Task Sharing of Injectable Contraception Services in Pakistan: A Randomized Controlled Trial.

Provision of injectable contraceptive services by lay health workers is endorsed by normative bodies, but support for this practice is not universal. We assessed whether lay providers (lady health workers, LHWs) could perform as well as clinically trained providers (family welfare workers, FWWs) on appropriate screening, counseling, and injection of intramuscular and subcutaneous depot medroxyprogesterone acetate (DMPA) using a randomized controlled trial. In the urban sample (n = 355), 88 percent of FWW DMPA clients were appropriately screened versus 77 percent of LHW clients (noninferiority test p = 0.88). In rural facilities (n = 105), over 90 percent of both providers' clients were screened appropriately. Appropriate counseling was low overall, but LHWs were significantly noninferior to FWWs (p = 0.003). Notably, LHWs demonstrated better injection technique than FWWs. We could not conclude that LHWs screened new DMPA users as well as FWWs from an urban sample of providers but results from the rural sample suggests that service delivery context played an important role.

Provincial differences in levels, trends, and determinants of childhood immunization in Pakistan.

BACKGROUND: Efforts to improve immunization rates are urgently needed in Pakistan but national statistics mask important local differences in immunization levels and determinants. AIM: In this study we aimed to determine how similar or different are recent trends and levels of immunization coverage in Pakistan's 4 main provinces [Punjab, Sindh, Khyber Pakhtunkhwa (KPK) and Balochistan], and what factors are associated with complete childhood immunization in each province. METHOD: We analysed data from the 2006-07 and 2012-13 Pakistan Demographic and Health Surveys. Trends in immunization coverage among children aged 12-23 months were calculated for each province. Bivariate and multivariate analyses were conducted to identify factors associated with complete immunization. RESULTS: The proportion of children completely immunized had risen significantly in Punjab but had fallen significantly in Balochistan. Complete coverage ranged from 16.4% in Balochistan to 65.8% in Punjab (2012-13). Tetanus toxoid injection during pregnancy was a significant predictor of complete immunization everywhere. Other predictors in specific provinces were: urban residence in Balochistan, wealth in Sindh and KPK, mother's education in Punjab and KPK, and distance to the facility in Punjab. CONCLUSIONS: Although some strategies to increase immunization coverage are relevant nationwide, programme managers need to seek solutions specific to provincial trends and predictors. This analysis demonstrates that viewing childhood immunization in Pakistan through a provincial lens can help achieve a deeper understanding of the challenges and potential strategies to boost coverage.

Students' perceptions about the family medicine course in Qassim, Saudi Arabia.

BACKGROUND: This study explores students' perceptions and attitudes regarding educational methodology, content and assessment methods in the Family Medicine (FM) Course at Qassim University College of Medicine (QUCOM) with a view to build innovations and improvements on its findings. RESEARCH DESIGN AND METHODS: Three batches of undergraduate medical students attending FM Course - 2011/12 participated in a cross-sectional questionnaire-based study. Data collected through anonymous self-administered questionnaires were analyzed using Statistical Package for the Social Sciences (SPSS). RESULTS: Participation rate was quite high; of the 79 students constituting the course cohort, 68 (86%) responded. Students' perceived problem-based learning (PBL) tutorials positively while both male and female students rated classroom lectures negatively. Primary health care training activities and evidence-based medicine received high positive scores. Male students assigned high positive scores to consultation skills and breaking bad news (BBN) modules, and to a lesser extent the medical audit module. By contrast, female students rated them negatively and gave significantly lower scores. These were the only areas indicating significant differences between opinions of male and female students. CONCLUSION: Although the degree of students' satisfaction with the different learning activities varied, students felt that having a variety of learning and teaching experiences was more appropriate.

Public sector rehabilitation services for physical disabilities in tertiary care hospitals of Karachi, Pakistan: A qualitative study.

BACKGROUND: Around the globe there are 2.4 billion people in need of rehabilitation. Disability and rehabilitation have not gained much importance in the public health arena, possibly due to limited research and awareness regarding the significance of rehabilitation. This study aimed to provide an in-depth understanding of the barriers and facilitators to the provision and utilization of rehabilitation services in public sector tertiary care hospitals of Karachi, Pakistan. METHODOLOGY: This qualitative exploratory study was conducted from August to September 2015 in two tertiary care hospitals of Karachi. The criterion for hospital selection included the availability of functional rehabilitation services. Twenty-four key informant interviews were conducted with health professionals, including doctors, physiotherapists, occupational therapists, prosthetists, orthotists, as well as patients and caregivers. Qualitative content analysis was performed using a consensual qualitative research approach. Responses from key informant interviews were coded into free nodes and then categorized into themes. RESULTS: Two themes emerged from the data: constraints to the provision of rehabilitation services, and barriers to the utilization of rehabilitation services. Basic infrastructure was available at both study sites; however, a lack of structured guidelines for referring patients to these services, a lack of information-sharing and guidance to the patients, and a limited supply of equipment (treatment modalities) hampered the provision of services. The barriers to rehabilitation services included cost pertaining to transport, environmental barriers, lack of support from the employer, and strain on and lack of support from caregivers. CONCLUSION: Rehabilitation services require attention and investment in research and allocation of funds to strengthen the service delivery system. Hospitals, alongside the department of health, need to develop a strategic plan to set future directions and standards of available rehabilitation services.

Factors associated with maternal health services utilization in Pakistan: Evidence from Pakistan maternal mortality survey, 2019.

BACKGROUND: This study investigates the factors associated with maternal health services utilization in Pakistan using two outcome indicators, ideal antenatal care (IANC), defined as the pregnant woman receiving all the essential services included in standard antenatal care, and skilled birth attendance (SBA). METHODS: This study used the Pakistan Maternal Mortality Survey 2019 data. The study utilized binary logistic regression models to investigate the adjusted association between the outcome variables, separately for IANC and SBA, and the independent variables, education, wealth, parity, and residence. RESULTS: Wealth showed a positive association with utilization of IANC (adjusted odds ratio [AOR] = 11.48, 95% CI = 7.76, 16.99) and SBA (AOR = 4.37, 95% CI = 3.30,5. 80). Maternal age was associated only with IANC for women aged 35 or more years (AOR = 1.31, 95% CI = 1.06, 1.62). Increased likelihood of utilization of IANC and SBA services was also observed for women with formal education. Women who had 3-5 previous live births had higher odds of using IANC and SBA than women who had 1-2 or more than five previous live births. Urban residency was not correlated with either IANC or SBA. CONCLUSION: When compared to the wealthy and educated quintile, women in the lower wealth quintile and those without any formal education were less likely to utilize ANC and SBA services. A comprehensive and multipronged approach from the health and education sectors is needed to improve maternal health in Pakistan.

Impact of community-based interventions on maternal and neonatal health indicators: Results from a community randomized trial in rural Balochistan, Pakistan.

BACKGROUND: Pakistan has high maternal mortality, particularly in the rural areas. The delay in decision making to seek medical care during obstetric emergencies remains a significant factor in maternal mortality. METHODS: We present results from an experimental study in rural Pakistan. Village clusters were randomly assigned to intervention and control arms (16 clusters each). In the intervention clusters, women were provided information on safe motherhood through pictorial booklets and audiocassettes; traditional birth attendants were trained in clean delivery and recognition of obstetric and newborn complications; and emergency transportation systems were set up. In eight of the 16 intervention clusters, husbands also received specially designed education materials on safe motherhood and family planning. Pre- and post-intervention surveys on selected maternal and neonatal health indicators were conducted in all 32 clusters. A district-wide survey was conducted two years after project completion to measure any residual impact of the interventions. RESULTS: Pregnant women in intervention clusters received prenatal care and prophylactic iron therapy more frequently than pregnant women in control clusters. Providing safe motherhood education to husbands resulted in further improvement of some indicators. There was a small but significant increase in percent of hospital deliveries but no impact on the use of skilled birth attendants. Perinatal mortality reduced significantly in clusters where only wives received information and education in safe motherhood. The survey to assess residual impact showed similar results. CONCLUSIONS: We conclude that providing safe motherhood education increased the probability of pregnant women having prenatal care and utilization of health services for obstetric complications.

Risk profile of coronary heart disease among the staff members of Qassim University, Saudi Arabia.

OBJECTIVE: To estimate the risk profile of coronary heart disease (CHD) among the staff members of Qassim University and assess their knowledge in a screening campaign in Qassim region, Saudi Arabia. METHODS: A cross-sectional study was conducted among male and female staff at Qassim University campus. All employees of Qassim University were invited to participate in the study. Data were collected through a self-administered questionnaire. The study sample size was 233 staff and employees. The data were entered and analyzed using SPSS version 18. The data analysis focused on providing point estimates for the risk factors. RESULTS: The study found that 30% of participants have one or more risk factors for CHD, namely obesity 20.6%, diabetes 10.3%, hypertension 12.4%, dyslipidemia 10.7%, and smokers (11.6%). About 54% of the participants have a family history of at least one chronic disease as a risk factor for CHD. CONCLUSION: The most common risk factor of CHD among the staff members is obesity by 20.6%. Risk factors for CHD are quite common among Qassim University staff. These findings need to increase the health education and disease promotion program as an important intervention to reduce the occurrence and severity of CHD risk factors and to improve the quality of the life of the staff members of Qassim University.

Chronic Venous Insufficiency: prevalence and effect of compression stockings.

INTRODUCTION: Chronic venous insufficiency (CVI) is a common disease affecting mainly lower limbs and significantly influencing the quality of life. This study aims to estimate the prevalence of CVI in the Qassim Region and test the effectiveness of compression stockings as an intervention option. METHODS: A cross sectional study was conducted to assess the prevalence of CVI among patients visiting primary health care (PHC) centers in the Qassim Region. CVI patients were diagnosed and classified using the clinical, etiologic, anatomical, and pathophysiological (CEAP) scale. They were randomly divided into two groups, one using compression stockings and the other standard medical therapy. A clinical follow up was done using multiple scale system including CEAP scale. Data analysis was performed using SPSS. RESULTS: Among the 226 screened patients, 138 (61.1%) were diagnosed as having CVI (69% female and 45% male, p<0.001). Compared to the baseline, both the clinical and venous scores for CVI at the follow-up were significantly lower among patients using compression stockings, p=0.002 and p=0.003, respectively. Regression analysis suggested that, after controlling for age, sex and body mass index, compliance was the main factor responsible for a significant reduction in the clinical score among CVI patients. CONCLUSIONS: Chronic venous insufficiency is very common in the Qassim Region. Compression stockings are highly effective in improving clinical symptoms and signs of CVI. TRIAL REGISTRATION: This study is registered at www.clinicaltrials.gov(NCT02050061).

Epidemiology of road traffic injuries in qassim region, saudi arabia: consistency of police and health data.

INTRODUCTION: In Saudi Arabia, road traffic accidents (RTA) are becoming a serious public health problem. Police reports are designed for legal purposes with very little information on the health consequences. Also, health system data include detailed health information, but not related or linked to the data obtained police reports. Examining the consistency of these sources is vital to build an accurate surveillance system that can track the risk factors and the health consequences, as well as establishing and evaluating prevention interventions. OBJECTIVES: This study is intended to: ▪ Examine the consistency of health -registration data with the data gathered by the traffic police department.▪ Elucidate the magnitude, risk factors and outcome of RTI in Qassim region of Saudi Arabia,▪ Compare the pattern of accidents in Qassim with those at different regions of the Kingdom. METHODOLOGY: Health care information was collected on visits of victims of road traffic accidents to emergency and outpatients' departments of the major hospitals in Qassim region during the year 2010. The information included the patients' demographics, and clinical characteristics. Traffic Police Department information was also collected on all accidents that occurred in the study region. A Questionnaire was also developed and pilot tested to collect data from a random sample of population attending hospital outpatient and Primary Health Care clinics. Data included previous involvement in road traffic accident, and information about any injury; fatality or disability due to these RTI. RESULTS: During the study period, road traffic death rate based on death registration data was almost twice as high as the rate reported by the police (P < 0.05). There was also a significant decline of 27% according to police-reported data during the study period, as opposed to a non-significant increase of 8% according to health registration data during the same period. Population Survey Information showed the overall age-sex-adjusted rate for non-fatal RTI was 20.7 (95% CI, 20.0 - 21.3)/100 persons/year. The rate for non-fatal RTI is higher in the 10-19 years age group (17.3%). Males had twice or more incidence rate for RTI requiring recovery period of ≤ 7 days as compared with females, however, RTI incidence for recovery period of >7 days is more than twice in females.. Also a total of 12 deaths due to RTI were reported in 5-49 years age group in the last 3 years, representing an estimated annual RTI mortality rate of 35.4/100,000 (95% CI 16.6 - 57.8). A total of 11 participants reported RTI related disability in the last 3 years representing an estimated annual RTI disability rate of 34.1/100,000 population (95% CI 11.4 - 55.7). Reports of the Traffic Police Department showed that 18623 accidents occurred throughout the year 2010. These accidents involved 23178 persons, and resulted in the injury of 2025 people and the deaths of 369. In contrast, the health system reports showed that 4232 people had been injured and 1054 had died. Comparison with local & Arab Rates showed that Qassim is among the highest 5 regions in the kingdom regarding the number of RTA Saudi Arabia is also having a very high level of road traffic accidents and fatalities compared to other Arab countries. CONCLUSION: RTI are responsible for significant loss of life, disability and injury in Qassim population and in Saudi Arabia. The inconsistency between police-reported data and health system data strongly suggests that active efforts to audit and monitor data quality are clearly necessary.

Academic accreditation process: experience of a medical college in saudi arabia.

OBJECTIVE: This study aims to describe effects of the accreditation process of the National Commission for Academic Assessment and Accreditation (NCAAA) and its impact on the quality of medical education in one medical college in Saudi Arabia. METHODS: We conducted a mixed (qualitative-quantitative) study in Qassim University College of Medicine, where an accreditation exercise led by NCAAA was recently completed. Data pertaining to impact of the accreditation process were collected through self-administered questionnaires and focus-group discussion. Data were aggregated and analyzed and compared with the information from prior to accreditation, where available. RESULTS: The accreditation process lasted about two years, culminating in the preparation of a self-evaluation report and a visit of external reviewers. The process itself brought significant changes in the educational processes and administration and implementation of the curriculum. Our analysis also indicated significant improvements in the quality of medical education in the College. CONCLUSIONS: The accreditation process was successful in improving quality of medical education, without imposing radical changes in curriculum philosophy or orientation. Better monitoring of students learning outcomes and continuous quality improvement will improve the quality of medical education in the college.

Impact of health education on lifestyles in central Saudi Arabia.

OBJECTIVE: To assess the impact of health education on diet, smoking, and physical activity among patients visiting the primary health care centers (PHCCs) in Al-Qassim province, Kingdom of Saudi Arabia (KSA). METHODS: We conducted an uncontrolled experimental study from January to October 2009 to evaluate the impact of health education on smoking, diet, and physical activity among attendees of PHCCs in Al-Qassim province, KSA. We trained the PHCC staff in health education skills and introduced health education seminars organized by the medical students. Baseline (n=1,254) and follow-up (n=1,011) sample surveys were conducted to measure the prevalence of risk factors in target population before and after intervention. We used logistic regression analysis to control for the effects of possible confounding variables. RESULTS: After the intervention, consumption of kabsa, bakery items, and dates decreased, and that of fish and fresh vegetables increased (p < 0.001). Compared to the baseline, male respondents in the follow-up survey were less likely to smoke and more likely to do regular exercise. These improvements persisted after controlling for gender, age, marital status, education, and presence, or family history of hypertension and/or diabetes. CONCLUSION: We conclude that enhancing the quality and scope of health education to patients visiting the PHCCs would improve the awareness and practice of healthy behaviors.

Dietary practices, physical activity and health education in qassim region of saudi arabia.

OBJECTIVES: Diabetes, hypertension and coronary artery disease are emerging threats to the health status in Saudi Arabia. These diseases are attributed largely to unhealthy dietary habits and lack of physical activity. Health education through primary health care (PHC) centers can play a significant role in changing behaviors and reducing the burden of non-communicable diseases. METHODS: We present the results of analysis of a moderately large dataset on dietary practices, physical activity and exposure to health education among patients visiting the PHC centers in Qassim region of Saudi Arabia. We examined this cross-sectional data to identify the relationships between these three variables after controlling for the effects of age, sex, marital status, education and disease status. RESULTS: Our results suggest that women, older people, divorced and widowed persons and those with low education are more likely to have poor dietary habits and lack of physical activity. Patients suffering from chronic illnesses are more likely to be exposed to health education from PHC centers, which help to significantly improve their dietary practices and, to some extent, increase physical activity at all ages. Our analysis indicates that health education provided through the PHC centers plays a modest but significant role in improving lifestyles and dietary practices. CONCLUSION: We conclude that better emphasis on high quality health education would significantly reduce the burden of non-communicable diseases in our target population.

Lifestyle related risk factors of type 2 diabetes mellitus in Saudi Arabia.

OBJECTIVE: To assess the impact of diet and physical activity on the risk of type 2 diabetes mellitus (T2DM) in the Kingdom of Saudi Arabia (KSA) after adjusting for family history of diabetes. METHODS: We conducted a case-control study in Al-Qassim, KSA to test the hypothesis that dietary practices and physical activity modify the risk of type 2 diabetes regardless of family history. Male and female Saudi citizens 30-70 years of age were eligible to participate. The sample included 283 cases (T2DM patients) and 215 non-diabetic controls randomly selected from patients visiting the primary health care centers from September to November 2009. We collected information on demographic variables, family history, dietary habits, and physical activity. Using logistic regression, we estimated adjusted odds ratios (AOR) for dietary habits and physical activity after controlling for the effects of gender, age, education, and family history of diabetes. RESULTS: There is strong association between diabetes and maternal history of diabetes, education, lack of exercise, and dietary habits. The AOR for regular eating of Kabsa was 5.5 (95% confidence limits [CL]: 2.3-13.5); for vegetables an AOR of 0.4 (95% CL: 0.2-0.7); for dates an AOR of 1.8 (95% CL: 1.0-3.3) ;and the AOR for sedentary lifestyle was 2.5 (95% CL: 1.2-5.0). CONCLUSION: Healthy diet and active lifestyle may significantly decrease the risk of T2DM in spite of having a family history of diabetes. Effective health education programs promoting healthy diet and regular exercise are needed to reduce the burden of diabetes in Saudi Arabia.

Validating the verbal autopsy questionnaire for maternal mortality in pakistan.

Maternal mortality represents the largest and the most persistent gap between developed and developing countries. The maternal mortality ratio (MMR), which measures the risk of death at each pregnancy, is up to 40 times higher in some African countries than the countries of Northern Europe. MMR is believed to be the most sensitive indicator of women's status in the society and of the quality and accessibility of maternal health services available to women. The primary purpose of the study was to determine the level of agreement in the cause and the category of death assigned by the hospital and the obstetrician who reviewed the completed VA questionnaire. The validation study was conducted during July-September 2006 by the National Institute of Population Studies (NIPS), which is also the executing agency for PDHS 2007. The primary objective of the study was to test the sensitivity and specificity of the VA questionnaire developed for PDHS 2007. An important lesson learned from this study is that the sensitivity of the VA technique can be further enhanced by rigorous training of the review panelists in the utilization of the information contained in the coded parts of the questionnaire.

Prevalence and Determinants of Self-reported Morbidity among Pregnant Women in Rural Areas of Pakistan.

BACKGROUND: The maternal mortality ratio (MMR) in Pakistan is estimated at 400 maternal deaths per 100,000 live births. Prevalence of minor and major illnesses related with pregnancy and childbirth is much higher. However, most births in the rural areas take place at home, conducted by untrained traditional birth attendants. Data on the prevalence of maternal morbidity is, therefore, limited. Self-reporting of illnesses related with pregnancy and childbirth is generally considered as unreliable, as women's perception of the seriousness of the health problems is inadequate. METHOD: The data were collected in a baseline survey that was conducted for an operations research project of the Ministry of Health, Government of Pakistan. The baseline survey comprised interviews with the ever-married women in the reproductive ages (15-49 years). For the selection of eligible women for the interview, a two-staged cluster random sampling procedure was applied. The response rate was 94.4% and interviews with 9,118 of the identified 9,655 females were successfully completed. The interviews were conducted by female interviewers having graduate degree or above. Completed questionnaires were edited and coded by a team of professional data editors. RESULTS: The prevalence of maternal morbidity in this study was 20%, which is considered to be high, although can be expected in this population. Nearly half of the women reported some kind of illness during pregnancy, which is also expected. This study also estimated that the unmet obstetric need among rural women was very high; this finding has policy implication, as the need for alternative and more operational indicators of maternal health is increasingly felt. CONCLUSION: It is recommended that population-based studies and national surveys routinely incorporate well designed questions to elicit information on self-reported maternal morbidity; the same studies can also be used to identify the determinants of common obstetric problems and to estimate the unmet need of obstetric care.