Inculcating health awareness in Karachi, Pakistan: How innovative, socially acceptable methods can help combat communicable diseases of poverty

In the megacity of Karachi, which has a population of more than 24 million, more than 9.2 million people (approximately 40 per cent) live in squatter settlements. Communities here are characterised by low socioeconomic settings, crowded living conditions, inadequate water and sanitation facilities, and poor health-related behaviours. Such conditions create an environment favourable to the spread of communicable diseases like tuberculosis (TB), hepatitis and dengue. Since 1985, the Department of Community Health Sciences at the Aga Khan University, Karachi, Pakistan has run the Urban Health Program (UHP), a community-campus partnership operating in these disadvantaged squatter settlements. Recent explosive increases in the spread of dengue, hepatitis and TB, however, necessitated special attention and activities on a scale and pace that was greater than could be accommodated as part of UHP’s core work. Thus, having an already well-established collaborative model with social accountability measures in place, a dedicated mass awareness program was initiated over the course of one year, from mid 2015: the AGAHI project. This article describes AGAHI’s innovative, low-cost, collaborative activities conducted in partnership with two squatter communities, Sultanabad and Rehri Goth, to build health awareness, improved care-seeking and compliance to treatment. Activities ranged from school sessions, role plays and awareness walks to laneway meetings, training of health care workers, door-to-door campaigns and collaboration with local religious leaders, public sector groups and NGOs. Building on the collaborative work of the UHP, in just 12 months AGAHI was able to conduct 80 health awareness sessions with 4000 participants. Moreover, high-risk and vulnerable populations were identified and referred for further treatment. A comparative cross-sectional survey afterwards revealed a significant increase in knowledge among Sultanabad residents as compared to the neighbouring settlement of Hijrat Colony. As a result, this article suggests that the need for and efficacy of targeted health awareness campaigns against the major infectious diseases of poverty cannot be overemphasised. By adopting community-based participatory models, couched in a framework of social accountability, activities that are low cost, innovative and scientifically robust hold real potential for improving health awareness in vulnerable megacities like Karachi

Views about women\u27s mental health: study in a squatter settlement of Karachi.

OBJECTIVE: Mental health of women is globally receiving particular attention. This study assessed community\u27s view on certain aspects of women\u27s mental health prior to introducing an intervention. SETTING: The study was conducted in an urban squatter settlement located in District West of Karachi in 1997 where the Aga Khan University has set up a Primary Health Care program in partnership with the communities. METHODS: Using convenient sampling, door to door household survey was conducted by medical students. RESULTS: Two hundred and eighty one residents were interviewed. Respondents were asked to list contributory factors which lead to mental distress in women. Two hundred and ten (75%) were able to list certain factors. The factors listed were; low family income (40%), dispute amongst spouses (30%), verbal abuse by in-laws (25%) and too many children (5%). When asked what women in the community did while they were mentally distressed 35% respondents reported that women talked to their husbands and 18% said counselling from a health provider was sought. Main channels of social support desired were; revenue generation (67%), membership of a women\u27s group (11%) and training of local community women in counselling skills (10%). CONCLUSION: Signs of awareness about mental health issues are present even in marginalized communities of Pakistan. In order to improve the mental health of women interventions should primarily focus on raising family income

The minds of mothers: maternal mental health in an urban squatter settlement of Karachi.

BACKGROUND: Community-based information on maternal mental health in developing countries is meager and nearly non-existent in Pakistan. OBJECTIVE: To determine the proportion of probable cases of women with mental disorders and examine the associated conditions and risk factors which contribute to maternal mental ill-health. METHODS: With convenient sampling 260 mothers in an urban squatter settlement of Karachi were interviewed. The tools consisted of a household questionnaire collecting information on basic demographic and other characteristics and the Aga Khan University Anxiety and Depression Scale (AKUADS), an instrument to assess psychiatric morbidity. RESULTS: The proportion of probable cases of mental disorder was 28.8% (n = 75). Reviewing the gradient of responses the most frequently expressed psychiatric symptoms were being worried and crying . Amongst somatic complaints the most frequently reported was headache. Study also suggests that women in the older age group (OR 2.30, CI 1.27-4.19, p = 0.0031) and those with longer duration of marriage (OR 1.80, CI 1.01-3.22, p = 0.032) are more likely to be mentally distressed. Arguments with husband (OR 5.0, CI 2.19-11.52, p = 0.00001) or in-laws (OR 2.43, CI 1.22-4.85, p = 0.0059), husband\u27s unemployment (OR 4.1, CI 1.27-13.6, p = 0.0058), not having permanent source of income and lack of autonomy in making decisions significantly contributed towards mental illness. CONCLUSION: Approximately 1 out of 4 women suffer from mental illness. This is alarmingly high. Besides counseling in cases of matrimonial disharmony, community-based interventions should aim to improve the socioeconomic status of households

Economic development and health status among the poor in squatter settlements of Karachi.

OBJECTIVE: Socioeconomic status is an important determinant of health outcome measures. This study examines and presents some of the important health outcomes amongst the higher and lower socioeconomic groups within the urban poor. SETTING: Data analysis is based on a Health and Demographic Survey conducted in urban squatter settlements of Karachi in 1996. METHODS: A structured questionnaire was administered to all households in the catchment area. The indicator used to assess economic status is ownership of assets. RESULTS: Comparison between the two economic levels shows that the lower socio-economic group was more likely to experience child mortality, (CI; 1.02-1.29, p = 0.02) have lower contraceptive usage (CI; 2.11-2.64; p \u3c 0.001) and childhood immunization rates (CI; 2.08-2.40, p \u3c 0.001). No significant association was observed between economic levels and prevalence of diarrhea. The housing, literacy and employment status was consistently better in the higher economic stratum who were more likely to be Pushto-Punjabi speaking as compared to the Sindhi speaking population. CONCLUSION: To have sustainable improvement in the health status of the poor, those who are most vulnerable need to be identified and programs aiming to improve health should also undertake broader development initiatives like raising family income

Does supportive supervision intervention improve community health worker knowledge and practices for community management of childhood diarrhea and pneumonia? Lessons for scale-up from Nigraan and Nigraan plus trials in Pakistan

Background: Lack of programmatic support and supervision is one of the underlying reasons of the poor performance of Pakistan\u27s Lady Health Worker Program (LHWP). This study describes the findings and potential for scale-up of a supportive supervision intervention in two districts of Pakistan for improving LHWs skills for integrated community case management (iCCM) of childhood diarrhea and pneumonia.Methods: The intervention comprised an enhanced supervision training to lady health supervisors (LHSs) and written feedback to LHWs by LHSs, implemented in Districts Badin and Mirpur Khas (MPK). Clinical skills of LHWs and LHSs and supervision skills of LHSs were assessed before, during, and after the intervention using structured tools.Results: LHSs\u27 practice of providing written feedback improved between pre- and mid-intervention assessments in both trials (0% to 88% in Badin and 25% to 75% in MPK) in the study arm. Similarly, supervisory performance of study arm LHSs was better than that in the comparison arm in reviewing the treatment suggested by workers\u27 (94% vs 13% in MPK and 94% vs 69% in Badin) during endline skills assessment in both trials. There were improvements in LHWs\u27 skills for iCCM of childhood diarrhea and pneumonia in both districts. In intervention arm, LHWs\u27 performance for correctly assessing for dehydration (28% to 92% in Badin and 74% to 96% in MPK), and measuring the respiratory rate correctly (12% to 44% in Badin and 46% to 79% in MPK) improved between baseline and endline assessments in both trials. Furthermore, study arm LHWs performed better than those in comparison arm in classifying diarrhea correctly during post-intervention skills assessment (68% vs 40% in Badin and 96% vs 83% in MPK).Conclusion: Supportive supervision including written feedback and frequent supervisor contact could improve the performance of community-based workers in managing diarrhea and pneumonia among children. Positive lessons for provincial scale-up can be drawn. Trial registration Both trials are registered with the \u27Australian New Zealand Clinical Trials Registry\u27. Registration numbers: Nigraan Trial: ACTRN1261300126170; Nigraan Plus: ACTRN12617000309381

Impact of water and sanitation and health education interventions on health and hygiene behaviors: a study from a northern Pakistani village

Introduction: Water and sanitation interventions were delivered in the northern areas of Pakistan as a joint venture of the Aga Khan University and the Aga Khan Health Systems Oshikhandass Diarrhea and Dysentery Project (1989-96) followed by the Aga Khan Water, Sanitation, Health and Hygiene Studies Program (WSHHSP). Through these interventions water treatment plants, new pit latrines along with a component of health education were introduced. Objectives: To explore perceptions, knowledge and practices of inhabitants of Oshikhandass village in Gilgit related to water quality, latrine use and hand washing following the intervention. Methods: Through a cross-sectional study during June-July 2012, six focus group discussions (FGDs) were conducted in various sectors of Oshikhandass supplied by filtered water (intervention area), piped water and mixed water (piped and channel water). The latter two were designated as the non- intervention areas. Participants included mothers (3 FGDs, 26 participants), LHWs (1 FGD, 5 participants) and youth (2 FGDs, 9 participants each). Results: Irrespective of health education by LHWs, residents of both intervention and non- intervention communities had learnt about proper hygienic practices from daily life experiences, parents, teachers and media. LHWs role at best had been that of a positive reinforcement. Despite uniformly good awareness, intervention communities still had relatively better health and hygiene knowledge and practices as compared to non-intervention areas. Conventional practices of water purification such as using gulk as domestic filter cum refrigerator was prevalent. Non-intervention communities, however, knew that accessibility to safe water makes a difference and they would have practiced better hygiene if they had resources. Inhabitants of intervention area commented that the functionality and coverage of the filtration plant was not enough to cater to the needs of the village. Conclusion: Knowledge alone is ineffective in modifying hygiene related behaviors. Sound context-specific integrated interventions for water and sanitation infrastructure development are much needed

Protecting and promoting the rights of the ‘reserve army of labour’: a policy analysis of structural determinants of migrant worker health in Pakistan and Qatar

Labour migrants who travel overseas for employment can face deep health inequities driven in large part by upstream social and structural determinants of health. We sought to study the ‘labour migrant health ecosystem’ between one sending country (Pakistan) and one host country (Qatar), with a focus on how the ecosystem realizes the rights of labour migrants when addressing the social and structural determinants (e.g. housing, employment law, etc.) of health. Study objectives were to (1) undertake an in-depth review of policies addressing the structural and social determinants of the health of labour migrants in both Pakistan and Qatar, analysing the extent to which these policies align with global guidance, are equity-focused and have clear accountability mechanisms in place, and (2) explore national stakeholder perspectives on priority setting for labour migrant health. We used a mixed methods approach, combining policy content analysis and interviews with stakeholders in both countries. We found a wide range of guidance from the multilateral system on addressing structural determinants of the health of labour migrants. However, policy responses in Pakistan and Qatar contained a limited number of these recommended interventions and had low implementation potential and minimal reference to gender, equity and rights. Key national stakeholders had few political incentives to act and lacked inter-country coordination mechanisms required for an effective and cohesive response to labour migrant health issues. Effectively addressing such determinants to achieve health equity for labour migrants will depend on a shift in governments’ attitudes towards migrants—from a reserve army of transient, replaceable economic resources to rights-holding members of society deserving of equality, dignity and respect

Gender-specific psychological and social impact of COVID-19 in Pakistan

Background: COVID-19 has rapidly spread across the world. Women may be especially vulnerable to depression and anxiety as a result of the pandemic.Aims: This study attempted to assess how gender affects risk perceptions, anxiety levels and behavioural responses to the COVID-19 pandemic in Pakistan, to recommend gender-responsive health policies.Methods: A cross-sectional online survey was conducted. Participants were asked to complete a sociodemographic data form, the Hospital Anxiety and Depression Scale, and questions on their risk perceptions, preventive behaviour and information exposure. Multiple logistic regression analysis was used to assess the effects of factors such as age, gender and household income on anxiety levels.Results: Of the 1391 respondents, 478 were women and 913 were men. Women considered their chances of survival to be relatively lower than men (59% v. 73%). They were also more anxious (62% v. 50%) and more likely to adopt precautionary behaviour, such as avoiding going to the hospital (78% v. 71%), not going to work (72% v. 57%) and using disinfectants (93% v. 86%). Men were more likely to trust friends, family and social media as reliable sources of COVID-19 information, whereas women were more likely to trust doctors.Conclusions: Women experience a disproportionate burden of the psychological and social impact of the pandemic compared with men. Involving doctors in healthcare communication targeting women might prove effective. Social media and radio programmes may be effective in disseminating COVID-19-related information to men