Barriers to safe anaesthesia care in South Asian countries: a virtual focus group discussion.

Objective: To identify barriers to safe anaesthesia practice across the South Asian region. METHODS: The qualitative study was conducted from September 2020 to August 2021 at the Department of Anaesthesiology at a leading medical university after getting exemption from the ethics review committee of the Pakistan Society of Anaesthesiologists. The sample comprised anaesthetists from 6 countries of the South Asian Association for Regional Cooperation. Data was collected through a focus group discussion held virtually using the Zoom app on September 22, 2020. The proceedings were transcribed and the data was subjected to thematic analysis. RESULTS: Of the 12 anaesthetists, 4(33.3%) were from India, 3(25%) from Pakistan, 2(16.7%) from Bangladesh, and 1(8.3%) each from Sri Lanka, Nepal and Afghanistan. There were 2 main themes identified; Safe anaesthesia and barriers to safe anaesthesia. They had 4 and 6 subthemes, respectively. The participants agreed that fresh medical graduates were not choosing anaesthesia as a preferred career specialty. One major concern raised was that qualified anaesthetists were leaving their countries for better-paid jobs abroad. Conclusion: The lack of a definition describing qualified anaesthetists in South Asian countries was pointed out. Lack of basic monitoring and drugs, brain drain, lack of ownership, lack of training programmes, lack of accountability, weak leadership, and disconnect between professional societies and governments were identified as the main barriers to safe anaesthesia.

Gaps in hygiene promotion at schools in Pakistan: qualitative descriptive research.

School health remains an ignored domain in Pakistan. This article presents gaps in understanding hygiene promotion efforts in school settings in urban squatter settlements by exploring perspectives of the key stakeholders and undertaking a review of the education curriculum. Using qualitative methodology, 13 in-depth interviews were held with the key informants (teachers, health and education officers) and three focus group discussions were conducted with 36 mothers. The study setting includes three schools located in a semi-urban area in the province of Sindh, Pakistan. The semi-structured guide was utilized to obtain perspectives of key stakeholders on factors constraining hygiene promotion efforts in school settings. The primary education curriculum was reviewed using the content analysis approach to assess the integration of hygiene concepts into the curriculum. Analysis of qualitative interviews and curriculum review resulted in five categories under a theme that addressed multiple factors constraining hygiene promotion in the school settings. These include (i) Gaps in the school curriculum, (ii) Poor accountability of the local administration in the upkeep of schools, (iii) Parent's negligence toward children's hygiene, (iv) Inadequate training of school teachers on hygiene concepts, and (v) Lack of interdepartmental coordination between health and education sectors. Hygiene promotion at schools has been deterred by multiple factors at the selected primary schools in Pakistan. Recommended actions include integration of health and hygiene concepts into the education curriculum, capacity building of teachers, reviving water, sanitation and hygiene infrastructure, coordination among Education and Health Departments and ownership among the local government to ensure cleanliness at schools.

Schools are not only expected to provide education to children, their mandate also includes health and hygiene promotion. Keeping in view the dearth of evidence in understanding the role of schools in hygiene promotion in the local context, this research was conducted in three semi-urban school settings in Sindh province, Pakistan. We aimed to identify factors that constrain hygiene promotion efforts at the school level. As part of this research, we interviewed multiple stakeholders. This includes (teachers, mothers, education and health officers) at the primary school level. Our findings revealed serious gaps in hygiene promotion at schools. This includes inadequate attention to hygiene concepts in the curriculum books, inconducive school environment, teachers' and parents' negligence toward children's hygiene and communication gap among them, and absence of coordination between health and education sectors. To conclude, multiple actions are needed to emphasize hygiene promotion at the school level. This ranged from revision in the education curriculum and training of teachers in hygiene promotion to instituting accountability mechanisms at the local Education Department and building strong coordination between Education and Health departments.

A pilot study of offering a positive disciplining module for public school teachers in Hyderabad, Pakistan: A quasi-experimental study.

A pilot quasi-experimental study was conducted in which participants in the intervention group (n = 31) received positive learning environment through Positive Disciplining (PLEPD) module, while those in the control group (n = 29) received routine training. Teachers' knowledge and attitude regarding corporal punishment (CP) and Beck Depression Inventory-II (BDI-II) were measured before (T0), immediately after (T1) and 3 months after the intervention (T2). Descriptive analysis and analysis of variance (ANOVA) were used to describe participants' characteristics and mean scores for knowledge and attitude among teachers. A total of 60 teachers completed the 16 hours training module. The overall response rate was >90%. Most participants recommended increasing the overall duration of the programme by reducing 4 to 2 hours per day, thus, increasing the period from 4 to 8 days of training. There were no differences between control and intervention groups at baseline regarding participant characteristics (p= > .05). The difference in depression (F = .0863, p = .357) and knowledge and attitude (F = 1.589, p = .213) scores among groups were not statistically significant. However, the mean score for knowledge and attitude followed a positive trend, increasing depression mean scores at T1 and T2. A positive disciplining programme is a feasible school intervention for public schools and may effectively reduce depression to ensure overall well-being.

Prevention of violence against women and girls: A cost-effectiveness study across 6 low- and middle-income countries.

BACKGROUND: Violence against women and girls (VAWG) is a human rights violation with social, economic, and health consequences for survivors, perpetrators, and society. Robust evidence on economic, social, and health impact, plus the cost of delivery of VAWG prevention, is critical to making the case for investment, particularly in low- and middle-income countries (LMICs) where health sector resources are highly constrained. We report on the costs and health impact of VAWG prevention in 6 countries. METHODS AND FINDINGS: We conducted a trial-based cost-effectiveness analysis of VAWG prevention interventions using primary data from 5 randomised controlled trials (RCTs) in sub-Saharan Africa and 1 in South Asia. We evaluated 2 school-based interventions aimed at adolescents (11 to 14 years old) and 2 workshop-based (small group or one to one) interventions, 1 community-based intervention, and 1 combined small group and community-based programme all aimed at adult men and women (18+ years old). All interventions were delivered between 2015 and 2018 and were compared to a do-nothing scenario, except for one of the school-based interventions (government-mandated programme) and for the combined intervention (access to financial services in small groups). We computed the health burden from VAWG with disability-adjusted life year (DALY). We estimated per capita DALYs averted using statistical models that reflect each trial's design and any baseline imbalances. We report cost-effectiveness as cost per DALY averted and characterise uncertainty in the estimates with probabilistic sensitivity analysis (PSA) and cost-effectiveness acceptability curves (CEACs), which show the probability of cost-effectiveness at different thresholds. We report a subgroup analysis of the small group component of the combined intervention and no other subgroup analysis. We also report an impact inventory to illustrate interventions' socioeconomic impact beyond health. We use a 3% discount rate for investment costs and a 1-year time horizon, assuming no effects post the intervention period. From a health sector perspective, the cost per DALY averted varies between US$222 (2018), for an established gender attitudes and harmful social norms change community-based intervention in Ghana, to US$17,548 (2018) for a livelihoods intervention in South Africa. Taking a societal perspective and including wider economic impact improves the cost-effectiveness of some interventions but reduces others. For example, interventions with positive economic impacts, often those with explicit economic goals, offset implementation costs and achieve more favourable cost-effectiveness ratios. Results are robust to sensitivity analyses. Our DALYs include a subset of the health consequences of VAWG exposure; we assume no mortality impact from any of the health consequences included in the DALYs calculations. In both cases, we may be underestimating overall health impact. We also do not report on participants' health costs. CONCLUSIONS: We demonstrate that investment in established community-based VAWG prevention interventions can improve population health in LMICs, even within highly constrained health budgets. However, several VAWG prevention interventions require further modification to achieve affordability and cost-effectiveness at scale. Broadening the range of social, health, and economic outcomes captured in future cost-effectiveness assessments remains critical to justifying the investment urgently required to prevent VAWG globally.

Community stakeholders' views on reducing violence against women in Pakistan.

BACKGROUND: Nearly half of the women experience violence across their lifespan in all the provinces of Pakistan at an alarming rate. Despite knowing the prevalence, there has been meager progress in developing strategies to combat violence at individual, family, or community level. Many interventions suggested in other countries have been pilot tested but the effects of those interventions had been limited. Therefore, the aim of this study is to understand the voices of stakeholders to reduce Violence Against Women (VAW) and to explore the possible community-based strategies that could be implemented in Pakistan. METHODS: A total of 14 Key Informant Interviews (KIIs) and 18 Focus Group Discussions (FGDs) were held across all four provinces of Pakistan. Participants were purposefully recruited and all the interviews were audio-recorded. Transcriptions were open coded and content analysis was done to emerge codes, categories and themes. Ethical approval was obtained from Aga Khan University Ethics Review Committee. RESULTS: Three major themes emerged on community members and stakeholders' views on VAW: a) community's perception of VAW b) the repercussions of VAW, and c) multiple voices regarding strategies to reduce VAW. Participants voiced the need of standing against the status quo, role of awareness and education: regarding capacity building skills, promotion of women rights and women empowerment through Life Skills Based Education (LSBE) through national health works program, has been proposed as an innovative strategy to reduce VAW. CONCLUSIONS: The responsibility to bring about a substantial change in behavior and attitudes must begin with engaging men in all the interventions that aim to reduce violence. Since, VAW is very much linked with the cultural norms, so, without community stakeholder's involvement and participation it could never be reduced. Keeping the existing socio-cultural dynamics in mind, the need of time is to design and implement innovative interventions that are culturally and contextually appropriate and can be expanded across the country.

School-based interventions to promote personal and environmental hygiene practices among children in Pakistan: protocol for a mixed methods study.

BACKGROUND: Poor personal hygiene and inadequate sanitation practices among young children leads to communicable diseases. There remains a gap in the holistic assessment of school children's hygiene literacy, practices and effectiveness of school-based hygiene interventions in Pakistan. Therefore, a school-based intervention protocol has been designed to promote personal and environmental hygiene practices for primary school children. Towards improving children's hygiene behaviors, the study will also focus on enhancing mothers' hygiene knowledge and practices. METHODS: Using quasi-experimental design with mixed methods data collection approaches, this study will be conducted in schools located in an urban squatter settlements in Pakistan. To assess primary grade children and their mothers' hygiene status, a survey will be held in the pre-intervention phase. This phase also includes qualitative exploration of key stakeholders (mothers, teachers, health & education authorities representatives') perceptions about the factors facilitating and impeding the adaption of hygiene behaviors among school children. In-depth guides and focus group discussion tools will be used for this purpose. This will be followed by multi-component intervention phase with behavior change strategies to improve children's and mothers' hygiene literacy and behaviors. The post-intervention phase will assess the intervention effectiveness in terms of enhancing hygiene knowledge and practices among school children and mothers, alongside exploration of mothers and teachers' insights into whether or not the intervention has been effective in improving hygiene practices among children. Paired t-test will be applied pre and post-intervention to measure the differences between the mothers and children's hygiene literacy and knowledge scores. Similar test will be performed to assess the differences in children's hygiene knowledge and practice scores, pre and post-intervention (< 50 = poor, 50-75 = good and > 75 = excellent). Thematic analysis will be carried out for qualitative data. DISCUSSION: Multi-component intervention aimed at improving personal and environmental hygiene among primary school children offers an opportunity to design and test various behavioral change strategies at school and in home settings. The study findings will be significant in assessing the intervention's effectiveness in improving children's overall hygiene. TRIAL REGISTRATION: Retrospectively registered with ClinicalTrials.gov (NCT03942523) on 5th May 2019.

Perceptions of stakeholders about the role of health system in suicide prevention in Ghizer, Gilgit-Baltistan, Pakistan.

BACKGROUND: Suicide is a serious global public health problem, with more than 800,000 people dying by suicide worldwide every year. 79% of suicides happen in Low and Middle-Income Countries (LMICs), where lack of national suicide prevention programs coupled with inadequate MH facilities for early identification and treatment of mental disorders add to seriousness of the problems. Although there is paucity of research, studies suggest that the rate of suicide in district Ghizer, Gilgit-Baltistan (GB), in northern Pakistan may be higher compared to rest of the country. METHODS: This study aimed to explore the perceptions of stakeholders about the role of the health system at District Ghizer, GB using a qualitative descriptive exploratory research design. A total of 12 face to face in-depth interviews were conducted from the stakeholders using purposive sampling technique. RESULTS: The study results led to three broad themes, 1) Suicide as A Social Issue, 2) Role of Health System in Suicide Prevention, and 3) Challenges for Health System in Suicide Prevention. Theme one was sub-categorized into; a) Perceived situations contributing to suicide, b) Environmental factors. Theme two was subdivided into; a) Major hurdles for Health system, b) Lack of MH services in the available health system. Theme three was subdivided into; a) Lack of collaboration across-sectors, b) Unavailability of MH professionals, and c) Financial issues. The study findings reveal that there are multiple challenges for health system including, lack of awareness on mental issues, shortage of resources and lack of collaboration in the community. Moreover, existing policies or strategies need to be modified to overcome the existing challenges for the effective prevention. CONCLUSION: This study emphasized creating awareness about MH issues, introduction of school health programs, parental counseling session and strengthening of the health system by allocating suitable budget for MH issues and suicide prevention strategies.

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

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

Needs assessment regarding occupational health and safety interventions among textile workers: A qualitative case study in Karachi, Pakistan.

OBJECTIVE: To determine the perceived health and safety needs identified by textile workers, managers and experts as well as direct observation of the prevailing health and safety practices in the textile industry. METHODS: The qualitative study using the needs assessment conceptual framework was conducted in July-August 2015 in Karachi, and comprised focus group discussions with textile workers, in-depth interviews with factory managers and health and safety officers, and key informant interviews with relevant stakeholders and experts. A walk-through survey was also conducted in selected mills for which the Checklist of hazards in textiles was used. RESULTS: A total of 6focus group discussions, 6 in-depth interviews and 5 key informant interviews were conducted. Workers were found to have limited knowledge of occupational hazards, preventions and diseases. They identified lack of awareness and non-existent safety mechanisms as areas for improvement. Managers thought preventive practices and health services were not standardised while influence of buyers in the form of international business regulations and legislations were thought to be the enabling factors for enforcing health and safety standards. Poor governance, lack of knowledge regarding labour rights, low literacy level, poor compliance and low wages were the barriers for health promotion at workplace, as identified by the experts. Walk-through survey found mechanisms in place for fire safety, but the workers and managers were generally not using Personal Protective Equipment despite the presence of several hazards at workplace. CONCLUSIONS: There was found a need for context-specific occupational health and safety interventions at individual, organisational and policy levels.

Measuring socio-economic status of an urban squatter settlement in Pakistan using WAMI Index.

OBJECTIVE: To determine the socio-economic status of a peri-urban community. METHODS: The cross-sectional study was conducted at Deh Chuhar village, Gaddap Town, Karachi from December 2015 to February 2016. The Water/Sanitation, Assets, Maternal Education and Income Index was used. All variables were given a score on the scale of 0-8. The resulting index was illustrated in the form of quintiles. RESULTS: : A total of 254 households were surveyed. Total population was 2117 with mean number of household members being 8±4. Mean index score was 0.39±0.14 and the median score was 0.375. Percentile distribution of the score indicated that 152(60%) households scored below 0.40 whereas, 51 (20%) were in the highest quintile with a score above 0.50. CONCLUSIONS: Water/Sanitation, Assets, Maternal Education and Income index suggested poor socio-economic status of the community studied.

The intersection of adolescent depression and peer violence: baseline results from a randomized controlled trial of 1752 youth in Pakistan.

BACKGROUND: Depression and peer violence are global issues impacting youth. We are presenting baseline data as part of a cluster randomized control trial underway, on adolescent depression, and associated factors among boys and girls in schools. METHOD: Cluster randomized control trial is underway for measuring the effectiveness of school-based play intervention program of the NGO Right to Play, in a sample of 1752 grade 6 youth in 40 public schools of Hyderabad, Pakistan. Students responded to Child Depression Inventory (CDI-2), the Peer Victimization Scale (PVS), the Peer Perpetration Scale (PPS), and investigator-driven seven-item School Performance Scale. RESULTS: We report baseline assessments to examine the prevalence of depressive symptoms, and associated occurrence of peer perpetration and victimization. Boys report significantly more depressive symptoms as well as perpetration and victimization compared to girls (p ≤ .0001). Our analysis indicates that among boys, depression was found associated with greater age, food insecurity, poorer school performance and working for money, as well as being beaten at home and witnessing beating of their mother by their father or other relatives. Among girls, depression was associated with a younger age, greater food insecurity and poorer school performance. Depression was also associated with a great likelihood of engagement in peer violence, experience of punishment at home, and witnessing their father fighting with other men or beating their mother. CONCLUSIONS: Engagement in violent behaviors, exposure to violent acts and poverty surfaces as detrimental to mental health in youth age groups, suggesting strong measures to address youth violence, and poverty reduction for positive mental health outcomes in school age children.

Schools of public health in low and middle-income countries: an imperative investment for improving the health of populations?

BACKGROUND: Public health has multicultural origins. By the close of the nineteenth century, Schools of Public Health (SPHs) began to emerge in western countries in response to major contemporary public health challenges. The Flexner Report (1910) emphasized the centrality of preventive medicine, sanitation, and public health measures in health professional education. The Alma Ata Declaration on Primary Health Care (PHC) in 1978 was a critical milestone, especially for low and middle-income countries (LMICs), conceptualizing a close working relationship between PHC and public health measures. The Commission on Social Determinants of Health (2005-2008) strengthened the case for SPHs in LMICs as key stakeholders in efforts to reduce global health inequities. This scoping review groups text into public health challenges faced by LMICs and the role of SPHs in addressing these challenges. MAIN TEXT: The challenges faced by LMICs include rapid urbanization, environmental degradation, unfair terms of global trade, limited capacity for equitable growth, mass displacements associated with conflicts and natural disasters, and universal health coverage. Poor governance and externally imposed donor policies and agendas, further strain the fragile health systems of LMICs faced with epidemiological transition. Moreover barriers to education and research imposed by limited resources, political and economic instability, and unbalanced partnerships additionally aggravate the crisis. To address these contextual challenges effectively, SPHs are offering broad based health professional education, conducting multidisciplinary population based research and fostering collaborative partnerships. SPHs are also looked upon as the key drivers to achieve sustainable development goals (SDGs). CONCLUSION: SPHs in LMICs can contribute to overcoming several public health challenges being faced by LMICs, including achieving SDGs. Most importantly they can develop cadres of competent and well-motivated public health professionals: educators, practitioners and researchers who ask questions that address fundamental health determinants, seek solutions as agents of change within their mandates, provide specific services and serve as advocates for multilevel partnerships. Funding support, human resources, and agency are unfortunately often limited or curtailed in LMICs, and this requires constructive collaboration between LMICs and counterpart institutions from high income countries.

Unveiling school community perceptions of nutrition-friendly school initiatives in preschool settings in rural Sindh province, Pakistan: an exploratory study.

Introduction: In 1995, the World Health Organization launched its Global School Health Initiative to expand the Health Promoting School (HPS). The objective of this study was to explore the perception of the school community in implementing nutrition-friendly school initiatives in preschool settings. Methods: This paper delineates the exploratory phase of a mixed-method study, which broadly aims to assess the adoption of the Nutrition Friendly School Initiative (NFSI) through a preschool preparedness intervention package in rural Sindh province, Pakistan. The study sites include three campuses of the Aga Khan School (Mirpur Sakro, Junior Campus Vur, and a community-based school in Sujawal). Participants were selected purposively from these campuses and constituted a committee named 'school community,' which was responsible for implementing all activities outlined in the intervention package. Data was gathered through in-depth interviews and consultative meeting with the school community. Thematic analysis was employed for data analysis. Results: The analysis established five major themes that represent the participants' perception of school-based nutrition interventions in preschool settings. These five themes include (i) Challenges in health and nutrition for pre-school age children, (ii) Clarity in roles and responsibilities for school-based nutrition intervention, (iii) Advancing school-based nutrition activities and interventions, (iv) Recognizing resources requirements, (v) Opportunities and challenges for the way forward in school-based nutrition. Findings also suggest sustainability and scalability measures that include the aligning School Nutrition Policy with the school handbook, ways to engage with parents, a nutrition theme corner, the inclusion of a parenting component in the nutrition manual, and capacity building of the school community. Conclusion: Qualitative findings have guided the refinement of the intervention package, proposing additional measures for sustainability and scalability across AKES, P. The school community is hopeful that the implementation of the refined intervention package will enhance preschool preparedness toward achieving nutrition-friendly school checklist items. This study holds strong potential for replication in a public school setting and presents an opportunity to launch a school accreditation program to certify schools as Nutrition-friendly.

Assessment of preschool preparedness intervention package on adoption of nutrition friendly school initiative in rural Sindh, Pakistan: a pre-and post-intervention design.

Background: In 1995, the World Health Organization launched its Global School Health Initiative intending to expand this health promotion approach throughout schools globally. In this study, we aim to assess the preparedness of preschools in the adoption of intervention packages under the Nutrition Friendly School Initiative (NFSI) checklist. Methods: From three campuses of the Aga Khan School located in the Thatta and Sujawal districts of the Sindh province, Pakistan, all eligible preschool children were selected for this study. Using a pre-and post-intervention design, we assessed preschool preparedness using the NFSI checklist, knowledge of parents/caregivers regarding health and nutrition promoting behaviors, and anthropometric measurements (i.e., mid-upper arm circumference (MUAC), weight, and height) for preschool children. The NFSI checklist was analyzed with differential scores, while descriptive statistics were used for anthropometric and knowledge data. Continuous variables (i.e., height, weight, MUAC) were presented as means, while categorical variables (knowledge) were expressed as numbers and percentages. Paired t-tests for dependent samples were used to statistically assess mean differences in MUAC, height, weight, height-for-age Z-score, weight-for-age Z-score, weight-for-height Z-score, and changes in parental knowledge of preschool children. Results: Data from 164 preschool children (ages 24-84 months, mean age 56.7 months) were analyzed over 3 months. School preparedness scores improved from 10 to 22 points (out of 26). Parental knowledge on nutrition and health increased by 7.2 points (out of 25). Children showed mean increases in MUAC (0.27 cm), weight (0.36 kg), and height (0.62 cm) (p < 0.001). Stunting and overweight/obesity rates remained the same (7.3 and 4.3%), while underweight and wasting rates dropped from 10.4 to 7.3% and 7.9 to 6.1%, respectively. The initiative effectively reduced underweight and wasting but did not impact stunting and overweight. Conclusion: The NFSI has greatly enhanced preschool readiness for nutrition-friendly schools. Engaging the private sector in addressing nutritional challenges has paved the way for future public-private partnerships to tackle malnutrition. The nutrition policy formulated through this initiative could serve as a blueprint for a National School Nutrition Policy.

Safe motherhood: A hidden reality in Pakistan.

OBJECTIVE: To explore the perceptions and experiences of healthcare professionals, including female health visitors, female health workers, community midwives, and heads of departments of healthcare facilities, regarding the importance of the Safe Motherhood Initiative (SMI), its pillars, and its foundational principles. DESIGN: Qualitative descriptive exploratory study. SETTING: This study was conducted in healthcare centres in 10 districts in Pakistan: six in Gilgit Baltistan, two in Chitral, and two in Sindh. PARTICIPANTS: Healthcare professionals were recruited using a purposive sampling technique. In total, 14 in-depth interviews were conducted. FINDINGS: The following themes emerged through thematic analysis: (1) health and well-being of mothers and newborns; (2) strengthening the SMI pillars; (3) equity of health services; and (4) effective strategies for behaviour modification. Each theme had two categories. KEY CONCLUSIONS: The health and well-being of mothers and newborns are key indicators; as such, interventions should be made to promote their quality of life. Capacity building and refresher training on antenatal care, childbirth, postnatal care, postabortion care, and family planning can be considered effective to enhance the competencies of healthcare professionals. IMPLICATIONS FOR PRACTICE: The findings of this study suggest that healthcare professionals should receive training to enhance their competencies and provide safe care.

Violence against women in Pakistan: contributing factors and new interventions.

Pakistan ranks 125th out of 169 countries on the Gender Development Index and has high prevalence rates of Violence against Women (VAW). Contributing factors toward gender based violence at the micro, meso and macro levels include the acceptability of violence amongst both men and women, internalization of deservability, economic disempowerment, lack of formal education, joint family systems, entrenched patriarchal norms and values, and a lack of awareness of legal and other support systems. These factors have a long-lasting impact on the health of women and children. The gender disparities in the experience of women seeking health care in Pakistan are well-recognized and documented. In the past, common government policy responses to these disparities have included developing the role of community health workers (CHWs) and lady health visitors (LHVs). Despite being commendable initiatives, these too have been unsuccessful in addressing these multi-faceted disparities. Within this complex scenario, new interventions to address VAW and its impact on health in Pakistan include Group Counselling, Economic Skills Building, Health-Based Microfinance, and Family-Based models that increase male involvement, especially at the primary health care level. The purpose of this article is to outline key contributing factors to VAW, explore tested and new interventions, and highlight the opportunities that exist in implementing them.

Enhancing the knowledge of parents on child health using eLearning in a government school in the semi-rural community of Karachi, Pakistan.

Education is one of the vital social determinants of health. Health and education share a symbiotic relationship for all cadre including children and adolescents to ensure that they are well equipped to combat the health risk in the environment. The current literature globally found some initiatives to create health awareness among school children. However, there is a dearth of studies available addressing parental health awareness through school platforms. Therefore, the current study aims to fill this gap, and the Aga Khan University School of Nursing and Midwifery initiated the School Health Program (SHP) in one of the remote communities in Sindh, Pakistan. The overall goal of the study was to improve children's health by enhancing the health awareness of the parents through school platforms utilizing online modalities. Another objective of this study was to identify the effect of using eLearning on parental knowledge and perceptions. The study utilized a sequential explanatory mixed-method design. Twelve health awareness sessions relevant to children's health using eLearning were conducted over one year. Parents' knowledge was assessed through a pre-posttest, which was administered after each teaching session. Subsequently, focused group discussions were carried out with parents, community leaders, and schoolteachers to gain insights regarding the effectiveness of the health education program. The pre-and post-test results showed again in knowledge in nine out of twelve sessions. The findings from qualitative content analysis yielded three key themes: Perceived usefulness of eLearning, Barriers affecting usability, and Way forward for eLearning through school platforms. The study showed parental satisfaction with the online health education awareness program. They exhibited enthusiasm and desire for further similar sessions in the future. The results demonstrated an enhancement in parental awareness about common health conditions among school children. This study may be replicated on a larger scale in the schools of Pakistan.

The impact of COVID-19 safety interventions on creating a controlled environment on campus.

Objectives: During COVID-19 the re-opening of educational institutes was frequently debated, however with the decline in the number of COVID-19 cases, The Aga Khan University (AKU) in Karachi, Pakistan opened its campus for medical and nursing students after more than 6 months of closure. To ensure gradual resumption of activities on-campus, a combination of interventions was diligently deployed to minimize student infection rates. Scarce literature exists on students' perceptions regarding decisions implemented by university leadership. The aim of the study was to determine the efficacy of these interventions. Methods: We conducted a convergent, parallel, mixed-methods observational study targeting medical and nursing students. An online questionnaire was disseminated to elicit students' degree of (dis)agreement on a four-point Likert scale. Focused group discussions (FGDs) were conducted to comprehend reasons for (dis)agreement. Results: Total of 183 students responded to questionnaire (59.0% nursing, 67.8% female), 11 FGDs were conducted with 85 students. Interventions with highest agreement were mandatory face masks policy (94.54%), weekly mandated COVID-testing (92.35%) and students' Academic Bubble (91.26%); highest disagreement was for Sehat Check application (41.53%); and stay strong campaign (40.44%). Four themes emerged from FGDs: Effective safety interventions, Safety interventions with limited effectiveness, Utility of Sehat Check Application and Future recommendations for informing policy. Conclusion: It is paramount to seek student-feedback at forefront of university re-opening strategy. Clear communication channels are as important as an administrative response system's robustness. Bidirectional communication channels are fundamental and requisite during ever-changing policies and regulations. Engaging student representatives in decision making or implementation processes (such as "pilot" before "roll-out") would allow any potential issues to be managed early on. Gather real-time anonymous feedback and identify key areas that need further promulgation and those that need to be replaced with more effective ones.

Issues related to pregnancy, pregnancy prevention and abortion in the context of the COVID-19 pandemic: a WHO qualitative study protocol.

INTRODUCTION: WHO has generated standardised clinical and epidemiological research protocols to address key public health questions for SARS-CoV-2 (COVID-19) pandemic. We present a standardised protocol with the aim to fill a gap in understanding the needs, attitudes and practices related to sexual and reproductive health in the context of COVID-19 pandemic, focusing on pregnancy, pregnancy prevention and abortion. METHODS AND ANALYSIS PLAN: This protocol is a prospective qualitative research, using semi-structured interviews with at least 15 pregnant women at different gestational ages and after delivery, 6 months apart from the first interview. At least 10 partners, 10 non-pregnant women and 5 healthcare professionals will be interviewed once during the course of the research. Higher number of subjects may be needed if a saturation is not achieved with these numbers. Data collection will be performed in a standardised way by skilled trained interviewers using written notes or audio-record of the interview. The data will be explored using the thematic content analysis and the researchers will look for broad patterns, generalisations or theories from these categories. ETHICS AND DISSEMINATION: The current protocol was first technically assessed and approved by the WHO scientific committee and then approved by its ethics review committee as a guidance document. It is expected that each country/setting implementing such a generic protocol adapted to their conditions also obtain local ethical approval. Comments for the user's consideration are provided the document, as the user may need to modify methods slightly because of the local context in which this study will be carried out.

Anti-gay "Honor" Abuse: A Multinational Attitudinal Study of Collectivist- Versus Individualist-Orientated Populations in Asia and England.

Cultural collectivism, a core feature of honor cultures, is associated with the acceptance of aggression if it is used in the name of so-called "honor." Currently overlooked in the research literature, this study explored perceptions of antigay "honor" abuse in collectivist-orientated honor cultures, where homosexuality, in particular, is considered to be dishonorable. To conduct exploratory and comparative analysis, this study recruited 922 students in four Asian countries (India, Iran, Malaysia, and Pakistan), as well as Asian British and White British students in England. All participants read a brief vignette depicting a man whose relatives verbally abuse him and threaten him with life-threatening violence, after suspecting that he is gay and has joined an online dating website to meet men. Participants then completed a short questionnaire that assessed the extent to which they thought the man's actions had damaged his family's honor and their approval of the antigay "honor" abuse depicted in the scenario. Broadly in line with predictions, data analyses revealed attitudes more supportive of antigay "honor" abuse in all five collectivist-orientated populations than the sample of individualistic-orientated counterparts in England. Notably, however, a series of one-way analyses of variance (ANOVAs) demonstrated that these results varied depending on country of residence, gender, religious denomination, educational status, and age. The findings show that individual and demographic differences influence perceptions toward homophobic "honor" abuse in collectivist cultures. These differences are useful indices of the psychosocial factors that underpin hostile attitudes toward gay males in cultures where homosexuality is denounced.