Health seeking behaviour and health services utilization trends in national health survey of Pakistan: what needs to be done?

In developing countries, health seeking behaviours and health care services utilization patterns have been studied and the determinants have been classified in physical, socio-economic, cultural and political contexts. This paper is based on a systematic review of peer-reviewed literature on the relationship of factors affecting health service utilization and the focus has been on Pakistan. For this purpose, National Health Survey (NHS) of Pakistan, conducted in 1990-1994, has been critically reviewed. The review reveals specific behaviours following gender differences, socio-cultural milieu, disease patterns, household economics etc. Thus it becomes imperative to design evidence based policies by developing the understanding of health behaviours and health care utilization trends and to give enough credence to all determinants in the background. Health sector reforms therefore necessitate developing mechanisms to deliver more need based and quality services, considering thoughtfully users\u27 concerns and perspectives. The advent of decentralization in Pakistan provides a unique opportunity for tackling multi-faceted issues by multisectoral approaches

Health seeking behaviour and health service utilization in Pakistan: challenging the policy makers

There is a growing literature on health seeking behaviours and the determinants of health services utilization especially in the context of developing countries. However, very few focused studies have been seen in Pakistan in this regard. This paper presents an extensive literature review of the situation in developing countries and relates the similar factors responsible for shaping up of a health seeking behaviour and health service utilization in Pakistan. The factors determining the health behaviours may be seen in various contexts: physical, socio-economic, cultural and political. Therefore, the utilization of a health care system, public or private, formal or non-formal, may depend on socio-demographic factors, social structures, level of education, cultural beliefs and practices, gender discrimination, status of women, economic and political systems environmental conditions, and the disease pattern and health care system itself. Policy makers need to understand the drivers of health seeking behaviour of the population in an increasingly pluralistic health care system. Also a more concerted effort is required for designing behavioural health promotion campaigns through inter-sectoral collaboration focusing more on disadvantaged segments of the population

Daily contact with a patient and poor housing affordability as determinants of pulmonary tuberculosis in urban Pakistan

Objective: This study aimed to evaluate the factors associated with pulmonary tuberculosis (TB) among individuals aged 15years or more in urban Karachi, Pakistan.DESIGN AND SETTING: A case-control design was implemented in three major tertiary-care hospitals to select cases (n=342) with active pulmonary TB (i.e. two sputum smears positive for Mycobacterium tuberculosis with clinical and radiographic evidence of current pulmonary TB and diagnosed between August 2002 and October 2003. Selected controls (n=342) were surgery patients from the same hospitals at time of recruitment of the cases, without clinical and radiographic evidence of pulmonary TB.Results: Multivariable logistic regression model showed that daily contact with a pulmonary TB patient (adjusted odds ratio [ORadj])=5.07; 95% CI: 3.31, 7.78), and poor housing affordability (i.e. rented vs. owned) (ORadj=1.59; 95% CI: 1.13, 2.26) were significantly associated with pulmonary TB status. The overall adjusted summary population attributable risk (%) for both the risk factors together was 38.7.CONCLUSION: Reaching out to underprivileged TB patients for delivery of DOTS and focused education of patients and their contacts about M. tuberculosis transmission mode may substantially minimize pulmonary TB risk in this and similar settings

Complementary and Alternative Medicine in Pakistan: Prospects and Limitations

Despite all the marvelous advancements in modern medicine, traditional medicine has always been practiced. More than 70% of the developing world's population still depends on the complementary and alternative systems of medicine (CAM). Cultural beliefs and practices often lead to self-care or home remedies in rural areas and consultation with traditional healers. Evidence-based CAM therapies have shown remarkable success in healing acute as well as chronic diseases. Alternative therapies have been utilized by people in Pakistan who have faith in spiritual healers, clergymen, hakeems, homeopaths or even many quacks. These are the first choice for problems such as infertility, epilepsy, psychosomatic troubles, depression and many other ailments. The traditional medicine sector has become an important source of health care, especially in rural and tribal areas of the country. The main reasons for consulting a CAM healer is the proximity, affordable fee, availability, family pressure and the strong opinion of the community. Pakistan has a very rich tradition in the use of medicinal plants for the treatment of various ailments. It necessitates the integration of the modern and CAM systems in terms of evidence-based information sharing. The health-seeking behavior of the people especially in developing countries calls for bringing all CAM healers into the mainstream by providing them with proper training, facilities and back-up for referral. A positive interaction between the two systems has to be harnessed to work for the common goal of improving health of the people

Cost-effectiveness of community-based strategies for blood pressure control in a low-income developing country: findings from a cluster-randomized, factorial-controlled trial.

BACKGROUND: Evidence on economically efficient strategies to lower blood pressure (BP) from low- and middle-income countries remains scarce. The Control of Blood Pressure and Risk Attenuation (COBRA) trial randomized 1341 hypertensive subjects in 12 randomly selected communities in Karachi, Pakistan, to 3 intervention programs: (1) combined home health education (HHE) plus trained general practitioner (GP); (2) HHE only; and (3) trained GP only. The comparator was no intervention (or usual care). The reduction in BP was most pronounced in the combined group. The present study examined the cost-effectiveness of these strategies. METHODS AND RESULTS: Total costs were assessed at baseline and 2 years to estimate incremental cost-effectiveness ratios based on (1) intervention cost; (2) cost of physician consultation, medications, diagnostics, changes in lifestyle, and productivity loss; and (3) change in systolic BP. Precision of the incremental cost-effectiveness ratio estimates was assessed by 1000 bootstrapping replications. Bayesian probabilistic sensitivity analysis was also performed. The annual costs per participant associated with the combined HHE plus trained GP, HHE alone, and trained GP alone were $3.99,$3.34, and $0.65, respectively. HHE plus trained GP was the most cost-effective intervention, with an incremental cost-effectiveness ratio of$23 (95 confidence interval, 6-99) per mm Hg reduction in systolic BP compared with usual care, and remained so in 97.7 of 1000 bootstrapped replications. CONCLUSIONS: The combined intervention of HHE plus trained GP is potentially affordable and more cost-effective for BP control than usual care or either strategy alone in some communities in Pakistan, and possibly other countries in Indochina with similar healthcare infrastructure

Social environment and depression among pregnant women in urban areas of Pakistan: importance of social relations.

Aspects of the social environment, including social conditions (socio-economic status, household situations, chronic illnesses) and social relations (attitude and behaviors of relations) are major determinants of depression among women. This study evaluates the relative power of social relations and social conditions in predicting depression among pregnant women in Pakistan. In the qualitative phase of the study, social environmental determinants were identified through literature search, and experts\u27 opinions from psychologists, psychiatrists, gynecologists, sociologists and researchers. Along with this, 79 in-depth interviews were conducted with pregnant women drawn from six hospitals (public and private) and two communities in Karachi, Pakistan. Identified determinants of depression were grouped into themes of social conditions and social relations and pregnancy-related concerns. In the study\u27s quantitative phase, the relative power of the identified themes and categories, based on their scores for predicting depression (determined by the Center for Epidemiological Studies-Depression Scale (CES-D scale)), was determined through multivariate linear regression. Social environmental determinants of pregnant women were described under the themes and categories of (1) social relations: involving husband, in-laws and children; (2) social conditions: involving the economy, illness, life events, household work, environmental circumstances and social problems; and (3) pregnancy-related concerns i.e. symptoms of pregnancy, changes during pregnancy, dependency and concern for unborn baby. Multivariate analysis found that among these themes, social relations and pregnancy-related concerns were significantly associated with total CES-D scores. Among the categories besides increasing age and less education, husband, in-laws, household work and pregnancy symptoms were significantly associated with total CES-D scores. The study highlights the importance of social relations compared to social conditions for determining depression in pregnant women

Community based lifestyle intervention for blood pressure reduction in children and young adults in developing country: cluster randomised controlled trial

Objective To assess the effectiveness of a community based lifestyle intervention on blood pressure in children and young adults in a developing country setting

Breast cancer risk factor knowledge among nurses in teaching hospitals of Karachi, Pakistan: a cross-sectional study

BACKGROUND: Breast cancer is the most common cancer among women in both the developed and the developing world. The incidence of breast cancer in Karachi, Pakistan is 69.1 per 100,000 with breast cancer presentation in stages III and IV being common (≥ 50%). The most pragmatic solution to early detection lies in breast cancer education of women. Nurses constitute a special group having characteristics most suited for disseminating breast cancer information to the women. We assessed the level of knowledge of breast cancer risk factors among registered female nurses in teaching hospitals of Karachi. We also identified whether selected factors among nurses were associated with their knowledge of breast cancer risk factors, so that relevant measures to improve knowledge of nurses could be implemented. METHODS: A cross-sectional survey was conducted in seven teaching hospitals of Karachi using stratified random sampling with proportional allocation. A total of 609 registered female nurses were interviewed using a structured questionnaire adapted from the Stager's Comprehensive Breast Cancer Knowledge Test. Knowledge of breast cancer risk factors was categorized into good, fair and poor categories. Ordinal regression was used to identify factors associated with risk knowledge among nurses. RESULTS: Thirty five percent of nurses had good knowledge of risk factors. Graduates from private nursing schools (aOR = 4.23, 95% CI: 2.93, 6.10), nurses who had cared for breast cancer patients (aOR = 1.41, 95% CI: 1.00, 1.99), those having received a breast examination themselves (aOR = 1.56, 95% CI: 1.08, 2.26) or those who ever examined a patient's breast (aOR = 1.87, 95% CI: 1.34, 2.61) were more likely to have good knowledge. CONCLUSION: A relatively small proportion of the nursing population had good level of knowledge of the breast cancer risk factors. This knowledge is associated with nursing school status, professional breast cancer exposure and self history of clinical breast examination. Since only about one-third of the nurses had good knowledge about risk factors, there is a need to introduce breast cancer education in nursing schools particularly in the public sector. Continuing nursing education at the workplace can be of additional benefit