What happens when private general practitioners receive incentivisation offers from pharmaceutical sales representatives? A qualitative study in Pakistan.

OBJECTIVES: Pharmaceutical incentivisation of physicians for profit maximisation is a well-documented health system challenge. This study examined general practitioners' (GPs) reactions to pharmaceutical incentivisation offers in one region in Pakistan. METHODS: We used the Standardised Pharmaceutical Sales Representative (SPSR) method and qualitative interviews with GPs. SPSRs were field researchers representing mock pharmaceutical companies who recorded their observations of 267 GPs' responses to pharmaceutical incentivisation offers. We triangulated SPSR data using qualitative interviews with a subset of the same GPs to gather information about how they interpreted different interaction outcomes. RESULTS: We found four major outcomes for GPs being offered incentives by pharmaceutical companies for prescribing medications. GPs might agree to make incentivisation deals, reject incentivisation offers, disallow PSRs to access them, or remain indeterminate with no clear indication of acceptance or rejection of incentivisation offers. GPs rejecting SPSRs' incentivisation offers indicated having active commitments to other pharmaceutical companies, not being able to work with unheard-of companies, and asking SPSRs to return later. CONCLUSIONS: The GP-pharmaceutical sales representative interaction that centres on profit-maximisation is complex as offers to engage in prescribing for mutual financial benefit are not taken up immediately. The SPSR method helps understand the extent of distortion of practices impacted by incentivisation. Such an understanding can support the development of strategies to control unethical behaviours.

Follow-up household assessment for child unintentional injuries two years after the intervention: A community-based study from Karachi, Pakistan.

BACKGROUND: Unintentional childhood injuries are a growing public health concern, and the home is the most common location for non-fatal injuries in children less than 5 years of age. This study describes the long-term effects of two injury prevention educational interventions for caregivers-an educational pamphlet and an in-home tutorial guide-by comparing the change in the prevalence of home injury hazards before and after the interventions. METHODS: This was a pre- (June and July 2010) and post-study with short-term follow-up (November-December 2010) and long-term follow-up (November 2012- January 2013). Neighborhood one included households that received only educational pamphlets after completing a baseline assessment; neighborhood two included households that received an in-home tutorial guide after completing the baseline assessment and receiving the educational pamphlet. The main outcome of this study was the reduction in home injury hazards for children under 5 years of age. RESULTS: A total of 312 households participated in the long-term phase to compare the effect of the interventions. Between the short-term to long-term follow-up, injury hazards significantly reduced in neighborhood two compared to neighborhood one. These included fall hazards (walker use) (IRR 0.24 [95% CI 0.08-0.71]), drowning hazards (open bucket of water in the courtyard and uncovered water pool) (IRR 0.45 [95% CI 0.85-0.98] and IRR 0.46 [95% CI 0.76-0.94]), burn hazards (iron, water heater within reach of child) (IRR 0.56 [95% CI 0.33-0.78] and IRR 0.58 [95% CI 0.32-0.91]), poisoning hazards (shampoo/soap and medicine within reach of child) (IRR 0.53 [95% CI 0.44-0.77] and IRR 0.7 [95% CI 0.44-0.98]) and breakable objects within reach of child (IRR 0.62 [95% CI: 0.39-0.99]). CONCLUSION: An injury prevention tutorial to caretakers of children supplemented with pamphlets could significantly decrease the incidence of falls, drowning, burns, poisoning, and cut injury hazards for children under 5 years of age in their homes in a low-resource setting. This intervention has the potential to be integrated in existing public health programs, such as Lady Health Visitors (LHVs), to disseminate injury prevention information in routine home health visits.

Spatiotemporal variation and socioeconomic factors of financial hardships of out-of-pocket health expenditure in Pakistan.

BACKGROUND: Financial hardships of out-of-pocket health expenditure (OPHE) is a growing concern for health policy makers in many low and middle-income countries. Spatiotemporal variation between Pakistan's four provinces over 2001-2015 is discussed, which would help comparing existing health services delivery and financial risk protection plans. AIMS: In this paper, we estimate financial hardship of OPHE in Pakistan. METHODS: We use the data sets of the household integrated economic surveys 2001-02, 2005-06, 2010-11 and 2015-16. We estimate OPHE share in household total and non-subsistence expenditure, catastrophic headcount at the threshold of OPHE ≥ 10% of total expenditure or OPHE ≥ 25% of non-subsistence expenditure. We estimate impoverishment of OPHE using national poverty lines. Finally, we explore socioeconomic factors of financial hardships of OPHE. RESULTS: Over the years, catastrophic headcount and impoverishment of OPHE had decreased at national level (-1.3% points) and in the provinces of Sindh (-7.8% points) and Khyber Pukhtoonkhawa (KPK), (-2.8% points). The province of KPK and the year 2005-06 witnessed the highest incidence of financial catastrophe (26.89% points) and impoverishment (4.8% points) of OPHE. Households in rural areas, in the middle and rich quintiles and those headed by a male were more likely to encounter financial catastrophe and impoverishment due to OPHE. CONCLUSION: Inter-provincial variation in financial hardships of OPHE provide aide to provincial level priority setting. The high impact of OPHE in the non-poor, in rural areas, and in KPK calls for enhanced targeting of financial risk protection plans.

Reliability and Validity of WATCH: Warwick Assessment InsTrument for Clinical TeacHing.

OBJECTIVE: To determine the reliability, validity, feasibility, acceptability and perceived educational impact of WATCH: Warwick Assessment insTrument for Clinical teacHing among doctors in Pakistan. STUDY DESIGN: Cross-sectional research study. PLACE AND DURATION OF STUDY: The College of Physicians and Surgeons, Pakistan, from September 2018 to August 2019. METHODOLOGY: Postgraduate trainees were asked to rate the clinical teaching sessions, using WATCH, which consists of 15 items. Percentage was used to calculate gender and participation from different specialties. Inter-item correlations of 15 items with individual mean scores, standard deviations and Cronbach's Alpha were reported, including Friedman test, in order to observe the scores across multiple conditions. The Hotelling's T2 test was used to test whether the answers provided by the study participants to the questionnaire were equal. Construct validity was determined using factor analysis while feasibility, acceptability, and educational impact was evaluated by seeking participants' feedback on five semi-structured questions. RESULTS: More than 80% ranked WATCH from good to excellent.  Oveall 8 items were perceived as excellent, while 7 items received rating of good. Inter-item correlation ranged from 0.61 to 0.81. Cronbach Alpha was reported to be 0.975, with significant difference in mean scores of different items (Friedman's Chi-Square=4285.54; p<0.001). The Hotelling's T2 test (21598.871 with F=185.249, df=14,2654; p<0.001) indicated that the mean values of the responses of different questions in the instrument were statiscally different. Factor analysis indicated one factor accounting for 73.97 of variance. The majority (93%) of the participants found the instrument easy to complete, most participants (91.5%) indicated it as an acceptable method of assessment, and majority (90.8%) perceived that it can improve clinical teaching. CONCLUSION: WATCH demonstrated valid, reliable, feasible, and acceptable results for assessment of teaching of medical doctors and it can be used for providing feedback and rewarding teachers who excel in teaching. Key Words: Clinical teaching, Validity, Reliability, Feasibility, Medical students, Residents, Doctors.

Psychosocial factors of deliberate self-harm in Afghanistan: a hospital based, matched case-control study.

BACKGROUND: Deliberate self-harm is not only a major global public health problem but also an important index of psychological distress and a risk factor for suicide. AIMS: We aimed to determine the psychosocial risk factors for deliberate self-harm in patients aged ≥ 16 years presenting to tertiary care hospitals in Kabul, Afghanistan. METHODS: A matched case-control study was conducted from February 2015 to May 2015. We recruited 185 cases (patients with deliberate self-harm) and 555 age- and sex-matched controls (patients with general medical conditions) from 4 tertiary care hospitals in Kabul. We developed a questionnaire to record the sociodemographic characteristics of the participants, history of domestic violence, drug abuse and details about the act of deliberate self-harm, including the methods used. To assess depression and anxiety, we used the WHO self-reporting questionnaire (SRQ-20). Matched odds ratios with 95% confidence interval using conditional logistic regression were used to determine statistically significant associations between psychosocial factors and deliberate self-harm. RESULTS: Family conflicts, domestic violence, interpersonal arguments and living in extended families were found to be significantly associated with deliberate self-harm. CONCLUSIONS: In Afghanistan, deliberate self-harm appears to be predominately related to interpersonal problems and family conflicts. About two-thirds of females and more than half of males scored positive for depression, yet none were receiving treatment for this. These findings have important policy implications for mental health and suicide prevention programmes in the country.

Role of Community Based Savings Groups (CBSGs) enhancing the utilization of community midwives in Chitral district of Pakistan.

BACKGROUND: Maternal and infant mortality rates in the district of Chitral in Pakistan are alarmingly high. One of the major reasons for this is the inability of women to access skilled care due to the high costs associated with traveling and utilizing such services. The Aga Khan Health Services, Pakistan (AKHSP) in partnership with the national and provincial Maternal, Neonatal and Child Health (MNCH) program, deployed 28 community midwives (CMWs) in remote villages of Chitral district. This program has also established Community-Based Savings Groups (CBSGs) to support and facilitate access to MNCH services, in particular those delivered by the CMWs. CBSGs are a simple yet cost-effective and sustainable means of providing basic financial services to low income, marginalized, rural populations.The link between CBSGs and utilization of MNCH services is not well understood. This study will assess the relationship between women membership of CBSGs and their utilization of MNCH services, specifically those offered by CMWs, in the community. METHODS: The research question will be answered through guided interviews of women in the target population who have delivered within one month. The outcome variable will be the utilization of full continuum of skilled MNCH care (disaggregated by 1+ ANC, 1+ PNC and skilled delivery). The primary independent variable of interest will be participation in a CBSG.Focus Group Discussions (FGDs) will be conducted to generate further understanding and information about the social and financial factors that contribute to health behavior and health provider decision-making during pregnancy.Analysis will be tailored to answer how CBSGs, directly or indirectly, facilitate greater financial and/or social access to CMW services for pregnant women. Furthermore, the extent to which financial or social empowerment through a CBSG leads to greater utilization of CMW services. DISCUSSION: The role of CBSGs and their interlink with the CMWs services to be replicated in other comparable areas in Pakistan as a viable mean to increase MNCH service utilization amongst rural, low income, and marginalized communities. Findings from this research will be disseminated through community, national, and international channels consisting of policy makers and social society groups.

Self-perceived health among school going adolescents in Pakistan: influence of individual, parental and life style factors?

BACKGROUND: Adolescents are at substantial risk of acquiring behaviors which might influence their health status. This study was aimed to assess the proportion of school going adolescents (both males and females) with poor self-perceived health and its associated factors. METHODOLOGY: A cross-sectional study was conducted in three major cities of Pakistan i.e. Karachi, Lahore and Quetta. From each city, six (6) secondary schools were randomly selected (3 public and 3 private). Pre-tested, self-administered questionnaire was distributed to students. Binary logistic regression analysis was conducted to determine independent factors associated with poor self-perceived health. RESULTS: Approximately 29% adolescents (119/414) reported poor self-perceived health. Individual and parental factors significantly associated with poor self-perceived health were being male (AOR = 1.75, 95% CI: 1.09 - 2.79), living in extended family (AOR = 2.65, 95% CI: 1.66 - 4.22), unskilled employment of father (AOR = 2.17, 95% CI: 1.35 - 3.48), lack of parental-child communication (AOR = 1.74, 95% CI: 1.03 - 2.91) and unfair treatment by parents (AOR = 1.80, 95% CI: 1.09 - 2.96). Life style factors such as use of smokeless tobacco (AOR = 2.14, 95% CI: 1.26 - 3.96) and unhealthy diet (AOR = 3.60, 95% CI: 1.76 - 7.33) were associated with poor self-perceived health. CONCLUSION: Better employment opportunities for father, parental counseling and increase awareness for adolescents about healthy diet are recommended to improve adolescent self-perceived health in Pakistan.

Assessment of quality of care for the management of type 2 diabetes: a multicentre study from a developing country.

BACKGROUND: Complications of diabetes can be prevented or delayed by providing high quality care. This study aimed to document the quality of care provided to people with type 2 diabetes in Pakistan and to identify the difference in care offered at various clinics. DESIGN: Cross-sectional multi-centre study. METHODS: Interviews were undertaken with 672 people with type 2 diabetes attending three different types of diabetes clinic (private clinic (A), non-governmental organisation (B) and public clinic (C)) in Karachi, Pakistan. A structured questionnaire was used to collect socio-demographic and clinical information from patients; quality of care indicators were also confirmed by reference to patients' medical records. RESULTS: Overall, 68% (A: 92%, B: 58% and C: 52%, P<0.001) of study subjects were informed about diabetes complications. Blood pressure (BP) monitoring at every visit was completed for 80% of study respondents (A: 100%, B: 79% and C: 57%, P<0.001). Foot examination was infrequent (53%, A: 98%, B: 52% and C: 8% (P<0.001). Lipid profiles of 48% of patients had been done in the past 12 months (A: 77%, B: 16% and C: 50%, P<0.001). Microalbumin testing had been performed in 32% of patients in the previous year (A: 77%, B: 09% and C: 05%; P<0.001). Most participants had elevated glycaemic (58.2%) and BP levels (84.7%) with higher prevalence among people who attended clinics B and C (P<0.001). Overall, 82.6% of study subjects had an elevated body mass index; this was almost equally prevalent across clinics. CONCLUSION: Many patients with type 2 diabetes do not receive optimal diabetes care in Karachi. Among the different settings, care provided in private health sector clinics was of a better standard. However, our results reveal a need for overall improvement in the quality of diabetes care. Further research is also needed to evaluate the reasons for poor diabetes care, and to identify the most cost-effective means to address these.

Pattern of health care utilization and determinants of care-seeking from GPs in two districts of Pakistan.

The aims of the study were to describe the pattern of health care utilization and out-of-pocket expenses incurred in seeking health care, and to identify the determinants of care-seeking from private general practitioners (GP) in two districts of Pakistan. During July-September 2001, we conducted a cross-sectional study in two districts in the Sindh Province of Pakistan. We selected 1,150 participants age > or = 3 months through a two-stage cluster sampling technique. Information was collected about contacts with healthcare providers during the past three months, presenting complaints, type of treatment received, and cost of the latest visit. Of 1,150 participants, 967 (84%) had at least one contact with health care providers during past three months. The mean number of contacts was 1.7. Most of the contacts (66.8%) were with private GPs. The average cost per visit was Pak Rs 106 (US dollar 1.7) and Rs 38 (US dollar 0.6) for GPs and public sector providers, respectively. A multiple logistic regression model revealed those living in urban areas, with monthly household income > Rs 2,500 (US dollar 39.7), an education level > 5 years, and who received both injections and oral drugs were more likely to visit private general practitioners.