and dietary practices did not match their knowledge. Medical students, being the future physicians and health care providers, must possess current knowledge about Vitamin D and should also look after their own health and dietary practices. Keywords: Vitamin D, knowledge, attitude, practices, sunlight, exposure

IntroductionVitamin D is essential and beneficial for strong, healthy bones and for overall health. It also improves the immune system to fight against infections. It helps in the absorption of calcium and phosphorous from the digestive system and helps in mineralization of bones. The importance of Vitamin D has been proved by researchers and some of the functions of Vitamin D are as follows: 1. Anti- cancer effect 2. Improves the immune system to fight against

infection 3. Improves the circulation and cardiovascular

health 4. Important for the keeping lungs and airways

healthy 5. Beneficial role in brain development 6. Improves muscle functionsThe studies indicate that the patients suffering from autoimmune diseases have low levels of Vitamin D which increases the chance of developing autoimmune diseases. Clothing can hinder Vitamin D synthesis from sun but only in those persons who cover themselves from

head to toe. In a study carried out by Diehl and Chiu, it was found that sun exposure causes cancer and use sunscreen is essential for protection .Around one billion people are suffering from Vitamin D deficiency globally and Pakistan is suffering from double burden of disease in the form of communicable and non- communicable diseases. Although many studies have shown the importance of Vitamin D, there is lack of positive attitude towards sunshine exposure and healthy dietary practices. The deficiency of Vitamin D is present all over the world but is much more prevalent in the sunny South Asia. .The knowledge gap in health professionals and the people is the hurdle in the vitamin D deficiency prevention . The aim of the study was to assess the knowledge, attitude and practices of future physicians as it would help in deciding if there would be a need to run an awareness program about sunshine exposure and dietary practices of Vitamin D.

Methodology This descriptive cross sectional study was conducted in district Swat from April to June 2016. The medical students of Saidu Medical College were taken as

01

Vitamin-D Among Student of Saidu Medical College, Swat

Pakistan Journal of Public Health Vol. 7, No. 1 March 2017

Fazale Haq, Rukhsana Khan, ZilleHuma Mustehsan

target population. Sample size was estimated on the basis of the expected 50% prevalence of knowledge Vitamin D (P) and 10% margin of error by using the formula: N =P(1-P) /,Z=1.96,P=50%,e=0.1as 10% margin of error. Sample size = 96, 10% of inflation so final sample size is 106. The sample size was calculated and 106 students were selected by simpler random sampling technique. The students studying in Saidu medical college willing to participate, the students of forth and final year were included and those who were absent or not given consent were excluded. The list of the students of forth year and final year was obtained and they were randomly selected. In the selected students who were not present than I selected next student to that person. Selected students were contacted in their free time or in break, the questionnaires were given to the students and were requested to fill it. The selected students were then contacted in their free time and pre-structured questionnaires were given to them to fill. The response rate was good but two students were excluded as they did not complete their questionnaire so results of 104 students are discussed here. The questionnaire was adopted from an Indian study done by Arora H, Dixit V, Srivastava N with the Title “Evaluation of Knowledge, Practices of Vitamin D and attitude towards Sunlight among Indian Students”. The first structured questionnaire was to assess knowledge, attitude and sunshine practices and comprised of 4 sections. Section A was about socio-demographic profiles of the student. Section B was to evaluate the knowledge regarding Vitamin D, which contained 7 questions. For example, “Have you heard about Vitamin D?”, “What is the main source of Vitamin D”? , “What is the average time needed to be in sunlight to have enough Vitamin D levels”?etc. The first question in section B was for the purpose of screening. Those who had heard about Vitamin D were required to complete the rest of the questionnaire.Section C and D were about attitude and practice towards sunlight exposure and dietary products which contain vitamin D. Section C consisted of questions on participants' fear, such as being tanned (color change into brown) by sunlight exposure and the possibility of developing skin cancer, and concerns about their Vitamin D levels. In this section, participants were also asked about the use of sun protection items such as sunscreen cream/lotions, umbrella, and involvement in any outdoor physical activity.To assess the dietary intake, the food frequency questionnaire was used and only those foods were selected which contain Vitamin D naturally. These food items were selected from the list of USDA National Nutrient Database for Standard Reference Release 28. The amount of Vitamin D was in

International units (IU). The USDA National Nutrition Database was used instead of Food composition table of Pakistan 2001 because it does not have the Vitamin D containing food list and quantity.The questionnaires were administrated under direct supervision of researcher so that discussion among students regarding questions and use of any kind of prompts such as the mobile internet can be avoided. It was pretested in Federal Medical and Dental College. The collected data was entered and analyzed in SPSS version 20.The ethical approval was obtained from internal review board of Health Services Academy, Islamabad. Written informed consent was obtained from the participant before filling the questionnaire.ResultsMost of the students were male that is 68(65.4%) and 36(34.6%) were female. In the target population 66(63.5%) respondents were 20-24 years old and 38(36.5%) were of 25-29 years old. The majority of the respondents, 73(70.2%), were living in the rural areas and only 31 (29.8%) were living in the urban areas. The fourth year MBBS students were 53(51%) and 51(49%) were final year MBBS students. Most of the respondent's family income was more than 50,000, 90(86.5%) and those who had a family income of up to 40,000-50,000 were 13(12.5%) and only 1(1.0%) of the respondent's family income was 30,000-40,000 per month.

Table 1: Knowledge Regarding Vitamin D

Knowledge scoring; there were seven questions about knowledge and the total score was seven. The minimum score of knowledge was four and the maximum possible score was 7 with the mean 5.88 and standard deviation was 0.71.Knowledge grouping; It was found by the researcher that 75(72.1%) of the respondents had good knowledge regarding Vitamin D and 29(27.9%) had poor knowledge about Vitamin D. Overall, majority had good knowledge about Vitamin D. Attitude regarding Vitamin D

02 Pakistan Journal of Public Health Vol. 7, No. 1 March 2017

Questions Frequency

(N=104)

Percentage

Have you heard about vitamin D?

Is Vitamin D synthesized in the body?

Which

is the main source of Vitamin D?

Is Vitamin D good

for bone health?

What is the minimum daily intake of

Vitamin D for an adult?

Which time of the day is good to be in

sunlight?

How much time a person should spend

outdoor to have enough Vitamin D in

summer?

104

104

91

102

97

57

57

100%

100%

87.5%

98.1%

93.3%

54.8%

54.8%

Vitamin-D Among Student of Saidu Medical College, SwatFazale Haq, Rukhsana Khan, ZilleHuma Mustehsan

Percentages of the respondents by attitude towards Vitamin D;, the majority respondents 92(88.5%) liked to go in sun for some time and 12(11.5%) liked to go in sun often. A total of 65(62.5%) of the students disagreed, 31(29.8%) agreed and 8(7.7%) strongly agreed that the exposure to sunlight is harmful for the skin. Among the respondents, 85(81.7%) answered never, 18(17.3%) sometime and 1(1.0%) often used parasol (Sunshade or Umbrella) to shade from the Sun. 46(44.2%) disagreed, 36(34.6%) agreed and 22(21.2%) strongly agreed that the sunscreens are the most effective way of controlling skin tanning. Among them 68(65.4%) responded that their Vitamin D status is Sufficient and 36(34.6%) answered Neutral that their Vitamin D status may be sufficient/deficient. Among participants, 90(86.5%) strongly agreed and 14(13.5 %) agreed that if a medical condition demanded for the test of Vitamin D they will go for it. Ninety nine (95.2%) of respondents strongly agreed and 5(4.8%) agreed that taking Vitamin D supplements reduces the risk of Vitamin D deficiency. Among them 85(81.7%) strongly agreed, 16(15.4%) agreed and 3(2.9%) disagreed that taking Calcium (Ca) supplement helps in maintaining Vitamin D levels in the body.Practices regarding Vitamin D In the survey questionnaire, there were some questions regarding vitamin D Practice. It has been shown that 62(59.6%) of the respondents used sunscreens in the summer season, only 3(2.9%) used it in winters and 39(37.5%) did not use sunscreens. When they were asked that how often they used sunscreens, 39(37.5%) had never used sunscreen, 23(22.1%) used sunscreen only they were playing in the sun, 21(20.2%) used sunscreen only once a day, 18(17.3%) did not use sunscreens regularly and 3(2.9%) of the respondents replied that they used sunscreens twice a day.. 25(24%) of the respondents said that it would be better to check sun protection fac to r (SPF) l eve l when pu rchas ing and 39(37.5%)replied that it is not better to check sun protection factor (SPF) while purchasing and 40(38.5%)of the respondents answered back that they were not using sunscreens. 17(16.3%) of respondents said that they were taking multivitamin supplements and 87(83.7%) were not taking any multivitamin supplements. Only 6.7% of respondents exposed their face, while 82.7% exposed both their face and arms and 10.6% exposed their face, arms and half legs during outdoor activities. Vitamin D Specific food Practices Score The Vitamin D specific foods practice was scored by calculating the population mean. The respondents were asked about the frequency of intake of three Vitamin D containing foods, for example, fish, egg and beef liver. The population mean of Vitamin D specific food practices was 25.9. The maximum was 82 and minimum was .00 with the standard deviation of 16.2.

Table : Vitamin D specific food Practice Grouping

= Max = 2, Min =1, Mean =1.34, S.D =.47

DiscussionThis was a cross-sectional study conducted in Saidu Medical College, Saidu Sharif; district Swat, Khyber Pakhtunkhwa, Pakistan. Saidu Sharif is near the main city of Mingora. The students of fourth and final year MBBS of Saidu Medical College were included in the study to assess the knowledge, attitude and practices and dietary practices regarding Vitamin D. Being the future medical practit ioners, they would be diagnosing and treating the people, so assessment of their knowledge, attitude and practices would help us decides if there would be a need to run an awareness program about sunshine and dietary practices of vitamin D. In this study, majority of the respondents were male as compared to females. Different findings were found in a study conducted by Arora and Dixit, where the majority of participants were females . The observed difference could have been due to different area and different culture. In KPK, males are preferred over females to get education so this might have been the reason of higher ratio of male to female. In this study and the one conducted in India by Arora and Dixit, the majority of the respondents were between the ages of 20-24 years. . The similarity was observed due to the fact that all the participants were students in both studies. There was a balanced distribution in the educational level as all of the participants were medical students and belonged to middle income families with more than Rs: 50,000 monthly family incomes. Similar findings were reported in the study conducted by Arora and Dixit in India . This similarity in both studies was due to similar economic conditions and similar education system of the countries, where poor cannot afford the fees of higher educational institutions. In this study, all students had knowledge about Vitamin D and about its synthesis in the body; similar results were reported in other studies . In all the studies, the study population was medical students so it could have been the reason for their good level of knowledge about Vitamin D. In some other studies the students had limited knowledge'– and this difference might have been due to different institute, location and

Dietary Practices Frequency Percentage)

N (%)

Good Vitamin D Specific food Practice

Poor Vitamin D Specific food

Practices

36 (35)

68 (65)

Total 104 (100)

03Pakistan Journal of Public Health Vol. 7, No. 1 March 2017


difference in educational system.The majority of the students knew that sunlight is the main source of Vitamin D, the peak UVB time of the day and time needed to be in sunlight for Vitamin D. Despite being aware, they disliked to be in sunlight. These study findings are comparable with other studies . The reason behind disliking to be in sunlight (sun exposure) could have been tanning of skin color. The majority of students were aware that Vitamin D is good for bones health and the same result were presented in the study conducted in India by Arora and Dixit and it may be because of literate participant selection. Most of the students were aware about the minimum daily intake of Vitamin D, that is 600 IU, but did not consume Vitamin D rich foods and did not use Vitamin D supplements to have sufficient levels of Vitamin D . The reason of not consuming Vitamin D rich foods was the limited dietary sources.Conclusion The findings of present survey suggests that high percentage of students had good knowledge about sources of Vitamin D . Our findings were different in terms of knowledge about time needed to be in sun and the daily intake of Vitamin D and it might have been due to study setting. The study participants did not have positive attitude regarding sunlight exposure. The majority of the students did not like to be in sun and while going in sun they used sunshades such as scarf, umbrella etc . In this study, the consistency among knowledge and attitude of students was observed but the majority of the students were using sunscreens only during the summer season ,the tanning of skin was found to be the reason for less exposure in the sun.

References1. Atkins GJ, Findlay DM, Anderson PH, Morris HA,

Feldman D, Pike J, et al. Target genes: bone proteins2011. 411-24 p.

2. Dissanayake A. Promoting healthy eating in children. InnovAiT: The RCGP Journal for Associates in Training. 2010;3(10):588-97.

3. Holmes VA, Barnes MS, Alexander HD, McFaul P, Wallace JM. Vitamin D deficiency and insufficiency in pregnant women: a longitudinal s t u d y. B r i t i s h J o u r n a l o f N u t r i t i o n . 2009;102(06):876-81.

4. Autier P, Gandini S. Vitamin D supplementation and total mortal i ty: a meta-analysis of randomized controlled trials. Archives of internal medicine. 2007;167(16):1730-7.

5. Maxmen A. The vitamin D-lemma. Nature. 2011;475(7354):23-5.

6. Matsuoka LY, Wortsman J, Dannenberg MJ, Hollis BW, Lu Z, Holick MF. Clothing prevents u l t r a v i o l e t - B r a d i a t i o n - d e p e n d e n t photosynthesis of vitamin D3. The Journal of

C l in ica l Endocr ino logy & Metabo l ism. 1992;75(4):1099-103.

7. Diehl JW, Chiu MW. Effects of ambient sunlight and photoprotection on vitamin D status. Dermatologic therapy. 2010;23(1):48-60.

8. Masood SH, Iqbal MP. Prevalence of vitamin D deficiency in South Asia. angiogenesis. 2008;1(11):12.

9. Christie FT, Mason L. Knowledge, attitude and practice regarding vitamin D deficiency among female students in Saudi Arabia: a qualitative exploration. International journal of rheumatic diseases. 2011;14(3):e22-e9.

10. Mangin M, Sinha R, Fincher K. Inflammation and vitamin D: the infection connection. Inflammation Research. 2014;63(10):803-19.

11. Arora H, Dixit V, Srivastava N. EVALUATION OF KNOWLEDGE, PRACTICES OF VITAMIN D AND ATTITUDE TOWARDS SUNLIGHT AMONG INDIAN STUDENTS. Asian Journal of Pharmaceutical and Clinical Research. 2016;9(1):308-13.

12. Pelletier DL, Frongillo Jr EA, Schroeder DG, Habicht J-P. The effects of malnutrition on child mortality in developing countries. Bulletin of the World Health Organization. 1995;73(4):443.

13. Audrey Sharmaine A/P Rajaretnam MAA, Hasanain Faisal Ghazi , Tiba Nezar Hasan,, Fuad MDF. Knowledge Regarding Vitamin D Among Private University Students in Malaysia. Annals of Nutritional Disorders & Therapy. 2014;1(2).

14. Zhou M, Zhuang W, Yuan Y, Li Z, Cai Y. Investigation on vitamin D knowledge, attitude and practice of university students in Nanjing, China. Public health nutrition. 2016;19(01):78-82.

15. Boland S, Irwin JD, Johnson AM. A Survey of University Students' Vitamin D–Related Knowledge. Journal of nutrition education and behavior. 2015;47(1):99-103.

16. Qureshi AZ, Zia Z, Gitay MN, Khan MU, Khan MS. Attitude of future healthcare provider towards vitamin D significance in relation to sunlight exposure. Saudi Pharmaceutical Journal. 2015;23(5):523-7.

17. Laleye LC, Kerkadi AH, Wasesa AA, Rao MV, Aboubacar A. Assessment of vitamin D and vitamin A intake by female students at the United Arab Emirates University based on self-reported dietary and selected fortified food consumption. International journal of food sciences and nutrition. 2011;62(4):370-6.



Original Article

Abstract

ROLE OF SOCIO-DEMOGRAPHIC AND CULTURAL FACTORS IN KNOWLEDGE, ATTITUDE AND PRACTICE OF USERS ABOUT FAMILY PLANNING METHODS AND SERVICES, RENDERING FROM RURAL PRIMARY HEALTH CARE CENTRE OF BANGLADESH

1Institute of Community Ophthalmology, University of Chittagong, Bangladesh.2School of Public Health, Tehran University of Medical Sciences, Iran.3Agha Khan University, Karachi Pakistan.Correspondence: Muhammad Shamsal Islam. Email: [email protected]

1 2 2Muhammad Shamsal Islam , Kourosh Holakouie Naieni , Hassan Eftekhar Ardebili , Abbas Rahimi 2 3Foroushani and Amjad Mirani

Background: The socio-demographic and cultural factors closely related with Knowledge, Attitude and Practice (KAP) of users at rural setting. Unfortunately studies on KAP of women about Family planning services from rural setting are almost absent. This study was designed to determine the responsible factors role on KAP of users for receiving family planning services from rural setting of Bangladesh.Methods: Qualitative descriptive analytical study was employed to follow a structured questionnaire format. A total 420 users were interviewed from two unions. Relevant literatures were reviewed to enhance our understanding of the issue in question. The questionnaires were pretest before finalization and it's has both open and close-ended questions. Results: The knowledge of users (87%) was mostly universal, while community women were more advanced than men. The unmet need for contraception's remains about 16% and 40% of mothers to have unintended births. Of all users, Pill was most known methods (68%), although IUCD (18%) and condom (14%) methods were common at community. Side effect (69%) and husband disapproval (31%) was barrier of practice of FPMs, although space for child bear (37%), health problems (30%), financial problems (25%) and education (8%) were push factors to users. Approximately 40% respondents travelled more than 4 kilometer to getting services. Factors were found to be significantly associated with KAP of users were: education (X2=29.73; p<0.001), occupation (X2=16.67; p<0.001) income (X2=17.61; p<0.011) family size (X2=25.44; p<0.022) distance (X2=18.75; p<0.013) cultural beliefs (X2=23.84; p<0.001, and accessibility (X2=23.67;p<0.00). Poor practice (44%) associated with schooling of users. Conclusion: Regular yard meeting with users' community and services allied persons may be arranged at community levels for upgrading the existing KAP. Stakeholders' from different ages, genders, and socioeconomic groups have to be engaged to promote evidence-based services. Extensive education and communication programs are needed to address family planning methods and services. Keywords: Cultural belief, rural setting, affordable, contraceptive, Bangladesh

Introduction:Bangladesh had started an official Family Planning (FP) programs beginning in 1960s and the programs went through different phases with commendable successes until mid-1990s [1]. Knowledge of FP is almost universal among Bangladeshi married women, although the pace of success has slow down after mid-1990s. The probable reason might be there is a big gap between users Knowledge, Attitude and Practice (KAP) and Family Planning (FP) services providers [2-3]. The gap adversely affected on programs implementation, Contraceptive Rate (CPR), Health of users, and country economy [3]. These gaps are associated with socio-demographic and socio-cultural factors and government programs strategies and policies [4-8]. Major barriers are to

adoption of family planning was absent of KAP about contraceptive methods, health side effects and poor effectiveness of the methods. These factors may also argue against increased continuity of contraceptive use. However, culturally appropriate counseling can mobil ize the presumably latent demand for contraception by reassuring potential clients of the social acceptability and by allaying their fears about side effects of contraceptive methods [9-11]. The ineffectual programs and socio-cultural related factors affect the KAP of users about FP programs and utilization of RPHC services. The study was designed to determine the importance of KAP of married women about FPMs, services, and suggests guidelines to improve the KAP of users for increase the numbers of CPR.

Family Planning Methods And Services


Muhammad Shamsal Islam and others

Knowledge, Attitude and Practice (KAP) towards FP methods and RPHC services are very few and far less on Rural Primary Health Care (RPHC) setting compared to family planning studies in Bangladesh. Relatively KAP of women about FP methods don't lessen its importance as subject of study as it is one of the major causes of poor uptake of family planning methods. We have reviewed limited number of very relevant studies of sub-continent and other selected countries to enhance our understanding of the issue in question. The Socio-demographic factors and socio-cultural factors has strong role on KAP of users regarding FP methods and services of RPHC [3-9]. Formal education and status of occupation has direct influence on KAP of women [10-12] and monthly income and family size encourage users to attend to RPHC services [1, 4, 12]. Misinterpretations of religious and cultural factors are responsible for poor practice of FPMs [12] Husband approval, fears of side effect play vital role in poor uptake of FP methods [9, 11, 13] To mapping the barriers of receives family planning services from Rural Primary Health Care Centre of Bangladesh.

Methodology: A cross-sectional descriptive analytical study was conducted by face-to-face interviews. A total of 420 married women were drawn as samples from two unions and attendees of those unions RPHC of lakshmipur district using random sampling technique. The questionnaires were pretest before finalization. Data for the study were collected through a simple survey with an interview schedule comprising both open and close-ended questions. Questionnaire on socio-demographic factors (age, sex, education, monthly income, toilet facility, house pattern, distance

of RPHC from the users residents, accessibility to RPHC services, family size), cultural factors (religion, false believe etc) and KAP related questions were used to measured the KAP of married women about family planning methods and services of RPHC. This questionnaire contain three domains including knowledge (source of information about FPMs, knowledge about FPMs, knowledge about FP services, and RPHC outdoor environment), attitude (FP staff behavior, mean waiting time, quality of RPHC services and management of RPHC) and practice (problems faced during practice of FPMs, current used FPMs and difficulties of getting services). The data has been analyzed using the Statistical Package for Social Science (SPSS). Descriptive of the results had been carried out using descriptive charts and graphs. Moreover, qualitative statistical tests such as an independent T-Test and Chi-squared had been used for our continuous response (mean score of knowledge, attitude and practice). Multiple regression models have been further used in order to determine different covariates on the outcome variables. For KAP analysis, different segment (Knowledge, attitude and practice) had been also analyzed separately as per required. The project has been approved by the Research Ethics Committee, International campus, Tehran University of Medical Sciences, Iran and District health office, Ministry of Health, Government of Bangladesh.

Results: Majority of the respondents (95%) had schooling and average number of years attending school was 6.32 years. Vast majority respondents (87%) had good knowledge and attitude about FPMs and services of RPHC but we observed poor practice (44%) among the users (Table-1).

KAP About

FPMs RPHC Services

Large family size

Distance from the RPHC

Weak Management

Availability of drug

Poor educa�on

Quality of RPHC Services

Cultural belief of the Community

Cost of Services

Occupa�on

Transporta�on facili�es

Unskilled staff

Socio-Economic condi�on

Poor counseling

Lack of awareness

Recrea�onal facili�es

Informa�on & communica�on facili�es

Figure 1. Web of causation of KAP of married women about FPMs and RPHC services




Pill method (68%) was most known to users but side effect (69) and husband disapproval (31%) were barriers to practice of FPMs. We found that adequate information about family planning methods exits at rural setting of Bangladesh. But they received these in format ion unofficia l channels ( tab le-02) .

Government of Bangladesh routinely disseminated this information through radio, newspapers, magazines, youth groups, community meeting and other public forum. In particular, the information focuses on the role of birth control methods to limit, postpone, and space children, preventing conception,

Title of the Question Yes I don’t Know Total

N % N % N %Do you know about family planning

services?

202 48.1 218 51.9 420 100

Do you know about family planning

methods?

364 86.7 56 13.3 420 100

Do you think that PHC

rendered FP

service quality is good?

251

59.8 169 40.2 420 100

Do you know, PHC FP services

hours from 9.00 AM to 2.00 PM?

215 51.2 205 49.8 420 100

Do you know that PHC outdoor &

indoor environment is clean and

Healthy?

187 44.5 233 56.5 420 100

Do you know that all FP products are

available in the PHC?

19 4.5 401 95.5 420 100

Do you know that FP officer must

visit your home weekly?

9 2.1 411 97.9 420 100

Table-1: Percentage distribution of Knowledge of users about FPMs and services of RPHC

Source of Information Frequency (F)

Husband 141

PHC 119

Relatives

51

Media 08

Neighborhood

21

Health Workers

30

Others (social media) 50

Total 420

Percent (%)

33.6

28.3

12.1

1.9

5.0

7.1

11.9

100.00

Table-2: Percentage distribution of source of information about FPMs and RPHC services




Table-3: One way ANOVA analysis (Post Hoc

Test ) for knowledge, attitude and practice of Respondents opinion facing problem during use of FPMS

Variables Knowledge Attitude Practice

F Mean

differenc

e

P

value

CI: 95% F Mean

differe

nce

P

valu

e

CI 95% F Mean

Differe

nce

P

valu

e

CI:

95%

Lower

Upper

Lowe

r

Upper

lowe

r

up

pe

r

Reasons for using Family Planning methods

Side

effe

ct

Husban

d

disappr

oval

5.673

-12.92

<.039

.455

25.38

.495

-

1.92

1

<..

68

6

-13.74

9.906

16.34

31.29

<.001

17.0

5

45.

53

Religiou

s faith

12.206

<.223

-4.12

28.54

.459

-15.03

15.95

21.17

2.52 39.

82

Hus

ban

d

disa

ppro

val

Side

effect

5.673

-12.92

<.039

-28.33

.412

.495

1.92

<9

76

-9.96

13.74

16.34

1.92

<.001

-

9.96

13.

74

Religiou

s faith

.714

<.223

-19.47

20.90

2.38

-16.77

21.53

2.38

-

16.7

7

21.

53

Reli

giou

s

faith

Side

effect

5.673

-12.20

<.039

-28.53

41.20

.495

-

4.59

.<..

68

6

-15.95

15.95

16.34

-21.17

<.001

-

39.8

2

-

2.5

2

Husban

d

disappr

oval

.714

<..223

-19.47

20.90

-

2.3

8

-

21.53

16.77

10.11

-

12.9

4

33.

18

KAP of respondents has increased with increasing the ages of the respondents. (Knowledge X2 = 6.10, P<.047; Attitude X2 = 1.12 P<0.509; Practice X2 = 1.13 P<0.568). If age of marriage of respondents has increased, the KAP score has uplift.

When we compared age of marriage of respondents, we found that <18 group KAP score was poor compared to >18 years group. Formal education was the most important factor associated with better knowledge about fami ly planning methods (Knowledge X2 = 25.44, P<0.001, Attitude X2 = 11.48, P <0.022, Practice X2 = 8.68 P <0.034). ). We found that KAP of respondents has increased 2 fold with the increasing of formal education. Occupation strongly associated with knowledge, attitude and practice of married women about family planning methods and services (knowledge X2 = 16.67; P<0.001, attitude X2 = 12.54; P<0.006, practice X2 = .8.68; P<0.034). Above statistical analysis demonstrated that dissemination of information could be effective if family planning counseling program followed by level of education, age and occupation of the users. There is an association between KAP of users and distance of service recipient home ((knowledge X2 = 7.63; P<.05, attitude X2 = 12.65; P<0.05, practice X2 =

5.55; P<0.136). The accessibility of getting services depends on distance between RPHC and users home. Service limitations of RPHC influence the KAP of users. We found that staff good attitude and counseling increase the KAP of users (Knowledge, f= 7.175; P<.001, attitude f= 11.771 P<.001, practice f= 12.250; P <.001). Side effect religious faith and husband attitude has significant predicators' role on KAP of users (Table-03). Discussion: There were two sets of data for the study. One collected from the attendees of the rural primary health care centre and another from the community using In-depth interviews. Although both groups were family planning methods users, they significantly differed in age structure. About 69% of attendees of RPHC were young aged (21 to 30 years) while community was only 58% (aged was 30+). This means young age women are more prone to practice family planning methods and attend to centre. From religion context, we found that there is no significance




difference among Islam and Hindu rel igion respondents regarding knowledge, attitude and practice of family planning methods and services. This meant that there is no difference among different religions and ethnic groups for getting family planning services from RPHC and they have almost same KAP about family planning methods. Scant of family planning products (51%), long waiting time (42%), weak management (39%), lack of female service providers (48%), unskilled staff (44%), absent of supportive facilities (16%) appears to be vexing problems for service recipients. Side effect (69%) of contraceptive methods and husband disapproval (31%) was barriers during practice of family planning methods. The reason could be poor counseling. The contents of the counseling remained to one or two issues, which were definitely inadequate. Of all users, Pill was most known methods (68%) to them, although IUCD (18%) and condom (14%) methods were common to the users' community. A noticeable respondent has mentioned about side effect (69%) and husband disapproval (31%) as a barrier of practice of family planning methods, although space for child bear (37%), health problems (30%), financial problems (25%) and education (8%) were push factors to the users regarding use of family planning methods. Source of information and dissemination of data about new products are important to increase the users' rate at community setting. Findings revealed that source of information were mostly followed by husband (34%), RPHC (28%), relatives (12%), neighborhood (5%), health workers (7%), social network (12%), and media (1.9%). The data showed that about 50% more information was disseminated through unofficial channel. The reason behind might be government poor effort through public channel. For widely dissemination of the information, media, IEC materials, and social network (Face book, Twitter, and LinkedIn) could be use. Local religions leader might be vital alternative for effective dissemination of family planning information of Friday prayer time. Some statistically significant differences were found among attendee age, education, income, occupation, family size, accessibility to RPHC services and distance of centre from service recipients. We found that respondents KAP was increased with increasing of ages. Unfortunately about 69% of girls of Bangladesh got married <18 years [7] and our study findings showed that about 71% girls went to marry <18 years. The possible solution of the problem is that to reform the existing law and extensive education and Behavioral Change and Communication (BCC) programs address to age of marriage. The education also have predictor role on KAP of users. We found that KAP of users has increased two fold, if education level increases from primary level to secondary level. Same findings were conducted at India, Ethiopia,

Nigeria and Cambodia [1, 4, 5, 9]. On an average 40% respondents were came from 4 Kilometer distance for receiving services from RPHC. We observed that these service recipients were pedestrian. Of our study, we found that about 87% had good knowledge, 82% had good attitude and 44% had good practice. These findings revealed that overall users had good knowledge and attitude but very poor practice level. The possible reasons behind the poor practice are low education, poor awareness program and low coverage of the programs at rural setting.Conclusion: The nature of KAP findings in the community setting was quite interesting. Among the users about 71% got married <18 years, while national statistics is 69%. Pill was most known methods to them. The most serious concern for users was side effect (69%) of the methods. Hence, regular yard meeting with users' community and allied persons involved with RPHC family planning services may be arranged at ward, union and upazila levels for upgrading the existing knowledge, attitudes and practice for selection of appropriate methods. Separate counseling unit about side effect of methods could be effective weapon for increasing the rate of users. All individuals from different ages, genders, and socioeconomic groups have to be engaged to promote evidence-based family planning. These findings suggestive of extensive education and communication programs are need to address misconceptions and myths about family planning methods.

Acknowledgements: This work would not have been possible without the commitment of the research team. We also acknowledge the Dean, SPH and Board of ethical research committee TUMS, International campus. References:1. Islam A, Sabu S, Peter W. Men and family

p lann ing in Bang ladesh: Bang ladesh-Demographic Health Survey 1999-2000; NIPORT and USAID, 2005; BGD 1999 DGS V01M.

2. Parhizkar S, Mahamed F, Shirazi AR. Impact of Family Planning Health Education on the Knowledge and Attitude among Yasoujian Women. Global Journal of Health Science, 2012; Vol. 4, No. 2; doi:10.5539/gjhs.v4n2p110.

3. Khuda B, Chandra NR, Rahman DM. Family Planning and Fertility in Bangladesh, Asia-Pacific Population Journal, 2000; 15, no. 1: 41–54

4. Islam S, Hasan M. Women Knowledge, Attitude, Approval of Family Planning and Contraceptive Use in Bangladesh. Asia Pacific Journal of Multidisciplinary Research, 2016; Vol. 4, No. 2.

5. Kamruzzaman M, Hakim A. Family Planning




Practice Among Married Women Attending Primary Health Care Centers in Bangladesh; International Journal of Bioinformatics and Biomedical Engineering, 2015; Vol. 1, No. 3, 2015, pp. 251-255.

6. Bangladesh Bureau of Statistics (BBS), Government of Bangladesh, Ministry of Planning, Bangladesh, (editorial); 2015, Vol. 01. www.bbs.gov.bd

7. Bangladesh Demographic and Health Survey; Summary report. NIPORT and USAID 2016; w w w . d g h s . g o v . b d : https://dhsprogram.com/pubs/pdf/FR311/FR311.pdf:

8. World Bank Country report. Bangladesh D e v e l o p m e n t U p d a t e , 2 0 1 5 . www.worldbank.org/en/country/bangladesh

9. Streatfield PK, Kamal N. Population and Family Planning in Bangladesh; Journal of Pakistan Medical Association, 2013; Vol. 63, No. 4

10. Rahman M, Mostafa G, Hoque A. Women's household decision-making autonomy and contraceptive behavior among Bangladeshi women. ELSEVIER, 2014; Volume 5, Issue 1.

11. Gily C, Tizta T, Stanley L, Wonduosen K et al., Family Planning Knowledge, Attitude and Practice among Married Couples in Jimma Zone, Ethiopia. PLoS One, 2013; 8(4): e61335,

12. Mwaikambo L, Speizer I. Schurmann A, Morgan G and Fikree F., What Works in Family Planning Interventions: A Systematic Review, Studies in Family Planning. NCBI, 2011;Vol.42 No. 2; www.ncbi.nlm.nih.gov/pubmed/21834409

13. Khan T, Khan A., Fertility behavior of women and their house hold characteristics- A case study of Punjab Pakistan. J Hum Ecol, 2010; 30:11-7.




http://www.bbs.gov.bd

http://www.dghs.gov.bd

https://dhsprogram.com/pubs/pdf/FR311/FR311.pdf

https://dhsprogram.com/pubs/pdf/FR311/FR311.pdf

http://www.sciencedirect.com/science/journal/18775756/5/1

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3634055/

CHALLENGES AND OPPORTUNITIES TO ACCESS HEALTH CARE IN URBAN SLUMS OF LAGOS-STATE IN NIGERIA

1Department of Community Health & Primary Care, College of Medicine, University of Lagos, Idi-Araba, Mushin, Lagos, Nigeria.2Department of Public Health Sciences Karolinska Institutet, Stockholm, Sweden

Corresponding Author: Bolaji Samson Aregbeshola. Email: [email protected]

1 1 2Bolaji Samson Aregbeshola , Olanrewaju Olusola Onigbogi and Samina Mohsin Khan

Original Article

Abstract

BackgroundAccess to healthcare is a major public health challenge, especially in developing countries. Many Nigerians cannot avail the healthcare services they need with those in the urban slums being the worst hit. The aim of the study is to determine the issues regarding accessibility ofhealthcare services in three urban slums of Lagos State in Nigeria. All the aspects of accessibility including the geographical, financial and socio-cultural factors affecting the healthcare access were assessed. Methods: A descriptive cross-sectional study was conducted among slum dwellers of three urban slums in Lagos-State.A sample size of 427 individuals was used. The subjects were recruited using multi-stage sampling technique. Data was collected using a structured self-administered and close-ended questionnaire that was adapted from World Health Organization. Variables on geographical accessibility, financial accessibility and social-cultural factors affecting accessibility were analysed. Data analysis was performed using SPSS version 15 software.Results: A total of 80.3% of the respondents had an estimated travel distance ranging from 6 to 10 km to reach a healthcare facility. About 10-20% of the monthly household income was spent on healthcare by 46.8% of respondents. A total of 97.9% of respondents had no health insurance coverage. Self-medication was reported by 77.8% of the respondents who were unable to pay for healthcare services. Only 43.1% of respondents utilized government hospitals as the first point of contact.Conclusion: Our study concludes that there is limited geographical and financial access to healthcare services for slum dwellers in Lagos-State especially due to their financial constraints that affect their accessibility to healthcare services. Access to healthcare services still remains a major issue in slums of Nigeria. Increasing the coverage of the National Health Insurance Scheme and strengthening the primary healthcare infrastructure would help in addressing the issues of accessibility to healthcare in urban slums.Keywords: Access to health care services, health system, urban slums, Lagos State, Nigeria

Introduction Accessibility still remains a major public health challenge to deal with in health systems research especially in low income countries (LICs). The meager resources in low income countrieslimitthe access to health services than high income countries (1). So is true for Sub-Saharan Africa where accessibility of health care services still plays a hurdle for optimum health systems performance (2). Many Nigerians cannot avail the health care services they need with those in the urban slum being the worst hit. Nigeria's health spending as a percentage of Gross Domestic Product (GDP) is 3.7 per cent while the out of pocket (OOP) health expenditure as a percentage of total health expenditure is 73 per cent (3).Alarmingly, out of pocket health expenditure as a percentage of private health expenditure is 95 per

cent (3). High out of pocket payment is a barrier to health care accessibility for poor communities andremains an inequitable means of financing health care system. This inequitable distribution of resources leads to inequitable and unequal distribution of both public and private health care facilities that adds to the dilemma. According to any country'sstandard, there should, at least, be a primary health center (PHC) within a five kilometer radius (4) from where most patients are examined and appropriate referrals are made (5). Improved access to health care has and continues to be a “fundamental objective of health-pol icy making” for opt imum health system performance (6).Despite that substantial research has been conducted focusing on access to health care and sustained attention to accessibility issues in health policies, in

Health Care in Urban Slums of Lagos-state In Nigeria


Bolaji Samson Aregbeshola and others

mailto:[email protected]

the context of health services research, community and policy makers continue to seek answers to this fundamental question (7). The large gap in access to health care services between different groups in both developed and developing countries is well established (8).Although many Nigerian have to walk more than five kilometres to access health care services which are often times inefficient, ineffective and not affordable but the situation especially adds to the vulnerability of people living in urban slums of Nigeria that pushes them in a vicious cycle of poverty and makes them to experience adverse health outcomes.Today, nearly 1 billion people or 32% of the world's urban population is estimated to be living in slums. An estimated 72 percent of the urban population in Africa now lives in slums. In sub-Saharan Africa, the proportion of urban residents in slums is highest at 71.9 per cent (9). While their physical forms vary to p lace and over t ime, s lums are uni formly characterized by the inadequate provision of basic infrastructure and public services necessary to sustain health such as water, sanitation and drainage (10).These poor or low-income urban human settlements, comprising between 25% and 75% of urban population occupies irregular settlements including squatter settlements, unauthorized land developments and rooms and flats in dilapidated buildings in city centre area (11). Although there are no accurate figures but Nigeria has a fair share of these low-income settlements (12). Many Nigerian cities are typified by substandard and inadequate housing s lums with lack of infrastructure, transportation problems, low productivity, crime and juvenile delinquency (13).So is the city of Lagos that represents the epitome of urban decay (14). The metropolis is replete with environmental problems ranging from slums and squatter settlements to crime and delinquency (14).In 1984, 42 settlements have been identified as blighted and the number has risen to about 100 in 2004 whereby a 2002 survey revealed that over 70% of the built up area of Lagos metropolis is blighted (14,15).In 2006, the Lagos State government embarked on a US$200 million World Bank funded urban upgrading project, the Lagos Metropolitan Development and Governance project designed to increase sustainable access to basic urban services through investments in critical infrastructure in nine target communities namely Agege, Ajegunle, Amukoko, Bariga, Ijeshatedo/Itire, Ilaje, Iwaya and Makoko (16). Inadequacy of decent housing has resulted in the Lagos State Section of the Lagos Mega-city region (LMCR) recording 42 slums areas in 1985 and over 100 in 2006 (17).Over two-third of the populat ion of Lagos consequently lives in the informal settlements and slums that are scattered around the city (18,19).The areas still face challenges of accessibility that

contribute to significant delays in accessing health care due to inadequate infrastructure including lack or poor condition of roads as well as poor transport systems (4).There is limited evidence on issues related to access and equity in health care delivery system in urban settings of Nigeria. This study aims to determine the issues regarding accessibility ofhealth care services in three urban slums of Lagos State in Nigeria. Specifically, the study examined all the aspects of accessibility including the geographical, financial and socio-cultural factors affecting the health care access in three urban slums of Lagos State. The study contributes to knowledge on access to health care services in urban slums of Lagos State in Nigeria.Methodology: The study was conducted in three urban slums of Lagos State namely Mushin-Idi-Araba, Ajegunle and IjoraBadia. These slums were selected among the over 100 slum communities in Lagos State using the simple random sampling technique between June and December 2012. The decision to carry out the study in these three urban slums was to ensure effective coverage and better focus thereby assuring the accuracy and quality of data. Lagos State is the commercial nerve center of Nigeria with an estimated population of 21 million people (20).However, Mushin Idi-Araba is located in Mushin Local Government Area of Lagos State. It is a slum community that is predominantly occupied by the Hausa ethnic group. Ajegunleis also located in Ajeromi-Ifelodun Local Government Area of Lagos State. It is a major slum with multi-ethnic population. The dominant ethnic groups in Ajegunle are the Ijaw, Urhobo and Isekiri. IjoraBadiais an urban slum settlement located in Apapa Local Government area of Lagos State.The respondents were recruited using multi-stage sampling technique as the same technique was utilized in similar type of studies carried out in Nigeria (21,22). The first stage involved the simple random sampling of three urban slums among the over 100 slum communities in Lagos. The second stage involved generating a list of houses in each slum. The third stage was the selection of one in three houses through a systematic sampling technique.The fourth stage involved the selection of individuals (men and women aged 20 years and older living in the urban slum) in each house by simple random sampling (balloting) where more than one individual met the inclusion criteria. The exclusion criteria aremen and women under the age of 20 yearsand not living in the urban slum. Where no individual met the criteria in a house, the next house was used. This was done until 10 individuals were selected per street in each of the three urban slums and till the required 427 respondents were recruited into the study.The study participants were individuals (men and women of 20 years and above) living in the three urban slums of




Table 1 – Population Characteristics of respondents

Geographical accessibility: Table 2 shows that a total of 80.3% of the respondents have an estimated travel distance from >5 km to 10 km to reach a health care facility. Only 71.2% of respondents spend between >15 – 30 minutes traveling to reach a health care facility. A total of 68.2% of the study population describe the condition of roads to health facility as bad. Two third (67.7%) of the study sample had a motorcycle (Okada) as the mode of transport to a health facility.Table 2 – Geographical accessibility

Lagos State. The sample size of 427 individuals was calculated using Cochrane equation (23). Based on the assumption that 50% of individuals living in the three urban slums would have no access to health care and a non-response rate of 10%, the sample size for the study was calculated as 384.Adjusted sample size therefore, the sample size for the study was 427. Sample size was equally divided within the three slum communities.Data was collected with the aid of a structured self-administered and close-ended questionnaire that was adapted fromthe World Health Organization (WHO) (24). The questionnaire was used to gather information regarding population characteristics of respondents, geographical accessibility, financial accessibility and socio-cultural factors affecting healthcare accessibility.Section A of the questionnaire seeks to generate information about the respondents. Section B focuses on geographical accessibil ity. Section C seeks information on financial accessibility. Section D of the questionnaire concentrates on the socio-cultural factors affecting healthcare accessibility. There were twenty nine questions altogether. The questionnaire was pre-tested by the researchers in the three urban slums to test its reliability and validity. The questionnaire was thereafter revised. Prior to administering the questionnaire, the researchers informed the respondents about the objectives of the study and obtained their informed consent. Each respondent completed the questionnaire between 15-30 minutes. The response rate was 100 per cent.Data was processed using EPI info windows version and analysed with SPSS version 15 software. Descriptive statistical technique was used for the analysis of data in the form of frequency tables and simple percentages for the population characteristics as well as the different measures of access to health care services.Ethical clearance was obtained from Lagos University Teaching Hospital Health Research and Ethics Committee and permission was sought from local authorities prior to data collection. Respondents were briefed on the purpose and objective of the study and their informed consent was thereafter obtained while the confidentiality of the data was assured and guaranteed. Results: The study population consisted of 156 (36.5%) and 271 (63.5%) males and females, respectively. The mean age of the respondents was found to be 42.44±13.76. The majority of the respondents were aged between 30 – 39 years (25.3%). Among the study population, 42.8% attained primary education while 28.6% had secondary education. Majority (85.5%) of respondents had trading and artisan as their occupation while 6.1% are unemployed. A total of 36.3% of respondents are Igbo while 32.8% are from the Yoruba ethnic group. The detai ls of the population characterist ics of respondents are shown in Table 1.



Variables Frequency ( n=427) Percent (%)Age at as last birthday20-29 96 22.530-39 108 25.340-49 83 19.450-59 78

18.3>60 62

14.5

Sex

Male 156

36.5

Female 271

63.5

Level of Education

None 20

4.7Primary 183

42.8Some secondary

77

18.0Secondary 122

28.6Tertiary 25 5.9

OccupationCivil service 21

4.9

Trading and Artisan

365

85.5

Unemployed 26

6.1Others 15

3.5Ethnic groupIgbo 155 36.3Yoruba 140 32.8

Hausa 83 19.4

Others 48 11.5

Variables Frequency(n=427) Percent (100%)

Estimated travel distance

Within 5 km – 5 km 72 16.9

>5 – 10 km 343 80.3

>10 – 20 km 12 2.8

Estimated travel time

< 15 minutes 117 27.4

>15 – 30 minutes 304 71.2

>31 – 45 minutes 6 1.4

Mode of transport to health facility (public and private)

Public bus 96 22.5

Walking 23 5.4

Motor Cycle (Okada) 289 67.7

Private car 19 4.5

Water - -


Socio-cultural factors affecting health care accessibility: English language was used as a medium of communication with health care provider by 69.8% respondents. A total of 37.9% and 36.7% of

Financial accessibility: More than half of the study population (58.1%) had a household monthly income of less US$64.1 while 38.6% had a monthly income between US$64.1 - US$128.2. A total of 23% of the study population spent less than 10% of household income per month on health care while 46.8% of respondents had spent between 10-20% of the household income. A higher proportion (70%) of respondents had between US$3.2 - US$6.4 as their monthly cost of transport to health care facility. Our study also found that 41.5% of the study population had between US$3.2 - US$6.4 as cost of consultation while 44% spent between US$6.4 - US$6.4 on consultation. A total of 61.1% of respondents had between US$12.8 - US$25.6 as the cost of treatment per month while only 23.9% spent less than US$12.8 as treatment cost on a monthly basis. It was found that 46.4% of the study population spent less than US$12.8 out of pocket for treatment per month while 43.1% spent between US$12.8 - US$25.6 as out of pocket expenditure for treatment per month. A total of 97.9% of respondents are not under any health insurance scheme. As high as 77.8% of the study population reported self-medication due to their inability to pay for health care services. Details are given in Table 3.Table 3 – Financial accessibility


Pakistan Journal of Public Health Vol. 7, No. 1 March 2017

Condition of roads to health facility (public and private)

Very bad 35 8.2

Bad 291 68.2

Normal 79 18.5

Good 18 4.2

Excellent 4 0.9

Total 427 100

Percentage Frequency (n=427) (100%)

< N10,000

(US$64.1)

248

58.1

N10,000 –

N19,999

(US$64.1 -

US$128.2)

165

38.6

N20,000 – N20,999 (US$128.2 -US$134.6)

6 1.4

N30,000 – N30,999 (US$192.3 -US$198.7)

1 0.2

>N40,000 (US$256.4) 7 1.6

Percentage of household income spent on health care

< 10% 98 23.0

10 – 20% 200 46.8

21 – 30% 125 29.3

31 – 40% 2 0.5

>40% 2 0.5

01

Monthly cost of transport to health facility (public and private)

< N500

(US$3.2)

60

14.1

N500 –

N999

(US$3.2 -

US$6.4)299

70.0

N1,000 – N1,999 (US$6.4 -US$12.8)

61 14.3

N2,000 – N2,999 (US$12.8 -US$19.2)

5 1.2

> N3,000 (US$12.8) 2 0.5

Cost of consultation per month

< N500 (US$3.2) 42 9.8

N500 – N999 (US$3.2 -US$6.4)

177 41.5

N1,000 – N1,999 (US$6.4 -US$6.4)

188 44.0

N2,000 – N2,999 (US$12.8 -US$19.2)

10 2.3

> N3,000 (US$19.2) 10 2.3

N2,000 – N2,999 (US$12.8 - US$19.2)

10 2.3

> N3,000 (US$19.2) 10 2.3

Cost of treatment per month

Free 12 2.8

< N2,000 (US$12.8) 102 23.9

N2,001 – N4,000 (US$12.8 - US$25.6)

261 61.1

N4,001 – N6,000 (US$25.6 - US$38.5)

34 8.0

>N6,000 (US$38.5) 18 4.2

Out-of-pocket expenditure for treatment per month

< N2,000 (US$12.8) 198 46.4

N2,001 – N4,000 (US$12.8 - US$25.6)

184 43.1

N4,001 – N6,000 (US$25.6 - US$38.5)

29 6.8

N6,001 – N8,000 (US$38.5 - US$51.3)

8 1.9

>N8,000 (US$51.3) 8 1.9

Under any health insurance scheme

Yes 9 2.1

No 418 97.9

Result of inability to pay for health care services

Ignored the illness 34 8.0

Delayed seeking healthcare

47 11.0

Self-medication 332 77.8


14

r e s p o n d e n t s r e p o r t e d w i f e / m o t h e r a n d husband/father, respectively as persons who determine when to seek health care. It was found that 57.4% of study population will not share health facility (public or private) with the Yoruba tribe while 25.3% of the respondents will not share health facility with the Igbo tribe. A total of 43.1% of the study population reported government hospital as their first point of contact when seeking health care while 32.6% reported chemist/pharmacy as their first point of contact. Only 24.1% of respondents reported private hospital as their first point of contact when seeking health care. There were misperceptions regarding health seeking behaviour among study respondents regarding various diseases. More than half of the respondents (59.5%) believed mental illness does not necessitate medical attention. Details are given in Table 4. Table 4 – Socio-cultural factors affecting health care accessibility

Discussion: Our study shows that there is limited access to health care services among slum dwellers in urban slums of Lagos State. The study revealed that 80.3% of the respondents had an estimated travel distance ranging from >5 km to10 km to a health care facility. This was similar to the result of studies conducted in Osun State and Kwara State in Nigeria where people traveled a distance ranging from 6 to 7 km to access and utilize health care services (25,26). A study in Ghana also found that majority of respondents (76.4%) travel more than 4km to the nearest health care facility (27). Conversely, a study in Istanbul revealed that majority of the people has a travel distance within 3km to a health care facility (28).Only 71.2% of respondents in the study spent between >15 - 30 minutes traveling to a health care facility while two third of the study participants (67.7%) had a motorcycleas their mode of transport to reach a health facility.A similar study in Kwara State, Nigeria reported that 55% of respondents spend less than 40 minutes to seek medical services while 48.8% of respondents indicated that they in order to seek health care services travel by foot to reach to health centres (26). A study in South Africa found that 70.9% of respondents traveled for 30 minutes or less to the clinic while 47% of respondents used a taxi as a mode of transportation to the nearest health facility (29). Results from a study in Indonesia also revealed that a large proportion of respondents (70%) spend about 10 minutes traveling to a health facility while 50.5% of respondents used motorbikes to visit the health centre(30).However, another study in South Africaindicated that 65% of respondents travel more than 1 hour or more to the nearest health facility while 60.8% of people walked to clinics in order to access health services (31). Findings from other studies in Lagos State (32) and Edo State in Nigeria (33) revealed that 40% and 75% of respondents used public buses respectively while only 38% of respondents in Lagos State (32) spend between 15-30 minutes traveling to government health facilities. More than half of the respondents (58.1%) had a household income less than US$64.1 per month. This agrees with a study carried out in Ajegunle, Nigeria where 48.3% of the residents earned less than US$64.1 a month (21). Our study also shows that 46.8% of respondents had 10 – 20% household income spent on health. This is in contrast with a study conducted in Nigeria (22) where 93.7% of the respondents spent over 5% of their income on health care, further it was found in a study from Mexico (34) where each year two to four million households spent 30% or more of their income on health. The findings are also in line with a study in Vietnam (35) where households spent on average 13.2% of their income on health care services. The majority of the respondents (70.0%) spent between US$3.2 - US$6.4 per month on transportation to a health



Frequency(n=427) Percent (100%)

Language used to communicate

English

298 69.8

Yoruba

61 14.3

Hausa

24 5.6

Igbo

- -

Others

44 10.3

Who primarily determines when to seek health care

Children

84 19.7

Extended family 15 3.5

Wife/Mother 162 37.9

Husband/Father 114 26.7

Others 52 12.2

Tribes slum dwe llers will not share public and private health facility with

Yoruba 245 57.4

Igbo 108 25.3

Hausa 63 14.8

Kanuri 8 1.9

Others 3 0.7

First point of contact

Chemist/Pharmacy 139 32.6

Private hospital 103 24.1

Government hospital 184 43.1

Others 1 0.2

Diseases that does not necessitate medical attention

Mental illness 254 59.5

HIV/AIDS 83 19.4

Leprosy 43

10.1

Tuberculosis

28

6.6

Others 19 4.5

Total 427 100


facility. This is in contrast to a household survey by the Lagos State Government which revealed that only 5% of households spent more than US$1.9 on transportation to and from government health centre (32).More than half of the respondents (61.1%) spent an amount between US$12.8 - US$25.6 on treatment per month. A similar study in Lagos State revealed that 48% of households reportedly spent less than US$32.1 on health care (32).In this study, it was revealed that 94.6% respondents did out-of-pocket expenditure on purchasing health care services. A similar study in Enugu State, Nigeria revealed that approximately 99%of payments for healthcare by consumers were out-of-pocket (36).In addition, the study also agrees with findings from Uganda (37) and Ebonyi State in Nigeria (38) where 77% and 69% of households respectively did out of pocket expenditure on health care. Majority of the respondents (97.9%) were not covered by any health insurance scheme. This is in contrast with a study in Oyo State in Nigeria where 83% of respondents were covered by the National Health Insurance Scheme (NHIS) (39).This could be due to high level of awareness about NHIS, high level of education as well as a high proportion of residents in Oyo State who are mostly government workers. However, the findings agree with a study among Hispanics in the United States (40) where 55% of the study sample respectively lacked health insurance. A higher proportion of respondents ( 7 7 . 8 % ) r e p o r t e d s e l f - m e d i c a t i o n a s a consequenceof their inability to pay for healthcare services. This is also in contrast with a study in Ghana where a higher proportion of the patients who did not seek health care (48.1%) either delay or postpone treatment (41).The majority of respondents (69.8%) used English language when communicating with healthcare providers. This is in contrast to a study in the United States where over two-thirds (69%) of Limited-English-Proficient (LEP) respondents and 41% of the English-proficient respondents reported that their physicians spoke their native language when communicating with them (42).Lack of health policies that disproportionately benefits urban slum dwellers has resulted in their continued plight. Governments should learn from the experiences of countries that have been able to effectively address the plight of urban slum dwellers. The provision of functional PHCs and the establishment of a government-run community based health insurance scheme is required to address the problem of accessibility to health care services in urban slums of Lagos State. Investing in health of urban slum dwellers will boost economic growth of the State. Conclusions: Our study concludes that there is limited geographical and financial access to health care services for slum dwellers in Lagos State especially due to their financial constraints that affect

their accessibility to health care services. Access to health care services still remains a major issue in slums of Nigeria. Increasing the coverage of the National Health Insurance Scheme (NHIS) and strengthening the health care system especially the primary healthcare infrastructure within the standard travel distance would help in addressing the issues of accessibility of health care in urban slums. Policy makers need to bring about the much needed change in order to improve the health seeking behaviour of slum dwellers in Lagos State.References:1. Grottret P, Schieber G. Health financing revisited:

a practitioner's guide. Washington DC: The World Bank; 2006.

2. Kruk EM, Freedman LP. Assessing health system performance in developing countries: a review of the l i terature. Health Pol icy 2008;85(3):263-276.

3. WHO. Atlas of African Health Statistics 2016: Health situation analysis of the African Region. Congo, Brazaville: World Health Organization Regional Office for Africa, 2016.

4. Kemboi TK, Waithaka EH.GIS location-allocation model in improving accessibility to health care facilities: A case study of Mt. Elgon Sub-County. International Journal of Science and Research2015;4(4): 3306-3310.

5. Chudi IP. Health care problems in developing countries. Medical Practice and Reviews 2010;1(1): 9-11.

6. Organization for economic co-operation and Development. The OECD Health project: Towards high-performing health systems. Paris, France: OECD; 2004.

7. Goldsmith LJ. Access to Health care for disadvantaged individuals: a qualitative inquiry. (PhD Thesis). The University of North Carolina at Chapel Hill; 2007

8. Ensor T, Cooper S. Overcoming barriers to health services access and influencing the demand side through purchasing. Health, Nutrition and Population (HND) discussion paper. The International Bank for Reconstruction and Development/The World Bank; 2004.

9. UN-HABITAT. The challenges of slums: global report on human settlement 2003. Available at http://mirror.unhabitat.org/pmss/listItemDetails.aspx?publicationID=1156Accessed 23 May 2013.

10. Sclar ED, Northridge ME. Slums, slum dwellers and health. American Journal of Public Health2003;93(9): 1381.

11. Chome J. Behavioural and spatial impacts of title registration in informal settlements: the case study of Blantyre city, Malawi. (MSc thesis). International Institute for Geo-Information Science & Earth Observation, Enschede, The




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Netherlands; 2002.12. Agbola T, Olatubara CO. “Private sector driven

housing delivery (in Nigeria): Issues, constraints, challenges and prospects”. A lead paper presented at the 2nd Annual National Workshop on private sector Driven Housing Delivery in Nigeria, University of Lagos, 30th -31st July, 2003.

13. Mabogunje A. Reconstructing the Nigerian city: the new policy on urban development and housing. Paper presented at a national conference on the city in Nigeria, Ile-Ife. 2002.

14. Oduwaye L, Lawanson TO. Poverty and environmental degradation in Lagos metropolis. 2 0 1 1 . A v a i l a b l e f r o m http://dspace.africaportal.org/jspui/bitstream/123456789/35409/1/Poverty%20And%20Environmental%20Degradation%20In%20Lagos%20Metropolis%20(1).pdfAccessed 23 May 2013.

15. Nubi TO, Omirin MM. Urban violence, land rights and the environment. Paper presented at International Conference on Environmental Economic and Conflict Resolution, Nigeria: University of Lagos; 2006.

16. Morka FC. A place to live: a case study of the Ijora-Badia community in Lagos, Nigeria. Case study prepared for enhancing urban safety and s e c u r i t y . 2 0 0 7 . A v a i l a b l e a t h t t p : / / u n h a b i t a t . o r g / w p -content/uploads/2008/07/GRHS.2007.CaseStudy.Tenure.Nigeria.pdfAccessed 23 May 2013.

17. Ilesanmi AO. Urban sustainability in the context of Lagos mega-city. Journal of Geography and Regional planning2010;3(10): 240 -252.

18. Federal Republic of Nigeria. Report of the presidential committee on redevelopment of Lagos megacity region. Abuja: Federal Republic of Nigeria; 2006.

19. World Bank. Nigeria - Lagos metropolitan development and governance project. 2006. A v a i l a b l e a t http://documents.worldbank.org/curated/en/142611468096552955/pdf/36433.pdfAccessed 23 May 2013.

20. World Population Review. Lagos Population 2 0 1 6 . A v a i l a b l e a t http: / /worldpopulat ionreview.com/world-cities/lagos-population/ Accessed 23 December 2016.

21. Olajide O. Urban poverty and environmental conditions in informal settlements of Ajegunle, Lagos, Nigeria. A review paper by REAL CORPS. 2 0 1 0 . A v a i l a b l e a t http://www.geomultimedia.org/archive/CORP2010_148.pdfAccessed 23 May 2013.

22. Olujimi JAB. Accessibility of rural dwellers to healthcare facilities in Nigeria: the Owo region experience. Pakistan Journal of Social

Sciences2007;4(1): 44 – 55.23. Cochran WG (1977). Sampling Techniques

(Third ed.). Wiley. ISBN 0-471-16240-X. A v a i l a b l e a t https://hwbdocuments.env.nm.gov/Los%20Alamos%20National%20Labs/General/14447.pdfAccessed 23 December 2016.

24. World Health Organization. Manual for the household survey to measure access and use of medicines. Geneva: World Health Organization; 2011.

25. Ajala OA, Sanni L, Adeyinka SA. Accessibility to healthcare facilities: a panacea for sustained rural development in Osun State, South Western Nigeria. Journal of Human Ecology2005;18(2): 121 – 128.

26. Usman BA, Sulyman OA. Transport and access to rural health centers in Ilorin East local government area, Kwara State, Nigeria. 2011. Avai lable atht tp: / /www.uni lor in .edu.ng. Accessed 12 June 2013.

27. Nyatepe DE. Accessibility to health care in the GA West Municipal Area. (MPhil thesis) University of Ghana, Legon; 2014.

28. Kara F, Egresi IO. Accessibility to health care institutions: A case study using GIS. International Journal of Scientific Knowledge 2013;3(4): 16-27.

29. Nteta TP. Accessibility & utilization of the primary healthcare services in Tshwane region. (MPH thesis) National School of Public Health, Faculty of Health Science, University of Limpopo; 2009.

30. Shrestha J. Evaluation of access to primary health care: a case study of Yogyakarta, Indonesia. (M.Sc thesis). International institute fo r Geo- in fo rmat ion Sc ience & Ear th Observation; 2010

31. Tanser F, Gijsbersten B, Herbst K. Modelling and understanding primary healthcare accessibility and util ization in rural South Africa: an exploration using a geographical information system. Social Science & Medicine 2006;63(3): 691-705.

32. Lagos State Government. Household survey 2010 edition. The Secretariat, Alausa, Ikeja: Lagos Bureau of Statistics, Ministry of Economic Planning & Budget; 2010.

33. Agbogidi J, Azodo CC. Experiences of the elderly utilizing health care services in Edo State. The I n te rna t i ona l Jou rna l o f Ge r i a t r i c s & Gerontology2009;5(2).

34. Knaul FM, Frenk J. Health insurance in Mexico: achieving universal coverage through structural reform. Health Affairs 2005;24(6): 1467-1476.

35. Segall M, Tipping G, Lucas H, Dung TV, Tam NT, Vinh DX et al. Economic transition should come with a health warning: the case of Vietnam. Journal of Epidemiology and Community




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Assessing the use and cost of health care services and catastrophic expenditure in Enugu and Anambra State. Policy Brief of the Consortium for Research on Equitable Health Sys tem (CREHS) . 2011 . Ava i l ab l e a t http://www.resyst.lshtm.ac.uk Accessed 12 June, 2013.

37. Ruhweza M, Baine SO, Onama V, Basaza V, Pariyo G. Financial risks associated with healthcare consumption in Jinja, Uganda. African Health Sciences2009;9(2):s86-9.

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SPECTRUM OF HEPATITIS C VIRUS (HCV) GENOTYPES AMONG DIAGNOSED CASES OF HCV IN RAWALPINDI AND ISLAMABAD REGION OVER THE PERIOD OF SIX YEARS

1Rawalpindi Medical College, Rawalpindi2Health Services Academy, Islamabad

3Department of Nuclear Medicine, Nuclear Medicine, Oncology & radiotherapy Institute (NORI), Islamabad

Correspondence: Muhammad Aleem Khan. Email: [email protected]

1 1 1 1 2Hamna Javed , Tehreem Arif , Saba Arshad , Saadia Khan Baloch, Bushra Anwar , Muhammad Aleem 3 3Khan and Muhammad Faheem Shahzad

Original Article

Abstract

Background: Determination of an individual's HCV genotypes prior to antiviral therapy has become increasingly important for the deciding clinical management and predicting prognosis of HCV infection. Relative genotype proportions are needed to inform to healthcare models, which should be geographically tailored. To our knowledge, there are no studies reporting genotype pattern in Rawalpindi/Islamabad region.We aimed to determine the frequency of different genotypes in HCV positive cases in the population of Rawalpindi/ Islamabad over the period of five years.Methods: Data of total of three thousand eight hundred and eighteen (n=3818) HCV positive adult of both genders were screened for genotype testing over the period of six years were analyzed. Results: Most frequent genotype identified in our study was genotype 3, accounting for 95.8% (n=3657) of HCV positive cases. The second most common genotype was Type 1 accounting for 2.9% (n=109) of HCV positive cases. Other genotypes were Type 2 (0.3%, n=12) and Type 4 (0.1%, n=5). Mixed genotype (Type 1 and 3) were detected in almost 1 % (n=35) of cases. We did not find genotype 5 and 6 in our study sample. No significant difference was observed among males and females in genotype distribution (P>0.05). Conclusion: The most common genotype among HCV patients were found to be genotype 3 followed by genotype 1 as the second most common in Rawalpindi/Islamabad region during the study period. Keywords: HCV, HCV genotype; interferon therapy, Viral Infection

Introduction:Hepatitis C virus (HCV) is a globally prevalent pathogen and one of the major causes of mortality and morbidity especially in developing countries like Pakistan.[1,2] Recent estimates revealed an increase in its seroprevalence over the last 10-15 years to 2.8%, corresponding to > 185 million infections worldwide.[3] Prevalence of HCV infections in Pakistani population has been estimated to be 8% and is increasing day-by-day.[4,5] HCV has been classified into 1-6 major genotypes on the basis of phylogenetic analysis of nucleotide sequences.[6] HCV genotypes have different biological properties, clinical outcome and response to antiviral treatment. Study of genotyping pattern provides important clues about transmission and pathogenesis as well as contributes to the development of an effective preventive and curative strategy. [7] HCV genotypes and subtypes have variable distribution around the globe. Predominant genotypes in the United States and Europe are 1a and 1b respectively.[8,9] HCV genotype 2 is more prevalent in countries of West Africa[10] while genotype 3a is more frequently found

in Australia and South Asia.[11] Moreover, genotypes 4, 5 and 6 are frequently found in Central Africa, South Africa and Asia.[12] All these HCV genotypes show 31-34% heterogeneity in their nucleotide sequences and approximately 30% heterogeneity in their amino acid sequences.[13]Although genotype 3 is reported as most prevalent form in Pakistan, yet, studies have shown regional variations in the prevalence of different genotypes. Other genotypes were also present in the patients infected with HCV, but were of lesser frequency. [14,15] Determination of an individual's HCV genotypes prior to antiviral therapy has become increasingly important for the deciding clinical management and predicting prognosis of HCV infection. It is the strongest predictive parameter for sustained virological response (SVR).[16] Patients with different HCV genotypes respond differently to antiviral therapy and characterization of these genetic groups may facil itate and contribute to the development of an effective vaccine against infection with HCV. Relative genotype proportions are needed to inform to healthcare models, which should be geographically tailored. To our knowledge, there are

Spectrum of Hepatitis C Among Diagnosed Cases of HCV in Rawalpindi and Islamabad


Hamna Javed and others


no s tud ies repor t ing genotype pat te rn in Rawalpindi/Islamabad region. This study was designed with intent to assess the genotype pattern of HCV in our region in order to provide inputs towards developing effective preventive and curative strategy against this infection. HCV is becoming a growing public health concern in Pakistan and knowing its genotyping pattern in our population will aid in developing effective vaccines against most common types. MethodologyIt was a retrospective cross-sectional study carried out at Nuclear Medicine, Oncology and Radiotherapy Institute (NORI), Islamabad, Pakistan. The study was observational in nature and all diagnosed cases of HCV infection referred for genotpye testing on routine basis were included (non-probability purposive sampling). Results of individual patient were duly informed and consent was taken for enrollment for analysis of consolidated results. We did not use any sample size calculation formula or pilot study to calculate the sample size. Data collected over a period of six years (Jan 2010 to December 2015) were analyzed. Study design was approved by the hospital ethical committee. HCV RNA was extracted and reverse transcribed to synthesis cDNA that was further subjected to nested PCR for detection of HCV viral RNA. The multiplex PCR genotyping for HCV was done only for the samples with detected HCV-RNA. Results:A total of three thousand eight hundred and eighteen (n=3818) HCV positive adults of both genders were screened for genotype testing during the period. Age and gender distribution in the study sample is summarized in table 1. Most frequent genotype identified in our study was genotype 3, accounting for 95.8% (n=3657) of HCV positive cases. The second most common genotype was Type 1 accounting for 2.9% (n=109) of HCV positive cases. Other genotypes were Type 2 (0.3%, n=12) and Type 4 (0.1%, n=5). Mixed genotype (Type 1 and 3) were detected in almost 1 % (n=35) of cases. We did not find genotype 5 and 6 in our study sample. No significant difference was observed among males and females in genotype distribution (P>0.05). Results are summarized in table 2 and 3. Table 1: Age and sex distribution

Table 2: Frequency of genotype in study sample

Table 3: Gender Based stratification

DiscussionHCV reported to exhibit high genetic diversity, characterized by regional variations in genotype prevalence. This poses a challenge to the improved development of vaccines and pan-genotypic treatments, which require the consideration of global trends in HCV genotype prevalence. Situation in Pakistan is even worse where published data is scarce and most data are based on relatively smaller sample size leaving a big question mark for the significance of the results published by these authors. It has been reported that Pakistan seems to have high prevalence of hepatitis C virus type 3.[17] About 10 million Pakistani population is infected with Hepatitis C virus (HCV). The prevalence is even more pronounced among high risk population.[18] In this study, we gathered dataover the period of six years and a total of three thousand eight hundred and eighteen (n=3818) HCV positive adult of both genders were screened for genotype testing during this period. Our results showed that Most frequent genotype identified in our study was genotype 3, accounting for

GENDER

n

MEAN AGE (YEARS)

STD. DEVIATION

MALES

1732

(45.4%)

39.6

12.2

FEMALES

2086 (54.6%)

41.1

10.7

TOTAL 3818 (100%)

40.4 11.4

HCV GENOTYPE

FREQUENCY PERCENT

TYPE 1

109 2.9

TYPE 2

12

0.3

TYPE 3

3657 95.8

TYPE 4

5

0.1

MIXED TYPE 1 AND 3

35 0.9

TOTAL 3818 100.0

GENDER

TOTAL

P-VALUE

CHI-SQUARE

HCV

GENOTYPE

MALES

FEMALES

TYPE 1

59

50

109

0.464

54.1%

45.9%

100.0%

TYPE 2

5

7

12

41.7%

58.3%

100.0%

TYPE 3

1650

2007

3657

45.1%

54.9%

100.0%

TYPE 42 3 5

40.0% 60.0% 100.0%

MIXED TYPE 1 AND 3

16 19 35

45.7% 54.3% 100.0%

TOTAL1732 2086 3818

45.4% 54.6% 100.0%




95.8% (n=3657) of HCV positive cases. The second most common genotype was Type 1 accounting for 2.9% (n=109) of HCV positive cases. No significant difference was observed among males and females in genotype distribution (P>0.05). Our results are comparable with one of the largest sample sized study conducted in Pakistan. Attaullah S et al,[19] reviewed 34 published papers (1996-2011) related to prevalence of HCV genotypes/serotypes and subgenotypes in Pakistan. HCV genotype/s distribution from all 34 studies was observed in 28,400 HCV infected individuals in the following pattern: 1,999 (7.03%) cases of genotype 1; 1,085 (3.81%) cases of genotype 2; 22,429 (78.96%) cases of genotype 3; 453 (1.59%) cases of genotype 4; 29 (0.10%) cases of genotype 5; 37 (0.13%) cases of genotype 6; 1,429 (5.03%) cases of mixed genotypes, and 939 (3.30%) cases of untypeable genotypes. Genotype 3 occurred predominately in all the provinces of Pakistan. Second more frequently genotype was genotype 1 in Punjab province and untypeable genotypes in Sindh, Khyber Pakhtunkhwa and Balochistan provinces. The apparent differences from the current study (78.9% vs 95.8%) may be explained by the changing trends over time. They reported data gathered till 2011 while we gathered data from 2010 to 2015. The difference may also be attributed to the geographical difference. We published data exclusively of Rawalpindi/Islamabad region and they reviewed data of whole of the country. Inherent heterogeneity of data problems in such kinds of systematic review may also be attributed to the apparent differences in the results these two studies. However, the trends are generally similar. Hussain A et al,[20] reported the frequency distribution of HCV genotypes in a tertiary care centre of Karachi, the largest metropolitan city of Pakistan, where people of all ethnic origins are found. HCV genotyping was performed on a total of 457 patients who tested positive for presence of Hepatitis “C” viral RNA. The most prevalent genotype was type 3 with 392 (85.8%) cases, followed by type 1 with 51 (11.2%) cases. Our results are also comparable with other numerous studieswhere genotype 3 reported asremain the most prevalent subtype infecting people in Pakistan.[21-35]When we compare our results with global prevalence data we found them comparable with Messina JP et al,[36] who in their large meta analysis included 1,217 studies in our analysis, representing 117 countries and 90% of the global population. They found HCV genotype 1 is the most prevalent worldwide, comprising 83.4 million cases (46.2% of all HCV cases), approximately one-third of which are in East Asia. Genotype 3 is the next most prevalent globally (54.3 million, 30.1%); genotypes 2, 4, and 6 are responsible for a total 22.8% of all cases; genotype 5 comprises the remaining <1%. While genotypes 1 and

3 dominate in most countries irrespective of economic status, the largest proportions of genotypes 4 and 5 are in lower-income countries. In another study by Petruzziello A et al,[37] who reviewed HCV prevalence and genotypes distribution worldwide reported HCV prevalence is estimated at 2.5% (177.5 million of HCV infected adults), ranging from 2.9% in Africa and 1.3% in Americas, with a global viraemic rate of 67% (118.9 million of HCV RNA positive cases), varying from 64.4% in Asia to 74.8% in Australasia. HCV genotype 1 is the most prevalent worldwide (49.1%), followed by genotype 3 (17.9%), 4 (16.8%) and 2 (11.0%). Genotypes 5 and 6 are responsible for the remaining < 5%. In summary, the most common type found in the region of Rawalpindi/Islamabad was genotype 3 over the study period. The results are comparable with other regions of Pakistanindicating that genotype 3 is the most prevalent genotype in the country. The good news is among all viral genotype 3 has shown to be a good responder to interferon therapy. HCV infection is becoming a public health issue in Pakistan and enormous efforts need to be done by public health authorities to educate the general population about the prevention and importance of early detection and start of curative therapy. The disease is generally affecting the poor masses and entails higher budget allocations for from the government for prevention and control. Centralized infectious diseases data registry system is needed which would pave the way towards effective control of the disease in Pakistan. Conclusion:The most common type found in the region of Rawalpindi/Islamabad was genotype 3 followed by genotype 1 as the second most common type. Our results are comparable with other regional and global studies. We recommend centralized infectious diseases data registry system which would pave the way towards effective control of this disease in PakistanReferences1. Cooke GS, Lemoine M, Thursz M, Gore C, Swan

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AWARENESS OF PROBLEMS DUE TO MENSTRUATION IN SCHOOL GOING GIRLS-HYDERABAD SINDH

1Health Services Academy Islamabad2Liaquat University of Medical and Health Sciences JamshoroCorrespondence: Shama Nawaz. Email: [email protected]

1, 1 2Shama Nawaz Rozina Khalid and Nandlal Serani

Original Article

Abstract

Background: Menstruation is a major stage of puberty in girls, one of the many physical signs that a girl is turning into a woman. Women having better knowledge about menstrual hygiene and safe practices are less vulnerable to RTI and its consequences. Therefore, increased knowledge about menstruation right from childhood may escalate practices and may help in mitigating the suffering of millions of women. This study carried out to gather information regarding menstruation, hygiene related practices and its related problems among adolescent girls along with to review perceptions, belief and expectations regarding menstruation among adolescent girls.Methods: A Cross-sectional study was conducted,314 girls of 12 to 15 years were identified as sample from 5 girls high schools. Pre tested pre designed questionnaire was used. Data were analyzed by using SPSS (Version 22). Descriptive statistics used to determine mean age of the subjects, age at menarche, frequency of menstrual disorders and activities affected by this condition. Results: Mean age of the sample was 14.25 years, with mean age of menarche 12.6 years. 52.6% of the girls belong to the mothers who are illiterate. 50.7% girls were aware of menstruation before menarche with major source of the information is mother (71.2%). 97.8% perceived menstruation as a normal process. 55.1% participants said they missed their school during menstruation. 96.4% experiencing pain and cloth was most common source of absorbent used by 60.2%. Conclusion: Mothers are the main source of information for young girls. Major reason for absenteeism from school was fear of stain, it has been suggested through cleanliness available for changing absorbent (pad/cloth) the ratio of absenteeism can be reduce. Keywords: menstruation, hygiene, puberty, perception

Introduction:Childhood to adulthood transition takes place during adolescence period which is characterized by major biological changes like physical growth, sexual maturation, and psycho-social development. As per World Health Organization (WHO), adolescence is the age group of 10-19 years and currently makes up 18 % of the world's population . It is marked by enhanced food requirement, increased basal metabolic and biochemical activities, endogenous processes like hormonal secretions with their influence on the various organ systems of which menarche is the most important event in case of adolescent girls that requires specific and special attention . It marks the beginning of woman's menstrual and reproductive life which occurs between 11 and 15 years with a mean of 13 years. It is qualitative event of major significance in woman's life, denoting the achievement of major functional state.Even though menstruation is a natural process, it is linked with several misconceptions, complex societal stigmas, fears, and malpractices which may result in

undesirable health outcomes. In one study it was viewed as an event that happens to girls during puberty occurring monthly where the body gets rid of spoiled blood. However, girls who had information about menstruation before menarche had a positive attitude.Poor hygiene during menstruation has been associated with serious il l-health, including reproductive tract and urinary tract infections. During menstruation, girls experience different feelings including fear, shame and guilt because of lack of prior information about menstruation. A study done among Nigerian secondary school girls revealed that adolescent girls gave different meanings to menstruation and perceived it as physiological process, as an assurance of fecundity, and as a release of bad blood.Repeated use of unclean cloth, and improperly dried cloth, before its reuse results in harboring of micro-organisms resulting in the spread of vaginal infections among adolescent girls (Paul 2007).During menstruation, girls experience different

Problems due to Menstruation in School Going Girls


Shama Nawaz, Rozina Khalid & Nandlal Serani


feelings including fear, shame and guilt because of lack of prior information about menstruation.Women having better knowledge about menstrual hygiene and safe practices are less vulnerable to RTI and its consequences. Therefore, increased knowledge about menstruation right from childhood may escalate practices and may help in mitigating the suffering of millions of women. With this in mind, the present study was carried out to gather information regarding menstruation, hygiene related practices of menstruation, and its related problems among adolescent girls along with to review perceptions, belief and expectations regarding menstruation among adolescent girls.MethodologyCross sectional study was conducted in girl's schools of taluka Qasimabad – Hyderabad District from Oct 2015 to Dec 2015. The data for eligible schools was obtained from the District Education Office, Hyderabad. Total registered girls of 12- 15 years in high schools of taluka Qasimabad was 349. Absent 13, parents of 22 girls did not give consent. 40 girls were excluded as they had not experience menstruation yet. Therefore 274 girls were identified as sample and interviewed through pre designed self-administered questionnaire after taking ethical approval from HSA, D.E.O Hyderabad, head of the schools and girl 's parents. For the ease of participants, main tool (questionnaire) was translated into local language (Sindhi). Tool was pre tested and necessary changes were made.The data were analyzed by using SPSS version 22.0.Results:In this survey the total sample was based on the female sample size falling in different ages.Figure 1. Percentage of respondents Please caption at the bottom of the figures

The survey covered total 274 girls of12 – 15 years age. Mean age of the sample was 14.25. out of 274 girls 18(6.6%) were of 12 years old, 39(14.2%) were of 13 years old, 71 (25.9%) were of 14 years old, and 146 (53.3%) were of 15 years old.Half of the girls out of 274 belongs to illiterate mothers i-e 144(52.6%).while 44(16.1%) with primary,

23(8.4%) with middle, 33(12%) with matric and 15 girls i-e 5.5% belongs to mothers having intermediate education. Only mother of 6 and 7 girls have graduation and post-graduation degree respectively. And 2 girls were not aware of their mother's education level

Figure 2. Percent distribution of mothers' education

Mean age of menarche among the sample was identified as 12.6 years. While most of the girls experience their first menstruation between the ages of 12 to 13 years. Only 3 experience it at the age of 10 years and 7 at 15 years of age.Table – 1: First Menstruation

Hundred thirty nine (139) girls i-e 50.7% were aware of menstruation before they had started menstruating while 135 girls i-e 49.3% had no prior knowledge about it.Chart – 3 Aware of Menstruation

First Menstruation

(Age)

Number Percentage (%)

10.00 3 1.111.00 21

7.7

12.00 101

36.913.00 110

40.114.00 32 11.715.00 7 2.6Total 274 100.0




Figure 4: Source of Information

Out of 274, 216 (78.8%) participant responded that during their periods their routine activities are affected and they did not perform as they perform during other days of month, while 53 (19.3%) said menstruation does not affect their routine activities.5 participants did not give any response.

Table – 2 Routine Activities

151 (55.1%) out of 274 participant said yes they missed their school while 121 (44.2%) said no. 2 (0.7%) participants did not give any response.

Chart – 5 absent from School

Out of 274, 151 participants who were asked the reasons of their absenteeism; majority that is 76

(50.4%) responded that due to fear of stain on their cloth they avoid to go to school during the days of menstruation. 49 (32.4%) said due to menstrual pain, 16 (10.6%) said due to heavy bleeding, 4 (2.6%) said due to lack of cleanliness of toilets in school, 3 (2%) said due to lack of water in school toilets while 3 (2%) did not give any response.86 (31.4%) experience nausea, 34 (12.4%) vomiting, 105 (38.3%) headache, 16 (5.8%) participant said they fainted sometime during their periods. 21 (7.7%) responded they experience symptoms other than these while 12 (4.4%) participants did not give any response.

Table – 3 Associated Symptoms

Different females use different sort of absorbent according to their culture and family background. Majority 165 (60.2%) participant during this survey are using cloth while sanitary pad is second most common type of absorbent used by 102 (37.2%) participant. Other rare type used is cotton by 4 (1.4%), 1 participant was using some other type while 2 (0.7%) did not give any response.

Figure 6 Absorbent Use

According to literature using home remedies to relieve pain is a very common practice, but when participant were asked about home remedies only 36 (13.1%) said they have used home remedies and majority 200 (73 %) said they never used any home remedy to relieve the pain and 38 (13.9%) did not give any response.

Routine Activities

Number Percentage

(%)

Yes 216 78.8

No 53 19.3

No Response

5 1.8

Total 274 100.0

Associated Symptoms


Nausea 86

31.4

Vomiting 34

12.4

Headache 105 38.3Fainting 16

5.8

Other 21

7.7No response 12 4.4Total 274 100.0




Table – 4: Home Remedies

DiscussionThe onset of menstruation is a life changing incident for girls across the world. The present survey was conducted with the aim to assess the prevailing knowledge of young school going girls about mens t rua t ion re la ted p rob lems and the i r management. Young people in Pakistan have very limited knowledge about sexual and reproductive health, and majority of them have different misconceptions. The level of educational of both parents and the sources of information about menstruation significantly associated with pre-menstrual training. Girls whose parents especially mothers are educated and those whose mothers are their main source of information are better aware of the problems associated with menstruation and menstrual hygiene. Mother is the first to whom children start to learn on their early stage, especially girls. If the mother is educated she can train their children much better especially regarding hygiene. So the level of education of mother is very important for girls in order to maintain their menstrual hygiene. Our studies reveals that 52.6% girls belong to illiterate mother while others belong to educated mothers.Though it is desirable to have school teacher or health worker to be the first source of information ensuring that right knowledge has been imparted, it was seen during this study that major source of information in the study was mother (71.2%) followed by sister 16.4% and friends (10.6%).This survey also find that 139 girls i-e 50.7% were already aware of menstruation before they had started menstruating through different source of information which is almost similar with observations i-e 45.5% made by a study conducted in East Delhi on awareness and practices of menstruation and pubertal changes amongst unmarried female adolescents, while other study reported lower levels of awareness (28%). These variations can be due to the different regions surveyed and differences in the socioeconomic status and literacy status of the study subjects in the respective studies.Interestingly, the source of information for about 195 (71.2%) girls was mother who first told them about menstrual periods and menstruation in the survey. This shows healthy sign of the society where the

relat ion of mother and daughter are more comfortable. As we earlier discussed that most of the mothers have no schooling in their life so it can be assume that they have limited knowledge and information about the menstruation. There are different perceptions of different people about menstruat ion. Faulty percept ions or misconceptions on menstruation and menstrual cycle will lead to faulty menstrual practices. Either of these may engender reproductive health problems.97.8% subjects included in this study perceived menstruation as a normal process while only 2.2% thinks it's not normal, and perceived it something else. Whereas one of the study conducted in turkey on perception about menarche and menstruation reveals that 64.2% females perceived their menarche as an unfavorable experience. 48.8% of them felt they had to keep their menstruation as a secret, and 2.2% believed that menstruating was a curse given by God.Taking regular bath and keep one's own self clean is important hygienically. Majority of sample were taking bath during their menstrual period while observation of similar type of study conducted in urban Karachi reported that nearly 50% of the participants reported that they did not take baths during menstruation.The reason for not taking bath was revealed during the survey that few participants were restricted by their mother from taking bath while others herself perceived that it is harmful for their health if they take bath during menstruation, these findings are similar which were observed during FGD conducted in Karachi that taking bath during menstruation was harmful to their health, as it actually causes fevers, backaches, an increase in menstrual pain and abdominal pains, while one study reveals entirely opposite finding that only 1.6% avoided bathing during menstruation.It has been noted from the survey finding that big junk a major portion of 78.8% participant responded that during their periods their routine activities are affected and they did not perform as they perform during other days of month and it is also observed by other study that daily routine of 60% girls was affected, they missed social activities and commitments, disturbed sleep and decreased appetite. 17.24% were fail to attained class and 25% had to abstain from work.It is also revealed from the survey that menstruation and related problems can affect school attendance and performance of young girls. This is why participants were asked during survey that did they ever missed their school due to menstruation or its related problems. 55.1% of participant said yes they missed their school due to menstruation while 44.2% said no. Moreover, when they asked with the option to provide the reason of absent, 50.4% responded that due to fear of stain on their cloth they avoid to go to school during the days of menstruation. 32.4% said due to

Home Remedies


Yes 36 13.1No 200 73.0No Response

38 13.9

Total 274 100.0




dysmenorrhea10.6% said due to heavy bleeding, 2.6% said due to lack of cleanliness of toilets in school. While In the study done by Desalegn Tegabu Zegeye et al, dysmenorrhea was the leading cause of short-term school absenteeism which is about 48.8% and more female students with moderate to severe dysmenorrhea (68%), as compared to mild (43.4%) were absent from school because of the pain.It was seen in present study that 60.2% used cloth as absorbent and 37.20% used sanitary pads which is similar to the findings of other study that74.8% of the girls used homemade sanitary pads, nearly 24% used ready-made sanitary pads, while 1.5% used cotton wool [ ]. Whereas in other similar type of study conducted it was found that sanitary pad was used by 73% girls, Cloth by 22%, other nonspecific absorbents by 5%. The use of cloths was higher which was probably due to the fact that pads were not in the reach or not affordable by majority of respondents as they belong to low socio economic families. It was observed that the usual practice was to wash cloth with soap and water after use and dry it at some secret place like house corner. To keep the clothes away from curious eyes, they are hidden in some unhygienic places. Privacy for washing, changing or cleaning purpose is something very important for proper menstrual hygiene. During one of the study 92% of the girls were restricted from worshipping, 70% were limited from participating in household activities, and 56% girls did not eat oily, cold, or spicy foods such as pickles during menstruation [ ]. As compare the restriction revealed during our study were like 62.4% girls were restricted to perform routine work and 55.1% were restricted to attend the school, possibly due to ignorance and false perceptions regarding menstruation. The reason for this may not be due to lack of prior knowledge regarding menstruation, but may be due to inadequate or wrong knowledge and low levels of education especially among the mothers.Type of remedies used by participants were observed to be 22.3% participants was drinking warm milk, 4(11.2%) were using boil egg, 8.3% using hot water massages and phakki respectively, 2.8% were using self-medication and zorr while 14 participants did not give any response.ConclusionKnowledge is an important factor, with adequate menstrual knowledge the girls will be able to cope with the important menstrual health related issues. Mothers are the main source of information for young girls. In any society, education plays a vital and key role for the development of human behavior and to understand the main issues of the society. It has been noted that in current survey though provide the education but still a part of quality education including menstrual and reproductive education is missing. Major reason for absenteeism from school was fear of

stain, it has been suggested that make necessary arrangement, including cleanliness available for changing absorbent (pad/cloth) the ratio of absenteeism can be reduce.

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sowc_2011_main_report_en_02092011.pdf

2. Abeer E, Houaida H, Wafaa E: Menstrual attitude and knowledge among Egyptian female adolescents. J Am Sci 2012, 8(6):555-565.

3. dasgupta a, sarkar m: menstrual hygiene: how hygienic is the adolescent girl.indian j community med 2008, 33(2):77-80. &prateek s, saurabh r: a cross sectional study of knowledge and practices about reproductive health among female adolescents in an urban slum of mumbai. j famreprod health 2011, 5(4):117-124

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5. Adinma B, Echendu D: Perceptions and practices on menstruation amongst Nigerian

secondary school girls.Afr J Reprod Health 2008, 12(1):74-83.

6. oche m, umar a, gana g, ango j: menstrual health: the unmet needs of adolescent girls' in sokoto, nigeria. sci res essays 2012, 7(3):410-418

7. s sangeetha balamurugan, a community based study on menstrual hygiene among reproductive age group year:2014,volume 3; issue 2:83-87

8. UZOCHUKWUUZOMAANIEBUE ET AL,THE IMPACT OF PRE-MENARCHEAL TRAINING ON MENSTRUAL PRACTICES AND HYGIENE OF NIGERIAN SCHOOL GIRLS; THE PAN AFRICAN MEDICAL JOURNAL. 2009;2:9. OI:10.11604/PAMJ.2009.2.9.48

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CHALLENGES OF HOSPITAL PREPAREDNESS IN DISASTERS IN BALOCHISTAN

1Department of Community Medicine Quetta Institute of Medical Sciences Quetta. Balochistan

2Sarhad University Islamabad CampusCorrespondence: Tabinda Zaman. Email: [email protected]

1 2 2 2Saleem ullah , Noureen Latif , Ali Nasre Alam , Tabinda Zaman ,

Original Article

IntroductionDue to unique geo-climatic conditions Pakistan is one of the most disaster prone countries in the world [1]. Besides the major threats of terrorist act due to instability in neighboring Afghanistan, our 40% of landmass is vulnerable to earthquakes, 6% to cyclones, 60% to floods and 25% of the Barani land under cultivation is vulnerable to drought [2]. 21st Century of seeing the skeptic social well being has witnessed an increase in low intensity conflicts. These conflicts are taking shape as man made disasters causing casualties and dislocation of various services which require to be restored not only to normal life pattern but also to bring down panic reaction at its lowest [3].Hospital would be among the first institution to be affected after natural or man made disasters. Because of the heavy demand placed on their services at the time of a disaster, hospitals need to be prepared to handle such an unusual workload [4]. Whenever a health care facility is confronted by a situation when it has to provide care and save lives of large number of patients in a limited time, which is

beyond its normal capacity, infrastructure, trained manpower and organization, the hospital can be said to be in disaster. The situation and additional contingency measures are required to control the event. When disaster strikes the society falls back upon the hospitals and they are required to provide immediate services in the form of emergency medical care. An event may have a problem for a smaller hospital and not so far a bigger hospital. Therefore disaster for a hospital is a temporary lack of resources which is caused due to sudden influx of unexpected patient load. So it is quite logical for hospitals to be prepared to deal with disasters. This necessitates a well documented and tested disaster management plan with regular test drills. Not only do these procedures allow for an organized response to a disaster but also allow for an ongoing process of quality improvements since these are the standards against which performance can be measured. It is essential to formulate a process plan which must be unique to specific situation in various types of disaster. Hospitals capacity and enhanced r e q u i r e m e n t o f p o w e r, w a t e r, f o o d a n d

Background: Unique geo-climatic conditions, natural calamities, political conflicts and skeptic social wellbeing with frequent acts of terrorism has made Balochistan more prone to disasters. The hospitals need to be prepared to save lives of large number of patients in a limited time.Objective: The purpose of this study was to identify the challenges faced by Publichospitals of Balochistan while preparing to deal with mass casualty incidents. Methods: A cross sectional descriptive, exploratory methodology was applied to study. Ten hospitals were selected on the basis of capability and locations so as to cover all regions of the province. An opinion survey and few semi structured informal interviews were also conducted with key hospital personnel. Questionnaire was based on standards specified by WHO on the subject .The study was completed in one and half year period.Results: Health sector in Balochistan is generally mismanaged and poorly developed where majority of population is deprived of healthcare facilities. People mostly rely on the trauma management facilities of military hospitals in emergency situations. Study revealed that 80 percent of the hospitals were without any formal written plan. Major weaknesses observed were regarding training of staff, mental health services, hospital networking, security of facility, and lack of an organized system of pre-hospital management of casualties.Conclusion: There is dire need of establishment of central command and crisis control system especially for Quetta city in case of disaster. Starting a prehospital care rescue service such as 1122 is needed. The Security issues of health care facilities should be dealt with in view of the threat perception and possible tactics adopted by terrorists nowadays. Thus a workable plan is required which needs review and refinement after each drill or crisis situation to meet the challenges of timely and efficient medical response.Keywords: Hospital preparedness, disaster drills, medical response, pre hospital care, disaster Plan.

Abstract

Hospital Preparedness in Disasters in Balochistan


Saleem ullah, Noureen Latif, ali Nasre Alam & Tabinda Zaman


Table 1: Organizational Framework for high emergency care response

Sr.No No(%)1 Awareness about emergency response 6 (60)2 Training of staff 2 (20)3 Management of incident command center 3 (30)4 Drills 2 (20)5 Behavioral health care 1 (10)6 Hospital utility services maintenance

4 (40)7 Maintenance of water & power supply 5 (50)8 Transport Arrangements for Patient Transfer 7 (70)9 Emergency supply of medical and non-medical materials 4 (40)10 Decontamination system 2 (20)11 Fatality Management 6 (60)12 Triage system 2 (20)13 Maintenance and Repair of Medical Equipment 3 (30)14 Fire Safety Plan 4 (40)

natural disasters, biological and chemical warfare, exp los ive incend ia ry te r ro r i sm inc iden ts , collaboration with outside organizations like public health department and emergency medical services like 1122, Edhi Ambulance, Chipa, Alkher, fire departments, civil defence, law enforcing agencies. The key hospital personnel should be trained to implement a formal command system, which is an organized procedure for managing resources and personnel during an emergency. The concern has been voiced about our health care system's ability to respond in disasters, there is both regional variability and variability in preparedness for specific types of events [6].In Pakistan disaster management is viewed in isolation from the process of main-stream development. Within the disaster management organizations there is lack of knowledge and information on hazard identification, risk assessment and management. The linkages between various organizations and bodies are faulty. Disaster management policie,e generally not influenced by methods and tools for cost effective and sustainable interventions. It is imperative to develop a national disaster management strategy in which the roles of all key players should be identified and ensured [7].Methodology:This was a cross sectional descriptive study done to explore the challenges of establishing a workable hospital disaster plan to help the hospitals dealing with disaster preparedness. Sample size was 10 hospitals in Balochistan. Sampling technique used for data collection was structured questionnaire. Questionnaire was developed on the basis of guidel ines and in ternat ional protocols for preparedness of disasters according to the criteria of accreditation of health care organizations and the

personnel discussions with the various experts in disaster management. I t contained mainly dichotomous items. Questionnaire was pretested at 2 hospitals and after some amendments, it was finalized for data collection.Study setting and location were government hospitals of Quetta and other parts of Balochistan. The schematic plan for the selection of hospitals was as follows: 1) Firstly, the hospitals were grouped on the basis of the number of beds available to patients for treatment as an indoor patient. They were classified into two categories, a) Hospitals with bed capacity of more than 100 beds. b)Hospitals with bed capacity less than 100 beds. 2) Secondly, the hospitals with less than 100 beds capacity were further divided/segregated on basis of their location so as to represent almost all the areas of the province.Key hospital's technical staff dealing with the planning decisions in case of emergency situation, its execution monitoring and evaluation (like CEO'S / Medical superintendents) was selected for data collection. Study duration was one and half year (January 2015 to August 2016). Data was coded and then analyzed by using SPSS 20 version.

ResultsA total of 10 hospitals from different locations of the province were selected and following results were found out.Levels of hospital preparedness for disasters within the hospitals of Balochistan were shown in the table-2. Majority of these hospitals had available infrastructure and manpower, few hospitals had reported that they were involved in conducted the regular trainings, rest of the hospitals had very limited existence of disaster plan, process and material regarding the disasters preparedness




Table 2: Level of Hospital Preparedness for Disasters in Balochistan.

HOSPITAL

Disaster Plan

Process

Manpower

Material

Training

Hospital Infrastructure

Bolan Medical Complex Hospital Quetta (Beds.861)

0%

0%

35%

40%

0%

20%

SandemanProvincial

(Civil) Hospital Quetta (Beds.780)

30%

20%

30%

40%

10%

20%

DHQ Hospital Loralai (Beds.200)

10%

0%

25%

25%

10%

5%

DHQ HospitalKhuzdar (Beds.150)

15%

10%

20%

25%

5%

20%

DHQ Hospital Turbat (Ketch)(Beds.128)

0%

25%

60%

45%

10%

50%

DHQ Hospital Sibi (Beds.100)

0%

15%

20%

20%

0%

20%

DHQ Hospital Zhob (Beds.50)

0%

5%

60%

50%

10%

70%

DHQ Hospital Panjgore (Beds.50)

0%

15%

60%

25%

5%

75%

DHQ Hospital Gwadar (Beds.35)

10%

5%

60%

40%

10%

50%

Rural Health CentreNukandai (Beds.20)

0%

15%

60%

20%

0%

20%

Regarding relative severity on disaster preparedness within the hospitals. Most of the hospitals were found that they had very high vulnerability of various

hazards. However, others hazards had high, medium, low and very low vulnerability for disaster reporting.Table 3: Relative severity of various hazards per district




S.No

District

Bomb Blast/

Terrorism E

arth

qu

ake

Flo

od

s

Dro

ug

ht

Cy

clo

nes

Co

mm

un

icab

le

dis

ease

Fir

e

Tsu

nam

i

Lan

dsl

ides

Lo

cust

s/ P

ests

Ind

ust

rial

&

Min

es A

ccid

ents

Tra

nsp

ort

A

ccid

ents

Ref

ug

ees

& I

DP

s

Co

mm

ents

1

Awaran

-

3

2

3

-

-

-

-

-

-

-

-

-

-

2

Bolan

3

2

5

3

-

-

-

-

-

-

2

2

-

-

3

Barkhan

2

1

2

-

-

-

-

-

-

-

-

-

-

-

4

Chaghi

1

1

4

3

-

-

-

-

-

-

1

-

-

5

DeraBugti

3

1

1

3

-

-

-

-

-

-

-

-

-

-

6

Gawadar

1

3

5

2

-

-

4

-

-

-

-

-

-

7

Harnai

-

-

-

-

-

-

-

-

-

-

-

-

-

-

8

Lehri

-

1

3

3

-

-

-

-

-

-

-

-

-

-

9

Sohbatpur

2

2

2

1

1

10

Jafferabad

-

-

1

-

-

-

2

-

-

1

-

-

-

-

11

JhalMagsi

-

-

2

3

-

-

-

-

-

-

-

-

-

-

12

Killa Abdullah

-

3

1

1

-

-

-

-

1

-

-

2

2

-

13

KillahSaifullah

1

3

2

1

-

-

-

-

-

1

-

-

-

-

14

Kohlu

2

1

2

3

-

-

-

-

-

-

-

-

-

-

15

Kharan

4

-

2

4

2

-

-

-

-

-

-

-

-

-

16

Kalat

3

4

2

2

-

-

-

-

-

1

-

1

-

-

17

Khuzdar

3

4

3

3

-

-

-

-

-

-

-

2

-

-

18

Kech

2

2

4

4

-

-

-

-

-

2

-

-

-

-

19

Lasbela

1

1

4

2

-

-

-

2

-

2

-

2

-

-

20

Loralai

1

4

3

3

-

-

-

-

-

1

-

1

-

-

22

Mastung

4

5

2

2

-

-

-

-

-

1

-

1

-

-

22

Musakhail

1

4

2

3

-

-

-

-

-

-

-

-

-

- 23

Naushki

2

1

2

4

2

-

-

-

-

-

-

1

-

-

24

Nasirabad

-

-

2

2

-

-

2

-

-

2

-

-

-

- 25

Panjgur

3

2

2

-

-

-

-

-

-

3

-

-

-

-

26

Pishin

-

5

2

1

-

-

-

-

-

2

-

-

-

-

27

Quetta

5

5

-

-

-

-

-

-

-

2

2

1

-

-

28

Sibi

3

3

4

2

-

-

-

-

-

-

-

-

-

-

29 Sherani - 3 2 2 - - - - - - - - - - 30 Washuk 1 - 2 4 3 - - - - - - - - - 31 Ziarat - 3 2 - - - - - 2 2 - - - - 32 Zhob 1 4 2 2 - - - - - 1 - - - -

Vulnerability levels of various hazards per district in Baluchistan province

SCORING KEYS

Very High 5 High 4 Medium 3 Low 2 Very Low 1 None -




DiscussionLike other regions of our country Balochistan is also facing disaster problems most of which are bomb blast / terrorism, earthquakes, floods, droughts, communicable diseases, fire and road accidents. Balochistan is the only region in Pakistan which has witnessed a rise in terrorism related fatalities in recent past. The frequency of sabotage incidents in Balochistan especially those related to bomb-blast, landmines, hand grenades, rocket fire is common in districts of Quetta, Mastung, Kharan, Sibi, Bolan, Khuzdar, Panjgur, Kalat, DeraBugti, Kohlu, Noshki and Lasbela[8,9]. study revealed that disaster preparedness plan was held in only 20 percent of the hospitals, lying without any implementation thus not helped in identifying the lack of resources which can be rectified before an emergency occurs. 80 percent hospital has not formulated an standing operative procedure for triage. Plan also lacks important aspect of coordination with other stake holders like PDMA,civil defense and army who can contribute significantly during mass casualty incidents. Hospi ta ls have Poor ly organized secur i ty arrangements despite past precedents. Job action plan was held in 50percent of the hospitals, shown only routine duties and not the essential part of multi role duties in case of unforeseen emergency situation. Similarly 80 percent of the hospitals not held disaster committees except two hospitals of Quetta city which lacks trained doctors, staff and availability of essentially required medical equipment. In trauma settings anessential element of the presence of multidisciplinary surgical team consists of specialists, well trained thoracic, ,vascular and , neurosurgeon was also found deficient. Balochistan is also lacking a burn centrewhich should be an integral part of a tertiary care hospital to provide life saving treatment to burn patients of bomb blast incidents and also give health care coverage to other burn patients of Quetta and far off places of Balochistan. Identification of dead bodies in mass casualty incidents especially dueto bomb blasts is problematic and time consuming procedure which required refrigerated mortuary arrangements and DNA testing facilities which have been lacked by almost all hospitals in Balochistan. Awareness about emergency response has been a situational factor as the staff mostly gained their experience out of frequently occurring mass casualty incidents in Balochistan. Hospital staff must be aware of the hospital environment, action / roles regarding emergency evacuation, use of equipment for calling staff, special alarms, phone lines for all departments, special exits, drills, hospital facilities, water, electricity, gas supplies and contingency resources. The lack of awareness about a disaster plan is quite alarming, as lack of required knowledge would lead to inability to manage disaster even if there is written plan [9]. The training aspect is found totally lacking specially

the planned simulator exercises / drills. The implementation of plan in coordination with other stakeholders is completely ignored. Disaster response requires a unique set of capabilities related to knowledge, skills and abilities. The disaster care competencies are intended to establish a baseline of knowledge for all levels of hospital personnel. This will enable staff in assigned disaster roles to function efficiently and effectively during emergency situations. Therefore, hospital staff is required to be trained on competency based strategy of training in capabilities based planning process to define specific activities in order to achieve the mission [10]. Disaster drills have been identified as a critical component of preparedness because they allow the institutions to test response capabilities in real time. Evaluation of those activities is essential to understand the strength and weakness of an institution's disaster response [11]. Evaluation is based on accurate observation using a standardized observation and evaluation approach allowing for a consistent record. Using a standardized evaluation also allows comparison between one drill and the next to determine improvement in areas where weaknesses have been identified. There is no concept of management of psycho trauma cases during the recovery phase of disasters in hospitals of Balochistan. The knowledge and acceptance of mental health issues is an integral part of the impact of disaster and the availability of mental health services during and well after the relief operation. The mental health relief plan is an integral part of hospital disaster plan. The plan must dictates the availability of psychological first aid to maximum, early detection, intervention and establishing a chain of referral for the severely effected cases, incorporating psychological care and rational use of psychotropic in medical and surgical care at all tiers of health services. The plan also includes strategies for public mental health education, community mobilization, caring for the relief workers and capacity building of local professionals, PHC physicians, teachers and groups of volunteer workers [12]. Load shedding of power supply is managed by backup generators, which were in functional state in only 50 percent of hospitals. The problems they face is that the generator fuel is not always available and causes a burden on the hospital budget. Hospitals need to be prepared for a potential loss of their water supply and electrical power. Hospital are required to have emergency generators, which must be sized to carry specific electrical loads based on design occupancy and provision of power to critical life safety equipment distribution panel for essential systems [13]. In case of water disruption, the hospital must plan the measures by assessing the response capabilities after conducting a water use audit. In addition to power and water needs, hospitals will also need supplies,




including medical supplies, medications and food. In a worst case scenario not only that the hospital will not be able to receive new shipments of supplies, but there will be an increased demand for medical needs . The joint commissionon accreditation of health care organizations. (JCAHO) mandates that accredited hospitals be able to survive without outside help from the community for up to 96 hours after a disaster [14]. Besides, disaster management in hospitals can be improved by using management systems, such as the Hospital Emergency Incident Command System (HEICS), appropriate organization of administrative assignments ,human resources, and establishing the unity-of-command principle [15-18]. It has been observed that the hospital plans have not addressed the important aspect of disaster drills in any hospital of Balochistan, therefore implementation of plan in coordination with other stakeholders who can contribute in emergency response is completely ignored. It is required that Hospital disaster plans be tested, evaluated at least twice a year by conducing the combined drills with other hospitals, public health and public health engineering departments blood banks, district and traffic police, frontier corps, Army, Ambulance services, Fire services Bomb disposal squad, civil defense PDMA, information department and other public safety and rescue services. [19-21]. Results revealed that hospitals, have not planned and organized participation and training of volunteers to work in emergency Hospitals have sufficient manpower as per their authorized strength but during mass casua l ty inc idents they need more manpower.Therefore hospitals may availthe services of skilled volunteers in an organized manner. Spontaneous volunteers can be a significant resource, but they are often ineffectively used and can actually hinder emergency activities by creating health safety and security problems and distracting responders from their duties. Volunteer service can also be used to augment emergency staff. Using volunteers with basic skills to address common tasks allows responders to focus upon specialized work. There are two major categories of risk associated with disaster volunteer response: 1) the failure to effectively utilize volunteers and 2) the actions of untrained and uncoordinated volunteers. In the first category, the failure of emergency managers to effectively utilize volunteers may create a poor public perception of the disaster response. In the second category, the actions of untrained and uncoordinated volunteers can harm disaster victims, emergency responders, and the volunteers themselves. Volunteers may arrive unequipped and require significant logistical support such as food and shelter. "More effort on the part of a strained system than they contribute to the resolution of the problem" [22-24]. At present the pre-hospital care and on the scene triage service are non existent in Quetta and other towns.

There is no government run ambulance service with trained paramedics for this purpose. However charity / Private Ambulance services work independent of each other and without a central dispatch centre, because of the absence of any disaster response plan. Majority of casualties are directed at their own to two major government run and a military tertiary care hospitals with mass trauma management facilities. Pre-hospital management is the integral part of the preparedness plan. Onsite triage of the victims and coordinated transfer will control the chaotic mismanaged influx of non triaged patients in to the trauma centers of the hospitals. It is further very disappointing to note that all serious casualties received by two major government hospitals of Quetta transferred to military hospital due to poor management, lack of facilities and non availability of staff for adequate standard of patient care at two biggest government hospitals of the province. The major Challenges that hospitals in Balochistan face in mass casualty incidents are Surge Capacity issues. The lack of trained doctors and Staff and non availability of additionally required medical equipment without back up support are the major short comings. Administrative and security concerns also need more emphasis in future policies [23]. The less severely injured patient received at the hospitals without having been triaged and arrived before more severely injured patients. It over whelms the receiving hospital and cause delay in treatment of more critically injured patients. Effective use of hospital resources and request for outside assistance hinges on knowledge of resources available within the institution. Lists of emergency supplies should be available in the Incident Command system (ICS). Stocks of common medicines, cots, and other emergency supplies should be purchased ahead of time in relation to the size and mission of the institution. The facility should have plans to operate and sustain itself for 96 hours without supplies / support from outside the region. Additional beds and flat-space areas should be identified prior to an event. During an event, additional triage and treatment areas needed. The newly arriving patients would require admission for definitive treatment therefore plans should be there to increase the bed capacity when needed. This can be achieved by reverse triage ie by discharging the stable recovering patients and stop admitting non emergency cases. Most of the surge capacity would have been available within 24 to 48hrs in an actual disaster situation. How many and what type of staff are needed may vary by incident. Mechanisms for calling back an appropriate number of staff may include initial, automatic callbacks with subsequent callbacks dependent on staffing worksheets and situational information. Staffing for the next operational period and subsequent staffing needs should be part of the planning process. For supplies




hospitals in a geographic area often depend on same vendors/suppliers. Pre-existing agreements may be needed with additional vendors or with jurisdictional emergency management. The mechanism to request supplies from community private and public partners should be understood and practiced [24-26]. This study has attempted to find out the challenges in preparedness of these hospitals for disaster management. A review of the available resources along-with their mobilization plan has been conceived and presented for meeting the crisis of disaster. The need for addressing the common issues of human resources, training, multi-sectoral coordination, pre hospital care, surge capacity, supplies, and security has been highlighted [27].ConclusionDisasters rarely, if ever are preceded by warning and when they occur the shock effect of devastation or carnage paralyses even the most sane and poised planners. In emergency hospitals are most vital organizations whose preparedness and offering on time service play vital role in reduction of injuries and death. It was seen that only trained staff through effective disaster prepared drills can act quickly to cope with crises situation. To meet the challenges of efficient medical response in disasters the study reiterates the need for addressing the issues of human resources, training, mult i -sectoral coordination , pre hospital care, supplies and security which all can be adopted by viable strategies and with little customized approach.

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7. Terry Fulmer. Organization-based Incident Management: Developing a Disaster Volunteer Role on a University Campus. Disaster Management & Response.2007.;5(3): 74-81

8. M ichae l B rown , Mohammad Dawaod , ArashIranlatab, and Mahmud Naqi, Balochistan Case Study, INAF 5493-S: Ethnic Conflict: Causes, Consequences and Management, June 21,2012, a va i lab le a t www4.car le ton .ca

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12. MuwadatH.Rana.Editorial, Mental Health Care An Integral Part of Disaster Management. PAFMJ, 2006, 56(4): 327-32.

13. OSPHD-Electrical Requirement for Health Care Facilities (2011) Retrieved on 20.7.2013. R e t r i e v e d f r o m h t t p : / / w w w. o s h p d . c a . g o v / F D D / P l a n -Review/electrical.Pdf

14. Board Brief, 2011 - The hospital Boards Role in disaster readiness. Retrieved on 20.7.2013. Retrieved from www.htnys.org//2011-05-17-board brief-disaster-preparedness.pdf

15. Sasuie Abbas Leghari, “The Balochistan Crisis,” News In ternat iona l , August 25 , 2012, www.thenews.com.pk/Todays-News-9-128196-The-Balochistan-crisis.

16. Muhammed Amir Rana, “The Growing Nexus: Ethnic/Sectarian Violence Is Expected to Continue to Be a Long Term Challenge,” News, July 29, 2012.

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http://carnegieendowment.org/files/balochistan.pdf

paper 150, July 2011. 21. Paper No. 286, Integrated Water Resource

Management in Pakistan, Symposium on Changing Environmental Pattern and its impact w i t h S p e c i a l F o c u s o n P a k i s t a n h t t p : / / p e c o n g r e s s . o r g . p k / i m a g e s / u p l o a d / b o o k s / 4 -ergrated%20Water%20Resource%20management%20in%20Pakistan%20%284%29.pdf"Balochistan quake: toll jumps to 825"

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'emits flammable gas'". BBC News. 27 September 2013

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http://www.bbc.co.uk/news/world-asia-24222760





PHYSICAL VIOLENCE AND ITS ASSOCIATED FACTORS AMONG MARRIED WOMEN IN MULTAN, SOUTHERN PUNJAB, PAKISTAN

1Department of College of Nusing, Narwala Road, Kothi Sadat, MarziPura road,Faisalabad, Pakistan2School of Nursing and Midwifery,Aga Khan University Hospital, Karachi, Pakistan.

3Department of Emergency, Aga Khan University Hospital, Karachi Pakistan.

4 Center for Gender Medicine, Karolinska University HospitalN3:06 171 76Solna, SwedenCorrespondence: ShahinaPirani. Email: [email protected]

1 2 2 3 4Shafquat Inayat ,Shahina Pirani , Tazeen Saeed Ali , Uzma Rahim Khan and Josefin Särnholm

Original Article

Abstract

Background: Physical violence is considered as a routine matter and is a neglected issue in the heavily populated society of Pakistan. The study aimed to estimate the physical violence and its associated factors among married women living in the district Multan, a city of Southern Punjab, Pakistan.Methods: A Cross-Sectional study was conducted among 375 married women living in the community of six towns of Multan. The data was collected from March 2013 to May 2013, through a questionnaire, based on the World Health Organization Multi-country Study on Women's Health and Life Experiences of Violence against Women. A univariate and multivariate analyses were recorded.Results: Out of 375 women surveyed, 62.93% reported physical violence.In the univariate analysis, women's age (28-60 years), women's occupation (non-professional,) and family categories, (combined/extended) were found to be significant, at 95% confidence interval (CI). In multivariate analysis, women's employment status, as non-earning (OR; 0.57CI:0.33, 0.98) was significant in last year, and in life time multivariate analysis, husband's nonprofessional status (OR; 1.06; CI: 0.635 1, 0.793) and women's non-earning status (OR; 0.57; CI: 0.33, 0.98) became significant. The combined family system (OR; 1.795, CI: 1.120, 2.878) was found to be significant in multivariate analyses. Conclusion: Physical violence of different forms is considered as a social and cultural norm by intimate partner. There is a pressing need for appropriate mechanisms particularly in primary health care, to identify and deal with physical violenceKeywords: Intimate partner violence, violence against married women, physical violence, associated factors, Pakistan

IntroductionIntimate partner Violence (IPV) is a pervasive human right violation and a serious public health concern. World Health Organization (WHO) defined IPV as "any behavior within an intimate relationship that causes physical, psychological, or sexual harm to those in the relationship and includes acts of physical aggression, psychological abuse, sexual coercion, and various controlling behaviors" (1) (p. 89). It is estimated that, globally one in three women experienced IPV in their life time as well as six out of every ten women experience physical violence in their lifetime from their intimate partners. More than 1.5 million women physically assaulted and 85% of executors are their intimate partners. (2,3)A multidisciplinary study on physical violence by the WHO identified that life time prevalence of physical violence against women ranges between 15- 71 and 4-49% of women reported having suffered serious physical violence from their intimate partners.(4,5)

Although physical violence is prevalent in different forms and setting, however women in developing countries experience higher rates of violence as compared to those in developed countries.6Physical violence is also prevalent among married women in Pakistan and 70-90% of the women are affected by IPV. (6)A study conducted in Pakistan revealed that more than fifty percent (57.6%) women experienced life time physical abuse, while 56.3% reported exposure to physical violence during the previous year. Similarly another study from Pakistan also found that more than 50% women (51%) experienced physical abuse, and 20% of the women experienced or sexual abuse.2 Battered women reported significantly serious health problems, such as: physical (injury, chronic pain, and gastro-intestinal disorders), psychological (depression, post-traumatic stress disorder, and suic ide), and sexual (pelv ic inflammatory diseases and sexually transmitted

Physical Violence and its Associated Factors Among Married Women


Shafquat Inayat, Shahina Pirani and others



a given population at one point, for a short period of time. (14) Furthermore, this design is appropriate for demonstrating association between the factors studied and the outcome of interest, at one point in time (15). It also measures the prevalence and frequency (last week, last month, and last year) of physical violence. A cross-sectional study also helps in providing information on the frequency of the characteristics of concerned by collecting data on both, the characteristics of the interested population and the risk factors(2).In the present study, this research design helped in determining the association of the outcome of interest (intimate partner violence i.e., physical, psychological and sexual) with the relevant factors (socio demographic and economic characteristics). This study was conducted in the community of Multan, a district of Southern Punjab, Pakistan. Multan is situated in the southern part of the province on the east bank of the Chenab River, somehow in the geographic center of the country and about 562 km from Islamabad, 356 km from Lahore and 966 km from Karachi Multan is divided into four tehsils (Multan Cantonment, Multan Sadar, Shujabad and Jalalpur Pirwala) which are further divided into six towns, as follows: 1.Bosan Town, 2. Shah Rukn e Alam. 3. Mumtazabad Town, 4. Shersha Town, 5. Shujaabad Town, 6. Jalapur Town. The rationale for selecting thepopulation of Multan as a study setting was to get married women with diverse socioeconomic and demographic backgrounds. The study setting gave a representation of the overall population of Multan which increased the external validity of the study by confirming the generalizability of the study setting. The selected population of this study was all currently married women, living with their husbands, and residing in the community of district Multan, Pakistan, from 25thDecember, 2012 to 25th February, 2013. Currently married women living with their husbands and residing in the community of district Multan, Pakistan were included in this study while pregnant women (IPV is less reported during pregnancy as compared to marital life time16 were excluded from the study. The sample size was calculated by using the statistical method of Epi Info software version 06. Firstly, the sample size was calculated for frequency/prevalence of IPV by taking physical violence as 57.7%, sexual violence as 54.5%, and psychological violence as 83.6%. This required sample size of 11, 12, and 8 married women, respectively. Secondly, the minimum number of women required to calculate the sample size for associated factors was assessed. The ratio of exposed (husband illiterate and family low SES) to unexposed (husband literate and family high SES) was 1:2. By taking the OR of 2.57 with 95% confidence interval and 80% power the minimum sample size calculated which was found to be 365. A

infections) problems(7). In Pakistani society, physical violence driven by cultural and traditional norms, religious and social institution. Women are considered personal belongings of their husbands and husbands control every aspect of women life even their activities and movements.(4)On account of various studies in the context of Pakistan several factors like socio-demographic disparity, women employment status and family characteristics are recognized as the contributed factors of physical violence.(2,6)Physical violence is considered as a routine matter and is a neglected issue in the heavily populated society of Punjab. In the southern part of this province, women face miserable conditions due to lack of awareness and sensitivity about the plight of women in these male dominated societies.8 Physical violence is wide spread in these areas, and most of the cases remain hidden and unreported, mainly because women have no independent access to the police and judiciary, therefore 70% cases remain unreported and the women remain silent due to the fear of their men's wrath.(8)Several studies worldwide highlighted physical violence and factors associated in respect to establish a holistic approach toward health environment.(9, 10) In Pakistan, a number of studies have highlighted the issue of IPV and its associated risk factors which have affected women's health. (2, 11,12) However, according to researchers knowledge, none of these studies have been conducted on married women living in the community of Southern Punjab (Multan), Pakistan. Moreover, the increasing surge of the violence acts against women in this region indicating an alarming sign, that the population of the city of Multan is different as compared to the rest of the country due to different socio cultural norms.(13) Therefore, the present study aimed to estimate the prevalence and frequency of physical violence and its association with socio-demographic characteristics among married women living in the district Multan, Southern Punjab, Pakistan. This study would be the first of its kind to examine the prevalence, frequency, and associated factors of physical violence among married women living in the communities of Multan, Pakistan. Moreover, the findings of the study can help community midwives, doctors, and nurses to promote awareness about IPV. Finally this study can also serve as the foundation for further research in the same field in the context of Punjab. Methodology: A quantitative research approach along with an analytical cross sectional study design was used in this study to answer the research questions as analytical cross sectional study design is beneficial when one wishes to assess the prevalence of a phenomenon as an outcome of the research topic for




collectors. The content validity index came out as 0.95 for 'relevancy' and 0.99 for 'linguistic clarity' and for reliability computed value of Cohen's Kappa was 0.99. In order to collect the data from Multan's eight union councils simultaneously, eight RAs who were living in the same locality were hired. The research assistants were trained by the PI and the research supervisor for a week, which included two days of official training, followed by three days of field training. Before starting the formal and collection process for the present study, the translated tool was pilot tested on 20 participants (i.e. 5% of the total sample size of 375).All data were entered in the SPSS version 19 by the data entry programmers. Before any analysis was conducted, the data entered was cross checked and cleaned by the investigators and research assistants. Percentages and frequencies distribution were calculated for nominal data (i.e., education, wife's earning, belonging and participation in any organization etc.) and ordinal data (health status, general health status problem in performing general activities, memory, concentration and socioeconomic status etc.). To assess the relation between various social demographics and the occurrence of physical violence, univariate and multivariate analysis was performed. The Multivariate analysis was run by backwards logistic regression for the various variables. The model was cross checked by using back and forth method where each and every variable was assessed how it is behaving. Finally the model which came from backward method was selected. Ethical approval for the present study was obtained from the Ethical Review Committee (ERC) of the Aga Khan University (AKU), district coordinator officer, social welfare department and the department of 1122 from district Multan and NGOs. As the study topic is a very sensitive social issue, the safety of the participants was ensured according to the ethical principle of WHO guidelines provided for the safety of women. 4 The participants were selected on voluntary basis. The confidentiality and safety of the participants was maintained by providing pseudo nyms to the respondents. All respondents were informed about their right to end their participation in the study whenever they wanted during the research process. The data was kept under lock and key and was accessible only to the chief investigator and the supervisor.

refusal rate of 10% was also estimated which led to an increase in the sample size from 365 to 402. Thus, a sample size of 402 was considered to be sufficient to address all the components of the study questions. However, data was collected from 375 participants and this was considered for analysis; this was because out of 402 women who were selected, initially 17 refused to participate during the data collection procedure. Additionally 10 forms were identified which had incomplete information or higher refusal for the actual variable. This resulted in a 93% response rate.In this study, a three stage sampling strategy was used. In the first stage purposive sampling was utilized to select the study setting; purposive sampling (a type of non-probability sampling) is operationally defined as the selection of a sampling unit in which purposely selected districts are judged on the characteristics of interest and are accessible 15. Multan has six towns namely: Shah Rukan- e-Alam Town, Shershah Town, Bosan Town, Mumtazabad Town, Shujabad Town, and Jalapur Pirwala Town. Within these districts there are 78 union councils, from which at eight union councils were randomly selected. This selection was based on the surveillance system of existing 37 non-governmental organizations (NGO) working in these areas on women health. In the second stage, from among the 37 NGOs only eight NGOs, working within the selected eight union councils and working on women's health, were selected. In the third stage, the systematic sampling technique was used to select the participants. First a list of all married women registered with the selected NGOs living in the community of Multan was developed. Then, every tenth woman from the list was selected. Only one woman from each house was selected as a participant. Among them 375 married women who met the inclusion criteria, and were currently living with their husbands were selected randomly, as this meant equal probability for each individual for being selected in the study. After determining the eligibility of the study participants and taking their written consent, the research assistants(RAs) completed the questionnaire based on the participants, responses. The process of interview took about 20 minutes (maximum). If the participants had any queries related to questions, an explanation was given to them. The participants were also assured of the anonymity and confidentiality of the information. The data was collected through a questionnaire based on the WHO Multi-country Study on Women's Health and Life Experience focusing on violence against women.2 The tool was translated into national language Urdu and went through face and content validity assessment by experts including a psychologist, an epidemiologist, a community-based medical doctor, the field supervisor, a public health specialist, and the





Purposive Sampling Non probability sampling

Selected 8 union

councils of Multan (6 towns and 78 union councils

Out of 37 NGOs, selected 8 NGO s working on women’s health in seven

union councils.

Systema�c sampling

Total 375 married women selected from the list of NGOs

1st stage

2ndStage

3ndStage

(

Figure 1: Flow chart of Participants' Recruitmentfor the Present study

Results

Table 1: Prevalence and frequency of physical violence over life time, last year and last month

Variable N (%) Life Time % N (%) Last Year % N (%) Last Month %

Number of events Number of events Number of events

1-2

3-4

5-6

>6 1-2

3-4

5-6

>6 1-2 3-4 5-6 >6

(n)%

(n)

%

(n) %

(n)

%

(n)

%

(n)

%

(n)% (n)

%

(n)% (n)

%

(n)

%

(n)%

Slapped 213

(56.8)

25

9

23

156

158 (42.1)

42

22

26

68 92 (24.5) 44 13 22 13

Threw

things that

causeharm

74 (19.7)

4

12

8

50

58 (15.5)

15

5

10

28 38 (10.1) 21 7 5 5

Pushed 140

(37.3)

16

10

14

100

111 (29.6)

30

17

24

40 62 (16.5) 35 7 12 8

Pulled Hair 79 (21.0)

7

5

8

59

59 (15.7)

15

8

12

24 39 (10.4) 20 5 6 8

Punched 72 (18.9)

10

3

8

51

49 (13.1)

15

2

9

23 32 (8.5) 18 3 3 8

Beat with

inanimate

object

43 (11.5)

6

1

5

31

29 (7.7)

8

3

3

15 21 (5.6) 11 4 2 4

Kicked 57 (15.2) 4 3 7 43 37 (9.8) 7 1 9 20 24 (6.4) 11 4 1 8

Dragged 42 (11.2) 3 1 4 34 33 (8.8) 7 2 6 18 21 (5.6) 12 1 4 4

Hit 120(32) 19 8 13 80 88 (23.4) 26 11 7 44 54 (14.4) 35 1 6 12

Strangled 36 (9.6) 5 2 4 25 27 (7.2) 9 2 5 11 18 (4.8) 11 1 3 3

Burned 21 (5.6) 6 4 0 11 16 (4.2) 7 1 2 6 13 (3.5) 10 0 0 3

Summary

measure of

physical

abuse

897/142

5=62.93

%

665/1425

46.6/%

414/1425

=29%



Table 2: Univariate and Multivariate Analysis to Show Association between Socio-Demographic Variable and past year Physical Violence

In all the forms of physical violence, a majority of the women (n=213, 56.8%) reported being slapped by their husbands. Thirteen women reported being slapped > 6 times in the last month; followed by 68 women who reported being slapped > 6 times in the last 12 months, and 156 women reported being slapped > 6 times over their life time.

Another kind of physical violence reported by most of the women (n=140, 37.3%) was being pushed by the husband. Eight women reported being pushed by their husbands > 6 times in the last month; followed by forty women who reported being pushed > 6 times in the last 12 months, and 100 reported being pushed > 6 times over their whole life time.




Characteristic

Past Year Physical violence

Absence of

Event n (%)

Presence of

Event n (%)

Physical OR

(CI, 95%)

Physical OR adj

(CI, 95%)

Women’s Age in Categories

16-27 61 (32.8%) 38 (20.1%)

28-60 125 (67.2%) 151

(79.9%) 1.93 (1.21,3.10)

1.83

(1.06, 3.156)

Women’s Educational level

Illiterate 109

(58.6%) 119 (63.0%)

Literate 77

(41.4%)

70

(37.0%) 0.83 (0.55,1.26)

Women’s Employment Status

Non-earning 39

(21.0%)

45

(23.8%)

Earning 147

(79.0%)

144

(76.2%) 0.85 (0.52,1.38)

0.57

(0.33, 0.98)

Women Occupation

Professional 14

(35.9%)

27

(60.0%)

Non Professional 25

(64.1%)

18

(40.0%)

0.37

(0.15, 0.90)

Husband’s Age

<45 years of age 136

(51.7%)

127

(48.3%)

˃45 years of age 50

(44.6%)

62

(55.4%) 1.32 (0.85,2.07) ------

Husband’s Occupation

Professional 110

(51.6%)

103

(48.4%)

Non Professional 54 (42.9%)

72 (57.1%)

1.42

(0.92, 2.22)

1.08

(0.66, 1.78 )

Children

1-4 117

(50.9%)

113

(49.1)

0, >4 69

(47.6%)

76

(52.4%) 1.14 (0.75,1.73)

Family Categories

Nuclear 133

(57.1%)

100

(42.9%)

Combined/extended 53

(37.3%)

89

(62.7%) 2.23 (1.45,3.43)

2.210

(1.40,3.47)

Socio-economic Status 0.76

(0.43-1.18)

Member Categories

<5 68

(55.7%)

54

(44.3%)

>5 118

(46.6%)

135

(53.4%) 1.44 (0.93,2.23)

2.21

(1.40, 3.47)

Husband’s Educational Status

Literate 148

(51.4%)

140

(49.6%)

Illiterate 38

43.7%

49

(56.3%)

1.36

(0.84, 2.21) -------

Husband’s Employment Status

Employed 164

(48.4%)

175

(51.6%)

Unemployed 22 14 0.59 0.61




In the univariate analysis some variables, including women's age (28-60 years), women's occupation (non-professional , ) and fami ly categor ies, (combined/extended) were significant, at 95% confidence interval (CI). Women who were between

the ages of 28-60 years were 1.93 times more likely to be protected from physical violence, as compared to women who were younger (OR=1.93; CI: 1.21, 3.10). Association between women's education level and physical violence was found to be significant when


univariate analysis was done for this variable. The employment status of women was also an indicating factor of physical violence among women. The employment status of women living in district Multan was service, selling goods, seasonal work, and stitching. The results of this study showed a significant association between the women's employment status and physical v io lence. Furthermore, women who were non-professional were 0.37 times more protected from physical violence as compared to professional women (OR=0.37; CI: 0.15, 0.90). The husbands' occupation was also a strong indicator of physical violence on women in this study. The husbands' occupation was defined in the context of professionals and non-professionals. Those who were professionals were employed, doing some kind of skilled work (military, police, and official work) and non-skilled work (manual work), whereas those who were non-professionals were unemployed. Statistical

measurement revealed that husbands who were unemployed (non-professional) had a significant association with physical violence on women. Women hav ing husbands w i th unemployed (non-professional) status were 0.59 times more likely to be protected from physical violence than women having husbands who had professional occupations (OR=0.59; CI: 0.29, 1.21 ). The type of family system (nuclear or combined) was also found to be a strong indicator of physical violence on women. Women who were living in a combined family were 2.23 times more likely to be protected from physical violence as compared to women who were living in a nuclear family (OR=2.23; CI:1.45, 3.43).However, the women's husbands' age, husbands' educational status, husbands' employment status, children, and family members had non-significant associations with physical violence when univariate analysis was done.



Table 3: Univariate and Multivariate Analysis to Show Association between Socio-Demographic Variable and life time Physical Violence

Characteristics

Physical Violence

Absence

of Event

N (%)

Presence of

event

N (%)

Physical OR (CI,

95%)

Physical OR Adj

(CI, 95%)

Women’s Age in Categories

16-27 49

(35.3)

50

(21.2)

28-60 90

(64.7)

186

(78.8)

2.02

(1.26,3.23)

1.740

(1.01, 3.00)

Women’s Educational level

literate 87

(62.6)

141

(59.7)

Illiterate 52

(37.4%)

95

(40.3%)

1.12

(0.73,1.73) ------------

Women’s Employment Status

Non- Earning 12 (40.0%) 29

(53.7%)

Earning 18 (60.0%) 25

(46.3%)

0.92

(0.56-1.53)

0.57

(0.33,0.98)




Women’s Occupation

Professional 12

(40.0%) 28

(53.7%)

Non professional 18

(60.0%) 25

(46.3%) 0.57

(0.32, 1.42)

Husband’s Age

<45 years of age 103

(74.1%)

160

(67.8%)

˃ 45 years of age

36

(25.9%)

76

(32.2%)

1.35

(0.85-2.15) ----------

Husband’s Educational Status

Literate 114

(82.0%)

174

(78.7%)

Illiterate 25

(18.0%)

62

(26.3%)

1.62

(0.96-2.73) ----------------

Husband’s Employment Status

Employed 126

(90.6%)

213

(90.3%)

Unemployed 13

(9.4%)

23

(9.7%)

1.04

(0.52-2.13)

0.61

(0.38,1.00)

Husband’s Occupation

Nonprofessional 85

(67.5%)

128

(60.1%)

Professional 41

(58.8%)

85

(39.9%)

0.1.37

(0.86,2.18)

1.0670

(0.63,0.79)

Children

1-4 91

(65.5%)

139

(58.9%)

0, >4 48

(34.5%)

97

(41.1%)

1.32

(0.86,2.04)

Family Categories

Nuclear 99

(71.2%)

134

(56.8%)

Combined/extende

d

40

(28.8%)

102

(43.2%)

1.88

(1.20,2.95)

1.79

(1.12,2.87)

In the current study, in multivariate analysis women's employment status, as earning (OR; 0.57CI:0.33, 0.98) was significant in last year, and in life time multivariate analysis, husband's nonprofessional status (OR; 1.06; CI: 0.635 1, 0.793) and women's earning status (OR; 0.57; CI: 0.33, 0.98) became significant. The Combined family system (OR; 1.795, CI: 1.120, 2.878) was found to be significant in univariate analysis in last year, and in multivariate analysis as wellDiscussion:In the current study, the prevalence of physical abuse was reported by more than half of the married women, i.e., 62.93% (n=236), which is higher as compared to other studies. The results of other studies, which were conducted in different parts of the world, also show a high prevalence of physical violence. For example 26% (n= 9938) in India 17, 30.9% (n= 883) in Vietnam 18, 58.6% (n= 278) in Brazil 19, and 56.3% (n= 759) in Pakistan2. This shows that the highest figures are emerging from Pakistani studies as reported by Ali et al.2from Karachi (56 %), whereasthe current study found62.93 % women exposed to physical violence.One of the reasons for high prevalence of physical violence in the current study is that the data was obtained from the different province (i.e., Punjab, which has different sociocultural norms and values) of Pakistan. The high rate of physical IPV is also supported by the data from a survey conducted by Sustainable Development Policy Institute (SDPI) that, physical violence against women in the province of Punjab is socially and culturally acceptable and a large proportion of men believed that there are situations in which it becomes necessary to use physical violence against women, and that banning of the physical violence is a “western concept” [20].In other studies the most frequent form of physical violence reported were slapping, pushing, hitting, kicking, choking, kicking, and beating2, 7,9. On an average, 9 different forms of physical violence have been reported in these studies. Similarly, in the current study, the most frequent form of physical violence includes: slapping (56.8%), pushing (37.3 %), and kicking (15.2 %). Similar forms of physical violence were identified among married women in Vietnam; for instance, the statistics show that slapping was 27.0 %, pushing 5.8 %, kicking 8.6 %, and choking 1.7 % 18. As reported by Ali et al. 2the

same forms of physical violence were reported among married women of Sindh, Pakistan, which included slapping (n=227,29.9%), Pushing (n=384, 50.6%), Kicking (n=330,43.5%), and choking (n=183, 24.1%). The findings of another Pakistani study shows similar forms of physical violence: i.e.,pushed, grabbed, and shoved (n=84, 47.7%), and slapped, hit and punched (n=69, 39.2%)21.In the current study, an association was found among socio demographic variables and violence in the past year, followed by life time exposure to physical violence. In univariate analysis women aged 28 to 60 years were found statistically significant to be at a greater risk of being exposed to physical violence. It showed that women of this age are at a greater risk of physical violence. According to many other studies18,2,22.women of older age are at more risk of being subjected to violence. The possible explanation of the current study's result is that the older women are more vulnerable than other age groups because of cultural (patriarchy, masculinity and femininity) and social factors (women empowerment and poverty) 23. The current study's results are not only congruent with the results of another study conducted in Pakistanbut are also similar to the findings of studies conducted in developed world as the findings of a study conducted in USArevealed that, physical violence increased among the women over 55 years of age2,22. An interesting finding of the current study is that unemployed women seem to be on safer grounds and protected from physical violence. This protected status can be seen not only in the past year multivariate analysis, but also with respect to life time prevalence. However, in studies conducted in different countries highlight the fact that women who are employed are the ones facing less violence, as compared to unemployed women.24,25One of the rationales for the findings of the current study is that; due to cultural constraints and husbands' controlling behavior, women accepts the husband's decision and stay at home 26. Furthermore, the acceptance of male dominancy and power makes women submissive which might prevent them from the exposed to physical violence 2In the univariate analysis relating to physical violence in the past year, another interesting finding was that the women who were nonprofessionals were found to

Physical Violence and its Associated Factors Among Married Women Shafquat Inayat, Shahina Pirani and others

Member categories

<5 44

(36.1%)

78

(30.8%)

>5 78

(58.6%)

120

(81.1%)

1.41

(0.91-2.20)


recommended for an in-depth understanding of the present phenomenon and the related associated factors that lead to physical violence. Moreover, this study provides a basis for planning interventional studies aiming at testing interventions to improve the health of women suffering from physical violence.AcknowledgementI acknowledge the significant input of my research supervisor Dr. TazeenSaeed Ali and all the committee memberswhose stimulating suggestions and encouragement helped me to complete this paper. References1. Xu X, Zhu F, O'Campo P, Koenig M, Mock V,

Campbell J. Prevalence of and Risk Factors for Intimate Partner Violence in China. American Journal of Public Health. 2005;95(1):78-85.

2. Ali, Asad, Mogren, Krantz G. Intimate partner violence in urban Pakistan: prevalence, frequency, and risk factors. International Journal of Women's Health. 2011;:105.

3. Emperatriz C, Guadalupe A, Monica G. Gender Violence in the Middle Level Superior [Internet]. Mexico City; 2014 p. 1-65. Available from: h t tp : / /www.eco r fan .o rg / l i b ros /D ia lne t -GenderViolenceInTheMiddleLevelSuperior-573080.pdf

4. World Health Organization. WHO multi-country study on women's health and domestic violence against women : initial results on prevalence, health outcomes and women's responses [Internet]. 2005 p. 1-198. Available from: http://www.who.int/gender/violence/who_multico u n t r y _ s t u d y / I n t r o d u c t i o n - C h a p t e r 1 -Chapter2.pdf

5. Dillon G, Hussain R, Loxton D, Rahman S. Mental and Physical Health and Intimate Partner Violence against Women: A Review of the Literature. International Journal of Family Medicine. 2013;2013:1-15.

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be protected. This indicates that women who are unemployed are less vulnerable to IPV, because they are submissive and behave the way culture is expecting from them. However, some studies which have been conducted on the same issue present quite a different view. The findings of these studies indicate that women who are professional and skilled workers are less vulnerable to partner violence.2,18Thus, these studies indicate that professional women are more autonomous, powerful, educated, tactful, and confident and are less vulnerable to partner violence. These women are also aware about their rights and they can raise their voice against violence and often take stand for their decisions; this is not acceptable to the society at large as well as their husbands. Therefore, they are more exposed to physical violence. In this study, the extended family system and the number of family members are significantly associated with exposure to physical violence, as women living in an extended family system and living with more number of family members are at a higher risk of exposure to physical violence. A study conducted in Jordan assessed the association of extended family with the occurrence of violence. The findings of this study revealed that there is a significant association of these two variables. They further identified that in an extended family system, men often witness violence from other family members and then they practice this act on their wives. In addition, the findings revealed that too many members living in one household, who share the same views, at times, ends up in subjecting a vulnerable person to violence (it is always the women who are the most vulnerable)8. Since a Pakistani study stated that, women are supposed to be obedient, silent, and dependent on their husband the reinforcement of these gender role increases expectations from a woman, from almost all the members of the extended family2. Hence, if any family thinks that the woman is unable to fulfill cultural norms, she has a risk of becoming the victim of violence2Conclusion:Violence against women is considered as a global human rights and public health concern which exist worldwide.The current study confirms the high prevalence of physical violence among married women, across all socio-economic settings, in Multan, a city of Southern Punjab Pakistan. It is considered a general behavior that physical violence is accepted as a cultural norm and women living in the context of Punjab, Pakistan, are subjected to it routinely, on a daily basis Physical violence requires prompt attention by the governing bodies. Legal action against this IPV should be strengthened and strictly implemented, not only for housewives but also for work ing women.A qual i ta t ive s tudy in



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23. Jewkes R, Morrell R. Sexuality and the limits of agency among South African teenage women: Theorising femininities and their connections to HIV risk practises. Social Science & Medicine. 2012;74(11):1729-1737.



Original Article

Introduction:About one quarter of all neonatal death are caused by birth asphyxia that can be prevented. Birth asphyxia is defined simply as the failure to initiate and sustain breathing at birth. All neonatal death 99% take place in poorest region and countries of the world, usually within hours of birth, mostly the cause of neonatal deaths is hypoxic event some non-breathing neonates responds to simple stimulation alone such as drying rubbing the back and feet some of these need Bag-Mask resuscitation so importantly skilled birth attendant should be trained in basic resuscitation as well as newborn care that is helping babies breath (HBB) training (1). Global reduction in child mortality was not proceeding rapidly to meet the goal to reducing the under 5 mortality by 2/3rdfrom 1990 level (2). Neonatal mortality is the single largest cause of under 5 mortality accounting for more than 40% of deaths (3). Neonatal Deaths occurred predominantly on the day of birth 98% in low and middle income countries (4). Death due to intra partum related events were a major cause of neonatal mortality and failure to

establish or sustain effective breathing birth (5). Birth asphyxia causes 23% of newborn deaths many of these deaths are avoidable by improving the facility based intra partum care including neonatal resuscitation may be prevent up to 30% intra partum related newborn mortality in low resource setting (6). Global efforts has been made in past decades to develop effective intervention that prevent mortality due to birth asphyxia a leading example of this effort is HBB program (7).Incompetent techniques such as poor or excessive ventilation with the bag and mask and high negative pressured suction being applied with some suction machines (8). When forecasting is done at the facility level there is a failure to prioritize newborn equipment needs (9).The objective of the study wasto access knowledge, practice and barriers of SBAs regarding HBB and the availability of equipment required for HBB at Thatta/sujawal, Pakistan.Methodology:Descriptive Cross-Sectional Study on SBAs as trained in HBB. All 46 SBAs trained on HBB working in

ASSESSMENT OF SKILLED BIRTH ATTENDANTS REGARDING HELPING BABIES BREATH INTERVENTION TO IMPROVE NEWBORN CARE IN RURAL DISTRICT OF SINDH

1Faculty Health Services Academy Islamabad.2Fellows Health Services Academy, Islamabad.Correspondence: ShehMureed: Email: [email protected]

1 2 2Sheh Mureed , Muhammad Hassan Gandro and Walid Hassan

Background: Globally, 3.1 million newborn deaths occur every year out of these estimated 400,000 neonatal deaths occur in Pakistan. All neonatal deaths 99% take place in poorest region and countries of the world, usually within hours of birth; mostly the cause of neonatal deaths is hypoxia.To access knowledge and practice of SBAs regarding HBB and to access the availability of equipments required for HBB. Methods: Descriptive Cross-Sectional Study on SBAs as trained in HBB.All 46 SBAs trained on HBB working in Labour room eight rural Health centers, four Taluka, One district Head Quarter Health Facilities and thirteen Mlbcs of the district, were included in the sample for study.All 41 SBAs were trained on HBB participated in the study. Results: Mean age of 30 years. Out of total 41 participants 25 were working in B-EmoNC (61%), 3in C-EmoNC (7.3%) and 13 in mid wife laid birth Centre (MLBC) or birth station (31.7%). About 92.7% of participants said that main purpose of HBB training is to decrease the NMR by improving newborn care. Drying of newborn is 82.7%, hand washing is 95.12% and 85.3% of the study participants said that they gave 30-40 breaths per minutes. Cord clamp and pair of ties was accessible to 85% of participants versus 14.3% who reported it's not accessible. Almostone quarter (34.1%) participants have low knowledge and practice. Knowledge and training had significant effect on the overall practices of the skilled birth attendants for skilled birth deliveries and reduce the neonatal deaths(P <0.001).Conclusion: Tools play a vital role for the implication of the knowledge into practices and tools were available almost to every participant. Although few barriers also identified for the less application of the helping hand babies trainings in the community.Keywords: Neonatal health, helping babies breath, Knowledge, practices, instruments.

Abstract

Helping Babies Breath Intervention to Improve New Born Care Sheh Mureed, Muhammad Hassan Gandro and Walid Hassan



Table 1: Sociodemographic characteristics of study participants

Responses of study participants about Practices showed that about 97% of participants said thatthey give skin to skin contact kangroo care within one golden minute. About 90% respondents said that they don't find any difficulty in identifying the helpers. Response percentage about keeping the babies in warm when the weather is hot was no by 85%.Usage of mask with firm seal was reported by only 24.3% of respondents. While ventilation usage was also

Labour room eight rural Health centers, four Taluka, One district Head Quarter Health Facilities and thirteen Mlbcs of the district, were included in the sample for study.the study tool consisted questions regarding Socio-demographics, knowledge (Birth preparedness: Hand wash, clean and ventilated area, identified helper and prepare an area for ventilation, Check equipment's) and practices were assessed and equipment were assessed. Study was conducted in period of three months i.e From September-November 2015. Data was collected from SBA working in labour room and were trained on HBB working at district thatta/ sujawal.The data was analyzed through SPSS version 21. The data was described using descriptive statistics. The Ethical approval was obtained from Institutional review board.Written consent was obtainedbefore enrolment in the study and strict anonymity and confidentiality was maintained for participants.Results:In table No.1 socio demographic characteristics of study participants were analyzed while in second section questions related to knowledge, practice, availability of tools and barriers to skilled birth attendants were analyzed. Age of study participants was calculated in means. On the basis of mean score age participants were categorized in two groups. First group included participants who had mean age of 30 years or less and second group included participants who had mean age greater than 30 years. Descriptive statistics for designation of study participants showed that out of 41 participants 14.6% (n=6) were doctors, 26.8% (n=11) were LHVs, 24.4% (n=10) were staff nurse, while 34.1% (n=14) were CMWs. About 10% of participants had work experience greater than15 years while 16 participants had work experience of 1-5 years. Similarly about 15% of the participants had salary range of greater than 20,000 PKR/month and when asked about residence status of study participants it was found that about 87% of participants had their own house. Descriptive statistics for designation of study participants about knowledge showed that about 92.7% of participants said that the main purpose of HBB training is to decrease the NMR. Drying is necessary for the new born is said by 82.7%. Similarly 95.12% of participant said that hand washing is necessary before conducting deliveries. About 85% respondents said that they cut the cord and move the babies to ventilation area when babies do not cry at the time of birth and 85.3% respondents said that they gave 30-40 breaths per minutes. If chest of the newborn babies moves and they breathe normally then 87% of participants said that they don't apply mask and positioning of head. More than 90% of participants correctly answered the steps involved in the hand washing

Rent 1 2.4

Variable Categories

Frequency

Percentage

Age <30 Years

13

31.7

Age

Age>30 Years 28 68.3 Health Facility B-Emonc

3

61

Type

C-Emonc

13

7.3

MLBC (Birth

Station)

6

31.7

Designation DOCTOR

6

14.6

LHV

11

26.8

STAFF NURSE

10

24.4

CMW

14

34.2

Marital Status SINGLE

12

29.3

MARRIED

29

70.7

WIDOW

0

0

Experience/Job 1-5 Years

16

39

Duration

6-10 Years

13

31.7

11-15 Years

8

19.5

16-20 Years

3

7.3

20 Years And Above

1

2.4

Current Salary 2000-10000 PKR

15

36.6

10001-20000 PKR 0 0

20001-40000 PKR 19 46.3

40001-60000 PKR 5 12.2

60000 And Above 2 4.9

Residence Government 4 9.8

Own 36 87.8



reported by a very small number of participants i.e 12.9% and 73% participants said that they clear secretion by just opening the mouth of new born babies as shown in Table No.2.

Variable Frequency % Do you prepare a ventilation area? 41 100 Kangaroo care is given within one golden minute?* 40 97.6 Do you check the equipment before conducting delivery? 40 97.6 You do not need to identify helper?* 37 90.2 Do you remove wet clothes just after delivery? 38 92.68 There is no need to keep the baby warm if the weather is hot?* 35 85.3 Does rubbing the back of neonate stimulate breathing? 41 100

Do you follow above instructions for those

newborn who cry 41

100

well?

Do you apply the mask with firm seal?

10

24.3

Do you start the ventilation within the golden minute?

5

12.19

You do not need to look for chest movement during ventilation?

82.9

34 Do you clear secretion by opening the mouth only?

30

73.17

support, HR availability, capacity and motivation are barriers for the helping baby's breath. Overall 34.1% had low knowledge about HBB according to mean score I.e. 9.8 and similarly the mean score for practices was 10.8 and 65.9% participants had good practices for the delivery of HBB.Cross-Tabulation was made between all the socio demographic characteristics of the study participants with their overall practices as shown in Table No.3. Calculated results showed that no significant association was found between age, health facility type, marital status, work experience, monthly income, residence and practices for HBB. However, Significant association was found between knowledge and practices of study part ic ipants for helping babies breathe (P Value=0.001).Table-3: Association between Socio-demographic variables and Practices

Respondents were when asked about of about accessibility of equipment that hand glove, bag mask, penguin sucker device and stylize scissor with un used blade was available to all the study participants at their workplace. Card clamp was accessible to 85% of respondents. More than 90% respondents said that they had availability of knitting cap for newborn. While more than two third of the participants reported the availability of stopwatch.Descriptive statistics for designation of study participants about Barriers showed that about 90% of participants said that community had the awareness regarding child and maternal health but its acceptance by community was reported only 4%. More than 90%agreed that financial issues are there for the helping baby's breath. Similarly more than 70% believe that geographic road condition and transport are barriers. Most of participants said that lack of community, family



Table-3: Association between Socio-demographic variables and Practices

Variable Categories AGE

Age <30 years

Good(N) Bad(N) P Value (Chi Square)

5

8

Age>30 years

9

19

0.691

Health Facility

Type

B-EmoNC

8

17

0.923

C-EmoNC

1

2

MLBC (Birth Station)

5

8

Designation

DOCTOR

1

5

0.675

LHV

5

6

STAFF NURSE

3

7

CMW

5

9

Marital Status

SINGLE

6

6

0.168

MARRIED

8

21

Experience/Job Duration

1-5 Years

7

9

0.535

6-10 Years

5

8

11-15 Years

2

6

16-20 Years

0

3

20 Years and Above

0

1

Current Salary

2000-10000 PKR

5

10

0.568

10001-20000 PKR

8

11

20001-40000 PKR

1

4

40001-60000 PKR

0

2

60000 and above

2

Residence

Government

0

4

0.228

Own

14

22

Rent

0

1

Knowledge

High

25

2

0.001*

Low

2

12

Africa decrease neonate death when they dry babies on time and cry the baby (12). While more than 90% of participants correctly answered the steps involved in the hand washing and a study conducted in Kenya shows that knowledge about the safe deliveries significantly increases through training about HBB (13). Almost three quarter of respondents said that they clear secretions by just opening the mouth of new born babies and almost same findings results closer to the past studies done in UK, Norway and Nepal [12,14-15]. More than two third of participants reported the availability of stopwatch and reduction in neonates deaths through safe deliveries by the use of

Discussion: Assessment of Skilled Birth Attendants regarding Helping Babies Breath(HBB) Intervention to improve newborn care was done in this study, In study conducted in Pakistan was found that the mean age of participants were about 24 years, nurses and doctors and mostly lived in permanent houses(10). Large number of participants said that main purpose of HBB training is to decrease the NMR and a study conducted in Rwanda had results that training had a sound impact on the reduction of the newborn death (11). Most of participants said that they gave 30-40 breaths per minutes. In South Asia and sub-Saharan



5. Lawn JE, Lee AC, Kinney M, Sibley L, Carlo WA, Paul VK, Pattinson R, Darmstadt GL. Two million intrapartum�related stillbirths and neonatal deaths: Where, why, and what can be done?. Internat ional Journal of Gynecology & Obstetrics. 2009 Oct 1;107.

6. World Health Organization. Guidelines on basic newborn resuscitation.

7. Van Heerdenl, B Cur, M CUR. An Introduction to Helping Babies Breath (HBB) The Golden Minute Is Here For South African Newborn Babies.

8. Majeed R, Memon Y, Majeed F, Shaikh NP, Rajar UD. Risk factors of birth asphyxia. J Ayub Med CollAbbottabad. 2007;19(3):67-71.

9. Rahim F, Jan A, Mohummad J, Iqbal H. Pattern and outcome of admissions to neonatal unit of Khyber Teaching Hospital, Peshawar. Pakistan Journal of Medical Sciences. 2007 Apr 1;23(2):249.

10. Singhal N, Lockyer J, Fidler H, Keenan W, Little G, Bucher S, Qadir M, Niermeyer S. Helping Babies Breathe: global neonatal resuscitation program development and formative educational evaluation. Resuscitation. 2012 Jan 31;83(1):90-6..

11. M e s m o G . M a s s a w e A . M m b a n d o D . “IMPLEMENTATION OF THE HELPING BABIES BREATHE (HBB) PROGRAM IN TANZANIA” 2013.

12. Lawn JE, Davidge R, Paul VK, von Xylander S, de Graft Johnson J, Costello A, Kinney MV, Segre J, Molyneux L. Born too soon: care for the preterm baby. Reproductive Health. 2013 Nov 15;10(1):S5.

13. Somannavar MS, Goudar SS, Revankar AP, Moore JL, McClure EM, Destefanis P, DeCain M, Goco N, Wright LL. Evaluating time between birth to cry or bag and mask ventilation using mobile delivery room timers in India: the NICHD Global Network's Helping Babies Breathe Trial. BMC pediatrics. 2015 Aug 6;15(1):93.

14. Musafili A, Essén B, Baribwira C, Rukundo A, Persson LÅ. Evaluating Helping Babies Breathe: training for healthcare workers at hospitals in Rwanda. Actapaediatrica. 2013 Jan 1;102(1).

15. Ashish KC, Målqvist M, Wrammert J, Verma S, Aryal DR, Clark R, Naresh PK, Vitrakoti R, Baral K, Ewald U. Implementing a simplified neonatal resuscitation protocol-helping babies breathe at birth (HBB)-at a tertiary level hospital in Nepal for an increased perinatal survival. BMC pediatrics. 2012 Oct 5;12(1):159.

16. M s e m o G , M a s s a w e A , M m b a n d o D , Rusibamayi la N, Manj i K, Kidanto HL, Mwizamuholya D, Ringia P, Ersdal HL, Perlman J. Newborn mortality and fresh stillbirth rates in Tanzania after helping babies breathe training. Pediatrics. 2013 Feb 1;131(2):e353-60.

safe birth tools also found in the study conducted in Tanzania, India and Pakistan[11,13,8]Similarities regarding barriers were also found in past study conducted in India (16). More than one third of Participants were with bad practices for the delivery of HBB while a study conducted in Tanzania showed that the skilled birth attendants were with practices (17). However Significant association was seen between knowledge and practices of respondents foe helping babies breathe and in studies conducted in Tanzania, Norway, Rwanda and Pakistan it was seen that knowledge and training had significant effect on the overall practices of the skilled birth attendants for skilled birth deliveries and to reduce the neonatal deaths (10, 11, 14 and 16). Conclusion:HBB strengthening management of newborn resuscitation holds great potential to reduce newborn mortality in low resource setting. Knowledge about the helping baby's breath found excellent and satisfactory and the skilled birth attendants all applied that knowledge in the form of practices. Tools play a vital role for the implication of the knowledge into practices and tools available almost to every participant. Although few barriers also identifiefd for the less applicable of the helping hand babies trainings in the community.Recommendations:It is recommended to refresh training should be conducted on helping baby's breath (HBB) for the health personnel, ensure availabil ity of the equipment, monitoring the practices of the health professionals regarding the practice of HBB and monitor to ensure knowledge and skills for the timely performance are being carried out.References:1. Persen M. Impact of Helping Babies Breathe

(HBB), a bas ic neonata l resusc i ta t ion educational program for birth attendants in low-resource setting: a systematic review (Master's thesis, UiTNorgesarktiskeuniversitet).

2. Lawn JE, Kerber K, EnweronuLaryea C, Massee Bateman O. Newborn survival in low resource settings—are we delivering?. BJOG: An I n t e r n a t i o n a l J o u r n a l o f O b s t e t r i c s &Gynaecology. 2009 Oct 1;116(s1):49-59.

3. Black RE, Cousens S, Johnson HL, Lawn JE, Rudan I, Bassani DG, Jha P, Campbell H, Walker CF, Cibulskis R, Eisele T. Global, regional, and national causes of child mortality in 2008: a systematic analysis. The lancet. 2010 Jun 11;375(9730):1969-87.

4. Liu L, Johnson HL, Cousens S, Perin J, Scott S, Lawn JE, Rudan I, Campbell H, Cibulskis R, Li M, Mathers C. Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000. The Lancet. 2012 Jun 15;379(9832):2151-61.



17. Reisman J, Martineau N, Kairuki A, Mponzi V, Meda AR, Isangula KG, Thomas E, Plotkin M, Chan GJ, Davids L, Msemo G. Validation of a novel tool for assessing newborn resuscitation skills among birth attendants trained by the Helping Babies Breathe program. International Journal of Gynecology & Obstetrics. 2015 Nov 1;131(2):196-200.



Original Article

Abstract

STUNTING AMONG CHILDREN OF 18 TO 36 MONTHS OF AGE IN BHAWALGHAR VILLAGE, DISTRICT LODHRAN: A CROSS-SECTIONAL STUDY

1Public Health Fellow, Health Services Academy, Islamabad.

2Director of Research, Human Development Research Foundation Islamabad.3Assistant Professor, Health Services Academy, Islamabad.

Correspondence: Haider Ali Younas.Email: [email protected]

1 2 3Haider Ali Younas ,Siham Sikander , Mudassar Mushtaq Jawad Abbasi

Background: Stunting is chronic restriction of growth in height indicated by low height-for-age. It is a reliable indicator of long-term under nutrition among young children. Stunted children are more prone to communicable diseases. The main causes of stunting are not providing proper nutritious food, not enough food and of poor quality, improper feeding practices and different infections including malaria, ARI and diarrhea. We conducted this survey to determine the frequency and determinants of stunting among 18 to 36 months old children in Bhawalghar Village, District LodhranMethods: We did cross-sectional study in Bhawalghar village of district Lodhran. All of the children from 18 to 36 months of age were included in this study from two randomly selected clusters.Results: Gender, parental education, income, type of housing, vaccination coverage, parity of women, height of child and number of food items were identified as determinants of stunting. There was a statistically significant relationship between stunting and the study variables. We found that about half (48%) of the children of age 18-36 months living in Bhawalghar Village, District Lodhran were stunted.Conclusions: Stunting is a major problem among the children of rural Punjab, Pakistan. There is a dire need to improve the nutritional status of the children in this region. Keywords: Stunting, nutrition, rural community, developing country

Introduction: Stunting is chronic restriction of growth in height indicated by low height-for-age. It is a reliable indicator of long-term under nutrition among young children. Good cumulative measure of “well being” for populations of children (because not affected by weight recovery). The main causes of stunting are not providing proper nutritious food, not enough food and of poor quality , . Improper feeding practices and different infections, including malaria, ARI and diarrhea (3), (4)Timing: Age of onset varies, but usually in first 2-3 years of life. First few months, infants in developing countries grow just as quickly as children in reference populations (developed countries like Japan, Norway, and Germany etc.). Growth retardation starts from 2-6 month of life (often associated with weaning). Infants at risk during this time because of high nutritional requirements and high rates of infections (breast fed infants often protected) (5), (6).Stunting undermines both physical and mental development with lifelong consequences (7), (8).In 2012 globally, 162 million under-five year olds were stunted. 56% of all stunted children lived in Asia and 36% in Africa. The global trend in stunting prevalence and burden continues to decrease. Between 2000

and 2012 stunting prevalence declined from 33% to 25% and the burden declined from 197 million to 162 million (9), (10).South-Asia bears 40% global burden of child stunting (11).In Pakistan in 1965 prevalence of stunting was 48%. In 2012-13 prevalence of stunting was 45%. Thus, not much change in more than 40 years. In 2012-13 stunting prevalence was (48%) in Rural areas, (37%) in Urban areas (12), (13).Globally stunting reduced by continued investments in nutrition-specific interventions. Improved access to nutrition-sensitive approaches; primary health care networks, education, agriculture and social protection. (14), (15).Methodology: A community based cross-sectional study was conducted in Bhawalghar Village, District Lodhran from 1st April to 30th June 2015. The Internal Review Board (IRB) of the Health Services Academy, Islamabad, granted ethical approval. Sample size of 104 was calculated onbasis of 45% prevalence of stunted children in Pakistan according to Pakistan Demographic and Health Survey 2012-13, with 95% confidence interval, 10% of margin of error/degree of precision. All the children from 18 to 36 months of age were included in the study from two randomly

Stunting Among Children of 18 to 36 Month of Age Haider Ali Younas, siham Sikander and others



Food Items

Frequency(n)

Percentage (%)

Number of Food Items

2

6 5.8

3

19 18.3

4

31 29.8

5 or more 48 46.2

Grains and Cereals

Yes

93 89.4

No

11 10.6

Vegetables

Yes

54 51.9

No

50 48.1

Fruits

Yes

11 10.6

No

93 89.4

Meat (white or red or both)

Yes

18 17.3

No

86 82.7

Dairy Products (especially milk)

Yes

93 89.4

No

11 10.6

Breast MilkYes 17 16.3

No 87 83.7

Oil and GheeYes 65 62.5

No 39 37.5

Other FoodsYes 91 87.5

No 13 12.5

Mixed DishYes 80 77

No 24 23

How many times Yesterday did Child Consume any Item from Food List

Once 14 13.5

Twice 57 54.8

Thrice 32 30.8

4 times or 1 1

selected clusters (localities) of Bhawalghar Village. Children with diagnosed congenital abnormalities and SAM (Kwashiorkor/Marasmus) were excluded from the study. Informed consent was obtained from mothers about feeding and food intake practices of the se lec ted ch i ld ren th rough s t ruc tu red quest ionnai re , accord ing to Wor ld Heal th Organization (WHO) standardized food intake questionnaire. Other questions were regarding social and demographic characteristics in relation with stunting. The nutritional status of children of l8 to 36 months old was measured anthropometrically. The height-for-age measurement status was, calculated shown in standard deviation (SD) units (Z-score) from the median of the reference population. Children with a measurement of <−2 SD units below the median of the reference population were considered short for their age (moderately stunted) and children with measurement of <−3 SD units below the median was considered to be severely stunted.Results: Bhawalghar Village comprises of four Mohallas. Each Mohalla was a cluster and total cluster were four. Two clusters were randomly selected using the lottery method. All of the children from eighteen months to thirty six months (three years) of age were included in the study. Children with diagnosed congenital abnormalities and SAM (Kwashiorkor/Marasmus) were excluded from the study.Boys and girls percentages were 53% and 47% respectively. 50% fathers and 78% mothers were illiterate. 43% target population living in Pakka, 30% in Katcha-Pakka and 27% in Katcha houses. Majority of the women (30.8%) mothers of 2, (29.8%) mothers of 3 and (30.8%) mothers of 4 children. The vaccination coverage of their children is above 90% (Table-1). Table 1: Descript ive analysis of Socio-Demographics and Vaccination Coverage

According to World Health Organization (WHO) standardized food intake practices of children , 30% children consumed 4 food items in the last 24 hours(including day and night) .46% consumed 5 or more food items.89% children consumed Grains and Cereals. Majority of the children were consuming Roti.89% consumed Dairy Products (especially milk). 52% consumed Vegetables. In Vegetables most were consuming Butter nut squash (gadu), Cabbage and Spinach. 77% children consumed Mixed Dish having 2 food items .Only 17% consumed Meat (white or red or both) and 11% fruits. Breast milk consumption was only 17% (Table-2).

Table 2: Food Items Consumed by Child in the last 24 Hours

The stunting of children was analyzed by Z score according to WHO guide lines. Those children having Z score < -2 SD were considered short for their age (Stunted). Children having Z score < -3 SD were considered severely stunted. Majority of the children, 54 children (52%) were normal, where as 34 (33%) were moderately stunted and 16(15%) were severely stunted. Stunting was higher in girls as compare to boys, 19(39%) girls moderately stunted and 9(18%) severely stunted. 15(27%) boys were moderately stunted and 7(13%) were severely stunted. As age groups continue to increase, normal children continue to decrease; moderately and severely stunted children continue to increase (figure-1).

Stunting Among Children of 18 to 36 Month of Age

Variables Frequency (n) Percentage (%)

Gender

Boy 55 53

Girl

49

47

Father’s Education

Illiterate

52

50

Primary

20

19.2

Middle 11 10.6

Higher 21 20.2

Illiterate

81

77.9

Primary 12 11.5

Middle 4 3.8

Variables Frequency (n) Percentage (%)

Mother’s Education Higher 7 6.7

Type of House

Pakka

45

43.3

Katcha-Pakka

31

29.8

Katcha

28

26.9

Number of Children

1 9 8.7

2

32

30.8

3

31

29.8

4

32

30.8

Vaccination Coverage

Full

94

90.4

Partial 8 7.7

No Vaccination 2 1.9

Haider Ali Younas, siham Sikander and others


Figure 1: Multiple bar chart of Gender and Age and their Z-Score

For the categorical variables, chi-square applied to see the association between study variables and Stunting. Frequency of Stunting was higher in girls than boys. Illiterate parents had highest frequency of Stunted Children. Parents Education Matriculation or above had lowest frequency of Stunted Children. Numbers of Stunted Children were more in Katcha and Katcha-Pakka houses than Normal Children. On the other hand in Pakka houses number of Normal Children was much higher than Stunted Children. Increasing parity linked to increase stunting. Results are strongly statistically significant. This means that socio-demographic characteristics highly influence the height for age (stunting) of children Table-3)Table 3: Association of categorical variables with Z-score of nutritional status

Note: *= significance level at p< 0.05

Children taking two or three food items were mostly moderately or severely stunted. Majority of the children were consuming four or five food items. As number of food items consumption by children increases, moderately and severely stunting decreases subsequently. The chi square test was applied to test the association between number of food items and nutritional status (stunting). The result is statistically significant and association found between study variable and number of foods (Table-4).Table 4: Association between Number of food Items with nutritional Status

Note: *= significance level at p< 0.05Discussion: The stunting of children was analyzed by Z score according to WHO guidelines. Those children having Z score < -2 SD were considered short for their age (moderately stunted). Children having Z score < -3 SD were cons idered severe ly stunted.Frequency of stunting in the study area is 48%; severe stunting is 15%, it's an alarming figure. According to Pakistan National Nutritional Survey (NNS) 2011 prevalence of stunting in rural areas is 46.3% and severe stunting in rural areas is 24% (13). According to Pakistan Demographic and Health Survey (PDHS) 2012-13 prevalence of stunting in rural areas is 48% (5).Gender wise males were 53% and females 47%.The frequency of moderate and severe stunting was higher in females as compared to males.Ignorance and negligence towards a female child in our society may be the cause of these results. (16). 50% fathers and 80% mothers were illiterate. Illiterate parents, especially mothers had the highest frequency of stunted children. Parental Education Matriculation or above had lowest frequency of Stunted Children. Malnutrition in children was lower for those whose mothers had a higher education status. (11). The monthly income of most (72%) families was 6000-12000. This income group had highest frequency of stunted children (34.6%). House hold income more than 15000 had lowest frequency of stunted children (3.8%). Thus increasing income is associated with decreasing stunting. 57% people living in Katcha and Katcha-Pakka houses had the highest frequency ofmoderately and severely stunted children.Mothers having one child had lowest number of moderately and severely stunted children. As

Variables

Normal

Children

Moderately

Stunted

(< -2)

Severely

Stunted

(<-3)

P-

Value

(<

0.05)

Gender

ofChildren

Boys 21 19 9 0.000

Girls 33 15 7

Father's

Education

Illiterate 20 17 10

0.002

Primary 10

8

4

Middle 10

4

1

Higher 14

5

1

Mother's

Education

Illiterate 36

27

14

0.000Primary 10

4

2

Middle 5

2

0

Higher 3

1

0

Type of

House

Pakka 26

15

4

0.000

Katcha-

Pakka 15 10 6

Katcha 13 9 6

Number of

children

1 8 3 1

0.0112 22 14 4

3 16 11 6

4 5 4 3

5 or more 3 2 2

Variable (Food Items)

Nutritional Status

P-ValueNormal

Children

(n)

Stunted

Children (n)

Number of

food items

2

2

7

0.000

3

10

16

4

16

12

5 15 11

6 8 4

7 3 1



number of children of a mother increases the number of moderately and severely stunted children also increases gradually. Thus Increasing parity linked to increasing stunting. (15)The vaccination status of the children in study population showed that 90% of the children were fully vaccinated. This high rate had many reasons; major reason was that that these people were aware of the importance of vaccination, nearby health facility and vigilant lady health workers. The PDHS 2012-13 shows that vaccination coverage in rural areas is only 48% (5).Breast feeding was very common in the study area, with 92% of the children ever breastfed, very close to 94% children of Pakistan ever breast fed by PDHS 2012-13(5). 89% children were consuming dairy products especially milk. Thus milk consumption was adequate.Grains and Cereals consumption was 89% which is satisfactory. Pulses consumption was less than 2%. In comparison to rest of rural areas of Pakistan, pulses consumption was very low. Mainly because pulses were not grown in that area and people were mostly consuming those food items which were grown locally. Vegetables intake to an extent was satisfactory but fruits and meat intake was very low. The main reason of low intake of f ru i ts and meat was poor socio-economic conditions.Children consuming 2 or 3 food items were mostly stunted. Children consuming 4 or 5 food items had a low frequency of moderately and severely stunted children. Thus the majority of the children were lacking balanced diet. A diet containing milk and other dairy products, grains and cereals, vegetables, fruits, meat (white or red or both), oil and ghee and pulses in sufficient quantity , quality and right proportion.ConclusionStunting is a major public health issue of children. It is clear from the study that the frequency of stunting in the study population was 48%. 48% stunting is an alarming figure. Gender, parental education, income, type of housing, parity of women, height of child and number of food items were identified as determinants of stunting. The association of stunting with parental education shows that the frequency of moderately and severely stunted children is high in children whose parents were illiterate. Increasing income was associated with decreasing stunting. There is a statistically significant relationship between stunting and different study variables.References 1. Bhutta DZA. National Nutrition Survey Pakistan

2011; 56-8.2. UNICEF.“Progress For Children: A Report Card

On Nutrition”. 3. Organization World Health. Essential Nutrition

Actions: improving maternal, newborn, infant and young child health and nutrition. 2013.

4. Interactions of: Malnutrition, Water Sanitation and Hygiene, Infections. Version 2005.

5. NIPS. Pakistan Demographic and Health Survey 2012-2013. National Institute of Population Studies.2013.

6. UNICEF.Improving child nutrition the achievable imperative for global progress, 2013.

7. C a u l i fi e l d L E , R i c h a r d S A , R i v e r a JA,MusgroveP,Black RE. Disease Control Priorities in Developing Countries.Washington (DC). World Bank; 2011.

8. Hunt J. ed. Investing in Child Nutrition in Asia. Asian Development Bank, 2000.

9. CaulifieldLE,Richard SA, Rivera JA, Musgrove P,Black RE. Disease Control Priorities in Developing Countries. Washington (DC). World Bank; 2011.

10. Black RE, Robert E, Cesar G, Victoria, Susan P, Walker et al. Maternal and child under nutrition and overweight in low-income and middle-income countries. The Lancet .2013;427-451.

11. UNICEF. Annual Report. 2011.12. NIPS. Pakistan Demographic and Health Survey

2012-2013. National Institute of Population Studies.2013.

13. PMRC. Pakistan National Nutrition Survey 2011. Pakistan.

14. Kristof, Nicholas D. 2009; “The Hidden Hunger”. New York Times.

15. World BANK: Scaling Up Nutrition :A framework for Action 2010.

16. Monika Blossner, Onis Md. Malnutrit ion Quatifying the health impact at national and local Levels. Environmental Burden of Disease. 2005.



SELF-MEDICATION PRACTICES AND PERCEPTIONS AMONG UNDERGRADUATE MEDICAL STUDENTS OF MULTAN MEDICAL & DENTAL COLLEGE, MULTAN

1, 2 Assistant professor, Department of Community Dentistry, Multan Medical & Dental College, Multan.

3 Assistant Professor, Department of Oral Pathology, Multan Medical & Dental College, Multan.4 Demonstrator, Department of Community Dentistry, Multan Medical & Dental College, MultanCorrespondence: Dr. Aftab Yousaf. [email protected]

1 2 3 4Asif Noor , Ejaz Hussain Sahu , Muhammad Umer Abdullah and Aftab Yousaf

Original Article

Abstract

Background: Self-medication can be defined as "the drugs which are used to treat self-diagnosed disorders or indications, or the irregular or continued use of a prescribed drug for persistent or recurrent disease or symptoms." Methods: A descriptive cross sectional study was performed to understand the perceptions and practices about self-medication among students admitted to one of medical colleges in Pakistan located in Multan. A structured Questionnaire was distributed to the consenting students. The data were coded, entered and analyzed by using the Statistical Package for Social Science (SPSS) version 20.0. Out of 95 medical students 47.7% (n=45) were males and 52.3% (n=55) were females. Results: Among participants, self-medication was found in 98% (n=93) cases. Among self-medication respondents, more than 50% treated themselves only once while 32% twice, 12% thrice and only 2.1 % more than thrice. Self-medication was equally common in 3rd year, fourth year and final year medical students. While 24.2% of respondents perceived as a good practice, 42.1% took it as an acceptable practice while33.7% were of opinion that it was a totally unacceptable practice. The study revealed different reasons for self medication and found that the most common reason was non-seriousness of disease i.e 43.2%, followed by convenience / time factor 42.1%, Cost saving 13.7% and least one was the non-availability of physician 1.1% . Regarding the use of drugs, antibiotics were the most common class used as self-medication 27.4%, followed by anti allergics 23.2%, vitamins 17.9%, pain killers 16.8% and antacids in 14.7 % cases.Conclusion: The study results indicate that Self medication was common among medical students from clinical classes and most of students treated themselves at least once. Key words: Self-medication, practices, perceptions, college students.

Introduction:Self-medication can be defined as the drugs which are used to treat self-diagnosed disorders or indications,[1] it involves using medicines without a prescription, use of old prescriptions to buy med ic ines [2 ] .Se l f -med ica t ion can lead to inappropriate use of drugs, waste of income, increased resistance of pathogens which can lead to serious health problems, possible undesirable and serious drug reactions and prolonged morbidity [3]. In developing countries like Pakistan, where drugs are available without prescription and health service provision is insufficient to meet the needs of the population self-medication is rampant [4].Self medication can be attributed to various factors i.e., socioeconomic and socio-demographic factors, easy accessibility of drugs, pharmaceutical advertisement, previous medical history and left over medicines at home. Moreover an emerging source is internet in most educated individuals.[5] The World Health

Organization has emphasized that self medication must be correctly taught and controlled.[1] In a survey of West Bengal, India undergraduate medical school students, 57% reported self-medicating. The type of drugs most frequently used for self-medication were antibiotics(31%), analgesics(23%), antipyretics (18%), antiulcerics (9%), cough suppressants (8%), multivitamins (6%), and anthelmintics (4%).[4] Another study indicated that 53% of physicians in Karnataka, India reported self-administration of antibiotics.[6] Another study at An-Najah National University showed that 98% of medical and nonmedical students practiced self-medication [7].In Bahrain, a study which was conducted among first year medical students, 76.9% of the study population preferred self-medication [8]. The habit of self-medication practice among doctors develops during their undergraduate training as obvious from studies of self-medication among medical students.[9] For medical undergraduates such practice has special

Self-Medication Practices and Perceptions Among Undergraduate Medical Students Asif Noor, Ejaz Hussain Sahu and others



significance as they are exposed to knowledge about diseases and drugs and availability of drugs on pharmacies due to their medical background, especially in Pakistan. This study was performed to understand the practices and perception of self-medication among undergraduate medical students in one of medical colleges in Pakistan, located in Multan.Methodology: A descriptive cross sectional study was undertaken to be familiar with perceptions and practices of medical students of Multan Medical & Dental College about self-medication. Simple Random Sampling technique was used to identify the potential sample. Sample size was calculated using the below mentioned formula and prevalence of self-medication in Pakistan according to a study done at Karachi.[10][11] i.e. 51%, the calculated sample size is 95. All undergraduate students from clinical side third, fourth and final year were included in study. Students currently on any drug regime for acute or chronic physical or mental illness were excluded from the study. A structured Questionnaire was distributed to the consenting students. The self-administered questionnaire consisted of 26 questions, which c o l l e c t e d d a t a r e g a r d i n g d e m o g r a p h i c , socioeconomic, and lifestyle factors. Students were asked to indicate if they had used any drugs in last 15 days, the duration and pattern of use, which drugs they had used, and whether the drugs had been prescribed by a doctor. The data were coded, entered and analyzed by using the Statistical Package for Social Science (SPSS) version 20.0.Results:Comparison of different diseases and use of self-medication for different diseases are presented in figure-1. A total of 95 medical students were given questionnaire. The response rate was 100%. The mean age of the respondents was 22.22± 1.7S. Out of 95 medical students 47.7% (n=45) were males and 52.3% (n=55). Among participants, self-medication was found in 98% (n=93) cases. More than 50% of the positive respondents treated themselves only once, while 32% self medicated themselves twice during the last six months, while only 2.1 % of the positive subjects went for self medication more than three times during last six month. Self-medication was equally common in 3rd year, fourth year and final year medical students. All (n=95) respondents knew about self-medication. 24.2 % of the respondent perceived self-medication as a good practice while for 42.1% it was an acceptable practice and 33.7% took it as totally unacceptable practice. The study revealed different reasons for self medication and found that 43.2 % of the people practiced it assuming the non-seriousness of the disease. While 42.1% practiced it for their convenience and time saving, 13.7% choose it to save cost, while only 1.1% had issue of non-availability of physicians as the study population was

already spending more than six hours in a teaching hospital (table-1).

Figure 1: Bar graph shows comparison of Self-Medication practice for different diseases

Table 1: Frequency distribution according to Source of information regarding Self-medication

Discussion:Self-care, including self-medication, has been a feature of healthcare for many years and people have always been keen to accept more personal responsibility for their health status [12]. Self-medication by itself has both pros and cons that depend on who and what one chooses to self -medicate [13]. Several studies have reported the practice of self-medication in medical and non-medical students. The present study showed that self-medication was widely practiced by the medical students of the institute. The prevalence of self-medication in our study was found to be 97.8%. While in other studies, the prevalence of self-medication among the medical students was shown to be ranging between 57.1% and 92% [14-16] . The students from non-medical background showed a prevalence of 80.1% in Tamil Nadu [17] and 87% in Uttar Pradesh [18]. In studies conducted in developing countries, the prevalence of self-medication was shown to be 25.4% and 43.2% in Ethiopia [19,20], 51% in Slovenia [21] , 55% in Egypt [22], 56.9% in Nigeria [23] and 80.9% in Malaysia [24]. Similarly, a nine-year follow-up study of

Source of information

Frequency Percentage (%)

Previous Doctor Prescription

28

29.5

Opinion of family members / friends

25

26.3

The advertisement /Media/Net

22 23.2

Recommendations by Pharmacist

20 21.1



a nationwide sample from Norway has reported a self-prescribing behavior among young doctors [25] .The results of our study show high prevalence then other developing countries. In our study, antibiotics were most commonly used as self-medication (27.4%), followed by anti allergics (23.2%), vitamins (17.9%), pain killers (16.8%) and antacids (14.7 %). The results of our study were correlated with the study by Sohair E Ali et al [26] which revealed that analgesics & antipyretics (30.2%), ear, nose & throat drugs (10.8%), vitamins & minerals (10.8%), GIT drugs (8.5%), anti-infectives (7.3%) and herbal medicines (3.5%) were commonly self medicated and similar were the findings of Patel MM et al [27] which showed that 43.03% of pain-relievers. 21.51% cough remedies. 7.27% of Antimicrobials were self medicated commonly. In the present study, different reasons for self-medication were found. Most common being the disease not serious (43.2%) followed by convenience / time factor (42.1%), Cost saving (13.7%) and least one was the non-availability of physician (1.1%). The results compared with the study by AnsamF.sawalha et al [28] also reported that the most commonly reported reason for self-medication practices was simplicity of the illness encountered. Analgesics, decongestants, herbal medicines and antibiotics were the most common classes reported in self-medication. According to the Economic Survey of Pakistan (2006-2007)[29], there was one doctor available for 1254 people whereas a WHO criterion for developing countries is minimum one doctor for 1000 population (Economic survey of Pakistan, 2006-2007). In Pakistan, almost every pharmacy sells drugs without a prescription; a phenomenon seen in many developing countries (Kiyingi and Lauwo, 1993)[30]. The relative low cost is important factor for resorting to self-medication and undesirable health seeking behavior. ConclusionThe study results indicate that Self medication is common among medical students from clinical classes and most of students treated themselves at least once. References1. World Health Organization: Guidelines for the

regulatory assessment of Medicinal Products for u s e i n s e l f - m e d i c a t i o n 2 0 0 0 . http://apps.who.int/medicinedocs/pdf/s2218e/s2218e.pdf

2. Loyola Filho AI, Lima-Costa MF, Uchôa E. Bambuí Project: a qualitative approach to self- m e d i c a t i o n . C a d S a u d e Publica.2004;20(6):1661–69.

3. World Health Organization: Report of the WHO Expert Committee on National Drug Policies 1 9 9 5 . http://apps.who.int/medicinedocs/documents/516221e/s16221e.pdf.

4. Banerjee I, Bhadury T. Self-medication practice among undergraduate medical students in a tertiary care medical college, West Bengal. J Postgrad Med. 2012;58:127–31.

5. Klemenc-Ketis Z, Hladnik Z, Kersnik J. A cross sectional study of sex differences in self- medication practices among university students in Slovenia. CollAntropol. 2011;35:329–34.

6. Deshpande SG, Tiwari R; Self medication--a growing concern. Indian J Med Sci, 1997;51: 93-6.

7. Sawalha AF. A descriptive study of self-medication practices among Palestinian medical and nonmedical university students. Res. Social. Adm. Pharm.,2008; 4 (2):164-172

.8. James H, Handu SS, Al Khaja KA, Otoom S,

Sequeira RP. Evaluation of the knowledge, attitude and practice of self-medication among first-year medical students. Med. Princ. Pract.,2006;15 (4): 270- 275

9. Medical, Pharmacy, Health Science Students in Gondar University, Ethiopia. Journal of Young Pharmacists, 2010; 2(3): 306-310.

10. Syed Nabeel Zafar, Reema Syed, Sana Waqar,Akbar Jaleel Zubairi, TalhaVaqar; Selfmedication amongst University Students of Karach i : P reva lence , Knowledge and Attitudes;Vol. 58, No. 4, April 2008 214-217J Pak Med Assoc

11. Haider S, Thaver IH, Self medication or self care: implication for primary health care strategies. J Pak Med Assoc 1995; 45: 297-8

12. Khantzian, E.J. The self-medication hypothesis revisited: The dually diagnosed patient. Primary Psychiatry.2003;10, 47-48, 53-54.

13. Hughes CM, McElnay JC, Fleming GF; Benefits and risks of self medication. Drug Saf, 2001; 24: 1027-1037.

14. Banerjee I, Bhadury T (2012) Self-medication practice among undergraduate medical students in a tertiary care medical college, West Bengal J Postgrad Med 2012;58(2):127–131.

15. Sontakke SD, Bajait CS, Pimpalkhute SA, Jaiswal KM, Jaiswal SR (2011) Comparative study of evaluation of self-medication practices in first and third year medical students. Int J Biol Med Res 2011;2(2): 561–564.

16. Badiger S, Kundapur R, Jain A, Kumar A, Pattanshetty S, et al. (2012) Selfmedication patterns among medical students in South India. Australas Med J 2012;5(4):217–220.

17. Kayalvizhi S, Senapathi R (2010) Evaluation of the perception, attitude and practice of self-medication among business students in 3 select ci t ies, South India. IJEIMS;1(3):40–44. Available: http://www.ijcns.com/pdf/40-44.



http://apps.who.int/medicinedocs/pdf/s2218e/s2218e.pdf

http://apps.who.int/medicinedocs/pdf/s2218e/s2218e.pdf

http://apps.who.int/medicinedocs/documents/516221e/s16221e.pdf

http://apps.who.int/medicinedocs/documents/516221e/s16221e.pdf

Accessed:2013 Feb 27.18. Verma RK, Mohan L, Pandey M (2010)

Eva lua t ion o f se l f med ica t ion among professional students in North India: proper statutory drug control must be implemented. Asian J Pharmaceutical Clin Res 2010;3(1) 60–64.

19. Abay SM, Amelo W (2010) Assessment of self-medication practices among medical, pharmacy, and health science students in Gondar University, Ethiopia. J Young Pharm 2010; 2(3):306–310.

20. Gutema GB, Gadisa DA, Kidanemariam ZA, Berhe DF, BerheAH, et al. Self-Medication Practices among Health Sciences Students: The C a s e o f M e k e l l e U n i v e r s i t y J A p p l Pharmaceutical Sci 2011;01(10):183–189

21. Smogavec M, Softicˇ N, Kersnik J, Klemenc-Ketisˇ Z An overview of selftreatment and selfmedication practices among Slovenian citizens Slovenian Med J 2010;79:757–763.

22. El Ezz NF, Ez-Elarab HS .Knowledge, attitude and practice of medical students towards self-medication at Ain Shams University, Egypt J Prev Med Hyg 2011; 52(4):196–200.

23. Fadare JO, Tamuno I .Antibiotic self-medication among university medical undergraduates in Northern Nigeria.J Public Health Epidemio 2011;l3(5): 217–220.

24. Ali SE, Ibrahim MIM, Palaian S .Medication storage and self-medication behaviour amongst female students in Malaysia. Pharm Pract 2010;8(4):226–232.

25. Hem E, Stokke G, Tyssen R, Grønvold NT, Vaglum P, et al. Selfprescribing among young Norwegian doctors: a nine-year follow-up study of a nationwide sample. BMC Med 2005;3:16.

26. S o h a i r E A l i , M o h a m e d I I b r a h i m , SubishPalaian;Medication storage and self-medication behaviour amongst female students in Malaysia;pharmacy practice, Vol 8, No 4 (2010)

27. Patel MM, Singh U, Sapre C, Salvi K, Shah A, Vasoya B. Self-Medication Practices among College Students: A Cross Sectional Study in Gujarat. Natl J Med Res. 2013; 3(3):257-260

28. AnsamF.sawalha; assessment o f se l f -medication practice among university students in p a l i s t i n e : t h e r a p e u t i c a n d t o x i c i t y implications.2007; 15(2): 67-82

29. Economic survey of Pakistan . Ministry of Finance, Government of Pakistan (2006-2007)

30. Kiyingi KS, Lauwo JAK. Dangers in the home: danger and waste. World Health Forum 1993; 14: 381-384



Original Article

Abstract

NUTRITIONAL STATUS AMONG PRIMARY SCHOOL GOING CHILDREN LIVING IN URBAN AREA OF SINDH PAKISTAN

1Fellow at Health Services AcademyandMedical Officer, Sindh Government Hospital Qasimabad, Hyderabad.

2Assistant Professor, Hazarat Bari Sarkar Medical College Islamabad.3Assistant Professor, LUMHS Hospital Hyderabad/Jamshoro.4Ph.D fellow at Institute of Chemistry, University of Sindh, Jamshoro.

5Post graduate trainee, LUMHS Hospital Hyderabad/Jamshoro.6Assistant Professor, Department of Health System & Policy; Health Services Academy, Islamabad.Correspondence: NandlalSeerani. Email: [email protected]

1 2 3 4 5Muhammad Faisal Qureshi ,Aneeta Rathore ,Nandlal Seerani ,Sumera Qureshi , Dr.Bisharat Faisal 6and Ramesh Kumar

Background: Children's health is very important for their better learning and timely nourishment everywhere in the world. Malnutrition among school going children has remained a big challenge in under developed countries.Methods: Cross-sectional study was conducted among 422 children of four Government Primary schools of Qasimabad, district Hyderabad after taking the proper consent and administration approval from the head of school. Multi stage simple random sampling technique was adopted. Study was approved from Institutional review board of Health Services Academy Islamabad.Results: Out of total, 217 (51.4%) were boys and 205 (48.6%) were girls. Mean Height of boys and girls were 128.09 cm (±SD 12.90) and 130.36 cm (±SD 12.50) respectively. Mean Weight of boys was 25.27 Kgs (±SD 6.17) while in girls mean Weight was 26.83 Kgs (±SD 7.03). 17.57 cm (±SD 2.34) was mean MUAC for all participants and mean BMI was 15.42 (±SD 2.02). Prevalent of stunting and wasting were 24.4% and 18.3% respectively. While in 13.7% thinness (BMI for age) was seen. Stunting was statistically significant in girls 9-10 year (p value=.015, CI: .118-.823, OR=.311) and 11-≥12 years (p value=.018, CI: .215-.874, OR=.434). Pallor was more in girls (17%) and Dental caries were higher in boys (20.8%). Insufficient breakfast was done by 347 (82.2%), whereas 75 (17.8%) were doing sufficient breakfast. 341 (80.8%) students became ill during last year, out of that 80 (19%) were having history of hospitalization.Conclusion: Poor polices and lack of food aid interventions regarding health of primary school going children was assessed during this study.Key Words: Stunting, wasting, thinness, children, government primary schools

Introduction:Children health is very important during their growth period. The school age period is nutritionally significant because this is the prime time to build up body stores of nutrients in preparation for rapid growth of adolescence.Malnutrition remains the world‟s most serious health problem and the single biggest contributor to child mortality, nearly one third of the children in the developing world are either underweight or stunted. The health status of an adult is also depending on his childhood nutritional status [1]. Malnutrition is defined as different forms of poor nutrition leading to both underweight and overweight conditions caused by a complex array of issues, including dietary inadequacy, infections, and socio-cultural factors. Good nutrition builds a stronger immune system, better health and productivity. Malnutrition can lead to deficiencies of macro and

micronutrients,wasting and stunting, and other diseases [2,3].The underlying factors like; clean drinking water, food security, education, good sanitation conditions and heath care services contribute to improve nutritional status in an individual and communities. These are caused by an association of dietary deficiencies; poor maternal and child health and nutrition; a huge burden of morbidity; and low micronutrient content in the soil, especially iodine and zinc. Many of these micronutrients have profound effects on immunity, growth, and mental development [4].Primary school going children need more attention regarding to their physical and mental growth and it is the neglected group to do any food aid programme implemented by government or donor agencies. Principal aim of study was to improve nutritional status of primary school going children, with

Nutritional Status Among Primary School Going Children Muhammad Faisal Qureshi and others


prevalence of stunting and underweight in primary school going children. Methodology:A cross sectional study was conducted in Hyderabad Sindh by adopting the multistage cluster sampling. In first stage four government primary schools (GPSs) were selected randomly in taluka Qasimabad, district Hyderabad provided. In second stage students of primary section studying in class first to fifth standard were selected randomly selected. After written consent, signed by their parents /class teacher, a detailed interview was conducted on World Health

Organization (WHO) adopted, pretested, validated questionnaire. Each questionnaire was consisting socio-demographic profile, Physical examination, anthropometric measurements,dietary practices and health profile regarding last year illness. Data was collected after a training of data collectors by Principal investigator prior to start the study. Ethical consideration was taken from Institutional Review Board (IRB) of Health Services Academy Islamabad.Results: A total of 422 students were selected from four GPSs of Qasimabad. 217 (51.4%) were boys and 205 (48.6%) were girls (Table:1)

Table 1: Number and percentage of participants in Government Primary Schools

S No:

Name of school

Boys

(%)

Girls

(%)

Total

(%)

1

GPS Shahbaz Town

83(57.2)

62(42.8) 145(34.3)

2 GPS BachalChandio 30(30) 70(70) 100(23.7) 3 GPS Shoro Goth 50(82) 11(18) 61(14.5) 4

GPS Peon Coloney

54(46.6)

62(53.4)

116(27.5)

Total

217(51.4)

205(48.6)

422(100)

The residential status of 329 (78%) were urban and 93 (22%) were belong to rural areas by birth. Parental occupation of 134 (31.8%) students was government servants and parents of 288 (68.2%) students were having private work or earn daily wedges. Government servants mostly were doing job like driver, peon, naibqasid, watchman, police constable and clerk. While parents were laborers, massons, shopkeepers, barbers, milk dispatchers and tea shop (dhaba) owners were categorized in private work.Fathers of 106 (25%) pupils were illiterate and 316 (75%) were literate of which 165 (52.2%) had passed their primary, 111 (35.2%) were matriculated and 40 (12.6%) were graduated.Where as literate mother was seen in 190 (45%) of study population among them 166 mothers (87%) were primary passed, 20 (11%) and 4 (2%) were matriculated and graduated mothers respectively. Remaining 232 (55%) participant's mothers were illiterate.Most of participants belonged to low and middle socioeconomic class. The mean income per month of participant's father/caregiver was Rs: 14681.27(±SD 7943.46).The Mean value of Mid Upper Arm Circumference (MUAC) was 17.57 cm (±SD 2.34) in whole study population. Gender wise in boys the MUAC Mean was 17.07 cm (±SD 1.96) and in girls Mean MUAC was 18.10 cm (±SD 2.59).the mean weight of study population was 26.03 Kgs (±SD 6.64) with the minimum value of 13.60 Kgs and the maximum value of 48.10 Kgs. While the mean weight of boys was 25.27Kgs (±SD 6.17) and in girls the mean weight was 26.83 Kgs(±SD 7.03). Total of study population were 5-10 years (whom WA z-score are

available in WHO References 2007), 46 (18.3%) were underweight. Gender wise underweight was more seen in girls 18.7% (20) than in boys 17.9% (26). Thinness (BMI for age) was seen normal in 86.3% (364) and in 13.7% (58) thinness was present, out which 4.5% (19) were severely thinned.Regarding to illness in last year 341 (80.8%) were replied yes, and 81 (19.2%) said that, they were all right. The Mean BMI in the subject population was 15.42 (±SD 2.02) with the minimum value of 10.70 and maximum of 25.60. Boys were having the average of15.30 (±SD 1.84), while girls were at the average of 15.53. The physical examination revealed that, the prevalence of Pallor in the study population was 25.8% (109). Xerosis was present in 5.5% (23). Bitot's spots were observed in 2.6% (11), Koilonychia was absent in all 422 (100%) pupils, 33.9% (143) were having Dental caries, Mottled enamel was seen in 23.2% (98) participants and BCG vaccination mark was present in 59.2%(250) students (table 3).



Table 2: Sociodemographic characteristics of the study participants

Pallor was more observed in 5-6 years age group 56% and in 11-≥12 years age group 30%. Dental caries

were also more seen in 5-6 years (43%) and were less seen in 11-≥12 years (28%). BCG vaccination mark was present higher in 5-6 years 75% as comparatively was less in 11-≥12 years age group.Stunting was statistically significance in girls (9-10 years) 16, out of 58 girls were stunted (p value=.015, CI: .118-.823) as compare to boys, who were 7, out of 66 were stunted. Stunting was also statistically significant in girls (11-≥12 years) present in 37, out of 98 (p value=.018, CI: .215-.874) as 15 out of 57 were having stunting. Thinness or BMI for age was also significance who were doing insufficient breakfast as 57 out of 347 were having <-2 SD BMI for age (p value=.002. CI: .033-.584) as who were doing sufficient breakfast seen in 2 out of 75 (table-2). Stunting was seen significantly associated in 97 out of 347, who were doing insufficient breakfast (p value<.001, CI: .094-.533) as compare to sufficient breakfast, in which 6 were stunted out of 75.Prevalence of Stunting (HA) in study population was present in 103 (24.4%). Gender wise prevalence of stunting of boys was seen in 18.9% (41), but in girls stunting was present in 30.2% (62), which is statistically significance (p value=0.007, CI:.384-.844).

Variables Percentage (numbers)

Child’s father education

Literate

316 (75)

Illiterate

106 (25)Child’s Mother education

Literate

190 (45)Illiterate

232 (55)Monthly income

14681.27

Mean (422)Age

5-6 years

167-8 years

1129-10 years

12411-≥12 years

170Age group wise mean weight

5-6 years

16

7-8 years

112

9-10 years

124

11-≥12 years 170Under weight Children

Boys

17.9(26)Girls 18.7(20)

Thinness BMI for age Present 13.70(58)Absent 86.30(364)

Illness in last year Reported ill 81(341)All right 19(81)

Age wise stunting 5 – 6 years 57 – 8 years 239 – 10 years 2311 – ≥12 years 52

Physical examination

Boys

Girls

p value

Pallor

37

72

<.001*

Xerosis

9

14

0.225

Bitot’s spots 7 4 0.411

Koilonychia 0 0 Dental caries

88

55

0.003*

Mottled enamel

60

38

0.027*

BCG mark

116

134

0.013*

*Significant p value

Table 3: Gender wise distribution between boys and girls

Mean height of study population was 129.19 cm (±SD12.74) with the minimum height of 95.00 cm and the maximum height of 167.10 cm. In the Boys Mean height was 128.09 (±SD 12.90) and in Girls the value of Mean height was 130.36 (±SD 12.50). The age group wise Mean height is given in Table: 9.Dietary Practices:Breakfast was categorized in two, one was sufficient breakfast consisting; egg, cereals, bread/roti, tea. And second category insufficient breakfast had; Rusk/biscuits, roti/bread and tea. 75 (17.8%) were doing sufficient breakfast and 347 (82.2%) were doing insufficient breakfast. 21.2% (46) boys were doing sufficient breakfast and 78.8% (171) were on insufficient breakfast. In girls 85.9% (176) were doing insufficient breakfast and 14.1% (29) were doing sufficient breakfast.Eating fruits regularly were told by 364 (86.3%) either bought by themselves or brought by their parents and 58 (13.7%) were denied to eat fruits. 276 (65.4%) replied yes to drink milk regularly

especially before sleeping at home and 146 (34.6%) did not drink milk because of reasons, more common was their parents/caregiver could not afford it.DiscussionStudy has observed most of the students were having late enrolment in all four Government primary schools which were included in the study. Study shows with similar findings [5]. The socio demography of Bangladesh is almost same as in context of Pakistan so there were almost same findings of stunting seen as in present study [6,7,8]. A community based survey was conducted among school going children in Addis Ababa Ethiopia. Results showed 19.6% and 15.9% were stunted and underweight respectively. That findings near to our study findings although in Ethiopia poverty and food security are problems but in our study low socio economic status might be cause of same findings. In above said study underweight increase significantly with an increase in age, family size, and order of birth and in the absence



of hand washing facility [9,10]. As study conducted among primary school going children of Lahore aged 5-12 year were participated in that study, 32% children were found under nutrition or thin [11]. A study done on prevalence of malnutrition among primary and secondary school children in Bangalore, India [12,13,14]. After seven days trail order was reversed, results of measurement of cognitive function showed self reported alertness improved significantly in whole study population, and male participants were feeling more positive after eating breakfast [15]. Physical examination of pupil revealed that pallor was more in girls 17%. Bitot's spots and dental caries were more in boys 11.3% and 20.8% respectively. In NNS 2011 62% children are anemic under five which more than double as in study pallor was seen in 25.4%. According to NNS-2011, nutritional status is slightly better in urban areas as compare to rural areas and boys are better with their nutritional status than in girls. Regarding PDHS 2012-13 food security, poverty and illiteracy in women are main factors in malnutrition. ConclusionThe study concludes that nutritional status of government primary school going children was not good enough as stunting, underweight and thinness is 24.4%, 15.3% and 13.7% respectively. Late enrolment of students in all four government primary schools was seen particularly in girls, whom mean age was 118.09 months (±SD 27.78). Pallor was present more in 72 (35.1%) girls. BCG vaccination mark was present in just more than half of the students (59.2%). Other contributing factors in malnutrition like low socio-economic status, illiteracy in parents, dietary pattern, food insecurity, poor health services and lack of micronutrients are major problems.References:1. Shivaparkash NC, Joseph RB. Nutritional Status

of Rural School Going Children (6-12 Years) of Mandya District, Karnataka. International Journal of Scientific Study.2014; 2 :( 2).

2. Moushagan NGT, Kujinga P, Chagwena D.T, Chituwu R, Nayabanga G. A Restrospective Study of the Nutritional Status of Primary School Children In Harare. Ajfand. 2014; 14:(03).

3. Izharul H, et al,An Assessment of Nutritional Status of the Children of Government Urdu Higher Primary Schools of Azad Nagar and its Surrounding Areas of Bangalore.Archives of Applied Science Research. 2011; 3 (3):167-176.

4. Mondal T, Mondal S, Biswas M. An Assessment of Nutritional Status of Children of Government Aided Primary School of West Bengal. I n t e r n a t i o n a l J o u r n a l o f E l e m e n t a r y Education.2014; 4( 3):41-45.

5. Siddique S, Ayub M, Shore N, Tariq U, Zaman S. Nutritional Status of Primary School Children in Abbottabad. J Ayub Med CollAbbottabad. 2013;25(1-2).

6. Amare B, Moges B, Fantahun B et al. Micronutrient Level and Nutritional Status of Children Living in North West Ethopia. Nutri J.2012;11: 108.

7. S a n g w a n L , K u m a r R , A r u n P e t a l . Anthropometric Characteristics and Nutritional Status of Primary School Children in Fatehabad City Haryana. Int J B &Appl Sci:2014; 4(2).

8. Rashmi M R, Shweta B, Fatimah F N et al. Prevalence of Malnutrition and Relationship with Scholistic Performance among Primary and Secondary School Children in Two Selected Private Schools in Banalore Rural District, India. Indian J Community Med. 2015;40 (2): 97-120.

9. Ara R, Houque S R, Adhikary M et al. Nutritional Status Among the Primary School Children in Selected Rural Community, J Dhaka Med Coll. 2001; 20(1): 97-101.

10. Müller K W, Hille K, Klenk J et al. Influence of Having Breakfast on Cognitive Performance and Mood in 13-to 20-Year-Old School Students: Result of a Crossover Trail. Ped J AAP. 2015; Vol 122 (2).

11. Khan T, Khan E A, Raza M A. Gender Analysis of Malnutrition: A Case Study of School Going Children in Bhawalpur. Asian development policy review J. 2015; 13(2):29-48.

12. D e g a r e g e D , D e g a r e g e A , A n i m u t A . Undernutrition and Associated Risk Factors among School Age Children in Addis Ababa, Ethiopia. BMC Public Health J. 2015;15:375.

13. Bernardo C, Pudla K et al. Factors Associated with Nutritional Status of 7-10 Year-old School Children: Sociodemographic Variables, Dietary and Parental Nutritional Status.2012;15(3):651-61.

14. Mishtaque M, Gull S, Shahid U et al. Family-based Factors Associated with Overweight and Obesity among Pakistani Primary School Children. BMC Pediatrics J. 2011;11:114.

15. Ashok N C, Kavitah H S, Kulkarni P. A Comparative Study of Nutritional Status between Government and Private School Children of Mysore City. Int J Health & Allied Sci. 2014;3(3): 164-169.



7TH ANNUAL PUBLIC HEALTH CONFERENCE 2016 AT HEALTH SERVICES ACADEMY: EXPERIENCES IN THE FIELD OF PUBLIC HEALTH AND WAY FORWARD

1 MSPH 1516 Student, Health Services Academy, Islamabad

2 Associate Professor, Health Services Academy, Islamabad3Associate Professor,Adjunct Faculty, Health Services Academy, IslamabadCorrespondence: Neelam A Khan. Email: [email protected]

1 2 3Neelam A Khan , Saima Hamid , Katrina Ronis

Report

Abstract

BackgroundHealth Services Academy held its 7th Annual Public Health Scientific Conference in December 2016 in Islamabad, Pakistan. The theme was Sustainable Development Goals (SDGs) in Health: Collaborating for Prosperity. Over seven hundred international and national public health specialists attended to share research initiatives, build partnerships and strengthen networks. Post-conference online survey was emailed to all participants to facilitate a more structured feedback and hence evaluation of the two day event.Methods: An online instrument was developed using the “Survey Monkey” template. Total participants (n=757) were invited to complete the online survey which consisted of five sections: Likert scales were utilised to ascertain how “informative” the conference was to the participants. Comment boxes were provided for each section to collect qualitative responses. The quantitative data was collated by Survey Monkey and presented in percentages. Manual thematic analysis was utilised for the qualitative data. Results: The final online surveys emailed was seven hundred and four and of these just over two thirds (67%) were opened and 33% (n=230) were unopened. The latter emails may have been in the “spam” box or not opened. Of the opened surveys (n=474) nearly two hundred were completed and emailed back, a response rate of forty two percent (n=199). The quantitative data revealed that the majority of respondents (75%) found the plenary sessions to be'very informative 'and approximately half of the respondents considered the scientific sessions to be 'extremely informative' or 'very informative'. With respect to how useful the conference was to the participant's field of public health, almost half (44%) responded 'very useful and over a third (34%) responded 'extremely useful'. The top three themes recommended for the 2017 Conference included Nutrition; Non-Communicable Diseases and Mental Health and Sustainable Development Goals. Conclusion: The majority of survey respondents agreed that the conference was a success and the theme was useful in their own field of public health. Several themes for the 2017 conference were provided with a focus on nutrition the most popular.Keywords: Public Health, Sustainable Development Goals, evaluation and online survey

IntroductionHealth Services Academy (HSA)was established in 1988 as an in-service training institute for the government health sector andhas evolved over the years into a premier institution of public health. It continues to function as an autonomous organisation under the 'Ministry of National Health Services, Regulations & Coordination', Pakistan.Its mission is to establish itself as a regional centre of excellence in public healthand support the vision of the World Health Organisation.Since 1988 more than eight hundred students have completed graduate level studies in public health from the Academy.A Doctor of Philosophy (PhD) program was inaugurated in 2012 and currently there are 19doctorate students. The HSA Alumni are working in

academia , resea rch , po l i cy mak ing , and management in the private and public sector nationally and internationally. In 2010, the Academy undertook the initiative to organize annual public health conferences which have attractedpublic health professionals across the country and from abroad.Each year the conference theme is set in accordance with Pakistan's priority public health issues.In December 2016, the 7th Annual conference's theme “Sustainable Development Goals (SDGs) in Health: Collaborating for Prosperity” focused on a world in which partnerships and prosperity are at the forefront for achievement of sustainable development in health. The SDGs are a set of 17 global goals which were adopted by the UN Member States at the

7th Annual Public Health Conference 2016Neelam A Khan, Saima Hamid and Katrina Ronis



“Sustainable Development Summit” on 25th September, 2015. Pakistan adopted the SDGs in February 2016 through a parliamentary resolution that was passed unanimously. Prioritizing health is resonated in the “Pakistan Vision 2025”and “National Health Vision 2016-25”.The 2016 conference provided a platform for over 700health experts, allied disciplines and students to communicate and share knowledge, experiences and best practices towards achieving the SDGs for Health. Additionally, it promoted discussion on identifying synergies and partnerships for building collective commitment and harnessing resources for development. The two day event provided an opportunity for public health colleagues to network and also attend theplenary and scientific sessions.A total of 39 papers were presented at the ten scientific sessions by international and national speakers. Eleven stalls were set up and included International Non-Government Organisat ions ( INGOs), Non-Government Organisations (NGOs), local health informatics companies and academic book vendors. The 2016 conference featured new elements: the 'comment wall' and 'photo frame' pledging a commitment to fulfilling the SDGs. In the past an informal feedback mechanism facilitated feedback from the conference participants. To promote and support the importance of monitoring and evaluationin public health,an online evaluation survey was emailedto all participants of the Academy's 7th Annual Public Health Conference. The main aim of this online survey was to assess how informativethe content of the conference was and to seek themes for the 2017 conference. Methodology:The research aim was “To ascertain how informative the 7th Annual Public Health Conference was forparticipants?” The research method utilised was an online survey with a quantitative and qualitative approach (i.e. mixed method). There were fivephases applied to the evaluation process: Selection of the Participants; Development of the Instrument; Surveying the Participants; Data Collection and lastly Data analysis and interpretation.First Phase: Selection of the Study ParticipantsA mailing list of all registered conference participants (n=757) was obtained from the “Conference Secretariat”. These participants included academics, s t u d e n t s a n d c o m p a n y r e p r e s e n t a t i v e s . Individualemail addresses were checked for correct formatting.Some of the public health professionals registered for the conference did not attend the conference but were included in the evaluation.Second Phase:Development of the Survey InstrumentAn online instrument was developed using the

“SurveyMonkey” template. This was piloted with four faculty members of the Academy. The online survey consisted of five sections pertaining to the conference sessions. A Likert scale of five levels were utilised to ascertain how “informative” the conference sessions were for the participants e.g. 'extremely informative', 'very informative', 'moderately informative', 'not at all informative' and 'did not attend'.Comment boxes were provided for each section to collect qualitative responses. A limitation of the online survey instrument was the absence of demographic data fields e.g. Age/Gender/Position/Province etc.Third Phase: Surveying the participantsThe online survey was emailed to all registered participants (n=757) however fifty two emails bounced. Of the remaining emails (n=705) one participant opted out. Of the remaining 704 participants 67% (n=474) were opened their survey and 33% (n=230) did not open their survey. The unopened emails and hence survey may have remained in the participants “spam” box, were not received or ignored. Fourth Phase: Data CollectionThe online survey was emailed out with an introduction to the survey and that all data would be treated confidentially. Weekly reminders were emailed to the participants to respond to the survey. This continued for four weeks.Fifth Phase: Data analysis and interpretationData from the online survey quantitative sections were automatically collated by SurveyMonkey(i.e. for the Likert scale responses) and presented in graphical format in percentages. Thematic analysis was undertaken manually for the qualitative data comments.Results:The onlinesurvey was emailed to seven hundred and fifty seven (n=757) participants. Fifty two emails bounced leaving a total of seven hundred and five (n=705) emails sent. From this amount four hundred and seventy four (n=474) participants opened their survey email and one hundred and ninety nine (n=199) responded (opened) and emailed back the survey, a forty two percent response rate (42%). However two hundred and thirty (n=230) emails remained unopened. These emails may have been in the participants “spam” box and not checked.Plenary sessions:The theme for the first plenary session was “Global Agenda for Sustainable Health Solutions”, and included three presentations. Overall, at least two thirds of respondents found the first plenary 'very informative', especially the “Sustainable Solutions for Sustainable Development presentation”. A small minority stated it was 'not informative' as shown in



Table 1: Informative levels of Plenary presentations on “Global Agenda for Sustainable Health Solutions”

Responses n=190

Sustainable Solutions for Sustainable Development

Gender, Health & Population Matters

Service delivery improvement for move towards UHC

Very informative

80% 74% 67%

Not informative

4% 8% 8%

Did not attend

16% 18% 25%

The second plenary session's theme was “Cross-Sector Partner Engagement in Building Sustainable Health Systems”. The majority of respondents found the three presentations almost equally 'very

informative' (average 71%). Those that found the presentations 'not informative' were on average 7%, with NCDs and Nutrition: Policies & Actions the least informative (9%) as shown in Table 2.

Responses

n=186 NCDs and Nutrition: Policies & Actions

SDGs - Health in all Policies

Development of Indicators for SDGs

Very informative

70% 73% 71%

Not informative

9% 8% 5%

Did not attend

21% 19% 24%

Table 2: Informative levels of Plenary presentations on “Cross-Sector Partner Engagement in Building Sustainable Health Systems”

There were a total of forty one (n=41) comments received on the plenary sessions. Of these almost halfwere 'positive' comments such as “good work”, “clearly presented”, “excellent” and “very helpful”. There wereless than a quarter that focused on aspects to improve upon such as “…the local context not included”, “…more elaboration needed” and“Question/Answer sessionswere needed”.Scientific Sessions:There were ten scientific sessions with responses on seven sessions that were conducted on Day 2. A list of the sessions is shown in Box 1.

Approximately two thirds (n= 178) found the sessions 'very informative'. The most informative session was on the “Nutrition”session (67%); the least informative

was the session on “Maximizing synergies between Maternal Nutrition and Birth Spacing”(8%). A comparison of how informative the sessions were is shown in Figure 1.

Figure 1: How informative were the Scientific Sessions?There were thirty ninewritten comments of which a third (n=13) were 'positive' remarks such as “amazing” and “highly informative”. Eleven (n=11) constructive comments related to some logistical issues and the quality of some presentations for example “…some multimedia not clear” and “…actual data not included”.

BOX 1: Scientific Session Themes

1. Role of Family Planning in achieving SDGs 2. Nutrition

3. International Health Regulations/Global Health Security

Agenda

4. Maximising synergies between Maternal Nutrition and

Birth Spacing

5. Innovative approaches to raise awareness and improve

service provision in Reproductive Maternal and New-born

Health in KP

6 Burden of Disease



Usefulness of Conference:Almost half of the respondents (43%) found the conference to be 'very useful' with respect to their personal field of public health. Just over a third (35%) responded as 'extremely useful' and 16% found it to be 'moderately useful' as shown in Figure 2.

Figure 2: Usefulness of Conference to Participants Twelve comments were provided of which a third (n=4) were 'positive' remarks such as “inspiring and motivating” and “relevant to Pakistan perspective”. Two constructive comments focused on improving thequality of some presentations and some posters. Learning Environment:Overall, the learning environment of the conference was perceived to be 'very good' by almost half (44%) of the respondents; 'excellent' by 32% and 'acceptable' by 17%as shown in Figure 3.

Figure 3: Learning Environment of ConferenceEleven comments were received and almost half provided positive feedback such as “opportunities to l e a r n ” a n d “ o u t s t a n d i n g ” . C o n s t r u c t i v e comments(n=3) included“…students should begiven the opportunity to present research” and attention needed for some of the seating arrangements.Logistics of conference:Over half (54%) of the participants were 'satisfied' with the logistics of the conference. About a third (34%) was 'very satisfied' and a small proportion expressed non-satisfaction (7%), as shown in Figure

4 .

Figure 4: Satisfaction with logist ics of Conference Eleven comments werereceived, of which the majority (n=8, 73%) were 'constructive feedback in that there was a need to address the“lack of communication between administration and participants”, “poor parking arrangements”, “water bottles not available for panel” and “poster certificate not received”. One participant stated “good work”. Suggestions of themes for the 2017Conference:Respondents provided a variety of themes for the next conference in 2017. However, the top five themes included:1. Nutrition and related topics ( Food security,

Obesity)2. NCDs and Mental Health (across the life-course)3. SDGs (Monitoring and Progress)4. Adolescent Health5. Gender related issues (Equity, Empowerment,

Violence against women); and SRH issues (across the life-course)

Table 3: Suggested Themes for the 2017 Annual Public Health Scientific ConferenceFinal comments and suggestions:

For this section seventy two commentswere received. About two thirds (n=45) provided supportive comments related to the overall success of the conference for example “…excellent arrangements”, “… beneficial to students”, “…expect even better for the 8th conference” and “best conference so far!” One respondent recommended more international speakers.Other comments (n=20) were related to the overall logistics and aspects to consider for the next conference given the ever increasing participants, which mainly focused on the need for a bigger venue and more than two days required. Other constructive

Themes for 2017 Conference

No. of Respondents

(total = 156)

Percentage of Respondents

Nutrition & related topics

18

12%

NCDs & Mental health

16

10%

SDGs 15 10%

Adolescent Health 12 8%

Gender & Health 10 6%



comments inc luded “… more t ime for the question/answer sessions” and “…softcopies of all presentations for the participants…”

DiscussionThe primaryaim of the 7thAnnual Public Health Sc ien t ific Conference o f Hea l th Serv ices Academywasto provide a platform for public health specialists to share research, evidence-based dataand concepts at a national and international level according to the SDG theme. For the 2016 event a more formal evaluation process was undertaken via the online survey tool “SurveyMonkey” to ascertain how informative the conference was and to receive constructive feedback for the 2017 conference. Those participants who received the emailed survey was four hundred and seventy four (n=474) of which 42% responded. A meta-analysis on response rates for Internet based or web based surveys revealed that the average response rates ranged from 34-40% and an acceptable response rate varies between 25-30%. For the 2017 conference, participants will be informed throughout the conference that an online survey will be sent from the Conference Secretariat to increase the number of participants who open the survey and who also check in their spam box.For the 2016 Conference Secretariat many aspects of the main findings were supportive and constructive in terms of planning for the 2017 event. The main data revealed that the plenary and scientific sessions were deemed to be very informative by at least two-thirds of the respondents, and in some cases up to three quarters. The majority of the online survey respondents found the conference useful to their individual field of public health and found the learning environment conducive. Overall, the logistics of the conference were found to be satisfactory by most of the respondents. Seating arrangements and technical glitches were highlighted as areas of improvement for the 2017 conference. Suggestions for themes for the forthcoming conference focused on nutrition and SDGs, however there was also an interest related to adolescent/youth health, NCDs and mental health and gender related topics. Additionally, increasing the duration of the conference was suggested by some participants. Regarding a change in venue which was suggested by some participants, the Health Services Academy prides itself on undertaking this annual event at its picturesque premises; however due to the overwhelming number of participants every year, adequately accommodating all of them in the scientific sessions is a challenge and an area for improvement. Providing participants with soft copies of presentations of speakers is a trend at many conferences and will be considered keeping in mind intellectual property rights. Some participants mentioned reducing the number of

concurrent sessions, as some sessionswere of interest to participants and a choice had to be made on which one to attend. Sharing the main findings from the online survey supports the Academy's quest to disseminate research findings to study participants. It is acknowledged that the 2016 online survey can be improved upon for the 2017 conference and greater communication to the participants regarding its usage as an evaluation tool.ConclusionAccording to the online survey evaluation the 2016 conference was informative and met participants' needs with respect to their field of public health. This may be attributed to theearly and extensive planning that was undertaken by the Conference Secretariat. The primary aim was achieved and local public health professionals' needs were generally met. Engaging international speakers was generally appreciatedand most of the participants were satisfied with how informative the conference content was and how supportive thelearning environment was. Using an online survey for evaluation has many positive attributes and is an instrument that will be re-considered for the 2017 conference.References1. Health Services Academy, Government of

Pakistan. Accessed online on 1 January 2017 through http://www.hsa.edu.pk/

2. National Health Services regulation and Coordination. Accessed online on 1 January 2017 through http://www.nhsrc.gov.pk/

3. World Health Organization. Accessed online on 1 January 2017 through http://www.who.int

4. Sustaiable Development Goals. Accessed o n l i n e o n 1 J a n u a r y 2 0 1 7 t h r o u g h http://www.un.org/sustainabledevelopment/sustainable-development-goals/

5. United Nations of Pakistan. Accessed online on 1 J a n u a r y 2 0 1 7 t h r o u g h http://www.un.org.pk/pakistans-challenges-sustainable-development-goals-2015-2030/

6. Planning Commission of Pakistan. Accessed o n l i n e o n 1 J a n u a r y 2 0 1 7 t h r o u g h http://pc.gov.pk/web/vision

7. Ministry of Planning Development and Reforms. Accessed online on 1 January 2017 through http://www.mopdr.com/vision/uploads/vision/pakistan_vision2025.pdf

8. Sarantakos S. Social research. Palgrave Macmillan; 2012.

9. SurveyMonkeys.Accessed online on 1 January 2 0 1 7 t h r o u g h http://www.SurveyMonkey.com/Official-Site

10. Cook C, Heath F, Thompson RL. A meta-analysis of response rates in web-or internet-based surveys. Educational and psychological measurement. 2000;60(6):821-36.



http://www.hsa.edu.pk/

http://www.nhsrc.gov.pk/

http://www.who.int

http://www.un.org/sustainabledevelopment/sustainable-development-goals/

http://www.un.org/sustainabledevelopment/sustainable-development-goals/

http://www.un.org.pk/pakistans-challenges-sustainable-development-goals-2015-2030/

http://www.un.org.pk/pakistans-challenges-sustainable-development-goals-2015-2030/

http://pc.gov.pk/web/vision

http://www.mopdr.com/vision/uploads/vision/pakistan_vision2025.pdf

http://www.mopdr.com/vision/uploads/vision/pakistan_vision2025.pdf

http://www.SurveyMonkey.com/Official-Site

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Challenges of hospital preparedness in disasters in BalochistanSaleem ullah, Noureen Latif, Ali Nasre Alam, Tabinda Zaman.......................................................... Physical violence and its associated factors among married women in Multan, Southern Punjab, PakistanShafquat Inayat, Shahina Pirani, Tazeen Saeed Ali, Uzma Rahim Khan and Josefin Särnholm ...........

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Stunting among children of 18 to 36 months of age in Bhawalghar village, district Lodhran: a cross-sectional studyHaider Ali Younas, Siham Sikander, Mudassar Mushtaq Jawad Abbasi...............................................

Self-medication practices and perceptions among undergraduate medical students of Multan Medical & Dental College, MultanAsif Noor, Ejaz Hussain Sahu, Muhammad Umer Abdullah and Aftab Yousaf ....................................

Nutritional status among primary school going children living in urban area of Sindh PakistanMuhammad Faisal Qureshi, Aneeta Rathore, Nandlal Seerani, Sumera Qureshi, Dr. Bisharat Faisal and Ramesh Kumar...............................................................................................................

7th annual public health conference 2016 at health services academy: experiences in the field of public health and way forwardNeelam A Khan, Saima Hamid, Katrina Ronis.....................................................................................

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