Bonded amalgam as a fissure sealant in low-income setting: A randomised controlled trial.

OBJECTIVES: To compare one year retention rate of bonded amalgam sealants (BAS) with that of conventional resin-based sealant (RBS). METHODS: It was a parallel group, equivalence, randomised controlled trial done during March 2018 to December 2019 at the dental clinics of Dow University of Health Sciences, and the Jinnah Sind Medical University, Karachi, Pakistan on children aged 12-16 years, who were randomly assigned to one of the two treatment groups (BAS vs. RBS). Complete retention of the sealant at one year follow-up was labeled as success. Multi-level mixed effect logistic regression model was employed. Study was registered at www.clinicaltrials.gov # NCT NCT03130725. RESULTS: There were 137 teeth (23 subjects) in the BAS and 128 teeth (15 subjects) in the RBS group that were evaluated for sealant retention at 12 months follow-up. Among the BAS group, 100/137 (73%) sealants were completely retained whereas 110/128 (86%) were fully retained in the RBS group. Nearly, 22/137 (16%) BAS and 10/128 (7.8%) RBS were completely dislodged. In multivariable analysis, subject age >15 years and male gender were found to be significantly associated with the dislodgement of sealants. CONCLUSIONS: At 12 months follow-up, the retention of bonded amalgam sealant (BAS) was significantly lower than that of the resin-based sealant (RBS). RCT REGISTRATION: www.clinicaltrials.gov with # NCT NCT03130725.

Lead In Food And Its Correlation With Blood Lead Levels Among Pregnant Women Of Sindh, Pakistan.

BACKGROUND: With increasing control of lead (Pb) in gasoline, food has emerged as an important secondary pathway for Pb exposure globally. This study assessed Pb levels in food duplicates and blood. Furthermore, it assessed the correlation of Pb in food duplicates and blood Pb levels with common food items taken by pregnant women of Sindh, Pakistan. METHODS: A cross-sectional study was conducted from August 2014 to November 2015, in urban (Karachi) and rural (Gambat, Khairpur) area of Sindh-Pakistan. A total of 103 venous blood samples (Karachi = 63 and Gambat = 40) of pregnant women were measured for blood Pb levels at the time of delivery. One month post-delivery, food frequency questionnaire (FFQ) was administered and three-day food duplicates (same number of cooked portions of food eaten by women) were collected. Food duplicates were analysed for Pb levels. Multivariable linear regression was conducted to identify the frequency of food items which contribute to blood and food Pb levels of pregnant women, separately. RESULTS: With 90% confidence interval, chapati (local flat bread) (ß=0.20, p<0.001), boiled rice (ß=0.35, p<0.001), cooked root vegetables (ß= 0.16, p=0.03), fried savory items (ß=0.15, p=0.03), sweet snacks (ß=0.13, p=0.08) were positively associated with elevated mother blood Pb levels. While cream biscuits (ß =-0.14, p=0.04), lassi (blend of yogurt, water and spices) (ß= -0.31, p<0.01), market milk desserts (ß=-0.22, p<0.001), fish (ß= -0.16, p=0.02), soft drinks (ß= -0.19, p=0.01) and supari/gutka (betel-nut) (ß=-0.13, p= 0.06) were negatively associated with mother Pb levels. Tetra-pak market juices (ß= 0.30, p<0.001) and cooked root vegetables (ß=0.19, p=0.05) were positively associated with mother food Pb levels, at 90% CI. CONCLUSIONS: Bread, boiled rice, fried savoury items, sweet snacks and cooked root vegetables were contributing to blood Pb levels of pregnant women in Pakistan. These food items may be contaminated with Pb during processing, packaging and storage. Inverse relation of Supari/gutka and soft drinks with blood Pb levels may be due its overall reduction in absorption capacity of the gut for nutrients. Objective individual food item analysis for Pb is warranted for further intervention.

Maternal depression: A major risk factor for psychosocial wellbeing among preschoolers.

This study aims to determine the prevalence of behavioural problems among preschoolers and their association with maternal depression. A cross-sectional study was carried out in three districts of Sindh province of Pakistan. Mothers were interviewed by using a structured questionnaire during household survey. Total 1566 children were assessed on Strength and Difficulty Questionnaire while mother was inquired about her mental health by using Aga Khan Anxiety and Depression Scale (AKUADS). Almost 23% children were rated as abnormal and 23.5% as borderline by their mother on SDQ scale. 21.5% mothers were found depressed. Maternal depression was found to be highly significant association with childhood behavioural problems (OR for borderline behavioural problems = 1.30, CI: 0.96-1.76; OR for abnormal behaviour = 2.04, CI: 1.53-2.71). The OR did not change significantly when adjusted for child's gender or age or both. Maternal depression was found to be a significant risk factor for childhood psychosocial wellbeing and behavioural problems.

Dietary practices of school children in Sindh, Pakistan.

BACKGROUND: Malnutrition in Pakistan has remained an unresolved issue for decades. Data on nutrient intake and variety in children's diet is lacking. AIM: This paper describes the dietary practices of school children across eight districts of Sindh. METHODS: A school-based survey of dietary practices among 1109 students from classes 2-5 in 36 schools was conducted using a pre-tested interviewer-completed questionnaire. RESULTS: Descriptive and comparative analysis of data showed that more than 75% school children ate breakfast, lunch and dinner regularly. However, 10% children skipped breakfast and nearly one-third of them skipped mid-morning and evening snacks. Skipping breakfast and snacks was related to low socio-economic status and rural residence. Children's intake of protein-rich food items and fruits also illustrated that urban residence and better socio-economic status have a positive effect on the frequency and variety of daily protein and fruit intake. Though affordability and geographic location were key determinants of children's dietary practices, significantly higher percentages of children studying in class 2, 3 and 4 consumed different kinds of protein-rich food items, fruits and vegetables more frequently as opposed to children studying in class 5. Junk food consumption was more common in urban areas and better socio-economic strata. CONCLUSION: Development of school-based nutrition education programmes and behavior change strategies emphasizing the regular intake of meals and nutrient-rich snacks, and encouraging consumption of easily available and affordable food items such as dried seeds, fruits, vegetables, milk and its derivatives is essential for addressing nutrient deficiencies.

Hematologic adverse effects and efficacy monitoring in chronic Hepatitis C patients treated with interferon and ribavirin combination therapy.

180 million people are affected by chronic Hepatitis C Virus infection globally and more than 50 million in South East Asia. Combination of Interferon and Ribavirin is the current anti-HCV therapy in practice and is associated with certain hematologic adverse effects. In this concurrent observational study the incidence rate of major hematologic adverse effects and efficacy outcomes of Interferon and Ribavirin combination therapy was evaluated in 288 chronic hepatitis C patients at Lahore General Hospital. Levels of Hb, TLC, and Platelets counts were monitored for hematologic adverse effects monitoring, whereas, ALT, AST and bilirubin levels were monitored for efficacy. PCR was done at week 4, 12 &36 for therapeutic success evaluation. A significant reduction in Hb levels (p<0.05) was observed after week 4, 8 and 12 of therapy. Frequency of anemia increased in both genders with body weight <65kg and platelet count <150,000/mm3. End Treatment Response (ETR) was achieved in 64.5%. Anemia was the major side effect of the combination therapy particularly in the males. Higher ETR was observed in patients who achieved RVR and were <50 years of age.

PERSPECTIVES REGARDING ANTENATAL CARE, DELIVERY AND BREAST FEEDING PRACTICES OF WOMEN FROM BALUCHISTAN, PAKISTAN.

BACKGROUND: Antenatal Care is one of the fundamental rights for women to safeguard their health. Neonatal mortality rates have remained relatively static, compared to the decline in infant and under 5 mortality rates, adverse practices regarding breast feeding and pre-lacteal feeds being the important factors responsible. This study aimed to explore the Antenatal Care, delivery and breastfeeding practices in three districts of Baluchistan. METHODS: It was a qualitative phenomenological design using Constructivist approach. The study was conducted in three districts of Baluchistan province, Gwadar, Quetta, Qila Saifullah. There were a total of 14 Focus Group Discussions with women regarding Antenatal Care, delivery and Breastfeeding practices, followed by audio taping, transcription as verbatim and analysis through Nvivo version 2. A process was deployed for identification and reporting of the components in order to ensure quality and validity of the qualitative findings. RESULTS: Across the sites, women attended ANC at least once. However, their descriptions of ANC often varied. The women preferred Dais instead of doctors, due to the affordability, customs and availability. A lack of trained doctors and long distances to get a check-up lead to home deliveries in the study setting. Colostrum was discarded by majority of the mothers, while prelacteal feed was a common practice. CONCLUSION: This paper has explored factors affecting ANC attendance, delivery and breast feeding practices across three settings. Both the demand and supply side factors have an important influence on practices.

A Pilot Study of a 6-Week Parenting Program for Mothers of Pre-school Children Attending Family Health Centers in Karachi, Pakistan.

BACKGROUND: Recently, parenting programs to address behavioural and emotional problems associated with child maltreatment in developing countries have received much attention. There is a paucity of literature on effective parent education interventions in the local context of Pakistan. This study aimed to assess the feasibility of offering a 6-week parenting program for mothers of pre-school children attending family health centres (FHCs) in Karachi, the largest metropolitan city of Pakistan. METHODS: A pilot quasi-experimental trial was conducted. Two FHCs were selected, one as the intervention and the second as the control. A total of 57 mothers of pre-school children (n = 30 intervention; n = 27 control) participated in this study. Mothers in the intervention group received SOS Help for parents module, while mothers in the control group received information about routine childcare. A parenting scale (PS) was administered before the program was implemented and repeated 2 weeks after the program was completed in both groups. Statistical analysis was performed to compare participants' attributes. Descriptive analysis was conducted to compare pre- and post-test mean scores along with standard deviation for parenting subscales in the intervention and control groups. RESULTS: A total of 50 mothers (n = 25 intervention; n = 25 control) completed the 6-week program. Attrition was observed as 5/30 (17%) in the intervention arm and 2/27 (2%) in the control arm. Mothers commonly reported the burden of daily domestic and social responsibilities as the main reason for dropping out. Furthermore, the majority of participants in the control group recommended increasing the duration of weekly sessions from 1 to 1.5 hours, thereby decreasing the program period from 6 to 4 weeks. Mothers in intervention group reported substantial improvement in parenting skills as indicated by mean difference in their pre- and post-test scores for laxness and over-reactivity. CONCLUSION: Parenting programs can be implemented for mothers attending FHCs in Pakistan. Mothers require positive reinforcement and constant encouragement at the participant level. Integrating such programs into primary healthcare at the population level has the potential to maximize child health benefits and to improve parenting skills at the country level.

A nutrition education intervention to combat undernutrition: experience from a developing country.

Introduction. Undernutrition in children is a major public health concern in Pakistan. A number of interventions which focused only on providing nutrient supplementation have failed to change child undernutrition status during the last 2 decades. The present study aimed to assess the impact of nutrition education on the nutritional status of children living in resource-limited environments. Methods. Subjects were 586 children from Tando Jam and Quetta, Pakistan, aged from 6 months to 8 years. Children were characterized as mild, moderate, or severely wasted on Z-scores. Anthropometry and 24-hour dietary recall were used for nutritional assessment. Intervention strategy was nutrition counselling targeting mothers. Primary outcome was decrease in the severity of wasting and changes in the feeding practices. Results. Nearly 36% children in Tando Jam and 32% children in Quetta progressed to a normal nutritional status. There was a significant increase in the number of meals taken per day (Tando Jam-P ≤ 0.000/Quetta-P ≤ 0.025). In Tando Jam, significant increase was reported in the intake of high starch food items, vegetables, and fruits (P ≤ 0.000). In Quetta, significant increase was noted in the intake of plant protein (P ≤ 0.005), dairy foods (P ≤ 0.041), and vegetables (P ≤ 0.026). Conclusion. Nutrition education was successful in reducing undernutrition in food insecure households.

Perceived Breastfeeding Support Assessment Tool (PBSAT): development and testing of psychometric properties with Pakistani urban working mothers.

INTRODUCTION: breast feeding is an essential source of nutrition among young babies; however, in Pakistan a gradual decline in prevalence of breast feeding, especially among urban working mothers, has been reported. Previous studies among Pakistani urban working mothers have revealed that ensuring exclusivity and continuation of breast feeding is challenging if social and/or workplace environmental support is minimal or absent. This problem indicated a crucial need to assess availability of breast-feeding support for Pakistani urban working mothers by using a comprehensive, reliable, and validated tool in their national language (Urdu). PURPOSE: to develop and test the psychometric properties of the 'Perceived Breastfeeding Support Assessment Tool' (PBSAT) that can gauge Pakistani urban working mothers' perceptions about breast-feeding support. METHODOLOGY: this methodological research was undertaken in five phases. During phase I, a preliminary draft of the PBSAT was developed by using the Socio-ecological model, reviewing literature, and referring to two United States based tools. In Phase II, the instrument was evaluated by seven different experts, and, in Phase III, the instrument was revised, translated, and back translated. In Phase IV, the tool was pilot tested among 20 participants and then modified on the basis of statistical analysis. In Phase V, the refined instrument was tested on 200 breast-feeding working mothers recruited through purposive sampling from the government and private health-care settings in Karachi, Pakistan. Approvals were received from the Ethical Review Committees of the identified settings. FINDINGS: the 29-item based PBSAT revealed an acceptable inter-rater reliability of 0.95, and an internal consistency reliability coefficient (Cronbach's alpha) of 0.85. A construct validity assessment through Exploratory Factor Analysis revealed that the PBSAT has two dimensions, 'workplace environmental support' (12 items; α=0.86) and 'social environmental support' (17 items; α=0.77). CONCLUSION: the study developed a 29-item based two-dimensional tool (in Urdu) that has acceptable psychometric properties. The PBSAT is context specific, comprehensive, and user-friendly, so it can be administered by health-care workers, employers, policy makers, and researchers to improve the quality of services of breast-feeding urban working mothers, and could ultimately improve child health in Pakistan.

Non fatal injuries among infants: a pilot study.

OBJECTIVE: To determine the incidence, nature and the extent of infant injuries in two suburban and rural communities of Pakistan. METHODS: The cross-sectional study was conducted on a cohort of 310 infants in suburban and rural communities of Pakistan in September 2007. The information was collected from primary care-givers based on any injury that had occurred to their infants during the preceding 3 months that required treatment at home or in a hospital. RESULT: The incidence of non-fatal injury for infants up to 1-year-old was found to be 19 injuries per 100 person (child) years of exposure (95% CI 9.90 - 27.21). In suburban area, the rate was 26 injuries/100 person (child) years (95 % CI 15.37 - 35.71), while in rural area, it was 13 injuries/100 person (child) years of exposure (95 % CI 4.79-18.39). Altogether, 13 episodes of injury were reported among infants in both the communities. The male to female infant ratio for injury was 1:2.2. Suburban area had more than double injuries compared to the rural area. CONCLUSION: The magnitude of infant injuries was quite significant, especially among suburban and female children. There is a dire need to develop community-based interventions creating awareness on the matter.

Anxiety and depression among outpatients with type 2 diabetes: A multi-centre study of prevalence and associated factors.

BACKGROUND: Anxiety and depression contribute to poor disease outcomes among individuals with diabetes. This study aimed to assess the prevalence of anxiety and depression and to identify their associated factors including metabolic components among people with type 2 diabetes. METHODS: We conducted a cross-sectional, multi-center study in four out-patient clinics in Karachi, Pakistan. In all, 889 adults with type-2 diabetes were included in this study. Anxiety and depression were measured by using the Hospital Anxiety and Depression Scale (HADS). Multivariable analysis using multiple logistic regression was carried out to evaluate the combined effect of various factors associated with anxiety and depression, while adjusting for confounding variables. RESULTS: Overall, 57.9% (95% CI = 54.7%, 61.2%) and 43.5% (95% CI = 40.3%, 46.8%) study participants had anxiety and depression respectively. Factors found to be independently associated with anxiety were physical inactivity, having hypertension and ischemic heart disease. For depression, being female, of older age, having hypertension and ischemic heart disease were significantly associated. Metabolic components found to be independently associated with both anxiety and depression were systolic blood pressure, fasting blood glucose and fasting blood triglycerides. Body mass index was independently associated with depression but not with anxiety. CONCLUSION: This study identified that a large proportion of adults with diabetes had anxiety and/or depression, and identified factors associated with these entities. These results alert clinicians to identify and treat anxiety and depression as common components of diabetes care. Additional studies are needed to establish the directional nature of this relationship and to test interventions.

Childhood injuries in Pakistan: results from two communities.

The study aimed at determining the incidence, nature, and extent of childhood injuries in two suburban and rural communities of Pakistan. The findings of the study are based on a cross-sectional survey of 2,292 children aged 1-8 years. Information was sought retrospectively from the primary caregiver on the occurrence of injury that required formal or informal medical consultation during the past three months. The incidence rate of non-fatal injuries that required care outside home for children aged 1-8 years was 19.7 injuries per 100 person (child)-years of exposure [95% confidence interval (CI) 16.41-23.51]: 26.5 injuries per 100 person (child)-years of exposure (95% CI 21.31-32.63) in the suburban area and 12.1 injuries per 100 person (child)-years of exposure (95% CI 8.68-16.66) in the rural area. The most common non-fatal injuries were falls (10.5 fall injuries per 100 person (child)-years of exposure), bums and scalds (3.5 burn injuries per 100 person (child)-years of exposure), and road traffic injuries (RTIs) (2 RTIs per 100 person (child)-years of exposure). One fatality due to drowning was also reported during the study period. The difference among sex was highly significant (p = 0.03). Boys (60%) were at a higher risk of injuries compared to girls (40%). The data also revealed that 61% of the injuries took place inside the home. The magnitude of childhood injuries in the two communities was significant compared to the findings of the National Health Survey of Pakistan (1990-1994). The fact that the majority (61%) of the injuries occurred inside the home raises many questions in relation to the household hazards and adequacy of safety and child-proofing measures in these households. There is a need to develop community-based interventions, creating awareness about the consequences of childhood injuries and educating families about preventive measures to reduce the incidence of injuries during early and middle childhood.

Assessment of quality of care for the management of type 2 diabetes: a multicentre study from a developing country.

BACKGROUND: Complications of diabetes can be prevented or delayed by providing high quality care. This study aimed to document the quality of care provided to people with type 2 diabetes in Pakistan and to identify the difference in care offered at various clinics. DESIGN: Cross-sectional multi-centre study. METHODS: Interviews were undertaken with 672 people with type 2 diabetes attending three different types of diabetes clinic (private clinic (A), non-governmental organisation (B) and public clinic (C)) in Karachi, Pakistan. A structured questionnaire was used to collect socio-demographic and clinical information from patients; quality of care indicators were also confirmed by reference to patients' medical records. RESULTS: Overall, 68% (A: 92%, B: 58% and C: 52%, P<0.001) of study subjects were informed about diabetes complications. Blood pressure (BP) monitoring at every visit was completed for 80% of study respondents (A: 100%, B: 79% and C: 57%, P<0.001). Foot examination was infrequent (53%, A: 98%, B: 52% and C: 8% (P<0.001). Lipid profiles of 48% of patients had been done in the past 12 months (A: 77%, B: 16% and C: 50%, P<0.001). Microalbumin testing had been performed in 32% of patients in the previous year (A: 77%, B: 09% and C: 05%; P<0.001). Most participants had elevated glycaemic (58.2%) and BP levels (84.7%) with higher prevalence among people who attended clinics B and C (P<0.001). Overall, 82.6% of study subjects had an elevated body mass index; this was almost equally prevalent across clinics. CONCLUSION: Many patients with type 2 diabetes do not receive optimal diabetes care in Karachi. Among the different settings, care provided in private health sector clinics was of a better standard. However, our results reveal a need for overall improvement in the quality of diabetes care. Further research is also needed to evaluate the reasons for poor diabetes care, and to identify the most cost-effective means to address these.

Association of depression with newly diagnosed type 2 diabetes among adults aged between 25 to 60 years in Karachi, Pakistan.

BACKGROUND: The combination of depression with type 2 diabetes is a public health problem. If diabetes is managed in its initial phase, the morbidity and mortality due to this combination may be prevented at an early stage. Therefore, we aimed to determine the association of depression with newly diagnosed type 2 diabetes among adults aged between 25 to 60 years in Karachi, Pakistan. METHODS: From July 2006 to September 2007, a matched case control study (n = 592) was conducted in Civil Hospital, Karachi. Incident cases of type 2 diabetes (n = 296) diagnosed within one month were recruited from diabetic Out Patient Department (OPD) of Civil Hospital, Karachi. They were matched on age and sex with controls (n = 296), who were attendants sitting in the medical out patient department of the same hospital, recruited on the basis of absence of classical symptoms of polyuria and polydipsia along with random blood glucose level of <200 mg/dl measured by a glucometer. Depression was identified by the Siddiqui Shah Depression Scale. Conditional logistic regression was applied to examine the association of depression and other independent variables with newly diagnosed type 2 diabetes at 95% C.I. and P < 0.05. RESULTS: The study comprised of 592 subjects with 432(73%) males and 160(27%) females. Depression was significantly associated with newly diagnosed type 2 diabetes having mild level (mOR: 3.86; 95%CI: 2.22,6.71) and moderate to severe level (mOR: 3.41; 95%CI: 2.07,5.61). History of (h/o) gestational diabetes (mOR: 2.83; 95%CI: 1.05,7.64), family h/o diabetes (mOR: 1.59; 95%CI: 1.04,2.43), nuclear family (mOR: 1.75; 95%CI: 1.14,2.69), BMI (mOR: 1.62; 95%CI: 1.01,2.60 for obese and mOR: 2.12; 95%CI: 1.19,3.79 for overweight vs healthy to underweight) were also significantly associated with outcome, adjusting for age, sex, marital status, h/o smoking and h/o high BP. CONCLUSIONS: Diabetics should be screened simultaneously for depression and concomitant preventive strategies for gestational diabetes, nuclear family and high BMI should also be used to prevent mortality/morbidity among patients between 25 to 60 years of age.

Prevalence and factors associated with intestinal parasitic infection among children in an urban slum of Karachi.

BACKGROUND: Intestinal parasitic infections are endemic worldwide and have been described as constituting the greatest single worldwide cause of illness and disease. Poverty, illiteracy, poor hygiene, lack of access to potable water and hot and humid tropical climate are the factors associated with intestinal parasitic infections. The study aimed to estimate prevalence and identify factors associated with intestinal parasitic infections among 1 to 5 years old children residing in an urban slum of Karachi Pakistan. METHODS AND PRINCIPAL FINDINGS: A cross sectional survey was conducted from February to June 2006 in Ghosia Colony Gulshan Town Karachi, Pakistan. A simple random sample of 350 children aged 1-5 years was collected. The study used structured pre-tested questionnaire, anthropometric tools and stool tests to obtain epidemiological and disease data. Data were analyzed using appropriate descriptive, univariate and multivariable logistic regression methods. The mean age of participants was 2.8 years and 53% were male. The proportions of wasted, stunted and underweight children were 10.4%, 58.9% and 32.7% respectively. The prevalence of Intestinal parasitic infections was estimated to be 52.8% (95% CI: 46.1; 59.4). Giardia lamblia was the most common parasite followed by Ascaris lumbricoides, Blastocystis hominis and Hymenolepis nana. About 43% children were infected with single parasite and 10% with multiple parasites. Age {Adjusted Odds Ratio (aOR) = 1.5; 95% CI: 1.1; 1.9}, living in rented households (aOR = 2.0; 95% CI: 1.0; 3.9) and history of excessive crying (aOR = 1.9; 95% CI: 1.0; 3.4) were significantly associated with intestinal parasitic infections. CONCLUSIONS: Intestinal parasites are highly prevalent in this setting and poverty was implicated as an important risk factor for infection. Effective poverty reduction programmes and promotion of deworming could reduce intestinal parasite carriage. There is a need for mass scale campaigns to create awareness about health and hygiene.

Tawana project-school nutrition program in Pakistan--its success, bottlenecks and lessons learned.

Tawana Pakistan Project, a multifaceted pilot project (Sept. 2002 to June 2005) was funded by the Government of Pakistan to address poor nutritional status and school enrollment of primary school age girls. The core strategy was to create safe environment empowering village women to take collective decisions. Through reflective learning process women learnt to plan balanced menus, purchase food, prepare and serve a noon meal at school from locally available foods at nominal costs (USD 0.12/child). Aga Khan University partnered the government for the design, management, monitoring and evaluation of the project, 11 NGO's facilitated implementation in 4035 rural government girls' schools. Training was provided to 663 field workers, 4383 community organizers, 4336 school teachers and around 95 thousand rural women. Height and weight were recorded at baseline and every 6 months thereafter. Wasting, underweight and stunting decreased by 45%, 22% and 6% respectively. Enrollment increased by 40%. Women's' ability to plan balanced meals improved and >76% of all meals provided the basic three food groups by end of project. Government bureaucracy issues, especially at the district level proved to be the most challenging bottlenecks. Success can be attributed to synergies gained by dealing with nutrition, education and empowerment issues simultaneously.

Identifying needs and barriers to diabetes education in patients with diabetes.

OBJECTIVE: To assess the needs, awareness and barriers to diabetes education for self management and to facilitate the initiation of an education programme promoting self care among diabetics and their families. METHODS: A qualitative study was conducted among adult diabetics attending outpatient clinics in a tertiary care teaching hospital in Karachi, Pakistan. Semi-structured interviews were conducted on 27 subjects (11 men; 16 women) to identify dominant themes and priority issues. RESULTS: Participants displayed great deal of variation with respect to level of knowledge and motivation for education. Most believed that diabetes was caused by stress. Family was perceived to be a source of positive support. Relative ease of adherence to pharmacological regimens as compared to diet and exercise was reported. Participants expressed frustration at chronicity of disease and fear of developing certain specific complications and inheritance by their children. Barriers to enhancing knowledge included 'No need for further information', distance from training institutions and other priorities. CONCLUSION: Knowledge, beliefs and fears about diabetes, family influence and accessibility of healthcare, affects management behaviours and learning. Understanding needs and expectations of people with diabetes is essential in initiating and improving the outcomes of education programme for diabetes self care.

Validating MOSPA questionnaire for measuring physical activity in Pakistani women.

BACKGROUND: Precise measurements of activity at a population level are important for monitoring trends and evaluating health promotion strategies. Few studies have assessed the measurement of physical activity in developing countries. The aim of this study was to validate the MOSPA (Monica Optional Study of Physical Activity) questionnaire which was developed for the WHO-Monitoring trends and determinants of cardiovasculr disease (MONICA) study sites. METHODS: The MOSPA questionnaire assesses energy expendtiture (EE) related to physical activity (employment, household work, transportation, and leisure time) over a one year period. This questionnaire has been described in the manuscript as the long term (LT) questionnaire. An adapted short term (ST) 5 day questionnaire was developed to assess convergent validity. Questionnaire data were compared with physical activity EE estimates from a Caltrac accelerometer and with body composition measures (height, weight and bioelectrical impedance) in 50 women from the Aga Khan University (AKU) hospital antenatal clinics, Pakistan. Other forms of EE i.e. resting EE and thermic effect of food were not assessd in this study. RESULTS: Subjects were aged 26 +/- 3.8 years and were 16.1 +/- 6.7 weeks pregnant. Their average weight was 58.8 +/- 10.7 Kg. The average EE/day assessed by the Caltrac accelerometer, was 224 kcal and by MOSPA LT questionnaire it was 404 kcal. The questionnaires and Caltrac data were reasonably well correlated: r = 0.51 and r = 0.60 (P < 0.01) for LT and ST questionnaires respectively. Energy expenditure from questionnaire data was not correlated with body composition measures. CONCLUSION: The MOSPA questionnaire is useful in assessing physical activity levels in a sedentary population over a one year period.

Diabetes and hypertension: public awareness and lifestyle - findings of a health mela.

OBJECTIVE: To determine the frequencies of diabetes, hypertension and their established lifestyle risk factors and to assess the level of awareness about diabetes and hypertension amongst persons attending a health mela at the Aga Khan University Hospital (AKUH), Karachi. DESIGN: Cross-sectional, analytical study. PLACE AND DURATION OF STUDY: One-day health mela held at AKUH, Karachi. SUBJECTS AND METHODS: A total of 264 participants were administered structured questionnaire to obtain demographic data and perceptions about diabetes and hypertension after taking verbal informed consent. Height, weight, blood pressure and random blood glucose were measured. RESULTS: Overall frequency of type 2 diabetes was 13.6%, impaired glucose tolerance (IGT) 8.3% and hypertension 24%. Frequency of diabetes and hypertension in both men and women increased with increasing age(p<0.001) and body mass index (p=0.02). Over half the men and women with type 2 diabetes (53% and 57% respectively) and 42% men and 60% women with IGT also had hypertension. Diabetes and hypertension were correctly defined by 52% and 37% subjects respectively and this was significantly associated with educational level (p=.001). Lack of physical exercise was observed in 59% participants, while 53.6% men and 67.5% women were overweight/obese. As compared to women, men used more additional salt (p=0.03) and had more outside meals (p<0.001) and snacks (p=0.01). CONCLUSION: High frequencies of diabetes, hypertension, obesity, unhealthy nutrition and lack of exercise were observed in the study population. Emphasis on health education is needed to increase public awareness of the warning signs and risk factors of these common conditions.