Where do they go, whom do they consult, and why? Health-seeking behaviors in the northern areas of Pakistan

Multilevel determinants of antiretroviral therapy initiation and retention in the test-and-treat era of Nepal: a qualitative study

BACKGROUND

The transition to the "test-and-treat" policy in Nepal in 2017, coupled with the rapid initiation of antiretroviral therapy (ART) in 2020, necessitates an in-depth understanding of factors influencing ART initiation and retention. This study investigates these factors from the perspectives of healthcare providers, families/communities, and people living with HIV (PLHIV).

METHODS

Employing a qualitative design, in-depth interviews were conducted with 24 ART clients and 26 healthcare providers across different provinces of Nepal. A comprehensive interview guide facilitated the exploration of experiences and perceptions. Interviews were transcribed verbatim, and thematic analysis was applied to distill key insights. Guided by a socio-ecological model, interviews were analyzed to identify the barriers and facilitators to ART initiation and continuation at the individual, family/community, and health system levels.

RESULTS

Facilitators and barriers were identified at three levels. Individual-level facilitators included fear of death, perceived health benefits, knowledge about HIV/ART, confidentiality, and financial support. Barriers encompassed concerns about lifelong medication, side effects, denial of HIV status, fear of disclosure, and financial constraints. At the family/community level, support from family and community health workers facilitated ART adherence, while social stigma and discrimination posed barriers. The health system's role was dual; the provision of free treatment, a client tracking system and a robust drug supply chain were facilitators, whereas logistical challenges and service accessibility during the COVID-19 pandemic were notable barriers.

CONCLUSIONS

This study highlights the various factors that influence ART initiation and retention in Nepal during the test-and-treat era. Tailored interventions should focus on increasing awareness about HIV and ART, strengthening healthcare systems, ensuring availability of medications, and providing accessible treatment during service disruptions. Furthermore, these interventions should encourage supportive environments at the individual, community, and healthcare system levels. Taking this holistic approach is essential for effectively implementing ART and achieving long-term health outcomes in light of changing public health policies.

Preferences for Health Care and Its Determinants Among Mentally Ill Patients of the West Shoa Zone Community, Oromia, Ethiopia

BACKGROUND

Over 9 million people die from mental diseases each year, making them the second highest cause of mortality and the primary cause of disability worldwide.

OBJECTIVE

To explore the preferences for health care and its determinants among mentally ill patients in the West Shoa Zone Community in Oromia, Ethiopia, from July 11-September 20, 2022.

METHODS

The preference for health care and its determinants among mentally ill patients in the West Shoa Zone community were explored using an ethnographical study. Purposefully, a total of 16 FGD participants and 10 unstructured interview subjects, who had pertinent experiences and perspectives, were carefully selected from the urban and district levels. Data was collected utilizing two approaches in a triangulated manner and then coded, findings were contextualized, and a thematic plot was developed for thematic analysis.

RESULTS

In this study, in response to the questions, three main findings were thematized according to the causes, and six sub-themes were framed under the themes according to the preferences for treatment among mentally ill patients. The themes that emerged from the data were; 1. Supernatural causes, 2. Traditional non-spiritual beliefs and practices; and 3. Medico-surgical problems. The majority of the participants responded that residents preferred religious spiritualists the most (46%), followed by traditional counselors (Wabeka) (19%), traditional spiritualists (15%), institutional care (12%), herbalists (4%), and psychologists (4%).

CONCLUSIONS AND RECOMMENDATIONS

In this study, the most commonly perceived causes of mental illnesses were bad spirits, devilish activity, and engaging in actions that violated social norms and regulations. Religious spiritualists were the study's first choice for mental health care. This study advises collaboration and a shared strategy between health care professionals and traditional and religious stakeholders.

Exploring the barriers to the antiretroviral therapy adherence among people living with HIV in Bangladesh: A qualitative approach

INTRODUCTION

Since the evolution of highly active antiretroviral therapy (ART), a near-perfect ART adherence level (>95%) is needed to control viral suppression. Non-adherence to treatment may lead to acquired immunodeficiency syndrome (AIDS) and drug resistance. Though the Bangladesh government provides free treatment and counselling services to people living with human immunodeficiency virus (PLHIV), only 22% of the identified PLHIV continue treatment. Therefore, this study aims to explore the barriers that obstruct the Bangladeshi PLHIV to ensure ART adherence.

METHODS

We conducted a qualitative study in Dhaka, Bangladesh, and recruited the sensitive study population following non-probability, mainly purposive sampling from a community-based registered organization for PLHIV. We conducted the in-depth interview using a semi-structured guideline with 15 consented respondents. We transcribed the audio-recorded interviews in the local language (Bangla) and then translated those into English for data analysis. During the data extraction process, the lead and corresponding authors independently extracted raw data to generate different themes and sub-themes and invited other authors to contribute when they could not solve any discrepancies.

RESULTS

The study identified three significant categories of barriers at the individual, community, and institutional levels that negatively interfered with ART adherence. The most dominant barriers were discrimination and rejection related to stigma, as almost all participants mentioned these barriers. Stigmatizing attitudes and the discriminatory act of the community people and healthcare providers critically affected their treatment adherence. Other leading barriers were improper inventory management of ART-related medicines and CD4 tests and lack of proper counselling. In addition, we found that a positive approach toward life and family support motivated some respondents to overcome the barriers.

CONCLUSIONS

We recommended strengthening Bangladesh's HIV/AIDS prevention, treatment, and management program with a special focus on the improvement of the supply chain of ART-related medicines and CD4 tests and ensuring proper counselling. In addition, we recommended strengthening the behaviour change communication and IEC activities at a large scale to destigmatize health facilities and community levels.

Cancer Care in Pakistan: A Descriptive Case Study

In this descriptive case study, we aimed to understand the experiences of cancer diagnosis, treatment, and palliative care in Pakistan. The case was limited to a hospital for cancer and hospice care in Karachi, Pakistan. Data collection included interviews with patients who had a cancer diagnosis, family members, healthcare providers, and unstructured observations. Two themes of suffering and late diagnosis were developed to describe the experiences of people with cancer. Suffering occurred as a result of poverty, social ideas about cancer, and physical suffering. Late diagnosis happened because of cultural ideas about health, low health literacy, and healthcare challenges, although both themes are interconnected. The findings illuminate three key pathways that will improve cancer diagnosis and palliative care in Pakistan: specifically, the need to (a) educate healthcare providers about cancer and palliative care, (b) eradicate corruption in healthcare, and (c) develop policies for universal access to health.

The effect of a culturally sensitive mental well-being module on Pakistani nursing students' knowledge and beliefs regarding their own mental health and illness

This study examined the effect of a mental well-being module on undergraduate nursing students' knowledge and beliefs regarding causes and treatment of mental health and illness, and explored the relationship between these variables and depression and anxiety. The one group design incorporated pre-intervention, intervention and post-intervention phases, in a consecutive sample of 246 students in a 4-year BScN programme in Pakistan. A culturally sensitive, interactive mental well-being module of four hours length was delivered to three groups of approximately 40 students per group. Repeated measures ANOVA was performed to assess the difference in the mean knowledge scores. Paired t-tests investigated between-group differences on the factor scores. A total of 112 students screened positive for anxiety and depression symptoms. Repeated measures ANOVA showed a significant difference in the mean knowledge scores regarding mental illness (P < 0.001). Factor analysis resulted in four factors for the aetiology items. Paired t-test showed significant differences (P < 0.001) between psycho-social and environmental factors, supernatural and religious beliefs, and neuro-genetics. For treatment, significant differences (P < 0.001) were found between all factors - Professional and Help from others, Religiosity and Socialization, and Alternative and Medical Treatment. There was a significant and positive change in students' mental health knowledge, beliefs and mental health-seeking behaviour and diminished stigmatized beliefs. Based on the findings, it is highly recommended to incorporate the mental well-being program in the curriculum.

A Community-Based Survey on Health-Care Utilization for Pneumonia in Children in Peri-Urban Slums of Karachi, Pakistan

Pneumonia, as defined by WHO, is a syndromic diagnosis characterized by presence of cough or difficult breathing. Presentation to health-care provider depends on timely identification of signs and symptoms by caretakers. We explored patterns of health-care utilization among caretakers of a randomly selected sample of 1,152 children aged 2-59 months, residing in low-income settlements of Karachi, Pakistan. Information on household demographics, occurrence of pneumonia-specific symptoms, care seeking, air quality, and knowledge regarding preventive measures for pneumonia was collected. Predictors of care seeking were estimated using weighted logistic regression. Prevalence of pneumonia with cough and rapid or difficulty in breathing was found to be 40.8% and 37.1% in infants (2-11 months) and children (12-59 months), respectively. Ninety-five percentage of caretakers sought care, 68.5% privately. Odds ratios (ORs) for independent predictors of care-seeking were as follows: younger age of child (infants compared with children), 3.60 (95% CI = 2.65-4.87); caretaker with primary education compared with none, 3.40 (2.46-4.70); vaccine awareness, 1.65 (1.45-1.87); and breastfeeding awareness, 1.32 (1.13-1.53). Presence of symptoms such as fever OR, 1.51 (1.30-1.76); tachypnea, 1.57 (1.35-1.83); chest indrawing, 2.56 (2.05-3.18); persistent vomiting, 1.69 (1.37-2.09); and recurrent illness, 2.57 (2.23-2.97) were also predictive. There is high health-care utilization for pneumonia with the skewed presentation toward private services. Strategies should be focused on making pneumonia care standardized, efficient and affordable, especially in the private sector.

Health seeking behaviour, delayed presentation and its impact among oral cancer patients in Pakistan: a retrospective qualitative study

Background

Delayed diagnosis of Oral Cancer (OC) can mean a difference in quality and expectancy of life for the patient. This delay could be from the healthcare side, or more importantly from the patient’s side. Globally, there are studies enumerating the causes for delays from the patients’ side in seeking healthcare for Oral Cancer; however, no similar research is found in the context of Pakistan. This study endeavoured to understand the health seeking behaviour, reasons for delay in consultation and the impact on OC patients’ lives.

Methods

In-depth interviews were conducted with randomly selected OC patients at a private sector tertiary care facility in Islamabad (who met the inclusion criteria of having successfully been treated for Oral Cancer) which caters to the most diverse population for the treatment of Oral Cancer. Theoretical saturation was achieved at 14 interviews. All participants gave verbal consent for participation, which was recorded prior to the interviews.

Results

Patients (age range 43–68 years) had received the surgical treatment and radiation. The reported delay before seeking a proper medical advice ranged from 1 month to 2 years. Lack of awareness about OC risk factors, symptoms, and whom to approach for treatment were the main reasons. Most respondents relied on self-treatment considering the non-healing wound/ulcer to be a minor issue until they were advised a consultation with a specialist. Treatment started within 1–3 months after a confirmed diagnosis on biopsy. The reported average expenditure on treatment was US$5000-10,000, mostly covered through a private health insurance and others borrowed the money.

Conclusion

A socio-behavioural change campaign for the general population can result in earlier presentation of the OC, minimizing the financial burden on the patient as well as the health system, and improving the quality of life of the patients.

Access to primary health care among women: the role of Ghana's community-based health planning and services policy

Background:

Ghana in 1999 adopted the Community-based Health Planning and Service (CHPS) policy to enhance access to primary health care (PHC) service. After two decades of implementation, there remains a considerable proportion of the country’s population, especially women who lack access to basic health care services.

Aim:

The aim of this paper is to understand the contribution of Ghana’s CHPS policy to women’s access to PHC services in the Upper West Region (UWR) of Ghana.

Methods:

A logistic regression technique was employed to analyse cross-sectional data collected among women (805) from the UWR.

Findings:

We found that women who resided in CHPS zones (OR = 1.612; P ≤ 0.01) were more likely to have access to health care compared with their counterparts who resided in non-CHPS zones. Also, rural-urban residence, distance to health facility, household wealth status and marital status predicted access to health care among women in the region. Our findings underscore the need to expand the CHPS policy to cover many areas in the country, especially rural communities and other deprived localities in urban settings.

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.

Developing Equitable Primary Health Care in Conflict-Affected Settings: Expert Perspectives From the Frontlines

Health systems are frequently among the casualties of conflict. Within these settings, increased knowledge is needed on how to rebuild and strengthen health infrastructure resilience, such as primary health care (PHC) systems, in context-specific ways that promote health equity. Therefore, this study aimed to explore perspectives of experts with experience working on frontlines of social crises to contribute to understandings of pathways toward equitable PHC in conflict-affected settings. Semistructured qualitative interviews with 18 expert participants were completed. Through engaging elements of grounded theory situational analysis, three themes emerged iteratively, including (a) Building Blocks, (b) Intermediating Factors, and (c) a Roadmap. These emergent themes contribute to conceptual frameworks explaining key contextually specific priorities, challenges, and facilitating factors for developing resilient health infrastructures under social crises. Findings inform policy and practical guidelines that address complexities of conflict conditions and underscore the importance of PHC development toward promoting health as a human right.

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 access: A sequence-sensitive approach

It is widely accepted that healthcare-seeking behaviour is neither limited to nor terminated by access to one single healthcare provider. Yet the sequential conceptualisation of healthcare-seeking processes has not diffused into quantitative research, which continues to analyse healthcare access as a "one-off" event. The ensuing lack of understanding healthcare behaviour is problematic in light of the immense burden of premature death especially in low- and middle-income countries. This paper presents an alternative approach. Based on a novel survey instrument, we analyse original survey data from rural India and China that contain 119 unique healthcare pathways among 637 respondents. We offer three applications of how such sequential data can be analysed to enhance our understanding of people's health behaviour. First, descriptive analysis of sequential data enables more a comprehensive representation of people's health behaviours, for example the time spent in various healthcare activities, common healthcare pathways across different groups, or shifts in healthcare provider access during a typical illness. Second, by analysing the effect of mobile technology on healthcare-seeking process characteristics, we demonstrate that conventional, sequence-insensitive indicators are potentially inconsistent and misleading approximations when compared to a more precise, sequence-sensitive measure. Third, we describe how sequential data enable transparent and flexible evaluations of people's healthcare behaviour. The example of a sequence-insensitive evaluation suggests that household wealth has no statistical link to an illustrative "ideal" form of public healthcare utilisation. In contrast, sequence-sensitive evaluations demonstrate that household wealth is associated with an increased likelihood of bypassing referral processes and approaching unregulated and costly informal and private practitioners before accessing a public clinic. Sequential data therefore do not only reveal otherwise neglected locational idiosyncrasies, but they also yield deeper insights into the drivers of people's health behaviours compared to a conventional approach to "access to healthcare."

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.

Assessing predictors of contraceptive use and demand for family planning services in underserved areas of Punjab province in Pakistan: results of a cross-sectional baseline survey

Background

Although Pakistan was one of the first countries in Asia to launch national family planning programs, current modern contraceptive use stands at only 26% with a method mix skewed toward short-acting and permanent methods. As part of a multiyear operational research study, a baseline survey was conducted to understand the predictors of contraceptive use and demand for family planning services in underserved areas of Punjab province in Pakistan. This paper presents the baseline survey results; the outcomes of the intervention will be presented in a separate paper after the study has been completed.

Method

A cross-sectional baseline household survey was conducted with randomly selected 3,998 married women of reproductive age (MWRA) in the Chakwal, Mianwali, and Bhakkar districts of Punjab. The data were analyzed on SPSS 17.0 using simple descriptive and logistic regression.

Results

Most of the women had low socio-economic status and were younger than 30 years of age. Four-fifths of the women consulted private sector health facilities for reproductive health services; proximity, availability of services, and good reputation of the provider were the main predicators for choosing the facilities. Husbands were reported as the key decision maker regarding health-seeking and family planning uptake. Overall, the current contraceptive use ranged from 17% to 21% across the districts: condoms and female sterilization were widely used methods. Woman’s age, husband’s education, wealth quintiles, spousal communication, location of last delivery, and favorable attitude toward contraception have an association with current contraceptive use. Unmet need for contraception was 40.6%, 36.6%, and 31.9% in Chakwal, Mianwali, and Bhakkar, respectively. Notably, more than one fifth of the women across the districts expressed willingness to use quality, affordable long-term family planning services in the future.

Conclusion

The baseline results highlight the need for quality, affordable long-term family planning services close to women’s homes. Furthermore, targeted community mobilization and behavior change efforts can lead to increased awareness, acceptability, and use of family planning and birth spacing services.

Perceived barriers to utilizing maternal and neonatal health services in contracted-out versus government-managed health facilities in the rural districts of Pakistan

BACKGROUND

A number of developing countries have contracted out public health facilities to the Non-Government Organizations (NGOs) in order to improve service utilization. However, there is a paucity of in-depth qualitative information on barriers to access services as a result of contracting from service users' perspective. The objective of this study was to explore perceived barriers to utilizing Maternal and Neonatal Health (MNH) services, in health facilities contracted out by government to NGO for service provision versus in those which are managed by government (non-contracted).

METHODS

A community-based qualitative exploratory study was conducted between April to September 2012 at two contracted-out and four matched non-contracted primary healthcare facilities in Thatta and Chitral, rural districts of Pakistan. Using semi-structured guide, the data were collected through thirty-six Focus Group Discussions (FGDs) conducted with mothers and their spouses in the catchment areas of selected facilities. Thematic analysis was performed using NVivo version 10.0 in which themes and sub-themes emerged.

RESULTS

Key barriers reported in contracted sites included physical distance, user charges and familial influences. Whereas, poor functionality of health centres was the main barrier for non-contracted sites with other issues being comparatively less salient. Decision-making patterns for participants of both catchments were largely similar. Spouses and mother-in-laws particularly influenced the decision to utilize health facilities.

CONCLUSION

Contracting out of health facility reduces supply side barriers to MNH services for the community served but distance, user charges and low awareness remain significant barriers. Contracting needs to be accompanied by measures for transportation in remote settings, oversight on user fee charges by contractor, and strong community-based behavior change strategies.

Health care seeking patterns and out of pocket payments for children under five years of age living in Katchi Abadis (slums), in Islamabad, Pakistan

BACKGROUND

Since 1990, Pakistan has faced an unprecedented rate of urbanization, thereby resulting in the uncontrolled proliferation of slums (Katchi Abadis) in all large cities. These areas lack the basic municipal services such as safe water supply, sanitation and waste collection. There is limited access to quality health care services, both curative and preventive. Therefore, communities living in katchi abadis are faced with health seeking challenges and catastrophic expenditure to pay for health care services (formal or informal).

METHODS

This cross-sectional quantitative study was conducted in Islamabad, using a semi-structured questionnaire with mothers of children 5 years of age. There are 34 katchi abadis, 11 are recognized by the Capital Development Authority, out of which seven were included in the study. The calculated sample size was 207.

MAIN FINDINGS

Average household income was found to be Pak Rupee 10,000 (approx.US$100) per month. Diarrhea, fever, common cold and cough were common illnesses among under 5 children. Approximately 43% of the mothers were illiterate and they preferred consulting a private doctor or a private dispenser in the katchi abadi. Mother's level of education was significantly associated with the type of health provider consulted. Majority had to spend out of pocket, while many either borrowed money from relatives or friends or sold a household item. Delay in seeking health care added to the out of pocket expense. The mean cost on child's treatment was approximately PkRs400 (approximately US$ 4) for a single consultation.

CONCLUSION

There are several factors associated with health seeking behavior of mothers of children under the age of 5 years, living in the katchi abadis of Islamabad. The latter population group is one of the most vulnerable given their poor standard of living conditions. A multi-sectoral approach is needed to address the provision of basic amenities, the availability of safety nets to pay for health care is crucial to avoid catastrophic expenditure and the provision of community-based health promotion programs are essential to improve health seeking behaviors whilst simultaneously promoting and protecting health.

Gender: shaping personality, lives and health of women in Pakistan

BACKGROUND

Gender norms determine the status of Pakistani women that influence their life including health. In Pakistan, the relationship between gender norms and health of women is crucial yet complex demanding further analysis. This paper: determines the reasons for reiteration of gender roles; describes the societal processes and mechanisms that reproduce and reinforce them; and identifies their repercussions on women's personality, lives and health especially reproductive health.

METHODS

As part of a six-country study titled 'Women's Empowerment in Muslim Contexts', semi-structured group discussions (n = 30) were conducted with women (n = 250) who were selected through snowballing from different age, ethnic and socio-economic categories. Discussion guidelines were used to collect participant's perceptions about Pakistani women's: characteristics, powers, aspirations, needs and responsibilities; circumstances these women live in such as opportunities, constraints and risks; and influence of these circumstances on their personality, lifestyle and health.

RESULTS

The society studied has constructed a 'Model' for women that consider them 'Objects' without rights and autonomy. Women's subordination, a prerequisite to ensure compliance to the constructed model, is maintained through allocation of lesser resources, restrictions on mobility, seclusion norms and even violence in cases of resistance. The model determines women's traits and responsibilities, and establishes parameters for what is legitimate for women, and these have implications for their personality, lifestyle and health, including their reproductive behaviours.

CONCLUSION

There is a strong link between women's autonomy, rights, and health. This demands a gender sensitive and a, right-based approach towards health. In addition to service delivery interventions, strategies are required to counter factors influencing health status and restricting access to and utilization of services. Improvement in women's health is bound to have positive influences on their children and wider family's health, education and livelihood; and in turn on a society's health and economy.

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.

Sex inequality, high transport costs, and exposed clinic location: reasons for loss to follow-up of clients under prevention of mother-to-child HIV transmission in eastern Uganda - a qualitative study

BACKGROUND

In Iganga, Uganda, 45% of women who tested HIV-positive during antenatal care between 2007 and 2010 were lost to follow-up (LTFU). We explored reasons for LTFU during prevention of mother-to-child transmission (PMTCT) from a client perspective in eastern Uganda, where antiretroviral therapy (ART) awareness is presumably high.

METHODS

Seven key informant interviews and 20 in-depth interviews, including both clients who had been retained under PMTCT care and those LTFU during PMTCT were held. Ten focus-group discussions involving a total of 112 participants were also conducted with caretakers/ relatives of the PMTCT clients. Content analysis was performed to identify recurrent themes.

RESULTS

Our findings indicate that LTFU during PMTCT in eastern Uganda was due to sex inequality, high transport costs to access the services, inadequate posttest counseling, lack of HIV status disclosure, and the isolated/exposed location of the ART clinic, which robs the clients of their privacy.

CONCLUSION

There is a need for approaches that empower women with social capital, knowledge, and skills to influence health-seeking practices. There is also a need to train low-ranking staff and take PMTCT services closer to the clients at the lower-level units to make them affordable and accessible to rural clients. Posttest counseling should be improved to enable PMTCT clients to appreciate the importance of PMTCT services through increasing the number of staff in antenatal care to match the client numbers for improved quality. The counseling should emphasize HIV status disclosure to partners and encourage partner escort for antenatal care visits for further counseling. The exposed and isolated ART clinic should be integrated with the other regular outpatient services to reduce the labeling stigma.

Care-seeking patterns for fatal non-communicable diseases among women of reproductive age in rural northwest Bangladesh

BACKGROUND

Though non-communicable diseases contribute to an increasing share of the disease burden in South Asia, health systems in most rural communities are ill-equipped to deal with chronic illness. This analysis seeks to describe care-seeking behavior among women of reproductive age who died from fatal non-communicable diseases as recorded in northwest rural Bangladesh between 2001 and 2007.

METHODS

This analysis utilized data from a large population-based cohort trial in northwest rural Bangladesh. To conduct verbal autopsies of women who died while under study surveillance, physicians interviewed family members to elicit the biomedical symptoms that the women experienced as well as a narrative of the events leading to deaths. We performed qualitative textual analysis of verbal autopsy narratives for 250 women of reproductive age who died from non-communicable diseases between 2001 and 2007.

RESULTS

The majority of women (94%) sought at least one provider for their illnesses. Approximately 71% of women first visited non-certified providers such as village doctors and traditional healers, while 23% first sought care from medically certified providers. After the first point of care, women appeared to switch to medically certified practitioners when treatment from non-certified providers failed to resolve their illness.

CONCLUSIONS

This study suggests that treatment seeking patterns for non-communicable diseases are affected by many of the sociocultural factors that influence care seeking for pregnancy-related illnesses. Families in northwest rural Bangladesh typically delayed seeking treatment from medically certified providers for NCDs due to the cost of services, distance to facilities, established relationships with non-certified providers, and lack of recognition of the severity of illnesses. Most women did not realize initially that they were suffering from a chronic illness. Since women typically reached medically certified providers in advanced stages of disease, they were usually told that treatment was not possible or were referred to higher-level facilities that they could not afford to visit. Women suffering from non-communicable disease in these rural communities need feasible and practical treatment options. Further research and investment in adequate, appropriate care seeking and referral is needed for women of reproductive age suffering from fatal non-communicable diseases in resource-poor settings.

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

INTRODUCTION

This narrative review was carried out to collate the work of researchers on health-seeking behaviour in Pakistan, to discuss the methods used, highlight the emerging themes and identify areas that have yet to be studied.

STUDY DESIGN

Review.

METHODS

An overview of studies on health-seeking behaviour in Pakistan, found via searches on scholarly databases intended to locate material of medical and anthropological relevance.

RESULTS

In total, 29 articles were reviewed with a range of different methodologies. A retrospective approach was the most common. A variety of medical conditions have been studied in terms of health-seeking behaviour of people experiencing such conditions. However, a wide range of chronic illnesses have yet to be studied. Nevertheless, some studies highlighting unusual issues such as snake bites and health-seeking behaviour of street children were also found. In terms of geographical area, the majority of studies reviewed were performed in the provinces of Sind and Punjab, with little research targeting the people from the two other provinces (Balochistan and Khyber Pakhtunkhwa) of Pakistan. Predominant utilization of private healthcare facilities, self-medication, involvement of traditional healers in the healthcare system, women's autonomy, and superstitions and fallacies associated with health-seeking behaviour were found to be the themes that repeatedly emerged in the literature reviewed.

CONCLUSIONS

The sociocultural and religious background of Pakistan means that health-seeking behaviour resembles a mosaic. There is a need to improve the quality of service provided by the public healthcare sector and the recruitment of female staff. Traditional healers should be trained and integrated into the mainstream to provide adequate healthcare. Serious efforts are required to increase the awareness and educational level of the public, especially women in rural areas, in order to fight against myths and superstitions associated with health-seeking behaviour.

In search of healing between two worlds: the use of traditional and modern health services by older women in rural Bangladesh

The objective of this study is to gain a deeper understanding of the use of traditional and modern medicine among older adult women living in rural Bangladesh. Factors are identified that guide the women's decisions about who to seek help from when they are ill. The findings provide evidence that, in spite of the availability of modern health care, traditional healers--faith-based and herbalists--are widely utilized. Reasons given for their choice of health care providers fall into two categories: belief in the effectiveness of the intervention and service delivery considerations. These data suggest that use of traditional healers persists among women in rural areas of Bangladesh and that health policy should be developed with an acknowledgment of these health practices.

Paradox in treatment seeking: an experience from rural Sri Lanka

Sri Lanka has had a pluralist health care system for centuries, in which Western biomedicine coexists with the Ayurveda system. However, recent studies suggest a declining trend in the use of the Ayurveda system. This study provides insights into the reasons for the low utilization of the Ayurveda system at present. The study findings reveal that low utilization of the Ayurveda system can be attributed to several factors, including the quick effect of Western medicines, the perception of being accustomed to Western medicines, a lack of competent Ayurveda practitioners, the high cost and low quality of Ayurveda medicines, and the rapidly changing lifestyles of villagers. However, for certain conditions such as fractures, snakebite, and paralysis, the majority of the Sri Lankan population still uses Ayurveda treatment. In conclusion, we suggest that health authorities should take into account these changes for future health planning in Sri Lanka.

Inadequate pre-antiretroviral care, stock-out of antiretroviral drugs and stigma: policy challenges/bottlenecks to the new WHO recommendations for earlier initiation of antiretroviral therapy (CD<350 cells/microL) in eastern Uganda

OBJECTIVE

This study explores reasons for late ART initiation among known HIV positive persons in care from a client/caretaker perspective in eastern Ugandan where ART awareness is presumably high yet AIDS related mortality is a common function of late initiation of ARVs.

METHODS

In Iganga, Uganda we conducted in-depth interviews with clients who started ART at 50-200 CD4 cells/microL and those initiated very late at CD4<50 cells/microL. Focus-group discussions were also conducted with caretakers of clients on ART. Content analysis was performed to identify recurrent themes.

RESULTS

ARV stock-outs, inadequate pre-antiretroviral care and lack of staff confidentiality were system barriers to timely ART initiation. Weak social support and prevailing stigma and misconceptions about ARVs as drugs designed to kill, cause cancer, infertility or impotence were other important factors.

CONCLUSION

If the new WHO recommendations (start ART at CD4 350 cells/microL) should be feasible, PLHIV/communities need sensitization about the importance of regular pre-ARV care through the local media and authorities. The ARV supply chain and staff attitudes towards client confidentiality must also be improved in order to encourage timely ART initiation. PLHIV/communities should be sensitization about drug package labeling and the use and importance of ARVs. Stronger social support structures must be created through public messages that fight stigma, enhance acceptance of PLHIV and encourage timely ART initiation.

Hygiene and sanitation among ethnic minorities in Northern Vietnam: does government promotion match community priorities?

Improving sanitation and hygiene to prevent infectious diseases is of high priority in developing countries. This study attempts to gain in-depth understanding of hygiene and sanitation perceptions and practices among four Ethnic Minority Groups (EMGs) in a rural area of northern Vietnam. It is based on extensive participatory observations in 4 villages and 20 case households over a period of six months (May-October 2008). In addition, 10 key informants and 60 household-members were interviewed and 4 focus group discussions conducted. The study found that among the four selected EMGs the cultural perceptions of hygiene and sanitation which inform everyday hygiene practices did not differ substantially and were similar to hygiene explanations found in the rural majority population elsewhere in Vietnam. However, the difficult living conditions, particularly in highland communities, reinforce a sense of marginalization among the EMGs, which had great impact on how they perceive and respond to government sanitation interventions. The enclosed latrines promoted by authorities are met with reluctance by the EMGs due to cultural perceptions of the body as permeable and therefore, vulnerable to 'dirty air' such as bad smells from human faeces. In addition, the prioritization of specific sanitation hardware solutions by the central government aimed at increasing coverage creates expectations and dependency among the EMGs that hygiene 'comes from the outside society', resulting in low levels of community initiated actions. Based on these findings, we suggest that future hygiene promotion strategies aim for a closer match between community priorities and government hygiene policies, e.g. by allowing for a larger diversity of low-cost sanitation solutions. Scaling up participatory community-based hygiene promotion is also recommended to curb dependency and spark initiatives in ethnic minority communities. Finally, interventions should focus on hygiene "software"--promoting hygiene behaviour changes known to effectively prevent hygiene related diseases.

Elder authority and the situational diagnosis of diarrheal disease as normal infant development in northeast Thailand

Research was conducted in rural Northeast Thailand to understand how mothers perceive children's acute illness episodes, and their resulting illness management strategies. Although diarrheal disease is one of the leading causes of illness among young children in Thailand, interviews revealed that mothers frequently do not classify infantile diarrhea as an "illness." Infantile diarrhea is commonly labeled thai su, a type of diarrhea believed necessary to "lighten the body" so that the infant can attain a new developmental stage, such as sitting up, standing, or walking. Consequently, mothers do not perceive infection-related diarrheal illness as common in infants, and therefore do not direct much attention to prevention, nor manage diarrheal cases in a manner consistent with biomedical recommendations. In this article I describe local explanatory models of diarrheal illness, and discuss the role of situational factors and elder authority in determining how illness episodes are assessed and managed.