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.

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.

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.

Role of media and the media hypes in the aftermath of mass casualty incidents a qualitative thematic content analysis.

Objective: To explore the role of media during mass casualty events and its impact on people. METHODS: The qualitative thematic content analysis was conducted at Jinnah Sindh Medical University, Karachi, from 2018 to 2020 and comprised of semi-structured in-depth interviews and focus group discussions involving participants from the health sector and policymakers at the provincial level. The Frontline Workers such as the ambulance drivers and the first-aid-givers were also included. Data was subjected to conventional content analysis to generate themes. RESULTS: There were 5 in-depth interviews and 4 focus group discussions in the study. Qualitative analysis revealed that the media has a great deal to do in times of a disaster. The media is the strongest weapon and largely impacts people's mind and behaviour, but it has been playing with their emotions and creating unrest among them. Conclusion: There is a need for the policymakers to set guidelines and define the role of the media in times of a disaster.

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.

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.

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.

Effect of low-cost interventions to reduce the incidence of violent events in two public sector tertiary-care emergency departments, Pakistan.

Background: Violence against health care workers has been widely reported in Pakistan. Aims: This study, from September 2019 to April 2020, aimed to determine the effect of low-cost interventions to reduce violent events in two tertiary-care emergency departments in Karachi and Peshawar, Pakistan. Methods: In phase one, a surveillance system was established in each department and information on violent events was recorded for three months. In phase two, low-cost interventions designed to reduce violent events were introduced, e.g. awareness-raising material on violence for patients, training for health care workers and visitor identification cards. Violent events were then recorded for another three months and the percentage difference in number of violent events was calculated. Results: In Karachi, 256 violent events occurred before the intervention and 225 after the intervention, a 12.1% reduction. Physical violence events decreased significantly by 42.9% (P = 0.044). The number of events perpetrated by health care workers decreased by 61.9% (P = 0.016) while those perpetrated by patients decreased only by 5.7% (P = 0.538). In Peshawar, 90 violent events occurred before the intervention and 45 events after, a 50.0% reduction (P = 0.009). The number of events perpetrated by health care workers was the same in both phases. Events perpetrated by patients or their companions decreased significantly by 59.72% (P = 0.001). Conclusion: Violence against health care workers can be reduced significantly by improving their prevention and de-escalation skills. Client educational interventions, supplemented with hospital regulations and patient guidance, can also help reduce the incidence of violent events.

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.

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.

Strengthening supportive supervision: A case study of the Expanded Programme on Immunization in Sindh, Pakistan.

BACKGROUND: Sindh, one of the provinces of Pakistan, has been showing a consistently low coverage of immunization. Evidence supports the independent role of supportive supervision in improving the performance of immunization services. However, there is a dearth of evidence regarding the implementation of supportive supervision by the Expanded Programme on Immunization (EPI) Sindh and factors affecting its implementation in the local context. METHODS: An exploratory case study was conducted in two districts of the province, Sindh ie, Hyderabad and Thatta. In total, 11 key informant interviews (KII) and 5 focus group discussions (FGDs) were conducted to obtain perspectives of various stakeholders of EPI, who play different roles in implementation of supportive supervision. Observations of EPI Checklist and review of current EPI policy and Module-4 of 'Mid-Level Manager training' by World Health Organization (WHO) for supportive supervision was also conducted. RESULTS: This study reveals a lack of clarity regarding the potential role of supportive supervision amongst the stakeholders. Lack of human resources, limited competencies of supervisors, lack of specific training of concerned personnel and feedback mechanisms are major bottlenecks affecting the implementation of supportive supervision by EPI Sindh. CONCLUSIONS: The study concludes that supportive supervision is severely affected by challenges such as a lack of comprehensive EPI policy, unavailability of selection criteria for supervisors, training guidelines and proper logistic support to supervisors. There is a lack of training, motivation, and accountability amongst EPI personnel.

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.

Comparison of OSCE scores of surgical clinical education after face-to-face vs. blended learning methods among undergraduate medical students.

OBJECTIVES: To compare the efficacy of blended learning with contemporary face-to-face teaching among medical students. METHODS: The quasi-experimental, cross-over study was conducted at the Dow University of Health Sciences, Karachi, from March to August 2014, and comprised third year medical students posted in the surgical units who were divided into two groups. In the first month, group A was taught by blended learning (BL), while group B was taught by face-to-face (f2f) teaching. Both groups were assessed using objective structured clinical examination. In the second month, the teaching method was flipped for the groups with new learning contents. Assessment tool remained the same. Data was analysed using SPSS 23. RESULTS: Thirty-one students completed OSCE in group A (BL) and 28 in group B (f2f). The mean score in group B was 78.01±13.29 compared to 85.12±13.77 in group A (p=0.49). CONCLUSIONS: Blended surgical learning was found to be more effective compared to face-to-face teaching.

General practitioner's (GP) home management guidelines for COVID-19 patients: Guidelines.

Carefully developed guidelines for clinical practice serve as an important tool for desirable changes in health care of a country. They act as an important source of information for physicians as well as policy makers and educational institutions thereby improving the quality of care of patients. The outbreak of Novel Coronavirus Disease (COVID-19) in 2019 has placed a huge burden on health care system globally. The first line health care provider bears the brunt of this disease with limited and varying sources of information as most of the patients present to them. Varied presentation of disease along with limited hospital facilities for admission is a huge challenge for appropriate management and referral of these patients. These guidelines, prepared after reviewing the interim guidelines in literature, will serve as a source of guidance for GPs to manage mild cases at home and refer those with moderate and severe disease to tertiary care hospitals.

Dental practice closure during the first wave of COVID-19 and associated professional, practice and structural determinants: a multi-country survey.

BACKGROUND: The coronavirus outbreak (COVID-19) in China has influenced every aspect of life worldwide. Given the unique characteristics of the dental setting, the risk of cross-infection between dental practitioners and patients is high in the absence of adequate protective measures, and dentists may develop severe anxiety in relation to the current pandemic. The limited provision of services and widespread closure of dental practices have raised concerns among dental professionals about the financial impact. The present study assessed the frequency of dental practice closure during the pandemic's first wave in several countries and whether closures and their associated factors differ between the private and non-private sectors. METHODS: An electronic cross-sectional survey questionnaire was sent to dentists in several countries, from April to May 2020. The survey assessed professional, practice related and country-level structural factors elucidating the reason for practice closure. Multilevel logistic regression was used to assess the association between practice closure and these factors, and differences were evaluated by sector type. RESULTS: Dentists from 29 countries (n = 3243) participated in this study. Most of the participants (75.9%) reported practice closure with significantly higher percentage in the private sector than the non-private sector. Greater pandemic-related fears were associated with a significantly higher likelihood of practice closure in the private (odds ratio [OR] = 1.54, 95% confidence interval [CI] 1.24, 1.92) and non-private (OR = 1.38, 95% CI 1.04, 1.82) sectors. Dentists in non-private rural areas (OR = 0.58, 95% CI 0.42, 0.81), and those in hospitals (overall OR = 0.60, 95% CI 0.36, 0.99) reported a low likelihood of closure. A high likelihood of closure was reported by dentists in the academia (OR = 2.13, 95% CI 1.23, 3.71). More hospital beds at the country-level were associated with a lower likelihood of closure in the non-private sector (OR = 0.65, 95% CI 0.46, 0.91). Private- sector dentists in high- income countries (HICs) reported fewer closures than those in non-HICs (OR = 0.55, 95% CI 0.15, 1.93). CONCLUSIONS: Most dentists reported practice closure because of COVID-19, and greater impacts were reported in the private sector than in the non-private sector. Closure was associated with professional, practice, and country-levels factors.

Systematic development and refinement of a contextually relevant strategy for undergraduate medical ethics education: a qualitative study.

BACKGROUND: Delivery of medical ethics education is complex due to various reasons, compounded by the context-dependent nature of the content. The scarcity of relevant resources in the contexts of some developing countries adds a further layer of difficulty to ethics education in these contexts. We used a consultative approach with students, teachers and external experts to develop a practical approach to medical ethics education. This study aimed to develop and refine a contextually relevant approach to ethics education in the region of Saudi Arabia. METHODS: The study utilised an explorative qualitative methodology to seek views of students and faculty of Rabigh Faculty of Medicine, Saudi Arabia, and international experts in the field of ethics and education to review and enhance a new ethics learning strategy which included a workbook-based tool. Three focus groups with 12 students, in-depth interviews with four faculty members and qualitative feedback from eleven external experts enabled the study participants to objectively critique the WBEL and provide feedback to enhance its quality. Thematic content analysis of the data was done to draw inferences which were used to refine the educational strategy. RESULTS: The analysis generated twenty-one sub-themes within four main themes: design features, content, teaching methods and assessment. These findings helped to design the educational strategy to improve its effectiveness in the given context. CONCLUSION: The study drew on the views of students, faculty and external experts to systematically develop a novel approach to ethics education for countries like Saudi Arabia. It also demonstrated the use of the consultative approach for informing a culturally relevant educational strategy in the Middle East context.

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.

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.

Review of ethics teaching in undergraduate medical education.

OBJECTIVE: To provide an overview of existing literature regarding ethics in undergraduate medical education around the world, and to identify gaps in literature for recommending areas for future research. METHODS: The scoping review was conducted in March 2016. PubMed and Web of Science search engines were used to identify English language literature on ethics in undergraduate medical education published over the preceding 20 years. Google search was used for grey literature. Two reviewers independently screened eligible studies for final study selection and review. Descriptive analysis of data was performed with mutual consensus. RESULTS: Of the 199 items located, 56(28%) were included; 37(33%) of 112 studies, and 19(22%) of 87 pieces of grey literature. Papers covered almost all regions of the world, including North and South America, Europe, Africa, and different Asian regions like Middle East, central, south-east and far east. The analysis identified several curriculum designs and teaching methods used for ethics education. CONCLUSIONS: The review identified gaps in evidence that required further research. These areas include theoretical underpinning of ethics curriculum, role of educators, standardisation and validation of teaching and learning strategies, and relevance to cultural context in the development and delivery of ethics curriculum, especially in Asian regions.