District decision-making for health in low-income settings: a qualitative study in Uttar Pradesh, India, on engaging the private health sector in sharing health-related data

Health information systems are an important planning and monitoring tool for public health services, but may lack information from the private health sector. In this fourth article in a series on district decision-making for health, we assessed the extent of maternal, newborn and child health (MNCH)-related data sharing between the private and public sectors in two districts of Uttar Pradesh, India; analysed barriers to data sharing; and identified key inputs required for data sharing. Between March 2013 and August 2014, we conducted 74 key informant interviews at national, state and district levels. Respondents were stakeholders from national, state and district health departments, professional associations, non-governmental programmes and private commercial health facilities with 3–200 beds. Qualitative data were analysed using a framework based on a priori and emerging themes. Private facilities registered for ultrasounds and abortions submitted standardized records on these services, which is compulsory under Indian laws. Data sharing for other services was weak, but most facilities maintained basic records related to institutional deliveries and newborns. Public health facilities in blocks collected these data from a few private facilities using different methods. The major barriers to data sharing included the public sector’s non-standardized data collection and utilization systems for MNCH and lack of communication and follow up with private facilities. Private facilities feared information disclosure and the additional burden of reporting, but were willing to share data if asked officially, provided the process was simple and they were assured of confidentiality. Unregistered facilities, managed by providers without a biomedical qualification, also conducted institutional deliveries, but were outside any reporting loops. Our findings suggest that even without legislation, the public sector could set up an effective MNCH data sharing strategy with private registered facilities by developing a standardized and simple system with consistent communication and follow up.

District decision-making for health in low-income settings: a feasibility study of a data-informed platform for health in India, Nigeria and Ethiopia

Low-resource settings often have limited use of local data for health system planning and decision-making. To promote local data use for decision-making and priority setting, we propose an adapted framework: a data-informed platform for health (DIPH) aimed at guiding coordination, bringing together key data from the public and private sectors on inputs and processes. In working to transform this framework from a concept to a health systems initiative, we undertook a series of implementation research activities including background assessment, testing and scaling up of the intervention. This first paper of four reports the feasibility of the approach in a district health systems context in five districts of India, Nigeria and Ethiopia. We selected five districts using predefined criteria and in collaboration with governments. After scoping visits, an in-depth field visit included interviews with key health stakeholders, focus group discussions with service-delivery staff and record review. For analysis, we used five dimensions of feasibility research based on the TELOS framework: technology and systems, economic, legal and political, operational and scheduling feasibility. We found no standardized process for data-based district level decision-making, and substantial obstacles in all three countries. Compared with study areas in Ethiopia and Nigeria, the health system in Uttar Pradesh is relatively amenable to the DIPH, having relative strengths in infrastructure, technological and technical expertise, and financial resources, as well as a district-level stakeholder forum. However, a key challenge is the absence of an effective legal framework for engagement with India’s extensive private health sector. While priority-setting may depend on factors beyond better use of local data, we conclude that a formative phase of intervention development and pilot-testing is warranted as a next step.

Measuring implementation strength: lessons from the evaluation of public health strategies in low- and middle-income settings

Evaluation of strategies to ensure evidence-based, low-cost interventions reach those in need is critical. One approach is to measure the strength, or intensity, with which packages of interventions are delivered, in order to explore the association between implementation strength and public health gains. A recent systematic review suggested methodological guidance was needed. We described the approaches used in three examples of measures of implementation strength in evaluation. These addressed important public health topics with a substantial disease burden in low-and middle-income countries; they involved large-scale implementation; and featured evaluation designs without comparison areas. Strengths and weaknesses of the approaches were discussed. In the evaluation of Ethiopia’s Health Extension Programme, implementation strength scoring for each kebele (ward) was based on aggregated data from interviews with mothers of children aged 12–23 months, reflecting their reports of contact with four elements of the programme. An evaluation of the Avahan HIV prevention programme in India used the cumulative amount of Avahan funding per HIV-infected person spent each year in each district. In these cases, a single measure was developed and the association with hypothesised programme outcomes presented. In the evaluation of the Affordable Medicines Facility—malaria, several implementation strength measures were developed based on the duration of activity of the programme and the level of implementation of supporting interventions. Measuring the strength of programme implementation and assessing its association with outcomes is a promising approach to strengthen pragmatic impact evaluation. Five key aspects of developing an implementation strength measure are to: (a) develop a logic model; (b) identify aspects of implementation to be assessed; (c) design and implement data collection from a range of data sources; (d) decide whether and how to combine data into a single measure; and, (e) plan whether and how to use the measure(s) in outcome analysis.

Taking knowledge users' knowledge needs into account in health: an evidence synthesis framework

The increased demand for evidence-based practice in health policy in recent years has provoked a parallel increase in diverse evidence-based outputs designed to translate knowledge from researchers to policy makers and practitioners. Such knowledge translation ideally creates user-friendly outputs, tailored to meet information needs in a particular context for a particular audience. Yet matching users’ knowledge needs to the most suitable output can be challenging. We have developed an evidence synthesis framework to help knowledge users, brokers, commissioners and producers decide which type of output offers the best ‘fit’ between ‘need’ and ‘response’. We conducted a four-strand literature search for characteristics and methods of evidence synthesis outputs using databases of peer reviewed literature, specific journals, grey literature and references in relevant documents. Eight experts in synthesis designed to get research into policy and practice were also consulted to hone issues for consideration and ascertain key studies. In all, 24 documents were included in the literature review. From these we identified essential characteristics to consider when planning an output—Readability, Relevance, Rigour and Resources—which we then used to develop a process for matching users’ knowledge needs with an appropriate evidence synthesis output. We also identified 10 distinct evidence synthesis outputs, classifying them in the evidence synthesis framework under four domains: key features, utility, technical characteristics and resources, and in relation to six primary audience groups—professionals, practitioners, researchers, academics, advocates and policy makers. Users’ knowledge needs vary and meeting them successfully requires collaborative planning. The Framework should facilitate a more systematic assessment of the balance of essential characteristics required to select the best output for the purpose.

Uncontrolled diabetes mellitus: prevalence and risk factors among people with type 2 diabetes mellitus in an Urban District of Karachi, Pakistan

AIMS

This study aimed to explore the prevalence of, and factors associated with, uncontrolled diabetes mellitus (UDM) in a community setting in Pakistan.

METHODOLOGY

A single-center, cross-sectional study, conducted in a community-based specialized care center (SCC) for diabetes in District Central Karachi, in 2003, registered 452 type 2 DM participants, tested for HbA1c and interviewed face-to-face for other information. Logistic regression analysis was conducted to identify factors associated with UDM.

RESULTS

Prevalence of UDM among diabetes patients was found to be 38.9% (95% CI: 34.4-43.4%). Multivariable logistic regression model analysis indicated that age <50 years (OR: 1.9; 95% CI: 1.2-2.9), being diagnosed in a hospital (vs. a clinic) (OR: 1.8; 95% CI: 1.1-2.8), diabetes information from a doctor or nurse only (vs. multiple sources) (OR: 1.8; 95% CI: 1.2-2.9), higher monthly treatment cost (OR: 1.3; 95% CI: 1.1-1.6; for every extra 500 PKR), and higher consumption of tea (OR: 1.5; 95% CI: 1.0-2.2; for every 2 extra cups) were independently associated with UDM.

CONCLUSION

The prevalence of UDM was approximately 39% among persons with type 2 diabetes visiting a community based SCC for diabetes. Modifiable risk factors such as sources of diabetes information and black tea consumption can be considered as potential targets of interventions in Karachi.

Women's empowerment and contraceptive use: the role of independent versus couples' decision-making, from a lower middle income country perspective

INTRODUCTION

There is little available evidence of associations between the various dimensions of women's empowerment and contraceptive use having been examined--and of how these associations are mediated by women's socio-economic and demographic statuses. We assessed these phenomena in Pakistan using a structured-framework approach.

METHODS

We analyzed data on 2,133 women who were either using any form of contraceptive or living with unmet need for contraception. The survey was conducted during May - June 2012, with married women of reproductive age (15-49 years) in three districts of Punjab. The dimensions of empowerment were categorized broadly into: economic decision-making, household decision-making, and women's mobility. Two measures were created for each dimension, and for the overall empowerment: women's independent decisions, and those taken jointly by couples. Contraceptive use was categorized as either female-only or couple methods on the basis of whether a method requires the awareness of, or some support and cooperation from, the husband. Multinomial regression was used, by means of Odds Ratios (OR), to assess associations between empowerment dimensions and female-only and couple contraceptive methods.

RESULTS

Overall, women tend to get higher decision-making power with increased age, higher literacy, a greater number of children, or being in a household that has superior socio-economic status. The measures for couples' decision-making for overall empowerment and for each dimension of it showed positive associations with couple methods as well as with female-only methods. The only exception was the measure of economic empowerment, which was associated only with the couple method.

CONCLUSION

Couples' joint decision-making is a stronger determinant of the use of contraceptive methods than women-only decision-making. This is the case over and above the contribution of women's socio-demographic and economic statuses. Effort needs to be made to educate women and their husbands equally, with particular focus on highly effective contraceptive methods.

Qualitative adaptation of child behaviour problem instruments in a developing-country setting

A key barrier to epidemiological research on child behaviour problems in developing countries is the lack of culturally relevant, internationally recognized psychometric instruments. This paper proposes a model for the qualitative adaptation of psychometric instruments in developing-country settings and presents a case study of the adaptation of 3 internationally recognized instruments in Pakistan: the Child Behavior Checklist, the Youth Self-Report and the Teacher's Report Form. This model encompassed a systematic procedure with 6 distinct phases to minimize bias and ensure equivalence with the original instruments: selection, deliberation, alteration, feasibility, testing and formal approval. The process was conducted in collaboration with the instruments' developer. A multidisciplinary working group of experts identified equivalence issues and suggested modifications. Focus group discussions with informants highlighted comprehension issues. Subsequently modified instruments were thoroughly tested. Finally, the instruments' developer approval further validated the qualitative adaptation. The study proposes a rigorous and systematic model to effectively achieve cultural adaptation of psychometric instruments.

Delivery should happen soon and my pain will be reduced: understanding women's perception of good delivery care in India

Background

Understanding a woman's perspective and her needs during childbirth and addressing them as part of quality-improvement programmes can make delivery care safe, affordable, and respectful. It has been pointed out that the patient's judgement on the quality and goodness of care is indispensible to improving the management of healthcare systems.

Objective

The objective of the study is to understand the aspects of care that women consider important during childbirth.

Design

Individual in-depth interviews (IDIs) and focus-group discussions (FGDs) with women who recently delivered were the techniques used. Seventeen IDIs and four FGDs were conducted in Jharkhand state in east India between January and March 2012. Women who had normal deliveries with live births at home and in primary health centres were included. To minimise recall bias, interviews were conducted within 42 days of childbirth. Using the transcripts of interviews, the data were analysed thematically.

Results

Aspects of care most commonly cited by women to be important were: availability of health providers and appropriate medical care (primarily drugs) in case of complications; emotional support; privacy; clean place after delivery; availability of transport to reach the institution; monetary incentives that exceed expenses; and prompt care. Other factors included kind interpersonal behaviour, cognitive support, faith in the provider's competence, and overall cleanliness of the facility and delivery room.

Conclusions

Respondents belonging to low socio-economic strata with basic literacy levels might not understand appropriate clinical aspects of care, but they want care that is affordable and accessible, along with privacy and emotional support during delivery. The study highlighted that healthcare quality-improvement programmes in India need to include non-clinical aspects of care as women want to be treated humanely during delivery – they desire respectful treatment, privacy, and emotional support. Further research into maternal satisfaction could be made more policy relevant by assessing the relative strength of various factors in influencing maternal satisfaction; this could help in prioritising appropriate interventions for improved quality of care (QoC).

A community-based study of early childhood sensory stimulation in home environment associated with growth and psychomotor development in Pakistan

OBJECTIVES

Sensory stimulation (SS) is a non-nutritional modifiable risk factor for early childhood development. We assessed SS in home environment and examined its influence on physical growth and psychomotor development (PD).

METHODS

A cross-sectional study was conducted in 26 communities in Pakistan among children aged <3 (n = 1,219). They were assessed at home visits using (1) Bayley's Infant Developmental Scale for PD, (2) home observation for measurement of the environment inventory for SS, (3) anthropometry and (4) socio-economic questionnaire.

RESULTS

In rural homes, SS provided was lower as compared to urban counterparts (Adj mean diff: 4.47, 95 % CI 3.78, 5.16) and showed an association with stunting (Adj mean diff: -1.30, 95 % CI -1.93, -0.66), and underweight (Adj mean diff: -1.04, 95 % CI -1.71, -0.38) not explained by type of neighbourhood or socio-economic status. SS was associated with PD more than combined contribution of socio-economic status and rural-urban factors (Adj mean diff: 0.47, 95 % CI 0.30, 0.63).

CONCLUSIONS

SS in rural homes may be a significant factor influencing the child development. There is a need to corroborate these results by additional research for integration in health policy initiatives.

Should oral misoprostol be used to prevent postpartum haemorrhage in home-birth settings in low-resource countries? A systematic review of the evidence

BACKGROUND

Using misoprostol to prevent postpartum haemorrhage (PPH) in home-birth settings remains controversial.

OBJECTIVES

To review the safety and effectiveness of oral misoprostol in preventing PPH in home-birth settings.

SEARCH STRATEGY

The Cochrane Library, PubMed, and POPLINE were searched for articles published until 31 March 2012.

SELECTION CRITERIA

Studies, conducted in low-resource countries, comparing oral misoprostol with a placebo or no treatment in a home-birth setting. Studies of misoprostol administered by other routes were excluded.

DATA COLLECTION AND ANALYSIS

Data were extracted by two reviewers and independently checked for accuracy by a third. The quality of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. Data were sythesised and meta-analysis was performed where appropriate.

MAIN RESULTS

Ten papers describing two randomised and four non randomised trials. Administration of misoprostol was associated with a significant reduction in the incidence of PPH (RR 0.58, 95% CI 0.38-0.87), additional uterotonics (RR 0.34, 95% CI 0.16-0.73), and referral for PPH (RR 0.49, 95% CI 0.37-0.66). None of the studies was large enough to detect a difference in maternal mortality, and none reported neonatal mortality. Shivering and pyrexia were the most common side effects.

AUTHOR'S CONCLUSIONS

The finding that the distribution of oral misoprostol through frontline health workers is effective in reducing the incidence of PPH could be a significant step forwards in reducing maternal deaths in low-resource countries. However, given the limited number of high-quality studies in this review, further randomised controlled trials are required to confirm the association, particularly in different implementation settings. Adverse effects have not been systematically captured, and there has been limited consideration of the potential for inappropriate or inadvertent use of misoprostol. Further evidence is needed to inform the development of implementation and safety guidelines on the routine availability of misoprostol.

Review of the theoretical frameworks for the study of child development within public health and epidemiology

BACKGROUND

Care for child development has gained international momentum in research and community-based programming. It encompasses various domains including cognitive, psychomotor, emotional, behavioural and social development, and a multitude of factors that have the potential to influence its trajectories. However, the multidisciplinary nature of child development initiatives is marred by a lack of unified perspectives across disciplines, especially basic conceptual understanding generated in the fields of education and psychology, which are not effectively exploited in public health programmes and epidemiological research.

METHODS

The article suggests a four-point evaluation criteria to child development theories based on the ability to communicate in (1) Cross-disciplines, (2) an Overarching facility to address various developmental domains, (3) the capacity to link child development with Lifelong developmental potentials and, most importantly, (4) Epidemiological capability to provide supporting empirical evidence for community-based public health interventions (COLE criteria).

RESULTS

Key child development theories have been reviewed by broadly grouping them into three categories on the basis of content and approach, such as descriptive theories, psychological construct-based theories, and context-based theories. The strengths and challenges of these theories have been evaluated on the basis of COLE criteria.

CONCLUSION

Although most of these theories can contribute at different levels in child development initiatives, context-based theories have been particularly proposed to practitioners, researchers and policy makers for community-based programming, principally for its potential to address issues of social inequality, poverty and childcare practices, which are at the core of public health initiatives, and provide multiple level of opportunities to intervene.

The role of family configuration in early childhood intellectual development in the context of an extended family system in Pakistan

CONTEXT

The confluence theory of intelligence by Zajonc and Markus emphasizes that individual intellectual difference of children manifests itself in the context of family configuration. Instead of assuming its generalizability, careful scientific work is required before applying the model to South Asian cultures where, predominantly, an extended family type exists.

AIMS

To assess the role of extended family configuration on the child's intellectual development in a South Asian setting.

SETTINGS AND DESIGN

A cross-sectional study was conducted on 4-5-year-old preschool children residing in Karachi, Pakistan.

MATERIALS AND METHODS

Three hundred and forty-two child and mother dyads were assessed through a validated cognitive psychometric tool and through a structured questionnaire. Children who were registered at the main Mother and Child Health Centres (MCH) of the Aga Khan Health Services, Pakistan (AKHSP) Karachi and who were born between July 1st 1993-June 30th 1994 with traceable birth records at the maternity homes, were considered for this study.

STATISTICAL ANALYSIS

Multivariate linear regression models were used to identify the individual effect of family configuration on the intellectual scores.

RESULTS

Family configuration variables such as number of co-residents ( P P CONCLUSION: The findings suggest the positive role of co-residents of an extended family environment on the intellectual development in early childhood.

Role of family type in the idealization of a larger number of children by husbands in Pakistan

This study focuses on determining the number of children considered ideal by Pakistani husbands and identifying the factors associated with this, with a special emphasis on family type. A cross-sectional survey was conducted among married males residing in four areas of Khairpur district. An equal number of study participants were selected systematically from each field site to achieve the required sample size of 500. Interviews were conducted by trained fieldworkers using a structured questionnaire to obtain information on background socioeconomic characteristics, family structure and reproductive health knowledge and practices, in particular family planning. Multivariate logistic regression analyses were used to assess the hypothesis that family type has an independent association with husbands' idealization of a larger number of children. The mean ideal number of children perceived by husbands was four. Living in an extended family (AOR = 1.81; 95%CI: 1.11, 3.35) and being illiterate (AOR = 2.13, 95%CI; 1.33, 3.42) are significantly associated with idealization of a larger number of children by the husband, while adjusting for socioeconomic status, family structure and family planning information. Understanding the dynamics of family type and its effects on husbands' opinions regarding ideal number of children can help strengthen population control efforts in Pakistan.

Residents' perceptions of work environment during their postgraduate medical training in Pakistan

BACKGROUND

In Pakistan, there is a lack of information about the work environment of residency programs. This lack is a major impediment in their improvement. One of the approaches for improvement in these programs can be directed through the residents' own perception of their working conditions. Therefore, we collected data which would reflect working conditions of residents.

AIM

To assess the perceived status of "work environment" in different specialities.

MATERIALS AND METHODS

A cross-sectional survey was conducted in four teaching hospitals of Karachi from July 1999 to January 2000. Residents from selected programs were grouped into four broad groups: specialist, medical, surgical and multidisciplinary. Responses of residents were obtained on a Likert scale of 0 to 4. Indices were formed for two components of work environment: academic and mistreatment.

STATISTICAL ANALYSIS

Differences between residents' groups were assessed through analysis of variance (ANOVA) at 5% significance.

RESULTS

A total of 341 registered residents responded (response rate: 75%). Surgical residents were working more than 80 h/week and this was more than the other three groups. Medical residents were spending the highest actual time on research and teaching activities (10% and 14%, respectively). Academic index score was highest for surgical group (15.81, SD = 4.69) and lowest for multidisciplinary group (11.82, SD = 4.80). Medical group had the highest perceived mistreatment index score (5.56, SD = 4.57).

CONCLUSIONS

In a study of work environment of residency programs, differential impact was found for the four groups on work environment perceptions. Most of the residents recognized undergraduate teaching, grand rounds, patient rounds and seminars or workshops as contributing to their academic learning. Reporting of sexual harassment was low, indicating either underreporting or cultural dynamics of our setting.

Residents' perceptions of communication skills in postgraduate medical training programs of Pakistan

BACKGROUND

The importance of communication skills in postgraduate medical training is likely to be highlighted given the convergence of research and educational forces. Assessment of these skills in residency training is vital since it can provide basis for policy undertaking among Pakistani medical academia for improving postgraduate training programs.

AIM

To assess the perceived status of communication skills of residents in different specialties.

MATERIALS AND METHODS

A cross sectional survey was conducted in four teaching hospitals of Karachi between July 1999 and January 2001. A total of 455 residents in different residency programs were contacted. Residents registered both with College of Physicians and Surgeons of Pakistan and Postgraduate Medical Education office of selected hospitals were included in this study. Responses of residents were obtained on 5-point Likert scale. Indices were formed for three components of communication skills: informative, affective and professional communication.

STATISTICAL ANALYSIS

Differences between residents' groups were assessed through analysis of variance.

RESULTS

Total informative communication index was lowest for multi-disciplinary (12.05, SD = 4.87) and highest for surgical (15.27, SD = 2.51) residents. Total affective index was lowest for multi-disciplinary (12.58, SD = 5.68) and highest for medical (15.74, SD = 3.59) residents. The group differences for four groups of residency programs were not statistically significant for either professional attributes separately or for the total professional index.

CONCLUSIONS

The residency programs must establish goals, process and outcomes to incorporate communication skills in postgraduate medical training since this can enhance residents' performance as effective health care providers. Accomplishment of better communication skills can be achieved if the importance of its teaching and training is valued by residency program coordinators.

A matched case-control study of risk factors for neonatal tetanus in Karachi, Pakistan

BACKGROUND

Previous studies have identified various risk factors for neonatal tetanus (NNT) in rural areas of Pakistan. The present matched case control study was conducted to further evaluate these risk factors in an urban setting.

AIM

The study was carried out to identify risk factors for NNT in Karachi.

MATERIALS AND METHODS

Patients of NNT (n = 125) diagnosed from January 1998 to February 2001 were recruited through a surveillance system of Expanded Programme on Immunization (EPI). Two neighbourhood controls (n = 250) were matched for each case for gender and date of birth of the case.

STATISTICAL ANALYSIS

Conditional logistic regression was performed to assess the independent effect of factors associated with NNT.

RESULTS

The final multivariable model identified subsequent application of substances on the umbilical cord (adjusted matched odds ratio [adj. mOR] = 5.1 [2.7-9.7]), home delivery (adj. mOR = 1.8; 95% CI: 1.1- 3.1) and illiterate mother (adj. mOR = 1.6; 95% CI: 1.0- 2.0) as risk factors for NNT after adjusting for other variables in the model. Population attributable risk per cent (PAR %) for subsequent cord application was 69% and PAR % for home delivery was 31%.

CONCLUSION

Health planners, while formulating control strategies through immunization programmes should also take into account the impact of post-delivery practices, such as 'subsequent cord application' along with pre-delivery practices. Health awareness regarding appropriate post-delivery practices should be promoted and counselling of pregnant women for giving preference to health care setting for delivery is also crucial.

Factors influencing the selection of surgical specialty among Pakistani medical graduates

CONTEXT

The delineation between selection of surgery and non-surgery residency programmes could provide a pragmatic view of the influences on medical graduates' careers. This would also help coordinators and educators of residency programmes in surgery to further understand the dynamics of specialty selection.

AIMS

To identify the different factors that influence the graduates to select surgical specialties in Pakistan.

SETTINGS AND DESIGNS

A cross-sectional survey was conducted in 4 teaching hospitals of Karachi between July 1999 and January 2001.

SUBJECTS AND METHODS

A total of 455 residents in 1-5 years of residency programmes were contacted. Three hundred and forty-one residents consented to the interview. Residents who were registered both with the College of Physicians and Surgeons of Pakistan (CPSP) and the Post Graduate Medical Education (PGME) office of the selected hospitals were included in this study. STATISTICAL METHOD USED: Logistic regression analysis.

RESULTS

Final multivariate analysis identified 4 factors that remained significantly associated with the selection of surgical specialty: deriving gratification from direct patient care (adjusted odds ratio [aOR] = 5.79; 95% confidence interval [CI]: 1.24, 26.99), procedure-based medical practice (aOR = 2.85; 95% CI: 1.23, 6.61), nature of clinical problems (aOR = 3.39; 95% CI: 1.47, 7.84), and lack of consideration of stress during professional work (aOR = 2.27, 95%CI: 1.25, 4.13).

CONCLUSIONS

Direct patient care is perceived to be an integral part of surgery residency and immediate patient outcome is a positive influence in selecting surgical specialty. The inclination towards surgery appeared to be determined by the type of procedures and technical skills involved in its practice. The nature of clinical problems is an important determinant of the choice of specialty. Stress was not perceived to be an important influencing factor for those who decided to select surgical specialties.

Demographic, socio-economic and environmental determinants of utilisation of antenatal care in a rural setting of Sindh, Pakistan

OBJECTIVE

Majority of the women in the developing countries are unable receive antenatal care for a variety of reasons. This study determines the factors affecting utilisation of antenatal care by women of a rural area in Sindh, Pakistan.

METHODS

A cross-sectional study was conducted during August 1997, in Union Council Jhangara, Sindh, Pakistan. Married women, who had delivered at least one child, were included in the study from each household and systematically 222 eligible women were selected. The effects of demographic, socio-economic and environmental factors on the utilisation of antenatal care, by women during their most recent pregnancy were also studied. Multivariate logistic regression analysis was used to assess independent effect of individual factors.

RESULTS

Among the study subjects, 29.3% (65) of the women utilised antenatal care during the last (most recent) pregnancy and out of them 72.3% (47) received it from the government health care provider. Presence of electricity in the house was strongly associated with the utilisation of antenatal care (AOR = 5.3; 95% CI 2.2-12.7). Women whose husbands were in white-collar occupation, were utilizing the antenatal care significantly more (AOR = 2.4; 95% CI 1.2-4.6) compared to women whose husbands were in blue-collar occupations.

CONCLUSION

The study shows that social status and economic condition of a woman is an important determinant of utilisation of antenatal care. Therefore, improvement of socioeconomic status is required to increase utilization of antenatal and perinatal care.

Comparison of clinical and laparascopic features of infertile women suffering from genital tuberculosis (TB) or pelvic inflammatory disease (PID) or endometriosis

OBJECTIVE

The objective of the study was to analyze the clinical and laparoscopic features, which may help to differentiate between infertility in females due to Genital Tuberculosis from Pelvic Inflammatory Disease (PID) and Endometriosis.

METHODS

This case control study was carried out in a teaching tertiary care hospital. Medical records were searched from 1st January 1987 to 31st December 2000 and 43 infertile women with biopsy proven genital tract tuberculosis were found. Equal number of infertile females with diagnosed PID and Endometriosis were randomly selected. Comparisons were done between features of Genital Tuberculosis with PID and Endometriosis separately and also genital tuberculosis with combined controls of PID and Endometriosis.

RESULTS

Patients with genital tuberculosis commonly had primary infertility. PID and Endometriosis patients had early menarche and increased duration of menstruation. On physical examination, patients with Genital Tuberculosis were found to have short heights. No significant findings were observes in the pelvic examination and menstruation history between the comparison groups. Laparascopic examination revealed that fallopian tubes were abnormal, tortuous, bilaterally blocked and thickly adherent more commonly in Genital Tuberculosis when compared to other groups.

CONCLUSION

The primary infertility patients with chronic malnutrition and massive adhesive fallopian tubes on laproscopic examination should be evaluated for genital tuberculosis.

Moving from concepts to study types approaches to classifying scientific inquiry

There is no such concept as "the ideal research method". Most study types are understood and taught in a relative vacuum without appreciating their philosophical context. However, to achieve an optimal approach is more a matter of resolving the congruence between research purpose and method. Proper location of research methods within a theoretical framework is therefore important, otherwise the resulting over-simplification will eventually lead to inappropriate use of study types. Designing any type of study encompasses the process of identification, exploration and explanation, and utilizes concepts such as manipulation, sampling, replication and time dimensions. Medical research has borrowed study types both from Epidemiology and Social Sciences and practiced as observational and experimental inquiries, and we offer in the present review a framework within which these various types may be understood.

Why a research study needs a design?

Medical research requires as much attention to management as it does to science. Effective research depends first upon the thoughtful statements of purpose and objectives, and related research questions. These important initial steps in turn drive key decisions regarding study type, plans for analyses and competent implementation within bounded timeframes and budgets. The research endeavour materializes by selecting appropriate study types based on coherent research questions, appropriate data collection, and ultimately concludes by drawing inferences on the basis of properly planned analyses. This article reviews these principles and inter-relationships.

Perspective on variables in medical research

Research concepts cannot be materialized until and unless study variables are carefully selected and clearly defined. However, emphasis on variables is not limited to data collection. It should be envisioned from the start that the contents of the variables recorded are congruent with the statistical analysis suggested. These two processes require a comprehensive understanding of variables in epidemiology and biostatistics disciplines. In this article classifications are discussed keeping in view their utility in medical research.

The proposition: an insight into research

Propositions form the basis for scientific research. The validity of a research study is, to a large extent, evaluated on the criteria of its propositions. For internal validity, study propositions provide information regarding precision of definitions, measurements, associations, confounding factors etc. that are considered in research. While for external validity, propositions form the premise for the deduction of inferences. The aim of this article is to help readers understand the propositions that are made in research. This article discusses those propositions, which are relevant to medical research.

Place research problem in theory--a theory research symbiosis

Theory gives a specific perspective to research by providing systematic guidance for the identification and investigation of the logical relationship in the phenomenon of interest. To critically appraise the theoretical bases of a research, it is important first to familiarize with the language of theory, which mainly comprises of concepts and propositions. Furthermore, models are developed to act as a springboard for theory generation and theory practice. To organise the research findings in order to develop a body of knowledge, the connection between theory and research should be explicit in the study.