Catalytic Framework: Intersectional Analysis for Community Engagement

The Community Engagement Centre (CEC) has been active across a range of diverse urban and rural populations throughout Pakistan and works closely with marginalised communities. The collective nature of Pakistani culture and its social inequities has required the CEC to recognize the intersections that shape contexts and situations, to promote local ownership, empower communities to identify and utilize existing resources for sustainable change, and improve health outcomes. Through an immersive community engagement (CE) strategy, CEC utilises participatory tools to collect stories from communities to understand their lived experiences, barriers and enablers to access, and the dynamics of power that influence these. To understand this complex relationship, a Catalytic Framework that examined the intersections within communities’ narratives was developed. Preliminary review of community narratives collected as part of programmatic operations yielded four significant elements: (1) unique, individual circumstances, (2) aspects of identity, (3) types of discrimination (if present), and (4) larger structures that reinforce exclusion (or enforce inclusion). A unique feature identified within the process of CE was the role of ‘catalysts’ – one or many people who may have transformative potential at any of these levels due to their influence, active facilitation, or agency. This novel framework enables an understanding of the threads of experience and identifying the elements and structures that impact lives of Pakistan’s diverse population. It works by recognizing the visible intersections of class, identity, gender, and power, as well as questioning what remains unarticulated, and thus promotes meaningful community engagement across different cultures and fields

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

GENDER TRAINING IN PAKISTAN: AN ANALYSIS FOR WAY FORWARD

The decade of 1970s focused on women and development, with 1974 declared as Women’s Year by the UN, followed by the decade for women (1975 – 1985). The First World Conference on women (Mexico 1975) drew attention to the need for bringing women into the development sector; by 1985 global discourse recorded a shift from women in development (WID) to gender and development (GAD). In Pakistan the notion of gender entered the development discourse by mid 1980s, and a proliferation of gender training took place. By 1995, when the Fourth World Conference on women took place in Beijing, gender training was well established in Pakistan, and a loose network of gender trainers was also established. . As gender trainings took place in different NGOs, a sense of having hit a plateau began to be felt by some gender trainers. There was no evidence available to gauge the impact of gender training or ascertain whether new depths are being explored. Furthermore, gender training appeared to have become de-politicized. This paper shares the findings of a scoping review undertaken to understand the scope (focus, depth and nature) of literature on gender trainings in Pakistan, and to highlight the gaps in training. The paper also discusses the efforts of an informal network of gender trainers that tried to extend the agenda of gender trainings and how these need to be incorporated in the gender agenda for a more holistic approach. A way forward is also identified in the paper

GENDER TRAINING IN PAKISTAN: AN ANALYSIS FOR WAY FORWARD

The decade of 1970s focused on women and development, with 1974 declared as Women’s Year by the UN, followed by the decade for women (1975 – 1985). The First World Conference on women (Mexico 1975) drew attention to the need for bringing women into the development sector; by 1985 global discourse recorded a shift from women in development (WID) to gender and development (GAD). In Pakistan the notion of gender entered the development discourse by mid 1980s, and a proliferation of gender training took place. By 1995, when the Fourth World Conference on women took place in Beijing, gender training was well established in Pakistan, and a loose network of gender trainers was also established. . As gender trainings took place in different NGOs, a sense of having hit a plateau began to be felt by some gender trainers. There was no evidence available to gauge the impact of gender training or ascertain whether new depths are being explored. Furthermore, gender training appeared to have become de-politicized. This paper shares the findings of a scoping review undertaken to understand the scope (focus, depth and nature) of literature on gender trainings in Pakistan, and to highlight the gaps in training. The paper also discusses the efforts of an informal network of gender trainers that tried to extend the agenda of gender trainings and how these need to be incorporated in the gender agenda for a more holistic approach. A way forward is also identified in the paper

Catalytic Framework: Intersectional Analysis for Community Engagement

The Community Engagement Centre (CEC) has been active across a range of diverse urban and rural populations throughout Pakistan and works closely with marginalised communities. The collective nature of Pakistani culture and its social inequities has required the CEC to recognize the intersections that shape contexts and situations, to promote local ownership, empower communities to identify and utilize existing resources for sustainable change, and improve health outcomes. Through an immersive community engagement (CE) strategy, CEC utilises participatory tools to collect stories from communities to understand their lived experiences, barriers and enablers to access, and the dynamics of power that influence these. To understand this complex relationship, a Catalytic Framework that examined the intersections within communities’ narratives was developed. Preliminary review of community narratives collected as part of programmatic operations yielded four significant elements: (1) unique, individual circumstances, (2) aspects of identity, (3) types of discrimination (if present), and (4) larger structures that reinforce exclusion (or enforce inclusion). A unique feature identified within the process of CE was the role of ‘catalysts’ – one or many people who may have transformative potential at any of these levels due to their influence, active facilitation, or agency. This novel framework enables an understanding of the threads of experience and identifying the elements and structures that impact lives of Pakistan’s diverse population. It works by recognizing the visible intersections of class, identity, gender, and power, as well as questioning what remains unarticulated, and thus promotes meaningful community engagement across different cultures and fields

Missing Dimensions in Addressing Child Malnutrition in Pakistan: Lessons from the Tawana Experience

This article uses the Tawana Pakistan Project (TPP) as a case study of how to promote self?sustaining improvements in nutrition status. The programme used a participatory approach to mobilisation around malnutrition, had a transparent information system for monitoring resources, and brought a focus on deeper structural issues to the analysis of malnutrition. We argue that Tawana was cancelled because it did not provide sufficient opportunities for leakage and diversion. This amply illustrates the political nature of nutrition. Yet efforts to reduce malnutrition continue to focus primarily on technical fixes. For long?term change researchers and programme implementers will need to understand the political space they operate within. Tawana was not perfect but it offered a glimpse of a different way forward, one that struck a balance between inclusiveness and action; transparency and accountability; and health and social science perspectives. It affected politics and was undone by them. It is not too late to include these concepts and approaches in future nutrition policies and interventions

Situation analysis of child labour in Karachi, Pakistan: A qualitative study

In Karachi, large employment opportunities, burgeoning population and the availability of cheap labour might be the contributing factors for the increasing prevalence of child labour. A literature review was conducted in 2007 that included published and unpublished literature since 2000. Various organizations working in the field were also covered, while the perception of the child labourers was covered through three focus group discussions. Common health issues among the child labourers in Karachi included respiratory illnesses, fever and generalised pains, as well as drug and sexual abuse. Organisations working for child labour could be broadly categorised into those working for legal advice and advocacy; those generating statistics; and those that are providing interventions. Discussion with children showed that irrespective of the immediate cause, the underlying determinant for child labour was poverty. The best practices identified included evening schools and drop-in centers for working children with provision for skill-based education and basic health facilities. There is need to have more such centres

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

Stretching the boundaries of medical education: A case of medical college embracing humanities and social sciences in medical education

Objective: Aga Khan University, a private medical college, had a vision of producing physicians who are not only scientifically competent, but also socially sensitive, the latter by exposure of medical students to a broad-based curriculum. The objective of this study was to identify the genesis of broad-based education and its integration into the undergraduate medical education program as the Humanities and Social Sciences (HASS) course. Methods: A qualitative methodology was used for this study. Sources of data included document review and in-depth key informant interviews. Nvivo software was utilized to extract themes. Results: The study revealed the process of operationalization of the institutional vision to produce competent and culturally sensitive physicians. The delay in the establishment of the Faculty of Arts and Sciences, which was expected to take a lead role in the delivery of a broad-based education, led to the development of an innovative HASS course in the medical curriculum. The study also identified availability of faculty and resistance from students as challenges faced in the implementation and evolution of HASS. Conclusions: The description of the journey and viability of integration of HASS into the medical curriculum offers a model to medical colleges seeking ways to produce socially sensitive physicians

Antimicrobial resistance and Neisseria gonorrhoeae multiantigen sequence typing (NG-MAST) genotypes in N. gonorrhoeae during 2012-2014 in Karachi, Pakistan

Background: Globally, increasing antimicrobial resistance (AMR) in Neisseria gonorrhoea has led to decreased treatment options for gonorrhoea. Continuous monitoring of resistance is crucial to determine evolving resistance trends in Neisseria gonorrhoea and to suggest treatment recommendations. Quality assured gonococcal AMR data from Pakistan are mainly lacking. This study was performed to determine prevalence and trends of gonococcal AMR and molecular epidemiology of local strains during 2012-2014 in Karachi, Pakistan. Methods: Gonococcal isolates (n = 100) were obtained from urogenital specimens submitted to the Aga Khan University Laboratory, Karachi, Pakistan. Antimicrobial susceptibility was determined using Etest and molecular epidemiology was assessed by N. gonorrhoeae multiantigen sequence typing (NG-MAST). Quality control was performed using N. gonorrhoeae WHO reference strains C, F, G, K, L, M, N, O, and P, and ATCC 49226. Results: Susceptibility to spectinomycin, ceftriaxone and cefixime was 100 % and to azithromycin was 99 %. All isolates had low ceftriaxone MICs, i.e., ≤0.032 mg/L. Resistance to ciprofloxacin, tetracycline and penicillin G were 86 %, 51 % and 43 %, respectively. NG-MAST analysis identified 74 different sequence types (STs). Conclusions: A highly diversified gonococcal population, 74 NG-MAST STs (62 novel STs) with an increased resistance to penicillin G, ciprofloxacin and tetracycline circulated in Karachi, Pakistan. Fortunately, no resistance to ceftriaxone was detected. Accordingly, ceftriaxone can continuously be recommended as the treatment of choice. However it is recommended to increase the dose of ceftriaxone from 125 mg intramuscularly to 250 mg intramuscularly due to ceftriaxone MIC creep and emerging resistance reported in the region. Furthermore, due to the high level of resistance to ciprofloxacin (86 %) it is essential to exclude ciprofloxacin from the recommended first-line therapy. It is imperative to significantly broaden the gonococcal AMR monitoring with participation from other laboratories and cities in Pakistan