Young Adults in Urban Pakistan; Barriers and Challenges for Improving Health Behaviors in the wake of the HIV/AIDS Epidemic

Background: HIV/AIDS is spreading globally more specifically among the younger generation. The impact of HIV/AIDS on the youth cannot be underestimated. According to the UNAIDS report 2008; an estimated number of 33 million people around the globe were living with HIV in 2007, and overall, 2.0 million people died due to AIDS, compared with an estimated 1.7 million in 2001. The HIV/AIDS epidemic is most likely to affect health status, economic conditions and family situations. Unprotected sex with an infected partner, contact with infected blood, sharing of drug needles or syringes and mother to child transmission are the modes which cause HIV infection. Surveillance data of Sindh AIDS Control Program, Pakistan suggest that HIV infection is rapidly increasing among injecting drug users (IDUs) and had reached 9% in 2004-5 indicating that Pakistan has entered the concentrated epidemic stage for HIV/AIDS i.e. the HIV prevalence in high-risk subpopulations is 5% or higher. This poses a serious threat of a generalized epidemic especially among the younger population of Pakistan. The prevalence of HIV infection among female sex workers was minimal. Cultural and religious constraints in discussing reproductive health issues and lack of youth clinics further makes the younger generation more vulnerable to HIV/AIDS. Aim: The overall aim of this thesis is to explore and describe young adults knowledge and perceptions on sexual and reproductive health with special reference to HIV/AIDS, future gender roles and implications for health behaviors and prevention in Karachi, Pakistan. Methods: The studies were conducted in the city of Karachi, Pakistan, which is the largest city and the economic and commercial hub of Pakistan and comprises of people from all ethnic backgrounds. Karachi is divided into 18 towns based on administrative units. This project has used both quantitative (study I and II) and qualitative methods (study III and IV). A population-based, cross-sectional study of 1,650 young adults (male n=826) and (female, n=824) aged 17-21 years living in Karachi was conducted using a structured questionnaire (study I and II). A multi-stage cluster sampling design was used to collect data representative of the general population in an urban area in all 18 towns of Karachi. School/college dropouts and preliminary knowledge about STDs were assessed (Study I), further knowledge about HIV/AIDS was assessed (study II). Bivariate and multivariate analyses were performed separately for males and females. A qualitative exploratory study was carried out (study III and IV). Focus group discussions were used for data collection. Participants, both males and females aged 17-21 years were purposively chosen from three different social strata. Altogether, six FGDs (6-8 participants in each FGD) were conducted in the local language Urdu, two from each social stratum. Knowledge and perceptions of HIV/AIDS and family planning were explored (study III), the perception of future life prospects and gender roles were also discussed (study IV). Qualitative content analysis was applied to identify manifest and latent content. Results/findings: Study I revealed that females were twice as likely to dropout of school/college as males. The risk factors for school/college dropout for both males and females were migrant residential status, living in an extended family and low socio-economic status. Furthermore, females exhibited a higher level of awareness about STDs and HIV/AIDS than the males, irrespective of whether they had dropped out of school or not. While the males who dropped out were considerably less aware than those who remained at school, there was no such difference among females. Knowledge of HIV/AIDS was assessed in detail (study II), and it was found that out of 1,650 subjects, 24 per cent (n=390) reported that they had not heard of HIV/AIDS. Among the males, those with a poor HIV knowledge were younger (AOR=2.20; 95 per cent CI, 1.38, 3.49) and had less than six years of schooling (AOR=2.46; 1.29 4.68) with no access to computer at home (AOR=1.88; 1.06 3.34). Among the females, the risk factors for poor knowledge were young age (AOR=1.74; 1.22, 2.50), low socio-economic status (AOR=1.54; 1.06, 2.22), lack of enrolment at school/college (AOR= 1.61; 1.09, 2.39) and being unmarried (AOR=1.85; 1.05, 3.26). Knowledge and perceptions of HIV/AIDS and family planning was further explored (study III). The main theme that emerged from the focus group discussions was Need for multilevel strategies to combat the spread of HIV/AIDS and enhanced acceptance of family planning . A knowledge gap was revealed concerning HIV/AIDS and family planning among young males and females, who had to rely on media and peers for seeking information. Participants perceived that HIV/AIDS is incurable and carries a social stigma. Female participants pointed at the existence of societal discrimination against women with HIV/AIDS. The opposition of family planning from religious leaders was revealed. Exploring the perceptions of future life prospects and gender roles (study IV), the main theme that emerged from the focus group discussions was Expectations of young adults in a changing society is hampered by psychosocial and gender equality constraints . Not only did young males but young females too perceive that good education and a respectable job are obligatory for better life prospects. The major obstacles in this regard were lack of merit system and scarceness of jobs. The younger generation believes that both men and women should share household tasks. Gender inequality and the lower status of women in society were considered obstacles to development. Conclusion: Pakistani young adults having inadequate knowledge and awareness are vulnerable to the global HIV/AIDS epidemic. Both young men and women are well motivated to acquire good education and employment; and seem to belief in gender equality. Transition to better education and gender equality will result in new health related challenges, which emphasize that these young people should be equipped with proper knowledge about STDs and health related behaviors. Religious and cultural barriers to discuss reproductive health issues further deteriorate the situation. Nevertheless, as the prevalence of HIV/AIDS is still comparatively low, the epidemic has not yet enforced a general discussion on the importance of a well-informed younger generation

Assessing the effects of training on knowledge and skills of health personnel: a case study from the family health project in Sindh, Pakistan

Background: The Family Health Project (FHP) was implemented in the province of Sindh during 1992-99 with the assistance of the World Bank. The project was designed to bring substantial changes in health care system for achieving improvement in the health status by strengthening the quality and integration of primary health care services. One of the major components of the project was to develop the institutional capacity of Ministry of Health in Sindh. This is a comparative analysis to assess the knowledge and skills of health care providers in Area Focus Approach (AFA) health facilities with the ones in non-AFA health care facilities.Methods: In order to obtain a representative sample, 8 districts were selected which included, Larkana, Khairpur, Nawabshah, Dadu, Tharparkar, Thatta, Karachi South, and Karachi West. A structured questionnaire was designed with various sections to assess the knowledge and skills of various cadres of health facility staff.Results: This comparative assessment has come up with some interesting results; there is a difference between the scores of knowledge and skills between AFA and non-AFA health care providers. This assessment identified some important methodological issues such as the use of base-line information for comparing the results and the selection of a comparable study population for controlling the confounding factors.CONCLUSIONS: These findings can be used as important lessons learned for producing better results of any post training assessment intervention

What do young adults know about the HIV/AIDS epidemic? Findings from a population based study in Karachi, Pakistan.

Background: HIVAIDS is spreading globally, hitting the younger generations. In Pakistan, the prevalence of HIV in high-risk subpopulations is five per cent or higher. This poses a serious threat of a generalised epidemic especially among the younger population. In the wake of HIVAIDS epidemic this is worrying as a well informed younger generation is crucial in restricting the spread of this epidemic. This study investigated Pakistani young adults\u27 (male and female) knowledge and awareness of the HIV/AIDS disease. Methods: A population-based, cross-sectional study of 1,650 male and female adults aged 17-21 years living in Karachi was conducted using a structured questionnaire. A multi-stage cluster sampling design was used to collect data representative of the general population in an urban area. Bivariate and multivariate analyses were performed separately for males and females. Results: Of 1,650 subjects, 24 per cent (n = 390) reported that they had not heard of HIV/AIDS. Among the males, those with a poor knowledge were younger (AOR = 2.20, 95 per cent CI, 1.38, 3.49), with less than six years of schooling (AOR = 2.46, 1.29 4.68) and no computer at home (AOR = 1.88, 1.06 3.34). Among the females, the risk factors for poor knowledge were young age (AOR = 1.74, 1.22, 2.50), low socio-economic status (AOR = 1.54, 1.06, 2.22), lack of enrolment at school/college (AOR = 1.61, 1.09, 2.39) and being unmarried (AOR = 1.85, 1.05, 3.26). Conclusion: Alarming gaps in knowledge relating to HIV/AIDS were detected. The study emphasises the need to educate young adults and equip them with the appropriate information and skills to enable them to protect themselves from HIV/AIDS. However, taboos surrounding public discussions of sexuality remain a key constraint to preventive activities

Young adults\u27 perceptions on life prospects and gender roles as important factors to influence health behaviour: a qualitative study from Karachi, Pakistan

The purpose of this qualitative study was to explore perceptions and expectations of young males and females, in Karachi, Pakistan, regarding their life prospects and gender roles, with resulting implications for health behaviour. The main theme emerging was Young adults\u27 prospects in life are hampered by psychosocial and gender equality constraints . Gender inequality and the low status of women in society were described as major obstacles to the overall development. Persistent withholding of information to the younger generation on sexual and reproductive health issues was perceived to increase exposure to health risks, particularly sexually transmitted infections (STIs). The present study reveals new discourses on equality among young adults, pointing towards an increasing, sound interaction between the sexes and aspirations for more gender equal relationships. Such views and awareness among the younger generation constitutes a strong force towards change of traditional norms, including reproductive health behaviour, and calls for policy change

Need for multilevel strategies and enhanced acceptance of contraceptive use in order to combat the spread of HIV/AIDS in a Muslim society: a qualitative study of young adults in urban Karachi, Pakistan.

This qualitative study explored knowledge, attitudes, beliefs and perceptions of sexual and reproductive health, focusing specifically on contraceptive use and HIV prevention among young unmarried men and women, 17-21 years, in urban Karachi, Pakistan. The main theme, identified as underlying meaning in the focus group discussions was Societal norms and perceptions create barriers to knowledge and awareness about sexual and reproductive health matters among young adults . A knowledge gap was revealed concerning HIV/AIDS and contraceptive use among young males and females, who have to rely on media and peers for information seeking. Study participants perceived that HIV/AIDS is incurable and carries a social stigma. It was further revealed, that there is an opposition towards contraceptive use from religious leaders. Young adults in Pakistan are in need of improved knowledge about HIV/AIDS and contraceptive use. Youth clinics and schools/colleges may play a significant role in this regard. The religious leaders need to be informed about the beneficial effects of contraceptives and they should be part of any family planning/contraceptive use program to ensure better community acceptance. At the structural level there is an urgent need for policies targeting the issue of sexual and reproductive health, particularly HIV/AIDS information and contraceptive use to target the young population. The health care services should be able to respond by offering relevant services

Knowledge, perceptions and myths regarding infertility among selected adult population in Pakistan: a cross-sectional study

<p>Abstract</p> <p>Background</p> <p>The reported prevalence of infertility in Pakistan is approximately 22% with 4% primary and 18% secondary infertility. Infertility is not only a medical but also a social problem in our society as cultural customs and perceived religious dictums may equate infertility with failure on a personal, interpersonal, or social level. It is imperative that people have adequate knowledge about infertility so couples can seek timely medical care and misconceptions can be rectified.</p> <p>We aim to assess the knowledge, perception and myths regarding infertility and suggest ways to improve it.</p> <p>Methods</p> <p>A cross-sectional survey was carried out by interviewing a sample of 447 adults who were accompanying the patients at two tertiary care hospitals in Karachi, Pakistan. They were interviewed one-on-one with the help of a pretested questionnaire drafted by the team after a thorough literature review and in consultation with infertility specialists.</p> <p>Results</p> <p>The correct knowledge of infertility was found to be limited amongst the participants. Only 25% correctly identified when infertility is pathological and only 46% knew about the fertile period in women's cycle. People are misinformed that use of IUCD (53%) and OCPs (61%) may cause infertility. Beliefs in evil forces and supernatural powers as a cause of infertility are still prevalent especially amongst people with lower level of education. Seeking alternative treatment for infertility remains a popular option for 28% of the participant as a primary preference and 75% as a secondary preference. IVF remains an unfamiliar (78%) and an unacceptable option (55%).</p> <p>Conclusions</p> <p>Knowledge about infertility is limited in the population and a lot of misconceptions and myths are prevalent in the society. Alternative medicine is a popular option for seeking infertility treatment. The cultural and religious perspective about assisted reproductive technologies is unclear, which has resulted in its reduced acceptability.</p

Prevalence and risk factors for underweight, wasting, stunting among children (5 years) in Jhangara Twon & Villages (Rural Sindh)

Project Summary: Malnutrition is a common problem worldwide, especially in developing countries including Pakistan. About 12 million of children under five who die each year in the developed countries mainly from preventable causes, the death of about 55% are either directly or indirectly attributable to malnutrition. Pakistan Demographic and Health Survey 199O/91 (PDHS) showed that 5O% of the children under five years were stunted while 40% of children were underweight and 9% were labeled as wasted. The main objectives of this cross sectional study conducted during July-September 1991 were to assess the prevalence and the associated risk factors for underweight, stunting and wasting. Apart from the already documented risk factors for malnutrition, present study came up with two new suggested factors i.e. the effect of consanguineous marriages and prolonged breast feeding on child nutritional status; consanguinity was identified as a risk factor for underweight while prolonged breast feeding (\u3e12 months) demonstrated a protective effect for wasting. The study was conducted in Jhangara Town and adjoining villages within 20 km area around Jhangara Town (rural Sindh). Only the last born child was enrolled, the questionnaire was administered to eligible respondent and anthropometric measurements of the child were noted. We did census in the study area and ended up with the enrollment of 800 children. The whole analysis was carried out in CHS department, Aga Khan University Karachi. Epi Info version 6.04 was used to calculate Z-Scores, simple frequencies and bivariate analyses, while SPSS package (7.5) was used to run multivariate models. This study revealed that the overall prevalence was, for underweight 54.3Vo, for wasting 21.57o and for stunting 6IVo in the study population, which was higher than the prevalence reported by PDHS 199O/91. Since underweight, wasting and stunting signifies three different categories of malnutrition, it is expected that their risk factors should be different. In multivariate analysis various risk factor for underweight were, consanguinity (OR = 1.5, 95% CI 1.08- 2.01), birth weight (OR=1.6, 95% CI 1.08 - 2.16), breast-feeding (OR =2.7, 95% CI 1.19 - 6.17). For wasting, area of residence (OR = 1.8, 95% CI 1.17-2.69) was identified as risk factors while prolonged breast feeding \u3e 12 months (OR = 0.6, 95% C 10.43-0.98) was identified as a protective factor. For stunting, ethnicity (OR = 2.1, 95% CI 1.21- 3.57) and birth interval (OR = 1.5, 95Vo CI 1.09 - 1.99) were identified as risk factors in multivariate analysis. Malnutrition is a silent emergency in rural areas with a number of risk factor involved. There is a clear and urgent need to formulate policies within our resources to address this issue. Effective strategies to discourage consanguineous marriages between first cousins are required. Birth interval of more than two years and breast feeding of more than one year are other factors that should be incorporated while designing control strategies to reduce morbidity and mortality due to malnutrition in children (\u3c 5 years)

Prevalence and risk factors for stunting among children under 5 years: a community based study from Jhangara town, Dadu Sindh

OBJECTIVE: To assess the prevalence and the associated risk factors for stunting in Jhangara Town, Dadu Sindh.METHODS: A cross-sectional survey was conducted in Jhangara Town, located in district Dadu, rural Sindh. A total of 800 children less than 5 years of age were enrolled. A questionnaire was used to elicit required information and anthropometric measurements were made.RESULTS: The overall prevalence for stunting was 61% in the study population, which was higher than the prevalence reported by Pakistan Demographic Health Survey (PDHS) 1990/91. In multivariate analysis various risk factors for stunting were ethnicity (OR = 2.1, 95% CI 1.27- 3.57) and birth interval \u3c two years (OR = 1.5, 95% CI 1.09 - 1.99).CONCLUSION: A large number of children below 5 years of age were stunted. Ethnicity and birth interval less than 2 years were the important risk factors

Assessing reasons for school/college dropout among young adults and implications for awareness about STDs and HIV/AIDS: findings from a population-based study in Karachi, Pakistan.

Background: Dropping out of school/college not only impedes economic prosperity but may also result in poor knowledge and awareness about sexually transmitted diseases (STDs). Purpose: This study investigated, among young adults in Karachi, Pakistan, the risk factors associated with involuntary school/college dropout and the implications for awareness about HIV/AIDS and STDs. Method: A population-based, cross-sectional study of 1,650 young males and females, aged 17-21years and living in Karachi, was conducted using a structured questionnaire. Bivariate and multivariate analyses were performed separately for males and females. Results: Females were twice as likely to drop out of school/college as males. Furthermore, migrant residential status, living in an extended family and lower socio-economic status were identified as risk factors for school/college dropout both for males and females. In the total sample, only 17% of males and 13% of females had heard of STDs (p=0.020). Furthermore, 26.8% of males and 20.5% of females had not heard of HIV/AIDS (p=0.003). The females exhibited a higher level of awareness on these matters than the males, irrespective of whether they had dropped out of school or not. While the males who dropped out were considerably less aware than those who remained at school, there was no such difference among females. Conclusion: Young adults from poor families are at increased risk of dropping out of school/college. Among the dropouts, males were clearly at risk of ignorance about STDs while females were somewhat better informed