Association of obesity measures and multimorbidity in Pakistan: findings from the IMPACT study.

OBJECTIVE: Obesity is a major factor leading to multimorbidity. However, the relative importance of obesity measures, including body mass index (BMI), body fat percentage (BF%) and visceral fat (VF), in relation to multimorbidity has not been extensively studied in Asia. Therefore, the objective of this study was to examine the relation of these measures of obesity with multimorbidity in a representative community sample in Pakistan. STUDY DESIGN: This is a community-based cross-sectional study. METHODS: This study was conducted among residents of Gulshan town, Karachi, Pakistan. Data on healthy individuals and individuals with chronic conditions were recorded. All self-reported chronic conditions were further assessed by physical examination, medical history of the participants and laboratory findings. Multivariate logistic regression and receiver operating characteristic (ROC) curve analyses of BMI, BF% and VF as predictors of obesity were used to examine the association with multimorbidity. RESULTS: A total of 1500 participants (738 men and 762 women) were recruited, with a median age of 54.5 years. Multivariate logistic regression showed a significant association of BMI (odds ratio [OR] = 1.28, 95% confidence interval [CI] = 1.00-1.81, P-value 0.049) and BF% (OR = 2.28, 95% CI = 1.50-3.45, P-value <0.001) with multimorbidity. However, the ROC analysis for BMI, BF% and VF showed very similar results, even when the analysis was stratified by gender. In this exploratory analysis, increasing age and female gender were significantly associated with multimorbidity compared with their counterparts. CONCLUSIONS: Adult populations with high BF% levels carry a higher risk of multimorbidity than those with high BMI scores. In a population with differing metabolic characteristics, BMI might be less precise than direct adiposity measurements. Additional studies are needed to confirm the potential use of measuring the anatomical location and metabolic characteristics of lean and fat mass to identify risk of diseases.

Research education in an undergraduate curriculum: Students perspective.

OBJECTIVE: This study aims to investigate the attitude and practice toward undergraduate research studies among medical students at Qassim University in Buraydah, Saudi Arabia. METHODS: An online cross-sectional survey developed based on previous studies. It was announced to all registered medical students who have active college's email (n = 448) at Qassim University in Buraydah, Saudi Arabia during the academic year of 2016. RESULTS: The response rate was 56.6% (n = 252). Less than half of the students have started their research projects (41.6%). Students complained about the lack of free time and the unavailability of a university hospital: 92.4% and 97.1%, respectively. One-third of students participated in extra-curriculum research, and female students were more involved. Only 15.2% have published their research and 26.7% have presented it in conferences. Male students have more journal publication in compared to their female collages while the females have presented their projects more often in conferences. To improve their curriculum vitae, 95.2% stated they are going to participate in extra-curriculum research in the future. CONCLUSIONS: Students believe in the importance of research for improving their future work life. The main reason for not participating in research, beyond deficiency of research activities, is lack of free time. Students are unsatisfied with research skills gained through academic life, although their interest toward research increases and they plan on participating in future research.

Census survey for a primary health care programme.

OBJECTIVE: To describe the process of gathering information from a census survey as a preliminary step for supporting the working of a primary health care center. It also presents briefly the results of the survey and its broader implications on the health needs of the local population. METHODS: A questionnaire was used to obtain basic information regarding the ethnicity/area of origin, number of household members and their breakdown according to gender, age and marital status. The medical students of different batches were involved in the data collection process, as part of their Survey Methodology course of Community Health Sciences (CHS) in first year. RESULTS: Data was obtained from 2,033 houses, having a total population of 16,118 persons. Fifty three per cent of the population was under fifteen years, 42% were between 15-49 and 5% were over 50 years of age. The overall percentage of males was 52% and females 48%. Approximately 79 percent people were Pushto speaking. CONCLUSION: Sikanderabad is a typical slum settlement, with an emigrant population being mostly of Pathan and Afghan refugees. The fertility rate in Sikanderabad is much higher than that of Karachi. This highlights the need for education and availability of family planning facilities. At the same time, due to the fact that there is a major portion of the population aged under five years, so facility for treating children must be appropriately provided. The Primary Health Care center established in Sikanderabad is based on the above information. The emphasis is on maternal and childcare, including antenatal and postnatal care; family planning and nutritional counseling.

Improving vaccination status of children under five through health education.

OBJECTIVE: To improve awareness and knowledge of mothers regarding vaccine preventable diseases and the immunization status of children under five through health education messages by medical students, at Gulshane-Sikanderabad, a squatter settlement adjacent to Ziauddin Medical University, Karachi. METHODS: The undergraduate medical students' visit families in the squatter settlement. This study compared the effect of intervention by medical students on vaccination status of children under five in the intervention households versus those without intervention. A baseline study was done in 1998 and a follow-up study was done after four years to assess the differences in knowledge and practices of mothers regarding immunization. RESULTS: A total of 110 houses from block I and 207 houses from block V were selected. An increase of 22% (52% vs 30%) in block-I (p = 0.003) and 19% (32% vs 13%) increase in block V was seen in the utilization of PHC Center for vaccination (p = 0.001). Mothers' knowledge regarding the age when first vaccine is administered to the child, increased in the follow-up from 60% to 76.5% (p < 0.01) in block I and from 50% to 62% in block V. The immunization status increased significantly in block I from 46.5% to 75% after the intervention (p < 0.005), no significant difference could be seen in block V (p = 0.16). In the follow-up survey a significant difference was seen in the vaccination status between the two blocks (p = 0.001). CONCLUSION: The health education messages significantly increased the vaccination status of children under 5 in the intervention area.

National Polio Day campaign in a squatter settlement through medical students.

OBJECTIVE: To provide maximum polio vaccination coverage to under-five (<5) year children of a squatter settlement through Ziauddin Medical University (ZMU) medical students. SETTING: ZMU has established a Primary Health Care Program in a squatter settlement, which is predominantly inhabited by migrants from North Western Province of Pakistan and Afghanistan. The total population is approximately 20,000 and the proportion of <5 year children is nearly 19%. METHODOLOGY: ZMU started Oral Polio Vaccination (OPV) campaigns from 1996; up to 1999. The OPV campaigns were confined to the National Immunization Days (NIDs). A different strategy of "door-to-door" OPV services by medical students was undertaken in 1997. In December 1999 the polio vaccination coverage of <5-year children was evaluated through duster sampling. This paper describes the steps for improving OPV coverage in Sikanderabad. RESULTS: The estimated number of <5 year children in the area is 4,600. In a duster sample survey after the 1999 NID campaign out of 620 under 5 year children living in 429 households, 529 (85%) received OPV, with a 95% CI for OPV coverage of 82 to 88%. The coverage before the campaigns initiated by ZMU was 52%. CONCLUSION: The results indicate that the polio coverage of <5-year children has risen with the change in strategy. Door-to-door coverage strategy with the help of medical students proved effective in providing vaccination. No case of suspected poliomyelitis has been reported from the area since October 1999.

Prevalence of anxiety and depression among medical students of private university.

OBJECTIVE: To assess anxiety and depression levels among medical students of a private university by using a self-administered anxiety and depression questionnaire. METHODOLOGY: A cross sectional study was done on the students of Ziauddin Medical University, who had spent more than six months in the medical school. A self-administered questionnaire was given to the students, present in the class and willing to participate in the study. During the survey students of 5th year were not available. The instrument used to asses the anxiety and depression levels was the, Aga Khan University Anxiety and Depression Scale (AKUADS). Additional questions regarding socioeconomic variables were also included in the survey instrument, such as student's birth order, monthly income, number of siblings, and monthly expenditure on education. Data analysis was done on Epi info version 6. RESULTS: There were 252 students in 4th year MBBS to 1st year MBBS. Of these 189 were present during the survey. Using anxiety and depression scale it was found out that 113 (60%) students had anxiety and depression. Prevalence of anxiety and depression in students of 4th year, 3rd year, 2nd year and 1st year was 49%, 47%, 73% and 66% respectively. It was significantly higher in 1st year and 2nd year, as compared to 3rd and 4th year (p < 0.05). It was seen that birth order, monthly income, number of siblings and monthly expenditure on education did not affect the prevalence of anxiety and depression. CONCLUSION: This study suggests that medical students experience anxiety and depression, the finding is consistent with other western studies, however there is no local data available to support our findings. The study finding highlights the need of psychiatric counseling and support services available to vulnerable students. These findings should be further explored in longitudinal studies to identify the stressors leading to these outcomes and appropriate interventions.

Maternal health care in a rural area of Pakistan.

OBJECTIVE: The need for effective strategies for delivery of healthcare to rural women is paramount and requires a study of maternal perceptions and experiences of the healthcare system. METHOD: This article describes knowledge, attitudes and practices regarding obstetric healthcare in a rural area of Pakistan. This is a cross sectional survey of a rural area of district Hyderabad, Pakistan. A multistage sample of 1,150 households was drawn from a population of 247,257 living in 30,653 households. Structured KAP questionnaires regarding maternal health were administered to male and female respondents in study household. RESULTS: A total of 1,178 married women and 1,146 married men were interviewed. The mean age of female respondents was 29 +/- 6 years. At the time of the interview 20% women were pregnant. Sixty-one percent women received antenatal care during their last pregnancy. The most frequent antenatal care providers were female doctors (55%). Majority (67%) of women had delivered at home with the assistance of traditional birth attendants (TBAs). Overall less than 40% of respondents could correctly identify signs of obstetric complications. Thirty-eight percent women experienced obstetric complications during their last pregnancy. Estimated annual maternal mortality ratio (MMR) was 689/100,000 live births. CONCLUSION: Women have inadequate access to obstetric care due to limited healthcare options and poor knowledge of obstetric complications. This can be corrected by improving services and increasing overall maternal health awareness in the community.

Utilising field assignments in survey methodology course at Ziauddin Medical University, Karachi.

OBJECTIVE: To describe the teaching-learning strategy employed in the module of Survey Methodology for undergraduate medical students at Ziauddin Medical University. SETTING: Medical students of Ziauddin Medical University, Clifton, Karachi. METHODS: The objectives of the Survey Methodology course were developed so that a student would be able to design and conduct a small survey independently. For this purpose the students were required to participate in a census survey of a squatter settlement. The questionnaire for the survey was developed with the students, which included the demographic information of the households. It was discussed and pretested with the medical students. The students edited and entered the data on computer using Epi-Info. They were trained in sampling methods, data collection, data editing and entry through lectures and small group sessions. At the end of the course, students filled the course evaluation form. RESULTS: Out of 117 students who responded, 63% found the course to be useful. Small group sessions were regarded as the most helpful teaching strategy by 91% of the students. Majority (74%) of the students recommended that field visits should be a part of teaching strategy. CONCLUSION: The Survey Methodology course reinforces the importance and practical application of research methods. The students appreciate the course especially the small group sessions and the field visits.

Constraints to adoption of appropriate breast feeding practices in a squatter settlement in Karachi, Pakistan.

Appropriate breast feeding practices (ABFP) are important for successful lactation. Constraints to adoption of ABFP by mothers in a squatter settlement in Karachi, Pakistan are reported. One hundred and two mother-infant pairs were followed from birth to 16 weeks of age. Eighty-seven infants received prelacteal feeds of honey as a quasi-religious ritual, 16 received ghutti for "cleansing of stomach", other prelacteal feeds were given as substitutes for breast feeding. Twenty nine mothers initiated breast feeding within 4 hours of birth. Supplemental water was given to 53 infants; major reasons being mothers' perception of thirst and diarrhoea in the infant. Supplemental milk was given to 24 infants. Insufficient milk and work load of mothers were main reasons for supplementation. Home remedies were given in 36 instances for prevention/treatment of indigestion or colds. Quasi-religious ritual of giving honey, perception that child birth was a major stress and early initiation of breast feeding adds to that stress, fear of dehydration and perception of insufficient breast milk were the major constraints to adoption of appropriate breast feeding practices.

Family medicine postgraduate training in Pakistan.

There is no organized system of postgraduate training for family medicine or general practice in Pakistan. This paper describes the status of primary health care delivery in Pakistan and the growth of family medicine throughout the world. It stresses the need for organized postgraduate training relevant to the needs of primary health care in Pakistan and describes efforts currently under-way in this regard at the Aga Khan University Medical Centre (AKUMC) in collaboration with the College of Physicians and Surgeons of Pakistan.

Addison's disease, hypertension, renal and hepatic microthrombosis in 'primary' antiphospholipid syndrome.

We describe a 14 year old boy with antiphospholipid syndrome who initially presented at the age of 10 with recurrent loin pain, fever, weight loss, leucocytosis, thrombocytopenia, hypertension and haematuria. He had primary adrenal insufficiency with bilaterally enlarged adrenals on computed tomographic (CT) scan consistent with adrenal infarction. Renal and liver biopsies showed microthrombi in the glomerular capillaries and hepatic sinusoids respectively. The case is unusual in that hypertension rather than hypotension was dominant and a CT scan was consistent with bilateral adrenal infarction without haemorrhage. He represented with evidence of persistent hypertension with glomerulosclerosis and glomerular microthrombi on repeat renal biopsy. He continues to have permanent adrenal insufficiency with complete atrophy of his adrenals.