Role of iron in the reduction of anemia among women of reproductive age in low-middle income countries: insights from systematic review and meta-analysis.

BACKGROUND: Iron deficiency anemia is a common public health issue among women of reproductive age (WRA) because it can result in adverse maternal and birth outcomes. Although studies are undertaken to assess iron efficacy, some gaps and limitations in the existing literature need to be addressed. To fill the gaps, we conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) assessing the role of iron in reducing anemia among WRA in low-middle-income countries (LMICs). METHODS: A comprehensive search strategy was used to search Medline through PubMed, Embase, and Science Direct for RCTs published between 2000 and 2020. The primary outcome was the mean change in hemoglobin level. We used standardized mean differences and their respective 95% CI to estimate the pooled effect. We used I2 statistics and Egger's test to assess heterogeneity and publication bias, respectively. This review was carried out in accordance with revised guidelines based on the Preferred Reporting Items for Systematic Review and Meta-analysis. RESULTS: The findings showed that iron therapy improved hemoglobin and ferritin levels, though the results varied across studies. An overall pooled effect estimate for the role of iron therapy in improving the hemoglobin levels among WRA was -0.71 (95% CI: -1.27 to -0.14) (p = 0.008). Likewise, the overall pooled effect estimate for the role of iron therapy in improving the ferritin levels among WRA was -0.76 (95% CI: -1.56 to 0.04) (p = 0.04). The heterogeneity (I2) across included studies was found to be statistically significant for studies assessing hemoglobin (Q = 746.93, I2 = 97.59%, p = 0.000) and ferritin level (Q = 659.95, I2 = 97.88%, p = 0.000). CONCLUSION: Iron therapy in any form may reduce anemia's burden and improve hemoglobin and ferritin levels, indicating improvement in iron-deficiency anemia. More evidence is required, however, to assess the morbidity associated with iron consumption, such as side effects, work performance, economic outcomes, mental health, and adherence to the intervention, with a particular focus on married but non-pregnant women planning a pregnancy in the near future. TRIAL REGISTRATION: Registered with PROSPERO and ID is CRD42020185033.

Predictors of iron consumption for at least 90 days during pregnancy: Findings from National Demographic Health Survey, Pakistan (2017-2018).

BACKGROUND: Iron supplementation is considered an imperative strategy for anemia prevention and control during pregnancy in Pakistan. Although there is some evidence on the predictors of iron deficiency anemia among Pakistani women, there is a very limited understanding of factors associated with iron consumption among Pakistani pregnant women. Thus, this study aimed to investigate the predictors of iron consumption for at least ≥90 days during pregnancy in Pakistan. METHODS: We analyzed dataset from the nationally representative Pakistan Demographic Health Survey 2017-2018. The primary outcome of the current study was the consumption of iron supplementation for ≥90 days during the pregnancy of the last birth. Women who had last childbirth 5 years before the survey and who responded to the question of iron intake were included in the final analysis (n = 6370). We analyzed the data that accounted for complex sampling design by including clusters, strata, and sampling weights. RESULTS: Around 30% of the women reported consumed iron tablets for ≥90 days during their last pregnancy. In the multivariable logistic regression analysis, we found that factors such as women's age (≥ 25 years) (adjusted prevalence ratio (aPR) = 1.52; 95% CI: 1.42-1.62)], wealth index (rich/richest) (aPR = 1.25; [95% CI: 1.18-1.33]), primary education (aPR = 1.33; [95% CI: 1.24-1.43), secondary education (aPR = 1.34; [95% CI: 1.26-1.43), higher education (aPR = 2.13; [95% CI: 1.97-2.30), women's say in choosing husband (aPR = 1.68; [95% CI: 1.57-1.80]), ≥ five antenatal care visits (aPR =2.65; [95% CI (2.43-2.89]), history of the last Caesarian-section (aPR = 1.29; [95% CI: 1.23-1.36]) were significantly associated with iron consumption for ≥90 days. CONCLUSION: These findings demonstrate complex predictors of iron consumption during pregnancy in Pakistan. There is a need to increase the number of ANC visits and the government should take necessary steps to improve access to iron supplements by targeting disadvantaged and vulnerable women who are younger, less educated, poor, and living in rural areas.

Unintended pregnancy and the associated factors among pregnant females: Sukh Survey-Karachi, Pakistan.

OBJECTIVE: Unintended pregnancy has become a substantially growing reproductive health concern in South Asian region. The objective of this survey was to assess the magnitude of unintended pregnancy along with its correlates among currently pregnant women residing in Karachi. METHODS: A community based, multistage, cross-sectional study was carried out among 612 currently pregnant women from squatter settlements of Karachi, inquiring for "unintended pregnancy", outcome of interest. Multivariable logistic analysis was done using SPSS v.19 to determine associated factors. RESULTS: Of 612 pregnant women interviewed, 168(27.4%) reported their pregnancies as unintended. The multivariable regression identified a high likelihood of unintended pregnancy among females aged ≥ 35 years (adjusted odds ratio =3.0, 95% Confidence Interval =1.2 to 4.9)], having: ideal family structure perceived as ≤ two children (Adj. OR=2.3, CI=1.3 - 4.5), no media exposure (Adj. OR=2.9, CI=1.7 to 5.0), no inter-spousal communication about planning a family (Adj. OR=1.5, CI=1.1 - 2.3), ≥5 children (Adj. OR=7.2, CI: 3.4 to 15.1), more sons than daughters (Adj. OR=4.0, CI=1.7 to 6.7), and positive attitude towards using family planning method (Adj. OR=1.8, CI=1.2 to 2.8). Unintended pregnancy decreased with increased age at marriage (Adj. OR= 0.8, CI=0.8, 0.7 - 0.9) and with use of contraceptive methods ever in life (Adj. OR=0.7, CI=0.5 - 0.9). CONCLUSIONS: We found important predictors which suggest policy measures for enhancing media exposure, promoting effective family planning usage, and incorporating behaviour change models in reproductive health clinics to modify fertility intentions of couples.

Desire to limiting child birth and the associated determinants among married females: Sukh Survey-Karachi, Pakistan.

OBJECTIVE: High rates of population growth negatively influence the social and economic development of a country. This study aimed to determine the women's desire to limiting child birth in future (fertility intention) and its determinants among Pakistani women of reproductive age resident of Karachi. METHODS: A community-based, multistage cross-sectional study was carried out among residents of the squatter settlements in Karachi. The were 4,485 married residents, and currently non-pregnant females of 18 to 49 years old. Framework adapted has been based on "Pullum 1980" to operationalize the outcome of determining the desire to limiting childbearing and the factors related with controlling the family size. Multivariable logistic regression using SPSS 13.0 was used. RESULTS: The survey comprised of a total sample of 4485 females who participated and acquiring a median (interquartile range) age of 30 (25 to 35) years. Whereas, the living children count was found to be [median: 3 children; (IQR: 2 to 4)]. From the total, 2109 (47%) wanted to limit the future child birth. Multivariable logistic analysis showed that women who did not want to limit child birth significantly (p-value <0.05) belonged to age groups 18 to 27 years (adjusted odds ratio [aOR]=0.25), and 28 - 37 years (aOR=0.39) compared to the women aged > 37 years (referent category), who belonged to poor wealth category (aOR=0.41), were ever contraceptive users (aOR=0.49), were currently not a contraceptive user (aOR=0.53), not educated (aOR=0.34), and having sons less than the daughters (aOR=0.74). Conversely, females with perceived family structure of ≤two children ideally (aOR=2.62), were autonomous (aOR=1.25) and who had equal daughters and sons (aOR=1.13) rather than more number of sons, had more probability to limiting child birth at a statistically significance (p-value) of less than 0.05. CONCLUSIONS: The survey highlights the strategic independent determinants and there is a need of devising behaviour modification modalities accordingly to expedite the use of contraceptive methods and to encourage fertility decline among women.

Epidemiology of asthma and associated factors in an urban Pakistani population: adult asthma study-Karachi.

BACKGROUND: This study was conducted in order to determine the prevalence of asthma and associated risk factors in the adult population of Karachi, Pakistan. METHODS: This multi-stage, cross-sectional survey was conducted from May 2014-August 2015; comprising 1629 adults in 75 randomly selected clusters in Karachi, Pakistan. Definitions included: 'self-reported asthma', 'reversibility in FEV1' and 'respiratory symptoms and reversibility in FEV1'. RESULTS: Prevalence of asthma was 1.8% (self-reported) (95% CI: 1.0-2.6), 11.3% (reversibility in FEV1) (95% CI: 9.4-13.3) and 6.6% (symptoms and reversibility in FEV1) (95% CI: 5.1-8.1). Asthmatics were more likely to belong to the age group ≥38 years according to 'reversibility in FEV1' and 'respiratory symptoms and reversibility in FEV1' (AOR: 1.9, 95% CI: 1.2-3.3) and (AOR: 2.1, 95% CI: 1.1-4.2), respectively. Asthmatics were more likely to report history of allergies (AOR: 1.9, 95% CI: 1.2-2.9) and (AOR: 2.8, 95% CI: 1.7-4.8); and were exposed to environmental tobacco smoke (AOR: 1.6, 95% CI: 1.1-2.5) and (AOR: 1.9, 95% CI: 1.1-3.3) according to 'reversibility in FEV1' and 'respiratory symptoms and reversibility in FEV1', respectively. Asthmatics were more likely to report pack years of smoking ≥5 (AOR: 2.3, 95% CI: 1.1-4.7) according to 'respiratory symptoms and reversibility in FEV1'. CONCLUSION: This study reports a high prevalence of asthma among Pakistani adults and calls for developing appropriate public health policies for prevention and control of asthma in the country. Further studies should be conducted to determine the national prevalence as well as follow-up studies to identify preventable causes for adult asthma.

Estimating the pre- and post-diagnosis costs of tuberculosis for adults in Pakistan: household economic impact and costs mitigating strategies.

BACKGROUND: Despite free tuberculosis (TB) care in Pakistan, patients still have to bear high costs, which push them into poverty. This study estimated the pre- and post-diagnosis costs households bear for TB care, and investigated coping mechanisms among adults ≥ 18 years in Karachi, Pakistan. METHODS: We conducted a cross-sectional study comprising of 516 TB patients identified with completion of at least one month intensive treatment from four public sector health facilities from two institutes in Karachi, Pakistan. A standardized questionnaire to estimate patient's costs was administered. The study outcomes were direct medical and non-medical costs, and indirect costs. The costs were estimated during pre-diagnostic and post-diagnostic phase which includes diagnostic, treatment, and hospitalization phases. A descriptive analysis including mean and standard deviation (± SD), median and interquartile range (IQR), and frequencies and proportions (%) was employed. RESULTS: Out of 516 TB patients, 52.1% were female with a mean age of 32.4 (± 13.7) years. The median costs per patient during the pre-diagnostic, diagnostic, treatment and hospitalization periods were estimated at USD63.8/ PKR7,377, USD24/ PKR2,755, USD10.5/ PKR1,217, and USD349.0/ PKR40,300, respectively. The total household median cost was estimated at USD129.2/ PKR14,919 per patient. The median indirect cost was estimated at USD52.0/ PKR5,950 per patient. Of total, 54.1% of patients preferred and consulted private providers in the first place at the onset of symptoms, while, 36% attended public healthcare services, 5% and 4.1% went to dispensary and pharmacy, respectively, as a first point of care. CONCLUSIONS: TB patients bear substantial out-of-pocket costs before they are enrolled in publically funded TB programs. There should be provision of transport and food vouchers, also health insurance for in-patient treatment. This advocates a critical investigation into an existing financial support network for TB patients in Pakistan towards reducing the burden.

Indoor Air Pollution and Respiratory Health in a Metropolitan City of Pakistan.

OBJECTIVE: We assessed the association of formaldehyde, carbon monoxide (CO), and particulate matter (PM 2.5 ) with respiratory symptoms, asthma, and post-bronchodilator reversibility. METHODS: We included 1629 adults in a community-based cross-sectional study in Karachi in 2015. Data were collected using the American Thoracic Society respiratory questionnaire and spirometry (available for 930 participants). YesAir eight-channel monitor was used for measuring concentrations of formaldehyde and CO, whereas PM 2.5 was measured using UCB PATS. RESULTS: Higher levels of formaldehyde and CO were associated with cough, phlegm, and wheeze, whereas those of PM 2.5 were associated with shortness of breath and presence of any of the respiratory symptoms (combined), as well as a "lower" risk of cough, phlegm, and bronchitis. CONCLUSION: Poorer household air quality was associated with poorer respiratory health in this population; however, further studies with a robust exposure assessment are required.

Relationship Between Physical Inactivity and Obesity in the Urban Slums of Lahore.

Introduction There are several factors such as physical inactivity, sedentary lifestyle, and diet that can be responsible for weight gain or obesity. Regular physical activity is important for better physical and emotional well-being. The objective of the study is to observe the prevalence of obesity or over-weight and how lack of physical activity contributes to weight gain and other health issues. Methods This cross-sectional study was conducted in Shalamar Town, Lahore on 646 participants. Data was collected using the WHO STEPS instrument. The inclusion criteria were a minimum age of 30 years and residents of Shalimar Town, Lahore for more than five years. The exclusion criteria were participants with comorbid conditions like HIV, TB, and terminal stage of cancer. Test of association and binary logistic regression analysis was performed to observe a significant association between demographic variables and non-communicable diseases among the participants involved in performing physical exercise. Results About 22.1% of the participants had normal BMI, 5.3% were underweight whereas 34.2% of the participants were overweight and 32.4% obese. Male participants were found to be more physically active compared to females. Hypertension and diabetes were statistically significantly associated with physical activity. BMI and waist-hip ratio were found to be associated with moderate physical exercise. Conclusion Most of the participants were not involved in moderate physical activity. Overall, an alarming 66.6% of the participants were either overweight or obese. In general, males were found to participate more in intense physical activity.

Burden of noncommunicable diseases in Pakistan.

Background: Cases of noncommunicable (NCD) diseases are increasing in Pakistan. They are responsible for 58% of all deaths and information on the risk factors is lacking. Aims: To determine the prevalence of diabetes, hypertension and abnormal heart rate and their risk factors in a multiethnic, low-income area of Lahore. Methods: This was a cross-sectional study conducted in an urban settlement of Lahore in 2018-2019. Eligible participants were aged ≥ 30 years and resident in selected settlements. We used a modified World Health Organization stepwise approach to NCD risk factor surveillance (STEPS) questionnaire to collect data from a random sample of 906 residents. The modified questionnaire had a Cronbach alpha of 80.0%. Participants were interviewed in their homes and their height, weight, heart rate, and hip circumference were measured. Results: Most of the respondents were women (64.5%). The greatest proportion of the participants were aged 30-39 years (42.4%). Of all the respondents, 40.1% had hypertension, 15.8% had diabetes and 17.0% had ischaemic heart disease. Of the risk factors examined, 68.8% of the respondents were overweight or obese, 37.0% had pre-hypertension, 13.6% used tobacco, and 1.8% used alcohol. Age was the most significant risk factor for noncommunicable diseases. Body mass index was significantly associated with diabetes in women, while family history of diabetes was significantly associated with diabetes in men. Conclusion: The prevalence of hypertension and diabetes was higher among our study participants in Lahore than reported in the national statistics. Significant proportions of the respondents had pre-hypertension and pre-diabetes, making them vulnerable to serious complications of hypertension and diabetes.

Prevalence of tobacco consumption and the associated factors among the adults in an urban slum: Findings from the WHO STEPwise survey.

INTRODUCTION: Despite Pakistan's stringent tobacco control policy, its effective implementation has always been a challenge, leading to rising tobacco consumption. The aim of the study is to determine the prevalence of tobacco consumption and associated risk factors in the adult population of deprived urban areas. METHODS: A community-based, cross-sectional survey was conducted from February to July 2019, comprising 607 adults residing in the urban squatter settlement of Lahore using a standardized questionnaire, the WHO STEPwise approach. The outcome was current use of tobacco and/or smokeless tobacco daily. Multivariable logistic regression was applied to determine factors associated with smoking and smokeless tobacco consumption. RESULTS: Among 607 participants, about 64% were females, 49.3% were illiterate, 64.9% were currently unemployed, and 47.1% belonged to the low-income group. The prevalence of tobacco smoke was 10.5% (95% CI: 8.07-12.93), and smokeless tobacco consumption was 8.6% (95% CI: 6.38-10.82). Multivariable logistic regression found that smokeless tobacco was more likely among the aged 50-59 years (AOR=4.1; 95% CI: 1.1-13.8) and unemployed (AOR=3.6; 95% CI: 1.1-12.2). Whereas tobacco smoking was more likely among the aged 30-39 years (AOR=5.5; 95% CI: 1.8-16.7), Urdu ethnicity (AOR=2.9; 95% CI: 1.2-7.3), unemployed (AOR=6.6; 95% CI: 2.9-14.9), and never exposed to any media (AOR=3.2; 95% CI: 1.8-17.4). Participants exposed to health warnings were less likely to smoke (AOR=0.02; 95% CI: 0.01-0.05). CONCLUSIONS: This study reports a high prevalence of tobacco consumption among adults and calls for effective policy implementation using a multi-pronged approach, including health professionals and media, to spread awareness about the harmful effects of tobacco and endorsement of health warnings on tobacco packaging.