Integration of geriatrics into a spiral undergraduate medical curriculum in Pakistan: evaluation and feedback of third-year medical students.

BACKGROUND: In the last decades there has been a sharp rise in the elderly population throughout the world. The unique needs of the elderly require a multidisciplinary and comprehensive medical approach. None of the 50 medical schools in Pakistan teach geriatrics in their undergraduate or postgraduate training. This paper discusses the development and implementation of the first geriatric curriculum in a medical school of Pakistan and its effect on knowledge and attitudes of third-year medical students. METHODS: The curriculum was designed through collaboration and approval of various academic departments at the Aga Khan University in Karachi Pakistan. After a review of existing geriatric curricula at other institutions, a problem-based, inter-disciplinary spiral curriculum was designed. Strategy of student and course evaluation was planned and incorporated in the curricular program. No extra resources or funds were used. A component of the new curriculum was assessed by evaluating pre- and post- course knowledge, and seeking feedback from participating third-year students. RESULTS: A significant improvement in mean scores for summed overall knowledge in geriatrics (pre-test mean 4.7 vs. post-test mean 6.4, p value of <0.001; out of a maximum possible of 9 was noted. Breakdown of knowledge mean scores into component areas of knowledge showed a significant increase in understanding in aging demographics (pretest 0.7 vs. post-test 1.7, p value of <0.001), geriatric history taking (pretest 0.64 vs. post-test 0.88, p 0.001) and geriatric assessments (pre- test 1.4 vs. post- test 1.7, p value 0.01). A strong majority (87%) of the students felt that the overall course objectives were achieved. All students were satisfied with the quality of teaching, 90% rating it good or higher. CONCLUSION: An important advance in medical education was achieved via integration of a low cost, spiral geriatrics curriculum in a medical university of Pakistan. We found that introduction of the geriatric curriculum improved the knowledge of third-year medical students. This was our school's initial step towards building professional capacity in response to a rising elderly population.

Late weaning: the most significant risk factor in the development of iron deficiency anaemia at 1-2 years of age.

BACKGROUND: The global prevalence of iron deficiency anaemia in young children is quite high and children between the ages of 1-2 years are at maximum risk. The complications of anaemia are well known, and side effects may go unnoticed and may have an adverse effect on child's life. Therefore, prevention of anaemia becomes enormously important, and the need to look for parameters and predisposing factors that may lead to iron deficiency anaemia in small children is imperative. This study was designed to determine the association of iron deficiency anaemia with late weaning in 1-2 years of children. METHOD: A case control study was conducted from July 1993-July 1995, at the Community Health Centre (CHC), of the Aga Khan University Hospital, at Karachi, Pakistan. The study included 50 cases and 100 controls. A questionnaire was filled by mothers after taking consent. Data was analyzed by chi-square; t-tests, bivariate analysis and multiple logistic regression. RESULTS: Through bivariate analyses, late weaning, family income, mother's education, the numbers of pregnancies, live births and living children, were found to be statistically significant. These variables were run through a multiple logistic regression model and late weaning was found to be the most significant. 60% of cases and 9% of controls were weaned late (p < 0.001). The mean age of weaning was 7.04 months among cases and 4.46 months among controls (p < 0.001). CONCLUSION: Among all the variables studied, late weaning was the most important predictor of iron deficiency anaemia in 1-2 years of age.

Association of iron deficiency anaemia in children of 1-2 years of age with low birth weight, recurrent diarrhoea or recurrent respiratory tract infection--a myth or fact?

AIMS AND OBJECTIVE: To investigate for the presence or absence of any association between low birth weight, recurrent diarrhoea or recurrent acute respiratory infections with iron deficiency anaemia in Pakistani children aged 1-2 years. METHODOLOGY: From July 1993 to July 1995 a case control study was conducted at the Community Health Centre (CHC). Fifty cases and 100 controls were included. Informed consent was taken from mothers for the blood tests of their children and a questionnaire was administered to them. Data obtained from the completed questionnaires was analyzed by chi-square and t-tests. RESULTS: There was no statistically significant difference in low birth weight (p = 0.712), recurrent diarrhoea or respiratory infections between anaemic and non-anaemic children at 1-2 years age (OR of 1.71 and 1.48 respectively). CONCLUSION: This study does not uphold the belief that low birth weight, recurrent diarrhoea or respiratory infections have a causal association with iron deficiency anaemia in 1-2 years children.

The relationship of socio-demographic factors with iron deficiency anaemia in children of 1-2 years of age.

OBJECTIVE: To investigate associations between different socio-demographic factors with iron deficiency anaemia in Pakistani children of 1-2 years of age. METHODOLOGY: A case control study, with 50 cases and 100 controls, was conducted at the Community Health Centre, an outpatient clinic of the Aga Khan University, Karachi, Pakistan, between July 1993-July 1995. Informed consent was taken from mothers for their children's blood tests and a questionnaire was administered to them. The data was analyzed using chi-square, t-tests and logistic regression. RESULTS: The numbers of pregnancies, live births and living children were more among cases than controls but the differences were not statistically significant. Although father's education did not show a significant association (OR 1.35, 95% CI 0.22-8.33), maternal education was significantly associated with the children's anaemic status (OR 3.55, 95% CI 1.40-9.02). The difference in monthly incomes between families of cases and controls was the most significant variable among all those studied (p-value 0.006). CONCLUSION: This study showed that while lack of maternal education and low monthly family incomes are both significantly associated with the development of childhood anaemia, low monthly income is most significant.

Center-based prevalence of anxiety and depression in women of the northern areas of Pakistan.

OBJECTIVE: To estimate the prevalence of anxiety and depression in women of the Northern areas. METHODS: A cross-sectional center-based study was conducted at Singal Medical Center (SMC), Gilgit, in the Northern Areas of Pakistan, using the Hospital Anxiety and Depression Scale (HADS). RESULTS: One hundred and twenty women, between the ages of 16 and 60, attended the SMC over a two month period and were included in the study. Using HADS, it was found that 50% of the women had anxiety and/or depression; 25% suffered only from anxiety, 8% from depression and 17% had features of both. CONCLUSION: This study supports the previous studies of stress in remote areas and also contradicts the belief that people who live in the remote rural areas lead stress-free lives or have low rates of psychiatric morbidity (JPMA 50:138, 2000).

The diploma in family medicine examination; a scientific exercise.

The Diploma in Family Medicine (DFM) Examination is a new certification offered by the College of Physicians and Surgeons of Pakistan, and its Department of Medical Education designed a scientific examination. First, the Expert Advisory Committee for Family Medicine was formed, relevant training objectives were determined, a training programme to achieve the objectives was designed and a valid syllabus was chosen. Then the examination was designed, where the candidates must pass the objective theory papers before taking the clinical examination. The clinical examination consisted of an Objective Structured Clinical Examination (OSCE) and traditional case presentations. The candidates had to pass each of the components, and attain an overall aggregate of 60%. In the first six examinations, 752 candidates sat for the theory examinations, 332 (44.14%) were eligible for the clinical examination, and 170 (23%) passed. If 60% marks obtained in case presentations is taken as the gold standard which is the current CPSP policy and compared to OSCE marks, then 75% marks in OSCE had a sensitivity of 67% and a specificity of 79%.

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.

Alma Ata and health for all by the year 2000. The roles of academic institutions.

The title of this article raises a complex set of questions. To begin, what happened at Alma Ata and the goal that emanated from it-Health for All by the Year 2000--are themselves controversial matters. At least there are some who are strongly critical of those events and ideas. Even without linking academic institutions with Alma Ata and HFA/2000, a controversy is spawned when one asks about the roles of such institutions in dealing with societal problems--which problems should a university address, and how deeply does a university become engaged in them, particularly if it carries the university out of the cloister into the trenches of societal conflict? Linking academic institutions with Alma Ata and HFA/2000 deepens the controversy but also provides a framework for examining the basic principles on which each is based, and for testing those principles against the realities of real world problems of health development. This article draws on recent critical assessments of both sides of the equation: a recent Consultative Committee to the Director General of WHO that analyzes the successes and failures of PHC development to date, and lays out conditions for greater effectiveness in the future; and the Technical Discussions of WHO on the Roles of Universities in the Strategy for Health for All that review traditional and progressive arguments about the roles of universities in their societies, and how HFA can be seen as fitting into that debate. The thinking contained in these documents provides ample opportunity to examine whether or not academic institutions should have a role that relates to Alma Ata and Health for All, and, in the end, takes the position that, indeed, this is an appropriate role for those universities prepared to make the commitment. The point is also made that such involvement cannot be effective if the scale of the institutional commitment is marginal--it must be substantial and institution-wide. An example is given of the Aga Khan University in Karachi, Pakistan, an institution avowedly committed to a community orientation and to health services development. The Network of Community-Oriented Educational Institutions for Health Sciences can be considered a movement of educational institutions in this direction. It is functioning with considerable creative initiative in addressing issues having to do with problem-based teaching methods, community orientation, and partnerships with governmental health services.(ABSTRACT TRUNCATED AT 400 WORDS)

PIP: In the context of the controversial conference at Alma Ata and the emergent plan of Health for All by the Year 2000 (HFA/2000), the role of academic institutions is discussed. At the risk of expanding the controversy over HFA/2000, institutional involvement facilitates the testing of principals against real world problems of health development. Views from both sides of the debate and controversy are considered with respect to the appropriateness of institutional involvement in HFA/2000. A consultative committee to the Director General of the World Health Organization (WHO) analyzing the successes and failures of primary health care development is 1st explored. Other views from technical discussions of WHO on the roles of universities in the strategy of HFA are then examined. Traditional and progressive arguments on the roles of university in society are reviewed, with an eye to how HFA fits in. The paper concludes that institutions capable of and willing to provide substantial, institution-wide commitment are appropriate candidates for involvement in HFA/2000. The Aga Khan University's commitment orientation and health services development is cited as an example of appropriate, positive institutional participation. The Network of Community-Oriented Educational Institutions for Health Sciences addressing problem-based teaching methods, community orientation, and partnerships with governmental health services is also exemplary. In closing, the paper queries the extent to which the movement will attract institutions around the world.