Building on the health policy analysis triangle: Elucidation of the elements

The health policy triangle first presented in the 20th century by Walt and Gilson has been extensively used at local, national, regional, and international levels to assess health policies related to communicable and non-communicable diseases, physical and mental health, antenatal and postnatal care, and human resources, services, and systems. However, the framework lacks intricate details for the four pillars in the triangle viz: \u27content,\u27 \u27context\u27, \u27actors\u27, and \u27processes. We propose a checklist of elements to be considered for each pillar; to ease and enhance the process of policy analyses for researchers and policymakers across the globe, including low- and middle-income countries. We suggest using Leichter\u27s categorization of situational, structural, cultural, and environmental factors for comprehensive contextual assessment. Kingdon\u27s multiple streams framework can be applied to determine the \u27window of opportunity\u27 allowing the politics, policy, and problem streams to unite, giving birth to the formulation of policies. Lastly, stakeholders\u27 analyses expounding the power, influence, interest, and involvement of intrinsic, extrinsic, implicit, and explicit players should be applied to explore the \u27actors\u27 in policy analyses. Robust policy analyses for generating evidence are of paramount importance for policymakers for informed decision-making. Our approach of dis-entangling and elaborating the pillars of the triangle will be helpful for health systems researchers at sub-national, national, regional and global levels to serve as a basis for evidence-based informed decision-making

The Effect of Breastfeeding on the Cognitive and Language Development of Children Under 3 Years of Age: Results of Balochistan-Early Childhood Development Project

Background: Breastfeeding is known to be an important factor in the overall growth and development of children. Breastfeeding is thought to lead to enhance cognitive and language development of a child. However, this association has not yet been scientifically and statistically established. This study aimed to explore this association in children under 3 years of age.Methods: This was a secondary data-analysis of the baseline data of “Balochistan – Early Childhood Development Project”. The final sample comprised of 604 children less than 3 years of age. The children were selected by three-stage stratified random sampling from three districts of Balochistan province; Gwadar, Quetta and Qilla Saifullah. The data for the duration of breastfeeding was categorized as less than 6 months, from 6 months to 12 months and greater than 12 months. The age appropriate language and cognitive development of children was assessed through the CDA (Care for development Appraisal) tool. We applied multivariate logistic regression model for the analysis.Results: In unadjusted analysis, children breastfed for more than 12 months were at an advantage for cognitive and language development (cOR=2.91, cOR=2.8; p\u3c0.05; respectively). After adjusting for a range of co-variates this developmental advantage decreased to aOR=2.42 for cognition and aOR=2.44 for language respectively (p\u3e\u3c0.05).Conclusions: The duration for which the child is breast-fed is integral for his language and cognitive development. Based on our findings we recommend that breastfeeding should be promoted for more than 12 months to bring out the maximum benefit in the language and cognitive development of a child

Effectiveness of simulation-based clinical skills training for medical students in respiratory medicine: A pilot study

Objective: To assess the effectiveness of high-fidelity simulation-based medical education (HF-SBME) in teaching and learning respiratory clinical examination in medical students.Study design: Quasi-experimental pilot study.Place and duration of study: The Aga Khan University, Karachi, from November 2018 to January 2020. Methodology: This study was conducted amongst third year medical students at the University. Students were assigned to intervention (IG) or control groups (CG). The IG underwent training for the respiratory clinical examination on a high-fidelity simulator mannequin, while the CG received the conventional practice session on standardised patients. Students were assessed on their respiratory clinical examination skills in five domains, and each domain was scored between 1-3 points (poor=1, fair=2, good=3) for a maximum composite score of 15. Feedback on use of SBME was also obtained from students.Results: There were no statistically significant differences in demographics for the CG (n=41) and IG (n=40). Composite score for control and intervention groups was not significantly different (CG: 12.9 ± 1.89 vs. IG: 12.0 ± 2.35; p=0.067). However, a greater percentage of CG students were rated good in all five domains, with the difference being statistically significant for ability to correlate findings with clinical history (CG: 87.8% vs. IG: 67.5%; p=0.028).Conclusion: Although medical students perceived HF-SBME as a beneficial teaching modality, it did not translate into improved performance. More research is required to determine the utility of HF-SBME in a developing country, like Pakistan

Brucellosis in Pakistan: A neglected zoonotic disease

Brucellosis is a zoonotic disease; endemic but neglected in the South Asian countries including Pakistan. It causes economic loss to the livestock sector and leads to systemic infection in humans. Brucellosis was neglected in Pakistan since long. According to the Staged Tool for the Elimination of Brucellosis (STEB), Pakistan carries a grim landscape of the disease with no structured control activities. This article describes the five-year national brucellosis control strategic plan (2018-2023) formulated by the government of Pakistan using the one-health approach for the prevention and control of disease across the country. The plan incorporates components of surveillance, research, diagnostic capacity, awareness and vaccination using a multi-disciplinary approach

Violence and abuse among working children in urban and suburban areas of lower Sindh, Pakistan

Background: Child labourers are exposed to an insecure environment and higher risk of violence. Violence among child labourers is an under-studied phenomenon which requires contextual assessment.Aims: We applied Bronfenbrenner\u27s ecological model (micro-, exo- and macro-system) to understand the interplay of individual, community, societal and policy context fuelling violence.Methods: Focus group discussions and family ethnographies of child-labourers working in common occupational sectors of suburban areas of Sindh were carried out to gain in-depth understanding of their immediate environment and abuse (micro-system). Frequency of emotional, physical and sexual violence (5-14 years; n = 634) was also determined. Indepth interviews with employers (exo-system, n = 4) and key-informant-interviews of prominent stakeholders in Pakistan (macro-system, n = 4) working against labour/violence were carried out Thematic-content analysis was performed using MAXQDA, version 8.0.Results: We estimated that 21%, 19% and 9% of children suffered from emotional, physical and sexual violence respectively. Child labourers\u27 interviews indicated the existence of all forms of abuse at home and in the workplace; sexual violence by grandfathers was highlighted (micro-system). Children reported frequent scolding and insults in the workplace along with physical violence that could be fatal (exo-system). The legal environment of violence in Pakistan was considered deficient as it did not address the hidden forms (touching, kissing, etc.; macro-system).Conclusion: We documented that all forms of violence were rampant among the child labourers, and improved efforts and comprehensive legislation is direly needed to alleviate the situation

Recommendations: Putting an end to child labour in Pakistan!

Child labour is rampant in Pakistan since ages. Laws, policies, programmes and strategies to eliminate child labour have been in place with little gain. Implementation of laws and sustainability of programmes offer barriers to eliminate the menace. We recommend a new approach of regulating child labour as a strategy to eliminate it in the longer run. Model districts with drop-in-centres offering free education to the working children should be constructed. The key stakeholders should unite on a common platform to formulate guidelines defining the nature and duration of work for children in various sectors such that they have sufficient time to visit the drop-incentres. Once a generation of children is educated, the cycle will start to break itself and gradually we will overcome child labour

Malnutrition and food insecurity in child labourers in Sindh, Pakistan: A cross-sectional study

Background: Child labour is common in low- and middle-income countries. Although child labour is widespread in Pakistan, no data are available on the health of child labourers.Aims: This study aimed to assess the food security, food intake and nutritional status of child labourers aged 5-14 years working in lower Sindh, Pakistan.Methods: Child labourers aged 5-14 years working in agriculture, manufacturing industry, hotels and restaurants, domestic work and migrant child labourers working in vegetable markets were recruited using a respondent-driven sampling technique. Sociodemographic and nutrition information was obtained by an interviewer questionnaire. The children\u27s height and weight were measured to assess stunting (height-for-age z scores less than -2) and wasting (weightfor- height z scores less than -2).Results: A total of 634 child labourers were included: 184 worked in agriculture, 120 in industry, 67 in hotels and restaurants, 63 in domestic work and 200 were migrant child labourers. Overall, 15.5% of the children were stunted and 30.0% were wasted. The prevalence of stunting was highest in children working in agriculture (27.2%) and the prevalence of wasting was highest in migrant child workers (35.0%). About half the children (51.1%) were suffering from food insecurity. Food inadequacy was mainly in consumption of vegetables/potatoes (98% of the children had inadequate intake), legumes (97%), fruits (96%), meat/ poultry (95%) and milk/dairy products (82%).Conclusion: The nutritional status and food insecurity of the child labourers of Pakistan are comparable with the general population, highlighting the grave situation of the country with regard to food security

Association of respiratory symptoms and lung function with occupation in the multinational Burden of Obstructive Lung Disease (BOLD) study

Background Chronic obstructive pulmonary disease has been associated with exposures in the workplace. We aimed to assess the association of respiratory symptoms and lung function with occupation in the Burden of Obstructive Lung Disease study. Methods We analysed cross-sectional data from 28 823 adults (≥40 years) in 34 countries. We considered 11 occupations and grouped them by likelihood of exposure to organic dusts, inorganic dusts and fumes. The association of chronic cough, chronic phlegm, wheeze, dyspnoea, forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV1)/FVC with occupation was assessed, per study site, using multivariable regression. These estimates were then meta-analysed. Sensitivity analyses explored differences between sexes and gross national income. Results Overall, working in settings with potentially high exposure to dusts or fumes was associated with respiratory symptoms but not lung function differences. The most common occupation was farming. Compared to people not working in any of the 11 considered occupations, those who were farmers for ≥20 years were more likely to have chronic cough (OR 1.52, 95% CI 1.19–1.94), wheeze (OR 1.37, 95% CI 1.16–1.63) and dyspnoea (OR 1.83, 95% CI 1.53–2.20), but not lower FVC (β=0.02 L, 95% CI −0.02–0.06 L) or lower FEV1/FVC (β=0.04%, 95% CI −0.49–0.58%). Some findings differed by sex and gross national income. Conclusion At a population level, the occupational exposures considered in this study do not appear to be major determinants of differences in lung function, although they are associated with more respiratory symptoms. Because not all work settings were included in this study, respiratory surveillance should still be encouraged among high-risk dusty and fume job workers, especially in low- and middle-income countries.publishedVersio

Peoples’ Perception towards Nuclear Energy

Perception towards nuclear energy is a vital factor determining the success or failure of nuclear projects. An online survey obtained attitudes toward nuclear energy, opinions on whether benefits of nuclear energy outweigh the risks, and views of using nuclear energy as an energy source. A total of 4318 participants from across the U.S. completed the survey. Logistic regression was used to predict perceptions of nuclear energy by participant demographics and geographical location. Participants living closest to Idaho National Laboratory (INL) were more likely to have positive attitudes towards nuclear energy (aOR: 7.18, p < 0.001), believe the benefits were greater than the risks (aOR: 4.90, p < 0.001), and have positive attitudes toward using nuclear energy as an electricity source (aOR: 5.70, p < 0.001), compared to people living farther from INL. Males and non-Hispanic white participants were more likely to have positive perceptions of nuclear energy. Developing and implementing awareness raising campaigns for people living further away from nuclear power plants, targeting females and Hispanic whites, may be key to improving the overall perceptions of nuclear energy

Review of the governance of public sector hospitals in Pakistan: Lessons for the future

Governance of public sector hospitals has been a major challenge in Pakistan. A framework has been adapted to assess governance at the macro- and micro levels of decision making. At the macro-level, the experience of hospital autonomy to improve efficiency and quality of care has been inconclusive in the absence of proper rules and regulations. Following devolution in health, the provincial governments have instituted regulatory regimes for improved governance and have experimented with PPPs to improve management of district hospitals. At the micro-level, the focus has been on institutional aspects of hospital management. Most public hospitals face challenges related to human resource, financial and supply chain management; lack of information technology, poor quality of care, and lack of disaster preparedness and management capability. This paper offers three strategic priorities for policymakers to consider – first, demonstrate consistency and commitment in implementing policies related to hospital governance; second, launch a countrywide capacity development program for hospital managers; and third, establish e-governance to enhance accountability, transparency and performance of hospitals