Enhancing satisfaction and respect for health care personnel: a mixed-methods case study of a community-based intervention.

Health care personnel (HCP) face violence as a result of lack of satisfaction and respect among community members. It is imperative for HCP to engage in social work by involving communities for enhancing satisfaction and respect for them. This study attempted to provide insight on this phenomenon by using a mixed-methods concurrent embedded approach. Communities were selected based on modified Solomon four-group design from Karachi in southern province and from three cities of northern province, Khyber Pakhtunkhwa of Pakistan. Focus group discussions and in-depth interviews took place for formulating the quantitative tool. Six hundred pretests were done prior to introducing low-cost community-based interventions followed by 601 posttests. We found increased levels of satisfaction in both provinces, whereas level of respect increased significantly in Karachi in the southern province only. Qualitative interviews revealed the important role played by media and religious leaders. These findings suggest that satisfaction and respect for HCP can be enhanced through community support, involvement of religious leaders, and effective media campaigns.

Violence against health care workers in rural areas of Sindh, Pakistan.

OBJECTIVE: To determine the magnitude of violence against healthcare workers in a rural setting, and the consequences of this violence on their personal and professional lives. METHODS: The descriptive, quantitative, cross-sectional study was conducted in 4 rural districts of the Sindh province of Pakistan from February to December 2019, and comprised healthcare workers, including doctors, nurses, support staff and field workers. Data was collected using a structured questionnaire. Data was analysed using SPSS 22. RESULTS: Of the 1622 subjects, 929(57.3%) were males and 693(42.7%) were females. The overall mean age was 35.55+/-10.05 years. The largest cluster was that of doctors 396(24.4%), followed by technicians 202(12.5%). Overall, 522(32.2%) subjects had a professional experience of 1-5 years. Violence at workplace in any form was experienced by 693(42.7%) subjects. Verbal violence had been experienced by 396(24.4%) subjects, while 228(14.1%) had witnessed it. The corresponding numbers for physical violence were 122(7.5%) and 22(1.4%). Verbal violence was more prevalent compared to physical violence (p<0.01). The major effect was that the healthcare workers remained alert 537(33.1%), felt frustrated 524(32.3%) and disturbed 503(31%). Also, 272(16.8%) subjects were planning to migrate or quit the profession. CONCLUSIONS: Violence was found to be a significant issue in rural Sindh.

Army Public School Terrorist Attack - Perceptions and Experiences of school children of Karachi.

Objectives: To explore the experiences and perceptions of school children of Karachi after the Army Public School (APS) attack. Methods: It was a qualitative transcendental phenomenological study. Data collection started nine months after the attack, in September 2015, and continued till November 2019. Study participants were school children from Army, Government, and Private schools. The sampling strategy was convenience. Data collection of 53 students was done by focus group discussions and in depth interviews. Data analysis was performed using the phenomenological analytical techniques of Colaizzi. Results: Inductive analysis of the qualitative data gave rise to three themes - The journey beyond fear, Response of parents and schools and Role of media. Conclusion: The study concluded that the APS attack was the source of emotional distress and fear for the school children of Karachi as they personalized the event due to the nature of the attack. Immediately after the incident, they were in anger, grief, and fear, which altered their daily life activities and caused apprehensions in socializing and attending school. However, later they became highly motivated to study and gained courage. This motivation is revenge from terrorists as they wanted to keep children away from schools.

Role of Politics, Guilds and Pedagogy in defining Policies in Medical Education: The Pakistan Scenario.

Politics in education is not a new concept and has been a sore point of discussion between academia and policy makers. The politics of medical education has led to the formation of informal guilds that have taken control over medical education. Policy decisions concerning medical/dental education affecting the lives of the community, at large are implemented without giving due consideration to the pedagogy of medical education. This paper delves into the definitions of politics, pedagogy and guilds and with evidence identifies that major policy decisions in medical education are strongly influenced by politics. The paper will discuss that politics of medical education is not necessarily a bad thing if it ensures public safety and is based on best evidence medical education. In the same context the guilds formed for medical education reforms should uphold the principles of pedagogy.

Prevalence of anxiety and depression in high school students of Karachi, Pakistan.

Objectives: Anxiety and depression are commonly occurring mental disorders in school-going students and if not considered can result in a worse outcome. The objective of our study was to determine the prevalence, risk factors and relationship of anxiety and depression with different variables among high school students of Karachi. Methods: This cross-sectional study was conducted in October - November 2020 in government and private high schools of four districts of Karachi. Two stage cluster sampling was used to select study sites with 400 students inducted. Data was collected by using Aga Khan University Scale of anxiety and depression. Relationship of outcome with predictor variables was examined by applying univariate and multivariate logistic regression analysis. Results: Overall 53.2% participants reported anxiety and depression out of which 78.8% were females. Participants who were studying in private schools (OR 0.39, CI 0.21-0.69 at 95%, p=0.002) and had mothers who were housewives (OR 0.28, CI 0.09-0.83 at 95%, p=0.022) were less likely to develop anxiety and depression. Participants whose fathers and mothers had a history of anxiety and depression were three times more likely to develop anxiety and depression (OR 3.12, CI 1.52-6.41 at 95%, p=0.002) and (OR 3.02, CI 1.39-6.59 at 95%, p=0.005) respectively. Conclusion: The study found a high prevalence of anxiety and depression among high school students. Female students of public sector school and those who had a family history of anxiety and depression were more likely to develop it. Early detection and management of anxiety and depression by screening are necessary to overcome this burden.

Caregiver strain and its predictors among parents of autistic children: a cross-sectional study.

Objective: This study estimates the frequency and predictors of caregiver strain (CGS) among parents of autistic children.Methods: Demographic details and CGS were collected through a validated tool from 403 parents of autistic children in Karachi, Pakistan. Regression modelling was performed to report associations between social, behavioural, and communication problems and socioeconomic predictors of CGS. Results were reported using adjusted beta-coefficients with 95% confidence intervals.Results: In total, 88.3% of the parents reported moderate to severe CGS. A high family income (ß = -4.31, 95% CI -7.55, -0.11), and caregiver's higher level of education (ß = -4.73, 95% CI -8.84, -0.61), along with care-recipient age group (ß = -9.35, 95% CI -15.17, -3.52) significantly predicted lower CGS. Diagnosis of more than 5 years (ß = 7.57, 95% CI 2.36, 12.79), tendency to self-harm (ß = 10.75, 95% CI 6.62, 14.88), and social withdrawal in the care-recipient (ß = 4.56, 95% CI 1.68, 7.44) were significantly associated with higher CGS.Conclusion: Parents of children on the autistic spectrum suffer from high CGS. There is a need to introduce tailored parenting interventions at the individual and community levels to help parents reduce the CGS, ultimately benefiting their child.

Difference in memory recall among medical students after reading printed text (hard copy) vs. on screen text (soft copy).

OBJECTIVE: To compare the difference in "memory recall" among undergraduates (UGs) and postgraduates (PGs) medical students reading printed text (hard copy) vs. on-screen text (soft copy). METHODS: Final year UGs medical students (Group A) were divided into two batches, one batch was given hard copy of 1258 worded text and other group was given a soft copy of the same text. Likewise PGs (Group B) were divided into two batches, each batch was given hard copy and soft copy of the same text material with identical physical attributes. All batches were asked to read the text in 15 minutes. Text was then removed and a proforma containing statements pertaining to recall of the text material was administered to all. RESULTS: The scores of students reading soft copy text were significantly higher compared to student reading text from hard copy (p<.008) in the proforma assessing memory recall. CONCLUSIONS: The memory recall from reading on screen text is better than reading printed (paper) text, implying that with the advancement of technology and early exposure to computer screen, students are developing the habit of reading on screen text more conveniently.

Assessment of a mass media campaign on giving way to ambulances in five cities of Pakistan.

OBJECTIVE: To determine the contribution of a mass media campaign towards encouraging more vehicles to give way to ambulances, and to identify the factors associated with higher likelihood of giving way to ambulances. METHODS: The three-phase observational study was conducted from December 2017 to March 2018 in Karachi, Lahore, Rawalpindi, Islamabad and Peshawar cities of Pakistan. Six road sites in different areas of each city were selected for observation. The surveys in each city were supervised by academic partners, including APPNA Institute of Public Health, Karachi, University of Health Sciences, Lahore, Al-Nafees Medical College, Rawalpindi and Islamabad, and Khyber Medical University, Peshawar. Three observation surveys were carried out before, during and after the media campaign on right of way for ambulances. Only those ambulances were observed which were rushing through and seeking space. The behaviour of only those vehicles was observed which had the space to change the lane when the space was sought from them. The association of the outcome of vehicles giving way to ambulances immediately or in a few seconds with the campaign was determined using logistic regression analysis. RESULTS: After adjustment for city of observation, timing of the day and type of vehicle, vehicles during and after the campaign were significantly more likely give space to ambulance (p<0.05) compared to cars, buses and vans were significantly less likely to give space (p<0.05). CONCLUSIONS: Media campaign produced better results in encouraging vehicle-owners to give right of way to ambulances to ensure timely medical assistance.

Attitudes of faculty and residents of surgical specialties towards professionalism at a tertiary care hospital of Islamabad.

OBJECTIVES: To determine the attitudes of faculty and residents of surgical specialties towards professionalism and to test the validity and reliability of a tool developed in USA for Pakistan. METHODS: An exploratory validation study was carried out at Pakistan Institute of Medical Sciences (PIMS), Islamabad from 01-Aug-2016 to 31-Jan-2017. Penn State College of Medicine Professionalism Questionnaire (PSCOM) was used, being a reliable and valid survey tools. Exploratory Factor Analysis of the inter-correlations of responses for 36 items was done using SPPS v 21 to give a factor solution to reflect the perceptions regarding attitudinal elements. RESULTS: There were 209 respondents including 172 residents and 37 faculty members. Response rate was 81.32%. Exploratory Factor Analyses of responses gave a seven factor solution of professionalism: accountability, honour and integrity, excellence, duty, altruism, equity and respect. Six of the factors that emerged reflect the six elements of professionalism reported by American Board of Internal Medicine (ABIM), except for 'equity', which was the new factor that emerged. Cronbach's alpha (Internal Consistency Reliability) for each element of professionalism was between 0.88-0.98. CONCLUSION: PSCOM is a valid, reliable, feasible and acceptable tool to assess attitudes of faculty and residents towards professionalism in Pakistan. 'Equity' emerged as a new factor which needs to be studied further.

Violence Against Health Care Providers: A Mixed-Methods Study from Karachi, Pakistan.

BACKGROUND: Violence against health care providers (HCPs) remains a significant public health problem in developing countries, affecting their performance and motivation. OBJECTIVES: To report the quantity and perceived causes of violence committed upon HCPs and identify strategies intended to prevent and de-escalate it. METHODS: This was a mixed-methods concurrent study design (QUAN-QUAL). A structured questionnaire was filled in on-site by trained data collectors for quantitative study. Sites were tertiary care hospitals, local nongovernmental organizations (NGOs) providing health services, and ambulance services. Qualitative data were collected through in-depth interviews and focus group discussions at these same sites, as well as with other stakeholders including media and law enforcement agencies. RESULTS: One-third of the participants had experienced some form of violence in the last 12 months. Verbal violence was experienced more frequently (30.5%) than physical violence (14.6%). Persons who accompanied patients (58.1%) were found to be the chief perpetrators. Security staff and ambulance staff were significantly more likely to report physical violence (p = 0.001). Private hospitals and local NGOs providing health services were significantly less likely to report physical violence (p = 0.002). HCPs complained about poor facilities, heavy workload, and lack of preparedness to deal with violence. The deficiencies highlighted predominantly included inadequate security and lack of training to respond effectively to violence. Most stakeholders thought that poor quality of services and low capacity of HCPs contributed significantly to violent incidents. CONCLUSION: There is a great need to design interventions that can help in addressing the behavioral, institutional, and sociopolitical factors promoting violence against HCPs. Future projects should focus on designing interventions to prevent and mitigate violence at multiple levels.

Findings from Healthcare in Danger Project: Pakistan security assessment of a public and private tertiary care hospital in Karachi: Gaps and way forward.

OBJECTIVE: To identify and compare security gaps in a public and private tertiary care hospital. METHODS: The study was conducted in January 2016 using a tool adopted from Ingersoll Rand Security Technologies, Occupational Safety and Health Association and findings of baseline research carried out by Health Care in Danger Project at a public and private sector hospital in Karachi. The names of hospitals were kept confidential. Areas assessed included adequacy of workforce, existing institutional mechanisms and campus security. The tool was completed by interviewing administration, security department, and healthcare workers in wards and the emergency departments as well as patients, attendants and through observation visits. RESULTS: The burden of doctors at the private-sector hospital was higher compared to the publicsector hospital (40 versus 22 patients per doctor per day) in the outpatient department. Privatesector hospital scored better than public-sector hospital with regards to compliance to security management standards (68% versus 50%), security perception of staff (90% versus 50%), security staffing (60% versus 50%), and visitor management (80% versus 40%). Campus security was better at private-sector hospital (56% versus 31%). Scores for employee orientation and training were low (30% and 20%), while scores for organisational partnerships were high in both hospitals (80% each). . CONCLUSIONS: Four-pronged strategic framework is recommended that shall comprise restricting access of attendants/visitors/vendors, improving interaction between patients/healthcare workers/guards, mechanisms of reporting and responding to violent events, and maintaining sufficient resources for enhancing and improving security in hospitals.

Multiple dimensions of violence against healthcare providers in Karachi: Results from a multicenter study from Karachi.

OBJECTIVE: To investigate the causes, consequences and possible solutions for violence against healthcare. METHODS: The qualitative study was conducted in Karachi June 2015 to December 2015 using in-depth interviews and focus groups discussions with all stakeholders. Transcription was done verbatim using both audio and videotapes of all the sessions. First open coding was done using inductive analyses by 3 researchers. After consensus, these codes were used for thematic content analysis. Interviews and discussions were stopped after saturation was reached and no new codes were identified.. RESULTS: Overall, 42 in-depth interviews and 17 focus groups discussions were held. Major forms of physical violence included beating, throwing things, abusive language, threats, harassment, damage to building, furniture, vehicles and equipment. The threshold of violence was very high for verbal violence and minor forms of physical violence. The causes were identified as behavioural (communication gap between providers and patients, attendants), institutional (capacity, resources and systems) and socio-political (growing illiteracy and intolerance). The sequelae of violence included guilt, night dreams, shame and 61.9 % (N=26/42 IDIs)% who faced violence did not report it officially. CONCLUSIONS: Violence faced by healthcare providers was multifaceted and needs interventions at varied levels, including training of healthcare staff in dealing with violence and its aftermaths, security measures at the healthcare institutions inclusive of ambulance services and policies at the national level to manage and de-escalate violence against healthcare.

Identifying a parsimonious model for predicting academic achievement in undergraduate medical education: A confirmatory factor analysis.

OBJECTIVES: This study was conducted to adduce evidence of validity for admissions tests and processes and for identifying a parsimonious model that predicts students' academic achievement in Medical College. METHODS: Psychometric study done on admission data and assessment scores for five years of medical studies at Aga Khan University Medical College, Pakistan using confirmatory factor analysis (CFA) and structured equation modeling (SEM). Sample included 276 medical students admitted in 2003, 2004 and 2005. RESULTS: The SEM supported the existence of covariance between verbal reasoning, science and clinical knowledge for predicting achievement in medical school employing Maximum Likelihood (ML) estimations (n=112). Fit indices: χ2 (21) = 59.70, p =<.0001; CFI=.873; RMSEA = 0.129; SRMR = 0.093. CONCLUSIONS: This study shows that in addition to biology and chemistry which have been traditionally used as major criteria for admission to medical colleges in Pakistan; mathematics has proven to be a better predictor for higher achievements in medical college.

Reliability and validity of the faculty evaluation instrument used at King Saud bin Abdulaziz University for Health Sciences: Results from the Haematology Course.

OBJECTIVE: To assess reliability and validity of evaluation tool using Haematology course as an example. METHODS: The cross-sectional study was conducted at King Saud Bin Abdul Aziz University of Health Sciences, Riyadh, Saudi Arabia, in 2012, while data analysis was completed in 2013. The 27-item block evaluation instrument was developed by a multidisciplinary faculty after a comprehensive literature review. Validity of the questionnaire was confirmed using principal component analysis with varimax rotation and Kaiser normalisation. Identified factors were combined to get the internal consistency reliability of each factor. Student's t-test was used to compare mean ratings between male and female students for the faculty and block evaluation. RESULTS: Of the 116 subjects in the study, 80(69%) were males and 36(31%) were females. Reliability of the questionnaire was Cronbach's alpha 0.91. Factor analysis yielded a logically coherent 7 factor solution that explained 75% of the variation in the data. The factors were group dynamics in problem-based learning (alpha0.92), block administration (alpha 0.89), quality of objective structured clinical examination (alpha 0.86), block coordination (alpha 0.81), structure of problem-based learning (alpha 0.84), quality of written exam (alpha 0.91), and difficulty of exams (alpha0.41). Female students' opinion on depth of analysis and critical thinking was significantly higher than that of the males (p=0.03). CONCLUSIONS: The faculty evaluation tool used was found to be reliable, but its validity, as assessed through factor analysis, has to be interpreted with caution as the responders were less than the minimum required for factor analysis.

Effect of course coordinator behavior and motivation on students' achievement: Results from five curriculum blocks of two undergraduate student cohorts at King Saud bin Abdulaziz University of Health Sciences.

OBJECTIVE: The purpose of the study was to assess the relationship between students' perception of course/block coordinators performance and attributes with students' assessment scores in respective courses. METHODS: This retrospective data based study was conducted at the College of Medicine, King Saud bin Abdulaziz University of Health Sciences (KSAU-HS). It was started in March 2013 and completed in June 2013 after the graduation of the fourth cohort. Exam score of 3(rd) and 4(th) cohort of students from the courses taught in the last two years of medical school were correlated with faculty and block evaluation done by the students. Scores from mid-block MCQs, portfolio scores, OSCEs and end-of-block MCQs were obtained. RESULTS: The Mean scores of all the assessments for all five blocks were not significantly different for both batches. There was significant difference between block coordinators for students' score on portfolio, midterm exam and the final written exam. The students' Score in OSCE had significantly strong correlation with quality of station monitors, coverage of content and flow between stations. Student's perception of the commitment and motivation of the coordinator was strongly correlated with block organization, availability of clinical cases, performance of block coordinator, cooperation with students, and organization of clinical activities. CONCLUSIONS: Block coordinator's motivation and commitment affects quality of block organization and student`s success. Faculty training programs should include block management competencies and components identified through self-determination theory for improving the intrinsic motivation for students success.

Validation of HF-Bioelectrical Impedance Analysis versus Body Mass Index in Classifying Overweight and Obese Pakistani Adults.

Purpose: To determine the validity of hand-to-foot bioelectrical impedance analysis (HF-BIA) versus body mass index (BMI) to assess overweight and obesity status in adults against a reference method, dual-energy x-ray absorptiometry (DXA). Patients and Methods: It is a validation study conducted on 206 Pakistani adults ≥20 years recruited through convenience sampling technique at PNS Shifa Hospital and Jinnah Post Medical Centre, Karachi, Pakistan. Results: HF-BIA showed better sensitivity of 90.1% and 100% specificity with no false positive, but 9% false negative as compared to BMI which indicated 80.3% sensitivity and 100% specificity with a false-negative rate of 19.6%.HF-BIA also showed better sensitivity 80.9-97.1% with 100% specificity and PPV across all age groups. The correlation coefficient between BMI and DXA bf% (r=0.67) was moderate and less than the correlation coefficient between HF-BIA and DXA bf % (r=0.87). Kappa agreement showed weak to a fair agreement between BMI and DXA bf % (0.1 overall; 0.22 men; 0.14 women) compared to HF-BIA, which had a better agreement between BIA bf% and DXA bf% (0.43 overall; 0.46 men; 0.34 women). HF-BIA bf % demonstrated a better discriminatory power than BMI (AUC of ≥0.91) and was better predictor of body fat than BMI. Conclusion: HF-BIA is a more accurate method than BMI and may be used consistently throughout the country in primary care and research to identify the fat-based overweight and obese in the Pakistani population.

Validation of a Public Health Tool used for the Assessment of Violence against Healthcare Providers in the Rural Areas of Sindh.

OBJECTIVE: To validate a public health tool for assessing violence and its effects against healthcare providers (HCPs). STUDY DESIGN: Cross-sectional study. PLACE AND DURATION OF STUDY: Rural districts of Sindh from June to December 2019. METHODOLOGY: The survey included all the HCPs from the five districts of Sindh such as Sanghar, Thatta, Sukkur, Nawabshah, and Larkana with a minimum of one-year experience. Those not willing to participate in the study were excluded. The main variables were socio-demographic variables, type of violence and effects of violence. Multi-stage cluster sampling was done. Within each district hospital, an equal number of HCPs were recruited from the Emergency, Medical, Surgical, Pediatric, and Gynecology Departments. The main factors of the public health tool were checked by performing principal component analysis, using varimax rotation, to assess the construct validity. Finally, Cronbach's alpha was used to check the reliability of the questionnaire. RESULTS: The Cronbach's alpha value was 0.724, showing satisfactory reliability of the questionnaire. Factor analysis yielded a five-factor solution accounting for 58% of the total variance in the data set. The principal component analysis revealed that the questionnaire used previously for measuring workplace violence and its effects had acceptable reliability and validity. CONCLUSION: This study revealed that this public health tool can be used for assessing violence against HCPs in the rural areas of Sindh. KEY WORDS: Construct validity, Factor analysis, Healthcare providers, Validation, Violence.

Comparison of Peer-Assisted Learning with Traditional Faculty-led Teaching in Family Medicine Clerkship: An Experimental Study.

OBJECTIVE: To compare the effects of reciprocal peer-assisted learning (PAL) with traditional faculty-led teaching on the academic performance of fourth-year medical students in Family Medicine clerkship. STUDY DESIGN: An experimental study. PLACE AND DURATION OF STUDY: Department of Health Professions Education and Department of Family Medicine, Shifa College of Medicine, Islamabad, Pakistan, from 22nd February 2019 to 25th February 2020. METHODOLOGY: The study was conducted longitudinally in three clerkship rounds of Family Medicine with 77 fourth-year students separated into a control group and an intervention group taught by faculty and peers respectively. All peer tutors were trained prior to their sessions and there were parallel peer-led and faculty-led sessions. Both groups were given a pre-test prior to the intervention and a post-test after the intervention. The data were entered in SPSS version 24 and analysed using chi-square, independent and paired sample t-tests. RESULTS: Participants of both intervention (PAL) and control (non-PAL) groups demonstrated a significant difference in post and pre-test scores with a p-value <0.05. However, the mean difference in the post-and pre-test scores between the two groups was not significant with a p-value >0.05. CONCLUSION: Students taught by peers performed as well as students taught by the faculty in this study, as depicted by their academic scores. Henceforth PAL is comparable to faculty-led teaching in acquisition of knowledge in Family Medicine clerkship. KEY WORDS: Peer-assisted learning, Reciprocal peer-assisted learning, Traditional teaching, Family medicine.

Does watching violent electronic and social media content lead to increased levels of aggression? A survey among adolescents in an urban slum of metropolitan Karachi.

OBJECTIVES: Increased levels of aggression and desensitization of adolescents has been witnessed as a result of exposure to violent social/electronic media content. It is imperative for policymakers to study such behavioral outcomes in order to make sound policies regarding media literacy. The objective of the study therefore was to assess relationship between violent electronic/social media exposure and level of aggression. METHODS: A cross sectional study was conducted among adolescents aged 9-19 years in peri-urban slum of Karachi. Content-based Media Exposure scale and Buss and Perry questionnaire, internationally validated tools were used to collect data. Level of aggression was the main outcome variable which was analyzed. RESULTS: Four hundred and twenty-two adolescents participated in the survey. Usage of television was significantly higher in the younger age group whereas the effect of watching violent content among the adolescents varied. It was observed that 153 (36.3%) respondents felt stressed and 24 (5.7%) felt aggressive after watching violent content on electronic and social media. The contents showing people who fight (39.6 ± 5.6, p-value<0.05), who steal (39.5 ± 7.5, p-value=<0.05) and destroyed someone else's belongings (40.6 ± 7.6, p-value=<0.05) had a significant effect on the level of aggression. Regression analysis predicted a strong positive association of exposure of violent content with level of aggression (ß=0.43). CONCLUSIONS: The usage of violent content on social and electronic media was popular among adolescents, and produced negative effects on the behavior of adolescents. Measures should be taken to introduce media literacy of the children in Pakistan, especially in the peri-urban slums.