What stops us from eating: a qualitative investigation of dietary barriers during pregnancy in Punjab, Pakistan.

OBJECTIVE: Adequate dietary intake during pregnancy is vital for the health and nutritional status of both mother and fetus. The nutritional status of reproductive age women in Pakistan is poor, with 14 % being underweight (BMI < 18·5) and 42 % experiencing Fe deficiency anaemia. This may stem from beliefs, practices and other barriers influencing dietary intake. This qualitative study seeks to determine which factors impact dietary intake during pregnancy in rural Punjab. DESIGN: In-depth interviews and focus group discussions were conducted and then analysed using thematic analysis. SETTING: Three purposively selected rural districts (Sahiwal, Okara and Pakpatan) with the highest prevalence of maternal and child malnutrition in the province of Punjab, Pakistan. PARTICIPANTS: Mothers with children under age two (n 29) and healthcare providers with at least 5 years of experience working in the district (n 12). RESULTS: We identified a combination of physiological, socio-cultural and structural barriers that inhibited healthful dietary intake during pregnancy. The primary physiological barriers to optimal dietary intake and dietary practices included food aversions and food cravings. Food classification, fear of a difficult childbirth, fear of high blood pressure and household food politics were the principal socio-cultural barriers. Additionally, two structural barriers, inadequate antenatal counseling and a lack of affordable food options, were identified. CONCLUSIONS: Our study demonstrates that complex barriers prevent pregnant women in the Punjab area from consuming adequate dietary intake and that antenatal health education programmes and structural interventions are needed to support healthful dietary practices during this critical period.

Smokeless Tobacco Initiation, Use, and Cessation in South Asia: A Qualitative Assessment.

INTRODUCTION: Smokeless tobacco (ST) is a significant South Asian public health problem. This paper reports a qualitative study of a sample of South Asian ST users. METHODS: Interviews, using a piloted topic guide, with 33 consenting, urban dwelling adult ST users explored their ST initiation, continued use, and cessation attempts. Framework data analysis was used to analyze country specific data before a thematic cross-country synthesis was completed. RESULTS: Participants reported long-term ST use and high dependency. All reported strong cessation motivation and multiple failed attempts because of ease of purchasing ST, tobacco dependency, and lack of institutional support. CONCLUSIONS: Interventions to support cessation attempts among consumers of South Asian ST products should address the multiple challenges of developing an integrated ST policy, including cessation services. IMPLICATIONS: This study provides detailed understanding of the barriers and drivers to ST initiation, use, and cessation for users in Bangladesh, India, and Pakistan. It is the first study to directly compare these three countries. The insight was then used to adapt an existing behavioral support intervention for ST cessation for testing in these countries.

We Won't Go There: Barriers to Accessing Maternal and Newborn Care in District Thatta, Pakistan.

Accessibility and utilization of healthcare plays a significant role in preventing complications during pregnancy, labor, and the early postnatal period. However, multiple barriers can prevent women from accessing services. The aim of this study was to explore the multifaceted barriers that inhibit women from seeking maternal and newborn health care in Thatta, Sindh, Pakistan. This study employed an interpretive research design using a purposive sampling approach. Pre-tested, semi-structured interview guides were used for data collection. The data were collected through eight focus group discussions with men and women, and six in-depth interviews with lady health workers and analyzed through thematic analysis. The study identified individual, sociocultural, and structural-level barriers that inhibit women from seeking maternal and newborn care. Individual barriers included mistrust towards public health facilities and inadequate symptom recognition. The three identified sociocultural barriers were aversion to biomedical interventions, gendered imbalances in decision making, and women's restricted mobility. The structural barriers included ineffective referral systems and prohibitively expensive transportation services. Increasing the coverage of healthcare service without addressing the multifaceted barriers that influence service utilization will not reduce the burden of maternal and neonatal mortality. As this study reveals, care seeking is influenced by a diverse array of barriers that are individual, sociocultural, and structural in nature. A combination of capacity development, health awareness, and structural interventions can address many if not all of these barriers.

Perceptions and experiences of healthcare providers during COVID-19 pandemic in Karachi, Pakistan: an exploratory qualitative study.

OBJECTIVE: To explore healthcare provider's perspectives and experiences of the barriers and facilitators to treat and manage COVID-19 cases. DESIGN AND SETTING: We conducted an exploratory qualitative study using a purposive sampling approach, at a private tertiary care teaching hospital in Karachi, Pakistan. Study data were analysed manually using the conventional content analysis technique. PARTICIPANTS: Key-informant interviews (KIIs) were conducted with senior management and hospital leadership and in-depth interviews (IDIs) were conducted with front-line healthcare providers. RESULTS: A total of 31 interviews (KIIs=19; IDIs=12) were conducted, between April and May 2020. Three overarching themes emerged. The first was 'challenges faced by front-line healthcare providers working in COVID-19 wards. Healthcare workers experienced increased anxiety due to the fear of acquiring infection and transmitting it to their family members. They felt overwhelmed due to the exhaustive donning and doffing process, intense work and stigmatisation. The second theme was 'enablers supporting healthcare providers to deal with the COVID-19 pandemic'. Front liners pointed out several enabling factors that supported hospital staff including a safe hospital environment, adequate training, a strong system of information sharing and supportive management. The third theme was 'recommendations to support the healthcare workforce during the COVID-19 crisis'. Healthcare workers recommended measures to mitigate current challenges including providing risk allowance to front-line healthcare providers, preparing a backup health workforce, and establishing a platform to address the mental health needs of the healthcare providers. CONCLUSION: This study provides an initial evidence base of healthcare providers' experiences of managing patients with COVID-19 in the early stage of the pandemic and highlights measures needed to address the encountered challenges. It offers lessons for hospitals in low-income and middle-income countries to ensure a safe working environment for front-line workers in their fight against COVID-19.

Prelacteal feeding practices in Pakistan: a mixed-methods study.

BACKGROUND: Prelacteal feeding, the feeding a newborn substances or liquids before breastfeeding, is a common cultural practice in Pakistan, but is associated with neonatal morbidity and mortality because it delays early initiation of breastfeeding. In this study, we sought to examine the social and cultural factors associated with prelacteal feeding in Pakistan. METHODS: This mixed-method study used data from the Pakistan Demographic and Health Survey (PDHS) 2012-13. Findings from the survey were complemented by qualitative interviews with mothers and healthcare providers. In a subset of PDHS dyads (n = 1361) with children (0-23 months), descriptive statistics and bivariate and multivariable logistic regression analysis examined factors associated with prelacteal feeding. The qualitative study included in-depth interviews with six mothers and six health care providers, which were analyzed using NVivo software version 10. RESULTS: In PDHS, a majority of children (64.7%) received prelacteal feeding. The most common prelacteal food was milk other than breast milk (24.5%), while over a fifth (21.8%) of mothers reported giving honey and sugar water. Factors associated with prelacteal feeding included: birth at public health facilities (AOR 0.46, 95% CI 0.02, 0.95), maternal primary education (AOR 2.28, 95% CI 1.35, 3.85), and delayed breastfeeding initiation (AOR 0.03, 95% CI 0.01, 0.61). In our qualitative study, the major themes found associated with prelacteal feedings included: easy access to prelacteal substances at health facilities, deliveries in private health facilities, prelacteals as a family tradition for socialization, insufficient breast milk, Sunna of Holy Prophet, and myths about colostrum. CONCLUSIONS: These data indicate that prelacteal feeding is a well-established practice and social norm in Pakistan. Policies and interventions aimed at promoting breastfeeding need to take these customs into consideration to achieve the desired behavioral changes.