Health-seeking behaviour in Pakistan: a narrative review of the existing literature

Disparities in age and gender-specific SARS-CoV-2 diagnostic testing trends: a retrospective study from Pakistan

BACKGROUND

Pakistan reported 1.57 million COVID-19 cases between 2020 and 2022, based on approximately 30.6 million SARS-CoV-2 RT-PCR (reverse-transcription polymerase chain reaction) tests conducted. This study utilized data from one of the largest in-country testing facilities, Aga Khan University Hospital (AKUH) in Karachi, Pakistan, to explore gender and age-related in RT-PCR testing patterns.

METHODS

We conducted a retrospective review of SARS-CoV-2 RT-PCR test data extracted from AKUH clinical laboratory records between February 2020 and February 2022. Gender and age distributions were examined in the context of testing patterns across the period. Multivariate regression models assessed independent associations between COVID-19 positivity and key variables.

RESULTS

We reviewed 470,249 RT-PCR tests, finding that most tests were in those aged 21-40 years (48.1%). Overall, COVID-19 test positivity was 20.6%. In all, 57.7% were performed for males, predominant amongst those tested across all age groups and waves. Females had significantly lower odds of testing positive for COVID-19 (OR: 0.9; 95% CI: 0.9-1.0). However, when adjusted for gender, age and pandemic phases, the positivity rates between males and females were the same. The odds of a positive result increased significantly with age; individuals aged > 80 years had 2.5 times higher odds of testing positive than those aged 0-10 years (aOR 2.5, 95% CI 2.3-2.7).

CONCLUSIONS

The analysis indicates a consistent male dominance in COVID-19 testing, with higher positivity rates in older age groups. Our study highlight the importance of examining demographic characteristics in disease associated data especially, representation of females amongst cohorts.

Use and perception of risk: traditional medicines of Pakistani immigrants in Norway

BACKGROUND

Pakistani immigrants are the largest non-Western ethnic minority group in Norway. Traditional medicines (TM) are extensively used in Pakistan, and studies show that ethnic minorities also use them to recover from illness after migration to the Western world. This study aims to explore Pakistani immigrants' experiences and perceptions of risk regarding the use of TM to treat illnesses.

METHODS

A qualitative study was conducted through in-depth interviews (n = 24) with Pakistani immigrants in Norway from February to March 2023. Participants were recruited through purposive and snowball sampling methods. The data was analyzed using Braun & Clarke's reflexive thematic analysis (RTA) using Nvivo.

RESULTS

RTA revealed three main themes and six sub-themes. The main themes were: (a) House of knowledge, (b) Choosing the best possible approach for health restoration, and (c) Adverse effects of TM used. A total of 96 different TM were identified, including herbs, food items, animal products, minerals, herbal products, and ritual remedies. All participants used TM to restore health in acute and chronic diseases, and many used TM along with conventional medicines. The participants' mothers were the primary source of knowledge about TM, and they passed it on to the next generation. They also frequently used religious knowledge to recover from illness. Although TM is considered safe because of its natural origin, some participants experienced adverse effects of TM, but none of them reported it to the health authorities.

CONCLUSION

The study helps to understand the experiences and perceptions of risk of Pakistani immigrants in Norway regarding traditional practices for treating health complaints. Public health policies to improve the health of these immigrants should consider the importance of TM in their lives. Further research is necessary to explore the safety and toxicity of those TM that are common in Pakistani households in Norway.

Assessment of factors associated with self-medication practices during the COVID-19 pandemic in southwestern Ethiopia: a community-based cross-sectional survey

BACKGROUND

Self-medication practices involve the use of medications without healthcare professional requests. The threat of coronavirus disease 2019 (COVID-19) caused the practice of a fittest to survive action, with the assumption that something is better than nothing. Moreover, owing to the lack of effective treatment for COVID-19, the general public has shifted toward self-medication and symptomatic treatment, with approximately 80% of people stockpiling medication for use during the pandemic. Thus, this study aimed to assess the factors associated with self-medication practices during the COVID-19 pandemic crisis in southwestern Ethiopia.

METHODS

A community-based cross-sectional study design was employed at selected drug retail outlets in southwestern Ethiopia for 415 community pharmacy clients from July 1, 2021, to September 1, 2021. Purposive sampling techniques were employed to select five drug retail outlets on the basis of high patient flows, and we took the study participants until the required quota allotted to each selected drug retail outlet had been filled. Bivariable and multivariable logistic regression analyses were employed to identify factors associated with self-medication. AORs with 95% CIs were used to report associations, and the level of significance was set at P < 0.05.

RESULTS

Self-medication was significantly associated with being female (AOR 3.51, 95% CI 1.04-12.41), having a college education or above (AOR 47, 95% CI 4.32-55.21), time wastage at public health facilities (AOR 2.71, 95% CI 3.47-5.21), being afraid of contracting COVID-19 (AOR 0.006, 95% CI 0.004-0.185), and having high fees at public health facility (AOR 0.006, 95% CI 0.004-0.185). The most frequently used medications to treat or prevent the COVID-19 pandemic were analgesics (42.4%) and cold medicines (29.5%). Headache (22.2%), fever (13.2%), respiratory infection (14.3%), and cold (21.4%) were the most frequently reported symptoms of the COVID-19 pandemic.

CONCLUSION

This study revealed high self-medication practices among study area residents during the COVID-19 pandemic. The primary reasons for self-medication in the context of COVID-19 are fear of the pandemic and time wastage at public health facilities. Therefore, special attention should be given to educating public and health care providers on the types of illnesses that can be self-diagnosed and self-treated and the types of drugs to be used for self-medication.

The influence of sociodemographic factors on parental health-seeking behavior for illnesses among the pediatric age group in Karachi: A cross-sectional study

Background

Health-seeking behavior (HSB) is an individual's reaction to sickness, for which they seek medical attention, regardless of the form such care may take. Poor HSB is frequently associated with lower health outcomes and greater mortality and disease rates in a nation. Sociodemographic factors, including age, gender, family structure, occupation, ethnicity, and rates of literacy and poverty, can influence a person's HSB. This study would benefit Pakistani parents of the paediatric population to make more informed health choices for their children.

Aim

This study aims to determine the influence of sociodemographic factors on parental HSB for illnesses among the pediatric age group in Karachi.

Materials and Methods

A cross-sectional study was conducted in which 214 parents were interviewed about their choices for health-seeking healthcare for their pediatric children of the pediatric age group (birth-18 years), who were attending the pediatric OPD and wards at Dr. Ruth Pfau Civil Hospital, Karachi in May 2023. Only parents or guardians with sick children were included. Their sociodemographic characteristics and health-seeking choices were asked. Informed consent was obtained, and all data were recorded. SPSS version 25 was used for analysis.

Results

For the first choice, the majority of parents (82.7%) preferred to seek healthcare for their children from medical doctors, followed by spiritual healers (10.7%), traditional healers (5.6%), and homoeopathic doctors (0.9%). For the second choice, the highest percentage was for a doctor (76.2%), followed by a spiritual healer (18.7%), a homoeopathic doctor (3.3%), and a traditional healer (1.9%). A significant correlation was found between the first visit and the decision makers (p = 0.019), the father's education level of the father (p = 0.001), the mother's occupation of the mother (p = 0.019), and the mother's education level of the mother (p = 0.001).

Conclusion

Sociodemographic characteristics greatly influence parents' HSBs of parents for their children. Despite having low-paying jobs and being uneducated, most people choose to refer to a doctor for their child due to awareness.

Development of palliative care clinical practice guidelines and referral care pathways for primary care practitioners in Pakistan

BACKGROUND

Despite a large burden of life-limitingillness, there exists a dearth of services of palliative care in Pakistan. International guidelines have questionable applicability in Pakistan due to the socioeconomic differences. We generated a protocol describing the process of developing comprehensive palliative care guidelines and palliative care referral pathways for primary care practitioners to adopt in Pakistan.

METHODS

A GRADE-ADOLOPMENT approach with modification has been employed to create guidelines for a Pakistani context. The "National Comprehensive Cancer Network Guidelines Insights: Palliative Care, Version 2.2021" was used as the source guideline. Recommendations from the source guideline were reviewed by two local palliative care specialists to either "Adopt," "Adapt" or "Exclude". The finalized recommendations were incorporated into the local palliative care guideline. Clinical diagnosis and referral pathways were made from the finalized guideline. Any gaps in management found in the pathways were filled by taking existing recommendations from other credible guidelines.

RESULTS

Twenty-seven recommendations were adopted without modification. No recommendations were deemed to be adapted and 15 were excluded. The referral care pathways created were reflective of the local guideline and included elements of initial assessment, preliminary management, reassessment, and referral. 6 additional recommendations were made.

CONCLUSION

The described clinical practice guidelines and primary care clinical referral pathways will aid to standardize palliative care provision in Pakistan. These can be used by other resource constrained settings to develop guidelines within their own local context.

Out-of-pocket expenditures associated with double disease burden in Pakistan: a quantile regression analysis

BACKGROUND

Pakistan is currently experiencing a double burden of disease. Families with members having both communicable and noncommunicable diseases are at a greater risk of impoverishment due to enormous out-of-pocket payments. This study examines the percentile distribution of the determinants of the out-of-pocket expenditure on the double disease burden.

METHOD

The study extracted a sample of 6,775 households with at least one member experiencing both communicable and noncommunicable diseases from the Household Integrated Economic Survey 2018-19. The dataset is cross-sectional and nationally representative. Quantile regression was used to analyze the association of various socioeconomic factors with the OOP expenditure associated with double disease burden.

RESULTS

Overall, 28.5% of households had double disease in 2018-19. The households with uneducated heads, male heads, outpatient healthcare, patients availing public sector healthcare services, and rural and older members showed a significant association with the prevalence of double disease. The out-of-pocket expenditure was higher for depression, liver and kidney disease, hepatitis, and pneumonia in the upper percentiles. The quantile regression results showed that an increased number of communicable and noncommunicable diseases was associated with higher monthly OOP expenditure in the lower percentiles (10th percentile, coefficient 312, 95% CI: 92-532), and OOP expenditure was less pronounced among the higher percentiles (75th percentile, coefficient 155, 95% CI: 30-270). The households with older members were associated with higher OOP expenditure at higher tails (50th and 75th percentiles) compared to lower (10th and 25th percentiles). Family size was associated with higher OOPE at lower percentiles than higher ones.

CONCLUSION

The coexistence of communicable and noncommunicable diseases is associated with excessive private healthcare costs in Pakistan. The results call for addressing the variations in financial costs associated with double diseases.

Acute physiology and chronic health evaluation score and mortality of patients admitted to intermediate care units of a hospital in a low- and middle-income country: A cross-sectional study from Pakistan

Background

Intermediate care units (IMCUs) serve as a bridge between general wards and intensive care units by providing close monitoring and rapid response to medical emergencies. We aim to identify the common acute medical conditions in patients admitted to IMCU and compare the predicted mortality of these conditions by acute physiology and chronic health evaluation-II (APACHE-II) score with actual mortality.

Methods

A cross-sectional study was conducted at a tertiary care hospital from 2017 to 2019. All adult internal medicine patients admitted to IMCUs were included. Acute conditions were defined as those of short duration (<3 weeks) that require hospitalization. The APACHE-II score was used to determine the severity of these patients' illnesses.

Results

Mean (standard deviation [SD]) age was 62 (16.5) years, and 493 (49.2%) patients were male. The top three acute medical conditions were acute and chronic kidney disease in 399 (39.8%), pneumonia in 303 (30.2%), and urinary tract infections (UTIs) in 211 (21.1%). The mean (SD) APACHE-II score of these patients was 12.5 (5.4). The highest mean APACHE-II (SD) score was for acute kidney injury (14.7 ± 4.8), followed by sepsis/septic shock (13.6 ± 5.1) and UTI (13.4 ± 5.1). Sepsis/septic shock was associated with the greatest mortality (odds ratio [OR]: 6.9 [95% CI (confidence interval): 4.5-10.6]), followed by stroke (OR: 3.9 [95% CI: 1.9-8.3]) and pneumonia (OR: 3.0 [95% CI: 2.0-4.5]).

Conclusions

Sepsis/septic shock, stroke, and pneumonia are the leading causes of death in our IMCUs. The APACHE-II score predicted mortality for most acute medical conditions but underestimated the risk for sepsis and stroke.

Relationship of Gender With Laser Retinopexy for Retinal Breaks

PURPOSE

To explore the relationship of gender with laser retinopexy for retinal breaks in the Pakistani population.

MATERIALS AND METHODS

This was a 10-year retrospective observational study conducted at Aga Khan University Hospital, Karachi, Pakistan. All consecutive patients who underwent laser retinopexy between January 2009 and December 2018 for a retinal tear or high-risk retinal degeneration (such as lattice degeneration) were included in this study. Data were collected from patients' files. Index eyes with a history of or treatment for retinal detachment were excluded. A structured pro forma was used to collect information. Descriptive statistics were used to explore the relationship between gender and laser retinopexy.

RESULTS

We identified 12,457 patients through the coding system of our hospital who underwent various laser procedures from January 2009 to December 2018. Yttrium aluminium garnet (YAG) laser, laser peripheral iridotomy (PI), and laser trabeculoplasty procedures were all excluded. A total of 3,472 patients' files were reviewed for this study, out of which 958 patients met the inclusion criteria. Males accounted for a higher number (n=515, 53.87%). The mean age was 43.99±15.37 years. For exploratory analysis, participants were divided into five age groups: <30 years (24.16%); 31-40 years (16.59%); 41-50 years (19.45%); 51-60 years (26.40%); and >60 years (13.49%). Bilateral laser retinopexy was performed in 48.12% of patients; 24.79% and 27.13% of patients underwent unilateral laser retinopexy for the right and left eyes, respectively.

CONCLUSION

In our cohort study, laser retinopexy was more commonly performed in men than in women. The ratio was not significantly different from the prevalence of retinal tears and retinal detachment in the general population, which has a slightly higher male preponderance. We did not find evidence of significant gender bias among patients who underwent laser retinopexy in our study.

Supernatural beliefs, religious affiliations, and HIV testing among recently arrived Asian-born men who have sex with men in Australia

HIV testing rates among recently arrived (≤5 years) Asian-born men who have sex with men (MSM) in Australia remain suboptimal. Research indicates that belief in supernatural determinants of health (supernatural beliefs) may be an important barrier to greater HIV test uptake. We examined potential associations between supernatural beliefs and HIV testing among recently arrived Asian-born MSM in Australia. In 2019, an online survey was completed by 186 self-identified MSM born in Asia, and who arrived in Australia within the past five years and were never diagnosed with HIV. Supernatural belief was measured as the extent to which one felt that health was influenced by supernatural forces. Measures of association were estimated with multiple logistic regression. Participants with supernatural beliefs were significantly less likely to have tested for HIV in the past year. The adjusted predicted probability of not testing for HIV in the past year was 44.8% among those who held supernatural beliefs (95% CI: 30.5-59.2%), but only 5.2% among those who did not hold supernatural beliefs (95% CI: 1.9-8.6%). Religious affiliation was not significantly associated with testing for HIV. Supernatural beliefs may be an important but underappreciated barrier to HIV testing among recently arrived Asian-born MSM in Australia.

Rural mothers' beliefs and practices about diagnosis, treatment, and management of children health problems: A qualitative study in marginalized Southern Pakistan

Introduction

Appropriate health-seeking beliefs and practices are indispensable for the survival and development of children. In this study, we explore childcare beliefs and practices of rural mothers and analyze the different ways childhood illness is diagnosed and managed in a marginalized rural community in Southern Pakistan.

Methods

Using purposive sampling, in-depth interviews are conducted to obtain qualitative data from 20 illiterate and rural mothers in addition to 15 healthcare providers in the district Rajanpur of South Punjab.

Results and discussion

The findings reveal that rural mothers' access to healthcare and therapeutic programs is impeded due to geographical isolation, structural inequalities, poverty, and illiteracy. Consequently, evil eyes, witchcraft, and spirits are recognized as potential threats to children's health and nutrition. Therefore, the treatment of childhood morbidity and malnutrition is mostly performed with folk, domestic, herbal, magico-religious remedies, and spiritual healing methods. The current study also highlights that many low-income and rural mothers tend to normalize childhood illness when they become unable to advocate for their children's health and nutrition. Besides improving low-income mothers' access to healthcare facilities, health education and risk communication at the field level through field health staff could be most effective for health promotion.

Predictors of Non-Obstructive Coronary Artery Disease in Patients Undergoing Elective Coronary Angiography

Background

Appropriate patient selection for coronary angiography (CAG) is essential to minimize the unnecessary risk of morbidities and exposure to radiation and iodinated contrast. This becomes even more relevant in low-to-middle-income settings where most health expenditures are out-of-pocket due to lack of medical insurance. We determined predictors of non-obstructive coronaries (NOC) in patients undergoing elective CAG.

Methods

CathPCI Registry®, single-center data was extracted for 25,472 patients who had CAG over an eight year period. After excluding patients for compelling conditions or known CAD, 2,984 (11.7%) patients were included in this study. Non-Obstructive Coronaries was defined as <50% left main coronary artery and major epicardial vessel stenosis. Multiple Cox proportional algorithm was employed to report prevalence ratios (PR) of predictors of NOC along with 95% confidence interval.

Results

Mean age of patients was 57.9 ± 9.7 years, 23.5% were women. Preprocedural non-invasive testing (NIT) was performed in 46% of the patients; of which 95.5% reported to be positive but only 67.3% were stratified as high risk. Of 2,984 patients undergoing elective CAG, 711 (24%) had NOC. Predictors of NOC included younger age <50 years (PR: 1.3, CI: 1.0-1.5), Women (1.8, 1.5-2.1), low (1.9, 1.5-2.5) and intermediate risk stratification (1.3, 1.0-1.6) on Modified Framingham Risk Score and inappropriate (2.7, 1.6-4.3) and uncertain (1.3, 1.1-1.6) classification of CAG on Appropriate Use Criteria. Patients with heart failure as an indication of CAG (1.7, 1.4-2.0) and No NIT or positive low risk NIT (1.8, 1.5-2.2) were more likely to have NOC.

Conclusion

Approximately one out of four patients undergoing elective CAG had NOC. Yield of diagnostic catheterization can be improved by adjudicating NIT especially in younger patients, women, patients with heart failure as an indication of CAG, patients classified as inappropriate on Appropriate Use Criteria and patients categorized as low or intermediate risk on MFRS.

Prevalence and determinants of home delivery among reproductive age women, Margibi County, Liberia

Background

The use of institutional delivery services is essential for improving maternal and child health. However, studies in Liberia reveal over 20% of women still deliver at home. We assessed the prevalence and associated factors of home delivery among women of reproductive age in Margibi County, Liberia.

Methods

We conducted a cross-sectional study among 438 women of reproductive age in Margibi County. Data were obtained using a semi-structured questionnaire. A simple random sampling approach was used to select the participants for the study. We performed binary logistic regression to identify factors influencing home delivery. Findings were summarized into tables displaying the frequencies, percentages, crude, and adjusted odds ratios (ORs) and 95% confidence intervals (CIs).

Results

Prevalence of home delivery in the County was 90.6% (95% CI = 87.5 – 93.0). Women who were ≥ 31 years (aOR = 6.74, 95%CI = 2.86—15.90), women who had two or more children (aOR = 9.68, 95%CI = 4.07—22.99) and those who had rapid onset of labor (aOR = 6.35, 95%CI = 1.59 – 25.27) were associated with increased odds of home delivery. Good attitude of health workers (aOR = 0.01, 95%CI = 0.001 – 0.08) and the availability of transport to the nearest health facility (aOR = 0.01, 95%CI = 0.003 – 0.03) were factors associated with a decreased odds of home delivery among the study participants.

Conclusion

The high prevalence of home delivery in the county is a call for urgent interventions by the government of Liberia and various non-governmental organizations. The government may need to supply the county with ambulances and ensure in-service training of health workers on good attitudes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04975-7.

Experience and Perception of Patients and Healthcare Professionals on Acute Leukemia in Rwanda: A Qualitative Study

Purpose

To explore challenges associated with the timely diagnosis, therapy, and prognosis of acute leukemia in Rwanda.

Methods

This is a qualitative study using a phenomenological approach that involved patients, patients’ guardians, and healthcare professionals such as physicians from district hospitals and specialists from referral hospitals, as well as healthcare administrators. The primary data were collected from district and referral hospitals and central healthcare administration in Rwanda. The data were collected between July and October 2019. In-depth interviews were conducted, and thematic analysis was employed to interpret the results.

Results

We identified barriers to seeking healthcare such as (i) insufficient knowledge within the population may lead patients and their guardians to consult traditional healers before seeking qualified medical care, and (ii) financial constraints that preclude payment of healthcare fees or other out-of-pocket cost related to diagnosis and treatment. We also observed that the referral system is tedious and primary healthcare facilities lack the competence and resources for the necessary diagnostic practices. Both may further delay diagnosis and therapy. Accordingly, healthcare professionals at the referral hospitals stated that most patients were seen at an advanced stage of the disease. For the treatment of acute lymphoblastic leukemia (ALL), only chemotherapy is utilized in Rwanda, while bone marrow (BM) transplantation is not available. Palliation is the only available treatment for the vast majority of Rwandan acute myeloid leukemia (AML) patients.

Conclusion

ALL and AML are likely under-reported in Rwanda and diagnosis may be delayed, which may be explained by patient-related factors (lack of knowledge, financial constraints), a tedious referral system, and suboptimal diagnostic resources.

Bringing Medicine from Pakistan and Self-Medication Among Pakistani Mothers in New Zealand

Worldwide migration leads to people bringing beliefs and practices from one country into another, including those related to self-medication. This study explores the self-medication practices of Pakistani mothers for their children and their reasons for self-medication. We interviewed 23 immigrants. Each interview lasted 60-80 min and was conducted in Urdu. Participants had been living in New Zealand on average 3.25 years. They talked about their prior knowledge and experiences regarding self-medication behaviour for their children. The majority of the mothers treat their children at home before visiting a general practitioner (GP) due to previous unsatisfactory experiences. There was a significant relationship between participants who had family members in healthcare professions, their experiences of healthcare services and self-medication. Bringing medicines from Pakistan is a key source for self-medication practices. Self-medication awareness programs could help mothers to practice safe and responsible use of medicines for the benefit of their children.

Self-Medication Practices in Medical Students During the COVID-19 Pandemic: A Cross-Sectional Analysis

Background and Objectives

During the pandemic, the growing influence of social media, accessibility of over-the-counter medications, and fear of contracting the virus may have led to self-medication practices among the general public. Medical students are prone to such practices due to relevant background knowledge, and access to drugs. This study was carried out to determine and analyze the prevalence of self-medication practices among medical students in Pakistan.

Materials and Methods

This descriptive, cross-sectional study was conducted online in which the participants were asked about the general demographics, their self-medication practices and the reasons to use. All participants were currently enrolled in a medical college pursuing medical or pharmacy degree. Non-probability sampling technique was used to recruit participants.

Results

A total of 489 respondents were included in the final analysis. The response rate was 61%. Majority of the respondents were females and 18–20 years of age. Self-medication was quite prevalent in our study population with 406 out of 489 individuals (83.0%) were using any of the drugs since the start of pandemic. The most commonly utilized medications were Paracetamol (65.2%) and multivitamins (56.0%). The reasons reported for usage of these medications included cold/flu, or preventive measures for COVID-19. The common symptoms reported for self-medication included fever (67.9%), muscle pain (54.0%), fatigue (51.7%), sore throat (46.6%), and cough (44.4%). Paracetamol was the most commonly used drug for all symptoms. Female gender, being in 3rd year of medical studies, and individuals with good self-reported health were found more frequent users of self-medication practices.

Conclusion

Our study revealed common self-medication practices among medical and pharmacy students. It is a significant health issue especially during the pandemic times, with high consumption reported as a prevention or treating symptoms of COVID-19.

Integrating lay knowledge and practice into snakebite prevention and care in central Africa, a hotspot for envenomation

The WHO has identified the goal of halving deaths and disability from snakebite envenomation (SBE) by 2030 through a four-pillar program that promotes accessible and affordable treatments, strengthens health systems, promotes community and multi-level engagement, and mobilizes partnerships, coordination and resources to advocate for global action. This initiative could accelerate multi-disciplinary research and action in central Africa, a “hotspot” for SBE, but it offers little specific guidance about anthropological research to be conducted. This commentary develops that research agenda. It surveys anthropological, ethnohistorical investigations in the central African forest to elaborate the socio-cultural and historical significance and practices around snakes and snakebites. It draws from south and southeast Asian and Latin American literatures to illustrate anthropological contributions to SBE research. It then outlines a Central African research agenda employing ethnobiological investigation of snake ecologies, participatory evaluations of humans-snake contacts, and interviews and participant-observation of local prevention and treatment practices and knowledge. This research will co-develop policies and practices with forest communities and leaders and regional and national authorities to reduce the burden of SBE.

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Central African forests are a hotspot for snakebite envenomation.

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SBE research in central Africa has not mobilized anthropological literatures or methodologies.

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Policies to reduce SBE burden in central Africa should build on participatory research.

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Policies to reduce SBE burden should be co-developed with local and national stakeholders.

Proactive Teleconsultation for Coronavirus Disease 2019 Cases Identified Through the Community-Testing Initiative in Karachi, Pakistan: A Low-Cost Value-Added Service to Support a Pandemic Response in a Resource-Limited Setting

Background: Coronavirus disease 2019 (COVID-19) struck Pakistan with a magnitude that required micro- and macro-level adjustments at national and provincial levels. Access to medical consultation became a challenge; hospitals were flooded with cases beyond their capacity and transport was halted due to lockdown. Global Health Directorate of The Indus Health Network supported the provincial government by rolling out several walk-in community-based testing initiatives across Karachi. Results were conveyed to the patients through each district government. With a disproportionate rise in cases, an increasing delay in reporting results was observed. Methods: To help the district government bridge this gap, two physicians were engaged to convey timely results to patients who tested positive, through a helpline. Subsequently, proactive teleconsultation was initiated. We present a retrospective review of data collected during teleconsultation for COVID-19 cases identified through community-based testing between April 5 and June 10, 2020. Results: A total of 4,279 tests were conducted, revealing a 28% positivity rate (1,196 cases). Out of these, 752 (62.9%) baseline positive patients were contactable. Most patients identified either a close contact (46.8%) or a household contact (30.1%) as the source of infection. 41.8% patients were asymptomatic, 52.9% had mild to moderate illness, and 1.1% needed referral to the emergency department. 82.7% patients reported no comorbidities. Conclusion: The rapid surge of cases could not be handled by a small team and an institutional strategy of integration into an existing call center service was adopted. We share our insights to help develop evidence-based policies to effectively tackle current or future threats in similar settings.

Health-Seeking Behavior of People in Indonesia: A Narrative Review

This review aims to locate existing studies on health-seeking behavior of people in Indonesia, identify gaps, and highlight important findings. Articles were retrieved from Medline, Scopus, Web of Science, Academic Search Complete (via Ebsco), and ProQuest with a number of key words and various combinations. Articles from Indonesian journals were also searched for with Google Scholar. A total of 56 articles from peer-reviewed journal databases and 19 articles from Indonesian journals were reviewed. Quantitative designs were applied more frequently than qualitative, and mixed methods designs were used in some studies. The majority gathered retrospective information about people's behaviors. Communicable diseases and maternity care were the most frequently studied conditions, in contrast to noncommunicable diseases. In terms of geographical distribution, most research was conducted on Java island, with very few in outside Java. Important findings are a model of Indonesian care-seeking pathways, an understanding of determinants of people's care choices, and the role of sociocultural beliefs. The findings from this narrative review provide insight to what and how Indonesians make decisions to manage their illness and why. This makes an important contribution to understanding the problem of underutilization of medical services despite the government's extensive efforts to improve accessibility.

Utility of teleconsultation in accessing eye care in a developing country during COVID-19 pandemic

OBJECTIVE

To evaluate the utility of teleconsultation in the provision of eye care services during the COVID-19 lockdown. Disparities in the consultation burden of sub-specialities and socio-demographic differences in teleconsultation utilization were also assessed.

METHODS

Al-Shifa Trust Eye Hospital Rawalpindi began audio and video teleconsultation using broadband telecommunication services during the lockdown. Patients' and consultations' data gathered during the first three weeks after the commencement of this programme were compared with data from the four weeks prior to lockdown. The weekly consultation ratio and overall consultation burden of sub-specialities were measured. Chi-Square tests of association determined the relationship between different variables (socioeconomic status and consultation characteristics) and consultation modality (on-site vs online).

RESULTS

In total, 17507 on-site consultations (4377/week) were conducted compared to 1431 teleconsultations (477/week), which maintained 10.89% of the weekly pre-lockdown eye care services. The post-lockdown teleconsultation programme saw a relatively higher percentage of service utility among female (47.09% vs 44.71%), younger-age (31.33±19.45 vs 41.25±23.32 years) and higher-socioeconomic-status (32.21% vs 0.30%) patients compared to pre-lockdown on-site consultations. The most common indication for teleconsultation was red-eye (16.70%). While cornea and glaucoma clinics maintained most of the pre-lockdown services (30.42% and 29% respectively), the highest dropout was seen in optometric and vitreoretinal services supporting only 5.54% and 8.28% of pre-lockdown services, respectively.

CONCLUSION

Digital initiatives could partially maintain eye care services during the lockdown. Focused strategies to improve teleconsultation utilization are required during the pandemic and beyond.

State, religion and the marginalisation of traditional healing in Gwadar, Pakistan

This ethnographic encounter explores suppression and domination faced by traditional health seekers in Gwadar, Pakistan. The study aimed to provide an insight into the ways in which practicing traditional healthcare becomes a challenge when it conflicts with the assimilationist project of the state. Qualitative research methods, including in-depth interviews and participant observation, were used to collect data on the encounters of traditional health seekers with the state and dominant religion. The findings show that traditional health seeking behaviour was stereotyped as non-civilised and archaic by medical staff, and labelled as non-religious, and thus, suppressed by radical Islamist groups and other state apparatuses. This situation has further negative effects on the health of traditional health seekers as the national healthcare system does not efficiently provide the services required by this population. State laws, a general environment of fear, and threats have led this population to legal consciousness and contextual awareness; they have further adopted multiple resistance strategies to navigate and circumvent oppressive laws and domination in order to follow their traditional healthcare practices. This study suggests that national cosmopolitan healthcare services provided to the fishing community should be tailored to and not suppress the culturally specific health needs of that population. Members of the fishing community should not be compelled to abstain from their traditional healthcare and health-seeking behaviours; traditional healthcare practices should be merged with cosmopolitan ones in order to address the sociocultural issues and meet the health needs of this marginalised population.

Traditional practices during pregnancy and birth, and perceptions of perinatal losses in women of rural Pakistan

OBJECTIVE

Understanding the sociocultural context and local practices during pregnancy and birth is imperative to identify factors related to perinatal mortality in countries where its burden is high. This study aims to explore the pregnancy and birth related cultural practices and the perceptions of women with a recent perinatal death in Sindh province, Pakistan.

DESIGN

This qualitative exploratory study consisted of in-depth interviews with women who had experienced a perinatal death in the year preceding the study. Women were identified and recruited with the help of lady health workers. After consent, women were interviewed in their homes and in their own language (Sindhi) by a local female interviewer.

SETTING AND PARTICIPANTS

Interviews were conducted with women from predominantly rural district of the southern province of Sindh in Pakistan between May and August 2018. The data were coded both inductively and deductively and then analysed using themes.

FINDINGS

Twenty-five women were interviewed. Traditional home remedies were commonly used to alleviate pregnancy symptoms such as general aches and pains. The health providers often delayed the information about the perinatal deaths in health facilities, which saddened the women. Most women had fatalistic opinions about what caused their losses, and explained the cause based on their own interpretation, which were not necessarily consistent with known causes of perinatal death. The women also desired to use contraception and believed that it would prevent future pregnancy loss; however, many women were unable to make that decision themselves.

CONCLUSIONS AND IMPLICATIONS

The high use of traditional home-based remedies may be a proxy measure for poor access to formal healthcare services. Many women described poor acknowledgement of their grief which may be harmful. Women's knowledge about the causes of perinatal mortality in general was very low, improving this knowledge may help women to seek appropriate healthcare services during pregnancy.

Functional venomics of the Big-4 snakes of Pakistan

In South Asia, the "Big-4" venomous snakes Naja naja, Bungarus caeruleus, Daboia russelii, and Echis carinatus are so-called because they are the most medically important snakes in the region. Antivenom is the only effective treatment option for snakebite envenoming but antivenom is not produced domestically in Pakistan making the country reliant on polyvalent products imported from India and Saudi Arabia. The present study investigated the toxin composition and activity of the venoms of Pakistani specimens by means of proteomic and physio/pharmacological experiments. To evaluate the composition of venoms, 1D/2D-PAGE of crude venoms and RP-HPLC followed by SDS-PAGE were performed. Enzymatic, hemolytic, coagulant and platelet aggregating activities of crude venoms were assayed and were concordant with expectations based on the abundance of protein species in each. Neutralization assays were performed using Bharat polyvalent antivenom (BPAV), a product raised against venoms from Big-4 specimens from southern India. BPAV exhibited cross-reactivity against the Pakistani venoms, however, neutralization of clinically relevant activities was variable and rarely complete. Cumulatively, the presented data not only highlight geographical variations present in the venoms of the Big-4 snakes of South Asia, but also demonstrate the neutralization potential of Indian polyvalent against the venom of Pakistani specimens. Given the partial neutralization observed, it is clear that whilst BPAV is a life-saving product in Pakistan, in future it is hoped that a region-specific product might be manufactured domestically, using venoms of local snakes in the immunising mixture.

Current Status of Malnutrition and Stunting in Pakistani Children: What Needs to Be Done?

Malnutrition is one of the greatest health challenges that affects about 2 billion people globally. Multiple factors including poverty, food insecurity, maternal health and nutritional status, mother's age at marriage and educational status, low birthweight or small for gestational age (SGA), premature births, suboptimal breastfeeding practices, unhealthy dietary and lifestyle patterns, health and immunization status of children, socioeconomic status of family, environmental and household conditions, together with cultural practices and myths, play vital role in affecting the growth of children at early age. Although child stunting has declined in Pakistan, the reduction rate is only 0.5%, which is very low. This may be due to ineffective or inappropriate intervention programs as they are mostly addressing only one issue at a time and don't use the multi-sector approach to address numerous determinants of stunting. It is therefore important to initiate cost-effective multi-tiered intervention approaches to be implemented at pre-conception, pregnancy and early postpartum stages to prevent the problems of malnutrition and stunting in Pakistani children. This review discusses the etiology of child malnutrition and stunting in Pakistan, role of various determinants of stunting and what type of intervention strategies and approaches should be developed and implemented to deal with these problems. Key teaching pointsMalnutrition is one of the greatest global health challenges.Poverty, food insecurity, socioeconomic status, unhealthy dietary patterns, maternal health and nutritional status, low birthweight, suboptimal breast feeding, environmental conditions, cultural practices and myths, are the main factors for child malnutrition and stunting in Pakistan.The slow reduction rate in child stunting may be due to inappropriate intervention programs.Cost-effective multi-tiered intervention approaches must be implemented at pre-conception, pregnancy and early postpartum stages to prevent child malnutrition and stunting in Pakistan.A holistic approach comprising nutrition and WASH interventions, together with strategies to improve the socioeconomic status be developed and implemented to resolve this dilemma.

Utilisation of Healthcare Services and Medicines by Pakistani Migrants Residing in High Income Countries: A Systematic Review and Thematic Synthesis

Migration, as a global phenomenon, gives rise to many challenges for healthcare professionals providing care to migrant populations. Migrants originating from diverse cultural backgrounds have unique beliefs and healthcare needs, and their utilisation of healthcare services and medicines is influenced by a number of factors. This review aims to assess the factors influencing the utilisation of healthcare services and medicines among Pakistani migrants residing in high income countries. The databases searched included PubMed/Medline, Scopus, EMBASE, Web of Science, CINAHL, and IPA. Of the 2566 publications initially obtained, 37 met the inclusion criteria. They included eight countries-the United Kingdom, United States of America, Canada, Denmark, Norway, Australia, United Arab Emirates and Cyprus. Eight descriptive themes emerged and two analytical constructs were established, as a result of thematic synthesis of included publications. The profile of utilisation of healthcare services and medicines among Pakistani migrants was multifaceted and influenced by their individual circumstances (socioeconomic characteristics; personal beliefs, preferences, and experiences; individual culture and religion; family and friends; and language and communication), and host country characteristics (work environment; healthcare organisation, access and affordability; and health professionals' education, practices, and preferences). Awareness of population-specific characteristics of migrant communities is important to promote and implement culturally appropriate healthcare practices and service provision.

Prevalence of chronic kidney disease in South Asia: a systematic review

Background

Chronic kidney disease (CKD) is becoming a major public health problem around the world. But the prevalence has not been reported in South Asian region as a whole. This study aimed to systematically review the existing data from population based studies in this region to bridge this gap.

Methods

Articles published and reported prevalence of CKD according to K/DOQI practice guideline in eight South Asian countries between December 1955 and April 2017 were searched, screened and evaluated from seven electronic databases using the PRISMA checklist. CKD was defined as creatinine clearance (CrCl) or GFR less than 60 ml/min/1.73 m².

Results

Sixteen population-based studies were found from four South Asian countries (India, Bangladesh, Pakistan and Nepal) that used eGFR to measure CKD. No study was available from Sri Lanka, Maldives, Bhutan and Afghanistan. Number of participants ranged from 301 in Pakistan to 12,271 in India. Majority of the studies focused solely on urban population. Different studies used different equations for measuring eGFR. The prevalence of CKD ranged from 10.6% in Nepal to 23.3% in Pakistan using MDRD equation. This prevalence was higher among older age group people. Equal number of studies reported high prevalence among male and female each.

Conclusions

This systematic review reported high prevalence of CKD in South Asian countries. The findings of this study will help pertinent stakeholders to prepare suitable policy and effective public health intervention in order to reduce the burden of this deadly disease in the most densely populated share of the globe.

Electronic supplementary material

The online version of this article (10.1186/s12882-018-1072-5) contains supplementary material, which is available to authorized users.

Potential drug-drug interactions in outpatient department of a tertiary care hospital in Pakistan: a cross-sectional study

BACKGROUND

Potential drug-drug interactions (pDDIs) are one of the preventable drug related problems having the risk of serious adverse events or therapeutic failure. In developing countries like Pakistan, this issue remains poorly addressed. The objective of this study was to explore prevalence of pDDIs in the Outpatient Department (OPD) of a tertiary care hospital in Pakistan. The secondary aim was to describe the levels of reported pDDIs and develop a list of widespread clinically relevant interactions.

METHODS

Prescriptions of 2400 OPD patients were analyzed for pDDIs through Micromedex Drug-Reax®. Prevalence, severity- and documentation-levels and widespread clinically relevant interactions were reported.

RESULTS

Of total 2400 prescriptions, pDDIs were present in 22.3%. Whereas, moderate- and major-pDDIs were found in 377 (15.7%) and 225 (9.4%), respectively. PDDIs were more prevalent in Medicine (9.2%) and Cardiology (2.6%) as compared with other OPD specialties. Total 942 pDDIs were identified, of which, the majority were either moderate- (61.9%) or major-pDDIs (32.1%). Some of the most common interactions were ibuprofen + levofloxacin (n = 50), ciprofloxacin + diclofenac (32), aspirin + atenolol (24), and diclofenac + levofloxacin (19). The potential adverse outcomes of widespread interactions were seizures, bleeding, QT-interval prolongation, arrhythmias, tendon rupture, hypoglycemia/hyperglycemia, serotonin syndrome, drug toxicity, and decreased therapeutic response.

CONCLUSIONS

OPD patients were at risk to pDDIs, particularly to major- and moderate-pDDIs. Screening of prescriptions for pDDIs and monitoring of pharmacotherapy in terms of response and associated adverse drug events will contribute to patient safety.

First Aid Practices and Health-Seeking Behaviors of Caregivers for Unintentional Childhood Injuries in Ujjain, India: A Community-Based Cross-Sectional Study

Data on types of community first aid use and treatment provided post-injury from many low‒middle-income countries, including India, are lacking. This cross-sectional study was conducted among children aged one month to 18 years of age, in Ujjain, India, to understand types of first aid given and health-seeking post-injury. A total of 1087 injuries in 1049 children were identified in the past year. A total of 729 (67%) injured children received first aid and 758 (70%) sought some form of health care. Children with burns received the most (86%) first aid, and most children (84%) with road traffic accidents (RTA) sought health care. Most children (52%) sought health care from a private health care facility; most children (65%) were transported to a health care facility within the golden hour. Motorbikes were the most preferred (50%) mode of transport. Only 1% of the injured used ambulance services. Commonly reported methods or substances for first aid included the use of coconut oil on wounds from falls (38%) and burns (44%), the use of antiseptic cream on wounds from RTA (31%), the application of turmeric for wounds from falls (16%), and rubbing of metal on a bitten area (47%). For most injuries, appropriate, locally available substances were used. Potentially harmful substances applied included lime, toothpaste, clay, and mud. The findings will help design community interventions to increase the provision of appropriate first aid for childhood injuries.

Sex differences in symptoms experienced, knowledge about symptoms, symptom attribution, and perceived urgency for treatment seeking among acute coronary syndrome patients in Karachi Pakistan

BACKGROUND

Patients' experience of acute coronary syndrome (ACS) symptoms is important in determining their prehospital delay.

OBJECTIVE

To explore gender differences in acute symptoms of ACS, knowledge about the symptoms, their attribution, and perception of urgency, among Pakistani ACS patients.

METHODS

Comparative, cross-sectional study design with 249 ACS patients.

RESULTS

The most commonly reported symptoms were ghabrahat (fidgetiness), chest pain, and chest heaviness. Most atypical symptoms were experienced more by women, such as nausea/vomiting (p < 0.001), backache (p < 0.001), palpitations (p = 0.004), and epigastric pain (p = 0.005). Chest pain and palpitations were the symptoms most commonly attributed to cardiac causes, whereas epigastric pain was most commonly attributed to non-cardiac causes by both men and women. Significantly more women than men perceived dyspnea (p = 0.026), nausea/vomiting (p = 0.027), sweating (p = 0.014), and palpitations (p = 0.01) as symptoms not at all urgent for treatment.

CONCLUSIONS

Gender disparity in symptom experience along with the women's perception of non-urgency for their symptoms, could lead to delayed care seeking.

Prospective daily diary study reporting of any and all symptoms in healthy adults in Pakistan: prevalence and response

OBJECTIVES

Prevalence of symptoms in everyday life and how people respond to these symptoms is little studied outside Western culture and developed countries. We sought to use modified diary methods to explore the prevalence of and responses to symptoms in Pakistan.

DESIGN

Prospective daily survey of symptoms and response.

SETTING

8 cities across four provinces in Pakistan.

PARTICIPANTS

Stratified intercept in each city to recruit 153 participants of which 151 completed.

PRIMARY AND SECONDARY OUTCOME MEASURES

Each day for 30 days, participants were prompted by text message (short message service (SMS)) to complete a symptom diary. On days where symptoms were experienced, participants also reported how they responded. Prevalence was adjusted to population age and gender distributions.

RESULTS

92% of participants experienced symptoms (adjusted prevalence 94%, 95% CI 91% to 97%), with musculoskeletal pain (83%, adj. 84%, 95% CI 84% to 90%) and respiratory symptoms (75%, adj. 77%, 95% CI 71% to 84%) the most prevalent types of symptoms. Self-medication and use of home remedies and traditional medicines were the most common responses. Seeking professional help or using conventional medicine were less common, and self-medication responses included the use of antibiotics without prescription. The range of home remedies and traditional medicines was very diverse.

CONCLUSIONS

While symptom experience in Pakistan was similar to Western countries, home remedies were much more frequently used to respond to symptoms. Understanding how people respond and manage their experience of symptoms outside formal healthcare is important for designing effective policy and interventions, and this needs to be understood within the broader context including the cultural and economic setting, the health system and other structural determinants of health.

Healthcare seeking behaviour among Chinese elderly

Purpose The Chinese population is rapidly ageing before they are rich. The purpose of this paper is to describe healthcare seeking behaviour and the critical factors associated with healthcare seeking behaviour. Design/methodology/approach Using a purposive sampling method, the authors recruited 44 adults aged 60 years or older from three provinces, representing the developed (Shanghai), undeveloped (Ningxia) regions and the regions in between (Hubei). From July to September 2008, using a semi-structured guide, the authors interviewed participants in focus group discussions. Findings The healthcare needs for chronic and catastrophic diseases were high; however, the healthcare demands were low and healthcare utilizations were even lower owing to the limited accessibility to healthcare services, particularly, in underdeveloped rural areas. "Too expensive to see a doctor" was a prime complaint, explaining substantial discrepancies between healthcare needs, demands and use. Care seeking behaviour varied depending on insurance availability, perceived performance, particularly hospital services, and prescription medications. Participants consistently rated increasing healthcare accessibility as a high priority, including offering financial aid, and improving service convenience. Improving social security fairness was the first on the elderly's wish list. Originality/value Healthcare demand and use were lower than needs, and were influenced by multiple factors, primarily, service affordability and efficiency, perceived performance and hospital service quality.

Barriers and perceptions regarding code status discussion with families of critically ill patients in a tertiary care hospital of a developing country: A cross-sectional study

BACKGROUND

In Asian societies including Pakistan, a complex background of illiteracy, different familial dynamics, lack of patient's autonomy, religious beliefs, and financial constraints give new dimensions to code status discussion. Barriers faced by physicians during code status discussion in these societies are largely unknown.

AIM

To determine the barriers and perceptions in discussion of code status by physicians.

DESIGN

Questionnaire-based cross-sectional study.

SETTING AND PARTICIPANTS

This study was conducted in the Department of Medicine of The Aga Khan University Hospital, Karachi, Pakistan. A total of 134 physicians who had discussed at least five code statuses in their lifetime were included.

RESULTS

A total of 77 (57.4%) physicians responded. Family-related barriers were found to be the most common barriers. They include family denial (74.0%), level of education of family (66.2%), and conflict between individual family members (66.2%). Regarding personal barriers, lack of knowledge regarding prognosis (44.1%), personal discomfort in discussing death (29.8%), and fear of legal consequences (28.5%) were the top most barriers. In hospital-related barriers, time constraint (57.1%), lack of hospital administration support (48.0%), and suboptimal nursing care after do not resuscitate (48.0%) were the most frequent. There were significant differences among opinions of trainees when compared to those of attending physicians.

CONCLUSION

Family-related barriers are the most frequent roadblocks in the end-of-life care discussions for physicians in Pakistan. Strengthening communication skills of physicians and family education are the potential strategies to improve end-of-life care. Large multi-center studies are needed to better understand the barriers of code status discussion in developing countries.

Quality of drug stores: Storage practices & Regulatory compliance in Karachi, Pakistan

OBJECTIVE

To assess and evaluate the drug storage quality and regulatory compliance among privately operated drug stores of Karachi Pakistan.

METHODS

A cross-sectional survey of drug stores located in Karachi was conducted from May to December 2013. A total of 1003 drug stores that were involved in the sales, purchase and dispensing of pharmaceutical products were approached by non-probability purposive sampling technique, and the information was collected using a close ended, structured questionnaire.

RESULTS

Out of 1003 drug stores inspected only 4.1%(n=41) were found compliant to regulatory requirements. Most of the stores 74.9%(n=752) were selling general items along with the drugs. Only 12%(n=124) stores were having qualified person working on the store, out of which 33% were pharmacist. 47.4%(n=400) of the stores had drug sales license displayed in the premises and 33.4%(n=282) of the stores had expired drug sales license. 11.4%(n=94) stores were found selling vaccines without proper refrigerator and only 11.7% stores had the power backup for the refrigerator. Only 40.2%(n=403) of stores were protected from direct sunlight and 5.4%(n=54) having air conditioning in the premises.

CONCLUSION

The regulatory compliance of majority of the drug stores operated privately in different areas of Karachi is below standard. Only a few drugs stores have adequate facilities to protect the drugs from extreme temperature, sunlight and provision of refrigeration. Very few of the drug stores carry out drug sales under the supervision of qualified pharmacist. There is a dire need to improve the storage practices in the drug stores by complying with the regulatory standards/laws as specified by the Drug Regulatory Authority of Pakistan.

Health care seeking behaviours in pregnancy in rural Sindh, Pakistan: a qualitative study

BACKGROUND

Pakistan has alarmingly high numbers of maternal mortality along with suboptimal care-seeking behaviour. It is essential to identify the barriers and facilitators that women and families encounter, when deciding to seek maternal care services. This study aimed to understand health-seeking patterns of pregnant women in rural Sindh, Pakistan.

METHODS

A qualitative study was undertaken in rural Sindh, Pakistan as part of a large multi-country study in 2012. Thirty three focus group discussions and 26 in-depth interviews were conducted with mothers [n = 173], male decision-makers [n = 64], Lady Health Workers [n = 64], Lady Health Supervisors [n = 10], Women Medical Officers [n = 9] and Traditional Birth Attendants [n = 7] in the study communities. A set of a priori themes regarding care-seeking during pregnancy and its complications as well as additional themes as they emerged from the data were used for analysis. Qualitative analysis was done using NVivo version 10.

RESULTS

Women stated they usually visited health facilities if they experienced pregnancy complications or danger signs, such as heavy bleeding or headache. Findings revealed the importance of husbands and mothers-in-law as decision makers regarding health care utilization. Participants expressed that poor availability of transport, financial constraints and the unavailability of chaperones were important barriers to seeking care. In addition, private facilities were often preferred due to the perceived superior quality of services.

CONCLUSION

Maternal care utilization was influenced by social, economic and cultural factors in rural Pakistani communities. The perceived poor quality care at public hospitals was a significant barrier for many women in accessing health services. If maternal lives are to be saved, policy makers need to develop processes to overcome these barriers and ensure easily accessible high-quality care for women in rural communities.

TRIAL REGISTRATION

NCT01911494.

Self-reported morbidity and health service utilization in rural Tamil Nadu, India

In Tamil Nadu, India, improvements have been made toward developing a high-quality, universally accessible healthcare system. However, some rural residents continue to confront significant barriers to obtaining healthcare. The primary objective of this study was to investigate self-reported morbidity, health literacy, and healthcare preferences, utilization, and experiences in order to identify priority areas for government health policies and programs. Drawing on 66 semi-structured interviews and 300 household surveys (including 1693 individuals), administered in 26 rural villages in Tamil Nadu's Krishnagiri district, we found that the prevalence of self-reported major health conditions was 22.3%. There was a large burden of non-communicable and chronic diseases, and the most common major morbidities were: connective tissue problems (7.6%), nervous system and sense organ diseases (5.0%), and circulatory and respiratory diseases (2.5%). Increased age and decreased education level were associated with higher odds of reporting most diseases. Low health literacy levels resulted in individuals seeking care only once pain interfered with daily activities. As such, individuals' health-seeking behaviour depended on which strategy was believed to result in the fastest return to work using the fewest resources. Although government facilities were the most common healthcare access point, they were mistrusted; 48.8% and 19.2% of respondents perceived inappropriate treatment protocols and corruption, respectively, at public facilities. Conversely, 93.3% of respondents reported high treatment cost as the main barrier to accessing private facilities. Our results highlight that addressing the chronic and non-communicable disease burdens amongst rural populations in this context will require health policies and village-level programs that address the low health literacy and the issues of rural healthcare accessibility and acceptability.

Evolutionary concept analysis of health seeking behavior in nursing: a systematic review

BACKGROUND

Although the research in health seeking behavior has been evolving, its concept remains ambiguous. Concept clarification, as a central basis of developing knowledge, plays an undeniable role in the formation of nursing sciences. As the initial step toward the development of theories and theoretical models, concept analysis is broadly used through which the goals can be used and tested. The aim of this study was to report an analysis of the concept of "health seeking behavior".

METHOD

Employing a rigorous evolutionary concept analysis approach, the concept of health seeking behavior was examined for its implications, use, and significance in the discipline of nursing between 2000 and 2012. After applying inclusion and exclusion criteria, a total of 40 articles and 3 books were selected for the final analysis.

RESULTS

The definition of attributes, antecedents, and consequences of health seeking behavior was performed through concept analysis. Core attributes (interactional, processing, intellectual, active, decision making based and measurable) were studied. The antecedents of concept were categorized as social, cultural, economic, disease pattern and issues related to health services. Health-seeking behavior resulted in health promotion and disease risk reduction. In addition, it led to predicting the future probable burden of the diseases, facilitation of the health status, early diagnosis, complete and effective treatment, and complication control.

CONCLUSION

Health-seeking behavior, as a multi-dimensional concept, relies on time and context. An awareness of health-seeking behavior attributes antecedents and consequences results in promoting the status, importance and application of this concept in the nursing profession.

Factors Associated with Low Birth Weight of Children Among Employed Mothers in Pakistan

Evidence shows that Pakistan has an increasing rate of children with low birth weight (LBW). Employed mothers in paid work (EMPW) in the country have predominantly been disadvantaged in terms of access to education and low-income employment; with negative consequences on maternal and child health. The objective of this study was to determine socio-demographic characteristics of EMPW and identify the association between maternal employment and child birth weight in Pakistan. Secondary data from the Pakistan Demographic Health Survey (PDHS) conducted for the year 2006-2007 was used. PDHS is a nationally representative household survey. Relevant data needed from the PDHS data file were coded and filtered. The sample size of EMPW with at least one child born in the last 5 years was 2,515. Data was analyzed by using SPSS. Descriptive and inferential statistics were used to see the association between EMPW characteristics and LBW. Findings confirm that the majority of EMPW in Pakistan are illiterate, poor, employed in unskilled work, and belonging to rural regions. Multivariate regression analysis revealed statistical association between EMPW and LBW among mothers who did not receive prenatal care from unskilled healthcare provider (AOR 1.92; 95% CI 1.12-3.30), had lack of access to information such as radio (AOR 1.88; 95% CI 1.28-2.77), during pregnancy did not receive calcium (AOR 1.19; 95% CI 1.05-1.34), and iron (AOR 1.33; 95% CI 1.05-1.69), had experienced headaches during pregnancy (AOR 1.41; 95% CI 1.12-1.76), and were not paid in cash for their work (AOR 1.41; 95% CI 1.04-1.90). EMPW in Pakistan, especially in low-income jobs and rural regions, need urgent support for healthcare awareness, free supplementation of micronutrients and frequent consultation with trained practitioner during the prenatal period. Long-term mobilization of social structure and governance is needed to encourage maternal health awareness, hospital deliveries, and formal sector employment for EMPW.

Potential use of school absenteeism record for disease surveillance in developing countries, case study in rural Cambodia

BACKGROUND

Disease surveillance allows prospective monitoring of patterns in disease incidence in the general community, specific institutions (e.g. hospitals, elderly care homes), and other important population subgroups. Surveillance activities are now routinely conducted in many developed countries and in certain easy-to-reach areas of the developing ones. However due to limited health resources, population in rural area that consisted of the most the vulnerable groups are not under surveillance. Cheaper alternative ways for disease surveillance were needed in resource-limited settings.

METHODS AND FINDINGS

In this study, a syndromic surveillance system using disease specific absenteeism rates was established in 47 pre-schools with 1,417 students 3-6 y of age in a rural area of Kampot province, Cambodia. School absenteeism data were collected via short message service. Data collected between 1st January and 31st December 2012 was used for system evaluation for future potential use in larger scale. The system appeared to be feasible and acceptable in the rural study setting. Moderate correlation was found between rates of school absenteeism due to illness and the reference data on rates of attendance at health centers in persons <16 y (maximum cross-correlation coefficient = 0.231 at lag = -1 week).

CONCLUSIONS

School absenteeism data is pre-existing, easily accessible and requires minimum time and resources after initial development, and our results suggest that this system may be able to provide complementary data for disease surveillance, especially in resource limited settings where there is very little information on illnesses in the community and traditional surveillance systems are difficult to implement. An important next step is to validate the syndromic data with other forms of surveillance including laboratory data.

Venom proteomic characterization and relative antivenom neutralization of two medically important Pakistani elapid snakes (Bungarus sindanus and Naja naja)

Intra- and interspecific variation in venom composition has been shown to have a major effect upon the efficacy of antivenoms. Due to the absence of domestically produced antivenoms, Pakistan is wholly reliant upon antivenoms produced in other countries, such as India. However, the efficacy of these antivenoms in neutralising the venoms of Pakistani snakes has not been ascertained. This is symptomatic of the general state of toxicological research in this country, which has a myriad of highly toxic and medically important venomous animals. Thus, there is a dire need for knowledge regarding the fundamental proteomics of these venoms and applied knowledge of the relative efficacy of foreign antivenoms. Here we present the results of our proteomic research on two medically important snakes of Pakistan: Bungarus sindanus and Naja naja. Indian Polyvalent Antivenom (Bharat Serums and Vaccines Ltd), which is currently marketed for use in Pakistan, was completely ineffective against either Pakistani species. In addition to the expected pre- and post-synaptic neurotoxic activity, the venom of the Pakistan population of N. naja was shown to be quite divergent from other populations of this species in being potently myotoxic. These results highlight the importance of studying divergent species and isolated populations, where the same data not only elucidates clinical problems in need of immediate attention, but also uncovers sources for novel toxins with potentially useful activities.

BIOLOGICAL SIGNIFICANCE

Pakistan Bungarus sindanus and Naja naja venoms are differentially complex. Naja naja is potently myotoxic. Neither venom is neutralized by Indian antivenom. These results have direct implications for the treatment of envenomed patients in Pakistan. The unusually myotoxic effects of Naja naja demonstrates the value of studying remote populations for biodiscovery.

A cross-sectional assessment of knowledge, attitude and practice among Hepatitis-B patients in Quetta, Pakistan

Background

Hepatitis-B is a life threatening infection resulting in 0.6 million deaths annually. The prevalence of Hepatitis-B is rising in Pakistan and furthermore, there is paucity of information about Knowledge, Attitude and Practice among Hepatitis-B patients. Better disease related knowledge is important to have positive attitude and that will bring the good practices which will prevent the further spread of infection. This study aimed to evaluate knowledge, attitude and practice of Hepatitis-B Patients in Quetta city, Pakistan.

Methods

A cross-sectional, descriptive study was undertaken with 390 Hepatitis-B patients attending two public hospitals in Quetta city, Pakistan. Knowledge, attitude and practice regarding Hepatitis-B were assessed using a pre-validated questionnaire containing 20, 7 and 8 questions for knowledge, attitude and practice, respectively. Descriptive statistics were used for elaborating patients’ demographic characteristics and mean scores for knowledge, attitude and practice of Hepatitis-B patients. Inferential statistics (Mann–Whitney U test and Kruskal Wallis tests, p < 0.05) were used to establish association between study variables. Spearman’s rho correlation was used to identify the association between the knowledge, attitude and practice scores.

Results

Out of 390 patients, 223 (57.2%) were males, with the majority (136, 34.9%) in the age group of 38–47 years. Mean age of the study cohort was 32.6 ± 9.5 years. One hundred and four (26.7%) had primary level education, with 110 (28.2%) working in the private sector. The mean scores for knowledge, attitude and practice were 8.48 ± 2.7, 3.87 ± 1.2 and 2.37 ± 1.0, respectively. Education, locality and occupation were significantly associated with knowledge, attitude and practice scores. Significant positive linear correlations between knowledge-attitude (r = 0.466, p < 0.01) knowledge-practice (r = 0.221, p < 0.01) and attitude-practice (r = 0.224, p < 0.01) were also observed from the study results.

Conclusion

The findings of this study indicate that Hepatitis-B patients lack a basic understanding of infection control and management. This can result in the further spread of Hepatitis-B infection. Extensive health education campaigns should be provided to the patients in the hospital as well as in community settings for rational control and management of the disease.