Association between residential green spaces and pregnancy outcomes: a systematic review and meta-analysis.

Residential exposure to greenness has shown positive influences on pregnancy outcomes like birth weight, preterm births, and small to gestational age (SGA) deliveries. We aimed to comprehensively review and investigate these associations by conducting a systematic review with meta-analysis. Relevant studies were retrieved from PubMed, EMBASE, ScienceDirect, and Google Scholar databases before June 2023. Summary effect estimates included birth weight, low birth weight (LBW), preterm births, and SGA which were calculated for 0.1 unit increase in residential greenness exposure. Overall quality of the evidence was examined through Joanna Briggs Institute (JBI) critical appraisal tool. The review included 31 articles and found a statistically significant increase in birth weight measured at 250 m buffer distance (ß = 8.95, 95% CI = 1.63-16.27). Green spaces were also associated with lower odds of LBW (OR = 0.97, 95% CI = 0.96-0.98). Residential greenness had positive impacts on pregnancy outcomes that calls for emphasis on urban planning, especially in developing countries.

Compliance with smoke-free legislation and smoking behaviour: an observational field study in Karachi, Pakistan.

Objective: To observe compliance with smoke-free law at different public places in an urban setting. METHODS: The cross-sectional study was conducted from January to June 2022 after approval from the ethics review board of Jinnah Sindh Medical University, Karachi, at public places, including public and private offices, health institutions, education institutions, malls, markets and eateries, in 5 districts of Karachi. Boundary, entrance, waiting areas/corridors, toilet areas and eating areas were assessed using a checklist for smoke-free law compliance. Places were considered compliant if no smoking activity, cigarette butt litter or ashtrays was found. Data was analysed using SPSS 21. RESULTS: Out of 400 places observed, there were 80(20%) in each of the 5 districts. Overall, 36(44%) of the venues showed indoor compliance and 10(12%) showed outdoor compliance. Presence of cigarette butts was observed at 350(87.5%) outdoor places around the boundary of the premises. Only 38(9.5%) of the places had no smoking boards outdoors and at the entrance, with 16(4%) being clearly visible. Also, 27(43%) of educational institutions had a cigarette shop within 50 metres of the boundary. Conclusion: The city was found to have poor implementation of smoke-free laws, especially for outdoor areas, exposing the public to constant second-hand smoke.

Exploring the gaps between training and expected job skills of public health graduates to identify: A way forward.

Objectives: To explore the non-alignment between what is taught in academic programmes for public health and what is actually needed or expected in the field. METHODS: The qualitative phenomenological study was conducted from October 2020 to April 2021 in Karachi after approval from the institutional ethics review board of Jinnah Sindh Medical University, Karachi. The sample comprised major stakeholders including representatives of public health institutions and organisations involved in the implementation of public health programmes. Data was collected through in-depth interviews and focus group discussions using a guide after content validation by an expert. Data was analysed using both inductive and deductive approaches. RESULTS: A total of 13 in-depth interviews and 5 focus group discussions were conducted. Regarding gaps in the process of curriculum development, 2 major concerns emerged; lack of comprehensive involvement of experts in different fields of public health in designing the curriculum, and the lack of incorporation of the feedback provided by students in revising the curriculum. Regarding the content of curriculum, three main themes emerged; theoretical nature of courses, lack of uniformity in all programmes, and poor local contextualisation. The casual approach of students and barriers faced by them in joining public health programmes also affected the quality of such programmes. CONCLUSIONS: Three broad areas of improvement were identified, which included improvement in curriculum, methods of learning, and improving students' approach.

Understanding ethics of reporting health related events in media: A qualitative phenomenological study in Karachi and Peshawar.

Objective: The specific objectives of this study were to identify the ethical issues in reporting of health-related events in media and suggest ways to improve it. Method: This was a qualitative phenomenological study conducted by APPNA Institute of Public Health, Jinnah Sindh Medical University in collaboration with Institute of Public Health, Khyber Medical University from January to April 2022. A total of 38 focus group discussions and in-depth interviews were conducted either face to face at place of convenience of interviewees or online. The participants were health reporters, healthcare workers (HCWs), and representatives of law enforcement agencies in two cities i.e., Karachi and Peshawar. Data were analyzed by using the deductive and inductive approaches, by four independent experts including the Principal Investigator (PI) and three research fellows. Results: Ethical issues related to health reporting in the field included interference of the reporters in rescue efforts during an emergency and interference in emergency medical care of the victims. In reporting, careless disregard for patient confidentiality and privacy; using unreliable sources of information; using wrong terminology; sensationalizing the news and jumping to conclusions in cases of malpractice were reported as main problems. Negative influences on health reporting included poor training of the reporters on health reporting ethics, organizational pressures, and lack of cooperation by relevant health authorities. Conclusion: The quality of health reporting can be improved by building the capacity of health reporters in understanding the ethical issues and their social responsibilities toward health.

Changes in caloric consumption, physical activity, body mass index and sleeping pattern during holy month of Ramadan among doctors of a public sector University.

Objectives: To determine the change in caloric intake, physical activity, body mass index and sleeping pattern during Ramadan among doctors. METHODS: The longitudinal study was conducted at a public-sector medical university in Karachi from April to May 2020, and comprised healthy doctors of either gender who planned to fast during Ramadan. Data was collected using a multitude of validated structured tools by trained data collectors. Data was analysed using SPSS 20. RESULTS: Of the 193 subjects, 103(53.4%) were females and 90(46.6%) were males. The overall mean age was 30.05±9.4 years. Caloric intake in the month before Ramadan was significantly higher 2288±495kcal/day than during Ramadan 2089±491kcal/day (p<0.001). Calories from proteins decreased and those from fats increased (p<0.001). Metabolic equivalent of task per minute per week increased significantly during Ramadan (p<0.001). Overall sleep per day decreased significantly, and there was an increase in daytime sleep and a decrease in night-time sleep (p<0.05). Body mass index also dropped significantly (p=0.005). CONCLUSIONS: Fasting during Ramadan had a positive effect on body mass index and physical activity levels of doctors, while the quality of diet and sleep was affected negatively.

How frequent is burnout among informal caregivers of disabled children? Findings from a cross-sectional study in Karachi, Pakistan.

BACKGROUND: Informal caregivers are those who care for children without getting paid. They are often more prone to stress due to their extra daily tasks which leads to burnout. This study aimed to determine the frequency and associated risk factors of burnout among informal caregivers of children with disabilities in Karachi. METHODOLOGY: A cross-sectional study was done in 10 rehabilitation institutes of Karachi with 310 mothers of children with disabilities from infancy till 18 years of age in 2019. Pretested questionnaire was administered to collect data in which 31 mothers were interviewed through convenience sampling from each rehabilitation institute. To assess burnout, the Maslach Burnout Inventory (MBI) was used. Association of different variables of study participants with the scores of its three subdimensions, Emotional Exhaustion (EE), Depersonalization (DP) and Personal Accomplishment (PA), were analysed using linear regression modelling. RESULTS: Mean EE score was high in 6.5% of the mothers while PA scores were low in 58.7% of the mothers. High EE with low PA (defined by our team as 'burnout') was found in 4.2% of the mothers, with none of them reporting high levels of DP. Linear regression analysis significantly predicted higher EE scores of mothers with more than one disabled child while lower EE scores were significantly predicted in highly educated mothers and mothers who spent more time in caregiving. Higher PA scores were also significantly predicted for highly educated mothers. DP scores were significantly predicted to be higher in mothers who had highly educated husband/guardian, employed mothers and those living in joint families whereas they were significantly predicted to be lower in highly educated mothers. CONCLUSION: We have identified that mothers who are less educated, have more than one child with disability and who live in joint families will need extra support and input to prevent burnout.

Nicotine dependence and intention to quit among electronic, conventional and dual cigarette users in Karachi.

OBJECTIVE: To compare nicotine dependence and intention to quit among different types of smokers. METHODS: The comparative cross-sectional study was conducted from November 2018 to October 2019 in Karachi after approval from the ethics review committee of the Jinnah Sindh Medical University, and comprised conventional, electronic and dual cigarette users. Data was collected using a structured questionnaire regarding socio-demographics, usage characteristics, and intention to quit. The validated Hooked on Nicotine Checklist was also used. Data was analysed using SPSS 22. RESULTS: Of the 246 subjects, 82(33%) were conventional cigarette users with a mean age of 27.41±8.7 years, 82(33.3%) were electronic cigarette users having mean age of 30.37±9.16 years, and 82(33.3%) were dual cigarette users with a mean age of 28.89±9.07 years. The use of electronic cigarette was more in people with higher age (p=0.01), married (p=0.001) and having higher income (p=0.05). Compared to conventional cigarette users, electronic cigarette users showed lower odds of high nicotine dependence (odds ratio: 0.38, 95% confidence interval: 0.18-0.80). No significant difference was observed in intention to quit among different types of cigarette users (p>0.05). CONCLUSIONS: Electronic cigarettes users were comparatively less nicotine-dependent compared to the users of other types of cigarettes. Electronic cigarettes should only be recommended to conventional users with the intention to quit.

Frequency and risk factors of musculoskeletal disorders in high risk occupation workers in Urban, Karachi.

OBJECTIVE: To determine the frequency and risk factors of musculoskeletal disorders in high-risk occupation workers in an urban setting. METHODS: The analytical cross-sectional study was conducted in Karachi from July to December 2020, and comprised office workers, operation theatre technicians and coolies. The presence of musculoskeletal disorders was assessed using the Nordic Musculoskeletal Questionnaire to determine factors associated with moderate to severe condition. Data was analysed using SPSS 20. RESULTS: Of the 300 male subjects, 100(33.3%) each were office workers, operation theatre technicians and coolies. The overall mean age was 33.25±6.8 years (range: 18-50 years). The overall prevalence of musculoskeletal disorders was 179(59.7%). Besides, 117(65.4%) patients with musculoskeletal disorders had intermediate stage of the disease. The lower back and neck were the most common site of trouble involved in preceding 12 months 111(43.6%) each. CONCLUSIONS: Prevalence of musculoskeletal disorders was found to be a common problem affecting high-risk occupational workers.

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.

Psychological impact of COVID-19 Pandemic and associated factors on college students.

OBJECTIVE: To determine the psychological impact of coronavirus disease-2019 pandemic on college students, and to explore factors influencing their anxiety and depression levels. METHODS: The cross-sectional study was conducted from October 2020 to January 2021 at the Jinnah Sindh Medical University, Karachi, and comprised medical students of either gender in the first to third year of the academic programme. Data was collected using a pretested online structured questionnaire comprising demographic information, academic problems, daily life difficulties and the 25-item Aga Khan University Anxiety and Depression Scale. Data was analysed using SPSS22. RESULTS: Of the 397 students, 72(18.1%) were males and 325(81.9%) were females. The overall mean age of the sample was 19.9±1.2 years. Of the total, 221(55.7%) students were found to be anxious and depressed. Factors related to academic difficulties and daily life issues had significant correlation (p<0.05) with anxiety and depression. Multiple linear regression analysis indicated that the need for some form of mental health support was the most significant (p<0.001) predictor of anxiety and depression, followed by family issues (p<0.001) and social media (p<0.001). Anxiety and depression were also significantly associated with fear of family or friend getting coronavirus disease-2019 (p=0.003), lack of attentiveness to study (p=0.040) and felt anxiety when ordering food online (p=0.019). CONCLUSIONS: With better understanding, academic institutions and healthcare policymakers may take measures and mitigate students' distress during the pandemic.

Characteristics, reasons and patterns of Road Traffic Injuries presenting in emergency department of a tertiary care public hospital in Karachi.

Objectives: To determine the main characteristics, reasons and patterns of road traffic injuries (RTIs) in a tertiary care public hospital of Karachi. Methods: It was a hospital based cross sectional study conducted in a public tertiary care hospital emergency department with a sample size 425 selected conveniently. Participants included the consenting victims or caretaking attendants of road traffic injuries (RTIs) from 25th May to 28th June in 2019. A structured questionnaire was developed after literature review and was translated into "Urdu" language. The questionnaire collected detailed information on socio-demographic characteristics, possible reasons of RTI's such as condition of vehicle, over speeding and breaking traffic rules. Data was analyzed by using software SPSS version 20. Results: Almost half of RTI victims (43.1%) belonged to the age group 18-29. Majority of the victims were males (86.6%). The most common vehicle involved was motorbike (87.50%) followed by Rickshaw (6.8%) and Car (2.4%). Majority of RTIs occurred on main road (75.30%). The most common sites of injuries were lower limb (64%), upper limb (37.60%) and head (32.2%). The severe injuries were significantly more likely to happen in events in which direct collision with other vehicle/thing was involved, road conditions were wet and pedestrian were crossing the road. Conclusion: Motorbikes were involved in majority of RTIs. Main reasons of RTIs included irresponsible road behaviors including over-speeding, careless road crossing, breaking the signal and riding on wet roads which lead to moderate to severe injuries in almost two thirds of participants.

Ethnic differences in the receptors status of estrogen, progesterone and Her2/Neu among breast cancer women: A single institution experience.

OBJECTIVE: To evaluate the Ethnic Differences in Estrogen (ER), Progesterone (PR) and Her 2/neu receptors among Women with Breast Cancer at JPMC, the largest public sector tertiary care hospital in Karachi. METHODS: The study was conducted at the oncology ward, JPMC Karachi from 1st July 2017 to 31st December 2018. During this period, more than 500 women with breast cancer of different ethnicities visited the oncology ward, however 450 patients were included in the study, as only they had the complete reports on the receptors status and tumour histology. The data collected included tumour histology, grade, receptors status, age and ethnicity. Data was analyzed with SPSS version 20 using the Chi-Square Test to observe statistical differences in the receptors status of different ethnicities. RESULTS: Analysis of receptors status as per ethnicity showed that ER was proportionately more positive in Pushtoon patients at the rate of 28 (75.7%) as compared to Urdu Speaking 116 (60.4%), Punjabis 48 (60%), Sindhis 38(38.7%) and Balochis 26 (61.1%). Similarly, PR and Her-2/neu receptor were also higher in Pushtoons at the rate of 24 (64.9%) and 15 (40.5%) respectively. The behaviour of Triple Positivity was also more prominent in Pushtoons at the rate of 9 (24.3%) and the Pushtoons were also proportionately less likely to be Triple Negative at the rate 05 (13.5%) as compared to other ethnicities. All the results were statistically non significant (p values>0.05). CONCLUSIONS: In this study we observed a relatively higher expression of ER, PR and Her 2/neu Receptors in Pushtoons as compared to other ethnicities. Understanding the factors underlying these differences may provide further insight into the breast cancer aetiology in different populations.

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.

Frequency and determinants of timely arrival among patients of acute myocardial infarction at a public sector tertiary care hospital in Karachi.

OBJECTIVE: To determine the time from onset of symptoms to start of fibrinolysis and treatment in acute ST elevated myocardial infarction patients and identify the factors which cause delay in treatment. METHODS: A cross sectional study was conducted at National Institute of Cardiovascular Diseases, Karachi on 360 conveniently selected patients of ST elevated myocardial infarction from July to September in the year 2017. Structured questionnaire was used to obtain detailed information on socio-demographics, factors which cause delay and timing of onset of symptoms to arrival of patient in emergency ward. RESULTS: Overall, the total average time from the start of symptoms to initiation of treatment was 119.85+-63.32 minutes.. Only 5.1% patient reached within one hour while 57.7% reached within two hours. Old age group of 60 and above was positively associated with timely arrival (OR=2.75, 95% CI 1.33-5.68, p=0.006). Significant positive association of using personal car as mode of transport to reach the hospital (OR=5.25, 95% CI 2.94-9.35, p<0.001) was also found as compared to using ambulance. Distance from facility was suggestive of negative association in the model but was statistically insignificant. CONCLUSION: According to the findings of this study, more than one third of patients reached the hospital within two hours of initiation of symptoms while only 5.1% reached within one hour. The delay was mostly pre-hospital attributed to arranging transport, stay at first medical contact and time taken from first medical contact to the hospital.

Out of pocket payment for diabetes mellitus in a public hospital of Karachi.

OBJECTIVE: To estimate the out-of-pocket payment on routine management of type 2 diabetes in patients attending a public-sector facility. METHODS: The cross-sectional study was conducted from December 2016 to May 2017 at Jinnah Postgraduate Medical Centre, Karachi, and comprised of persons with type 2 diabeties. A pretested questionnaire was administered to collect data from the patients. Comparisons of average out-of-pocket expenditure were done across different groups on the basis of gender, education, monthly income and duration of disease. SPSS 20 was used for data analysis. RESULTS: Of the 336 subjects, 178(53%) were males and 158(47%) were females. Overall mean age was 52.20+/-12.64 years, and 170(50.6%) were illiterate. The monthly mean cost on diabetes care was PKR2227}2217.70. People with academic level matriculation or higher spent more on the disease (p<0.001). Expenditure increased with the increase in number of years of disease (p<0.001). Participants with income of less than PKR15000 spent higher percentage of their income compared to the participants earning more (p<0.001). CONCLUSIONS: High out-of-pocket expenditure was incurred by people with diabeties. The coverage of social security nets and individual insurance should be broadened to help improve diabetes management.

Mixed method survey to assess the problems and propose solutions for implementation of CME/CPD in Sindh, Pakistan.

OBJECTIVES: To determine the type of CME/CPD sessions attended by doctors, identify the problems with implementation of CME/CPD program and propose possible solutions for successful implementation of CME/CPD Program. METHODS: This was a concurrent triangulation mixed method study. Quantitative questionnaires were filled by faculty and physicians from different specialties. The qualitative component had both focus groups and in depth interviews conducted with different professional bodies (PMA), faculty JSMU, College of Family Physicians. This study was done in 2016-2017. RESULTS: More than half of the participants (53.6%) reported that CPD/CME should be mandatory. Doctors who had graduated from outside Karachi were significantly less likely to report CPD/CME to be mandatory as compared to graduates from Karachi (p=0.004).Top three factors which influenced HCP's to attend CPD/CME included career progression (65.1%), interest (54.7%) and knowledge gap (50.5%). The most common perceived barriers were lack of study leave, cost and work-life imbalance. The implementation issues expressed by different stakeholders included lack of doctor's interest, busy clinical schedule and poor accessibility. CONCLUSION: Mostly medical practioners believe that CPD program is an important step toward enabling physicians to demonstrate their competency and professionalism to themselves and others. The PM&DC has to take practical steps to evaluate the cognitive, clinical, and humanistic attributes of certified doctors.

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.