Equity trends for the UHC service coverage sub-index for reproductive, maternal, newborn and child health in Pakistan: evidence from demographic health surveys.

BACKGROUND: Pakistan, the world's sixth most populous country and the second largest in South Asia, is facing challenges related to reproductive, maternal, newborn and child health (RMNCH) that are exacerbated by various inequities. RMNCH coverage indicators such as antenatal care (ANC) and deliveries at health facilities have been improving over time, and the maternal mortality ratio (MMR) is gradually declining but not at the desired rates. Analysing and documenting inequities with reference to key characteristics are useful to unmask the disparities and to amicably implement targeted equity-oriented interventions. METHODS: Pakistan Demographic Health Survey (PDHS) based UHC service coverage tracer indicators were derived for the RMNCH domain at the national and subnational levels for the two rounds of the PDHS in 2012 and 2017. These derivations were subgrouped into wealth quintiles, place of residence, education and mothers' age. Dumbbell charts were created to show the trends and quintile-specific coverage. The UHC service coverage sub-index for RMNCH was constructed to measure the absolute and relative parity indices, such as high to low absolute difference and high to low ratios, to quantify health inequities. The population attributable risk was computed to determine the overall population health improvement that is possible if all regions have the same level of health services as the reference point (national level) across the equity domains. RESULTS: The results indicate an overall improvement in coverage across all indicators over time, but with a higher concentration of data points towards higher coverage among the wealthiest groups, although the poorest quintile continues to have low coverage in all regions. The UHC service coverage sub-index on RMNCH shows that Pakistan has improved from 45 to 63 overall, while Punjab improved from 50 to 59 and Sindh from 43 to 55. The highest improvement is evident in Khyber Pakhtunkhwa (KP) province, which has increased from 31 in 2012 to 51 in 2017. All regions made slow progress in narrowing the gap between the poorest and wealthiest groups, with particularly noteworthy improvements in KP and Sindh, as indicated by the parity ratio. The RMNCH service coverage sub-index gap was the greatest among women aged 15-19 years, those who belonged to the poorest wealth quintile, had no education, and resided in rural areas. CONCLUSIONS: Analysing existing data sources from an equity lens supports evidence-based policies, programs and practices with a focus on disadvantaged subgroups.

Second-generation surveillance for HIV/AIDS in Pakistan: results from the 4th round of Integrated Behavior and Biological Survey 2011-2012.

OBJECTIVES: In an effort to fully analyse and understand the HIV situation and its epidemiology in Pakistan, a bilateral collaboration between the National AIDS Control Program and the Canadian International Development Agency resulted in the establishment of an effective second-generation surveillance (SGS) system for HIV/AIDS between 2004 and 2012 in accordance with the published guidelines. This paper presents findings from the 4th round of SGS. METHODS: A mapping exercise was initially conducted for size estimations of the key vulnerable populations: people who inject drugs (PWIDs), male sex workers (MSWs), hijra sex workers (HSWs), and female sex workers (FSWs), followed by an Integrated Behavioral and Biological Surveillance in 20 selected cities across Pakistan. RESULTS: The estimated sizes of the four key populations mapped in the 20 cities were 89 178 FSWs, 46 351 PWIDs, 23 317 HSWs and 19 119 MSWs. The HIV sero-prevalence among PWIDs was the highest among all key populations surveyed at 37.8% (CI 37.3 to 38.3) nationally, followed by a prevalence of 7.2% (CI 6.8 to 7.5) among HSWs, 3.1% (CI 2.8 to 3.4) among MSWs and 0.8% (CI 0.4 to 1.0) for FSWs. Various key risk behaviours, that is, sharing of syringes by PWIDs and inconsistent use of condoms by sex workers, were documented. CONCLUSIONS: Pakistan's HIV epidemic that once was characterised primarily by transmission among PWIDs is now increasingly characterised by significant sexual transmission, and all types of sex workers (male, hijra and female) exhibit epidemiological proportions of infection. There is a need to develop concrete strategic plans for each vulnerable subpopulation, initially focusing prevention resources on those with a higher risk or vulnerability.

Patient's perception, compliance to treatment and health education of antiretroviral therapy among HIV patients at a tertiary healthcare setting.

OBJECTIVE: To illustrate perceptions, compliance to treatment and satisfaction levels regarding health education services pertaining to the anti-retrovival therapy among HIV and AIDS patients. METHODS: The cross-sectional survey was carried out at the HIV Treatment Centre, Pakistan Institute of Medical Sciences (PIMS), Islamabad, from September 2009 to February 2010 in which patients were interviewed separately regarding their perceptions, compliance to treatment and satisfaction levels regarding health education services pertaining to the anti-retrovival therapy. All data collected was entered into SPSS version 15.0. The data was revalidated and analysed. RESULTS: One hundred and forty patients were interviewed; there were 99 (70.7%) males.. Of the total, 28 (20%) had no knowledge about the beneficial effects of the therapy, and 45 (32 %) ranked health education services extremely beneficial in understanding the anti-retrovival therapy. CONCLUSION: While a significant proportion of patients considered ART either somewhat beneficial or beneficial in treating their ailment, they were unclear about the impact of health education provided at the treatment centre and different forms of print media.

A Cross-Sectional Study to Assess HIV/AIDS-Related Stigma and Its Drivers Among Dental Healthcare Providers in Islamabad, Pakistan.

Introduction HIV-related stigma and discrimination among healthcare providers are some of the strongest obstacles to effectively responding to HIV and achieving health-related quality of life. In the Pakistani context, HIV-related discrimination has been explored mainly among people living with HIV (PLHIV), and no study has investigated HIV-related stigma from the perspective of dental healthcare providers. Aim This study aimed to investigate the HIV-related stigma among dental healthcare workers in Pakistan and understand the factors associated with it. Methodology This cross-sectional study was conducted for a period of three months (December 2021 to February 2022) among 601 consenting dental healthcare providers in all public and private dental healthcare facilities in Islamabad, Pakistan. Pretested questionnaires collected information on demographics, work-related characteristics, knowledge, attitudes, and practices regarding HIV/AIDS. HIV-related stigma was assessed through "the stigma index" developed by USAID and was measured as a continuous variable. Multivariate linear regression analysis evaluated the independent effect of different factors associated with HIV-related stigma. Results HIV-related stigma remains highly prevalent within both public and private dental healthcare facilities in ICT and among all cadres of dental healthcare providers. Among associated factors, misconceptions in HIV knowledge are highly significant (p < 0.001) and those with a higher score of incorrect HIV knowledge had higher levels of stigma. Healthcare providers who read any HIV-related manual or guidelines were found to be less stigmatized as compared to those who have not been exposed to any such literature (p=0.029). Dentists (p=0.04) showed higher levels of stigma as compared to dental assistants and dental hygienists, while employees of private hospitals (p=0.0) and private clinics (p=0.0) were far more stigmatized by HIV in comparison to dental healthcare providers in public hospitals. Conclusion This study provides the first-ever analysis of HIV-related stigma and its drivers in the dental healthcare settings in Pakistan and highlights multiple individual, clinical, and policy-level factors associated with it. In order to address this stigma, it is essential for healthcare institutions to create supportive and inclusive healthcare settings, by providing education and training to care providers in order to increase their understanding of the disease itself. In addition, healthcare institutions can take steps to ensure that their policies and practices are inclusive and non-discriminatory, such as implementing policies that prohibit discrimination based on HIV status and providing confidential care. On the other hand, care providers must work to recognize their own biases and strive to provide non-discriminatory and culturally sensitive care to all patients. The findings of this study could be used as a baseline and insight by organizations like the National AIDS Control Program into possible targets for future exploration and interventions to effectively reduce the stigma toward PLHIV in dental healthcare settings.

An assessment of facility readiness for comprehensive abortion care in 12 districts of Pakistan using the WHO Service Availability and Readiness Assessment tool.

Although Pakistan's Essential Package of Health Services was recently updated to include therapeutic and post-abortion care, little is known about current health facility readiness for these services. This study assessed the availability of comprehensive abortion care, and readiness of health facilities to deliver these services, within the public sector in 12 districts of Pakistan. A facility inventory was completed in 2020-2021 using the WHO Service Availability and Readiness Assessment, with a newly developed abortion module. A composite readiness indicator was developed based on national clinical guidelines and previous studies. Just 8.4% of facilities reported offering therapeutic abortion, while 14.3% offered post-abortion care. Misoprostol (75.2%) was the most common method provided by facilities that offer therapeutic abortion, followed by vacuum aspiration (60.7%) and dilatation and curettage (D&C) (59%). Few facilities had all the readiness components required to deliver pharmacological or surgical therapeutic abortion, or post-abortion care (<1%), but readiness was higher in tertiary (22.2%) facilities. Readiness scores were lowest for "guidelines and personnel" (4.1%), and slightly higher for medicines and products (14.3-17.1%), equipment (16.3%) and laboratory services (7.4%). This assessment highlights the potential to increase the availability of comprehensive abortion care in Pakistan, particularly in primary care and in rural areas, to improve the readiness of health facilities to deliver these services, and to phase out non-recommended methods of abortion (D&C). The study also demonstrates the feasibility and utility of adding an abortion module to routine health facility assessments, which can inform efforts to strengthen sexual and reproductive health and rights.

Assessment of Effective Coverage of Antenatal Care and Associated Factors in Squatter Settlements of Islamabad Capital Territory, Pakistan: An Analytical Cross-Sectional Study.

BACKGROUND: Effective coverage of antenatal care (ANC) goes beyond contact coverage and assesses the quality of service provided. We used World Health Organization's recommended positive pregnancy guidelines to assess effective coverage and factors associated with the utilization of ANC among women in squatter settlements of Islamabad Capital Territory. METHODS: We conducted a household survey in the study area with 416 women who had given birth in the past one year. Face-to-face interviews were conducted after the selection of study subjects was done through a systematic random sampling approach. Statistical analysis was carried out using Statistical Package for the Social Sciences 22 (SPSS 22; IBM corp. Armonk, NY). Effective ANC coverage was defined as four or more ANC visits along with all WHO-recommended interventions received at least once during ANC. Adjusted odds ratios (adjOR) with 95% CI were calculated using binary logistic regression to determine the independent effects of all associated factors on the outcome. RESULTS: Of the 416 women interviewed, 399 (95.6%) had availed ANC services at least once. The coverage of 4+ ANC visits was 92% but effective coverage was only received by 35% women. The proportion of women who received nutritional interventions, maternal and fetal assessment and other preventive measures was 68%, 51% and 80.8% respectively. Maternal education (adjOR, 95% CI = 4.8[2.4-9.3]), family income (2.3[1.1-5.1]), multiparity (1.7[1.1-2.9]), place of first ANC visit (4.2[1.7-10.5]) and distance from a health facility (2.2[1.3-3.6]) were independently associated with the non-utilization of effective ANC. CONCLUSION: Despite a very high crude coverage of ANC services, the study shows a very low proportion of women receiving effective coverage. This stresses the importance of measuring the proportion of the population that receives health services with quality to monitor progress toward achieving universal health coverage.