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

Exploring the Feasibility of Integrating Mental Health into a Family Planning Program in low-resource settings

Introduction: Mental health challenges remain a pressing issue, underscored by the glaring gap between the elevated demand and the scarce resources. Research has highlighted the effectiveness of integrating mental health services with primary care services, particularly in low-resource settings. Purpose: The objective of this research was to evaluate the perceived implications and feasibility of integrating basic mental health services into an existing community-based family planning initiative in Pakistan. By adopting a community-driven and co-produced methodology, our study not only ensured a deeper resonance with local needs but also paved the way for a sustainable and transformative uptake of mental health services in low-resource settings. This co-produced strategy, anchored in mutual collaboration and shared expertise with the community, promises a more holistic, enduring, and adaptive integration of essential health services within community frameworks.Methodology: This study utilized a qualitative research approach to obtain a comprehensive understanding of the program's feasibility and potential for expansion. Interview tools and guides, tailored to the regional language, were developed by the Research Associate to gather insights from the lady health workers involved in delivering the intervention, as well as from the clients. Overall, our team conducted 24 interviews, of which 9 were with the lady health workers and 15 with clients. The interviews were facilitated by the Research Associate and a Psychologist.Results: Utilizing the socio-ecological model, we thematically analyzed factors at individual, interpersonal, and community levels that support or hinder the integration of mental health services with existing community-based programmes. We also examined the intervention's impact on its users and the healthcare providers.Our analysis underscores the significant potential of integrating mental health services into existing community-based health programmes, such as family planning, in low-resource settings. Predominant themes highlighted women's willingness to use these services, influenced by strong relationships and trust in the lady health workers, ease of access to services, and community support. Identified barriers to integration included prevailing poverty, a preference for direct financial incentives in addition to counseling, confidentiality concerns in tight-knit communities, and the lingering stigma surrounding mental health.Conclusion: Our findings highlight the value of community collaboration in healthcare, particularly in low-resource settings. The co-production approach blends professional guidance with local insights, fostering community ownership and enhancing program sustainability. As the first to merge mental health with family planning in Pakistan, our research suggests that future health initiatives can greatly benefit from community-driven methods, leading to more sustainable and transformative health outcomes

Does empowerment matter? Perceptions of nursing leaders in Pakistan through qualitative approach.

Background: In a patriarchal society like Pakistan, where women are oppressed, women dominating professions like nursing is mostly seen as disempowered and requires considerable struggle to achieve its due recognition and respect. Aim: This study aims to explore the experiences of empowerment among the nursing leaders of Pakistan. Methods: This study uses a qualitative descriptive design. Total of twelve Pakistani Nursing leaders were interviewed using semi-structured interview guideline to explore their experiences of empowerment. Results: The study findings revealed five major categories which include: status of a nurse, nursing profession, power relationships, value-belief system, and leadership and management. Conclusions: Nurses’ empowerment is essential for enhancing the image and status of nursing profession in Pakistan. The study identified various personal and professional factors affecting nurses’ empowerment in the country and suggests various strategies, such as access to higher nursing education, development of enhanced nursing leadership competencies and understanding of power and politics of the organization, through which nurses can achieve empowerment

The COVID-19 pandemic as a catalyst for integrated global mental healthcare and tuberculosis care

Mental disorders are common among persons with tuberculosis (TB), and the COVID-19 pandemic has only amplified the mental and physical health consequences of this deadly synergy. Here, we call to attention the immense vulnerability of people with TB to mental disorders during the pandemic and highlight the unique challenges and opportunities that the pandemic brings to the future integration of global TB and mental healthcare. We argue that the pandemic era is an ideal period to accelerate this integration and we provide research and policy recommendations to actualise this urgent need

Prevalence and risk factors for hepatitis C virus infection in an informal settlement in Karachi, Pakistan

The burden of hepatitis C virus (HCV) infection in Pakistan is amongst the highest in the world. People living in slums are likely to be at high risk of infection. Here, we describe the results of a cross-sectional survey conducted in March 2022 that aimed to quantify the prevalence of HCV infection in Machar Colony, one of the largest and oldest slum settlements in Karachi. Risk factors for HCV seropositivity were identified using multi-level logistic regression. We recruited 1,303 individuals in a random selection of 441 households from Machar Colony. The survey-adjusted HCV-seroprevalence was 13.5% (95% Confidence Interval (CI) 11.1–15.8) and survey-adjusted viraemic prevalence was 4.1% (95% CI 3.1–5.4) with a viraemic ratio of 32% (95% CI 24.3–40.5). Of 162 seropositive people, 71 (44%) reported receiving previous treatment for chronic hepatitis C. The odds of HCV seropositivity were found to increase with each additional reported therapeutic injection in the past 12 months (OR = 1.07 (95% Credible Interval (CrI) 1.00–1.13)). We found weaker evidence for a positive association between HCV seropositivity and a reported history of receiving a blood transfusion (OR = 1.72 (95% CrI 0.90–3.21)). The seroprevalence was more than double the previously reported seroprevalence in Sindh Province. The overall proportion of seropositive people that were viraemic was lower than expected. This may reflect the long-term impacts of a non-governmental clinic providing free of cost and easily accessible hepatitis C diagnosis and treatment to the population since 2015. Reuse of needles and syringes is likely to be an important driver of HCV transmission in this setting. Future public health interventions should address the expected risks associated with iatrogenic HCV transmission in this community

Assessing the effectiveness and cost-effectiveness of a solution-focused resource-orientated approach (DIALOG+) to improving the quality of life for people with psychosis in India and Pakistan—a cluster RCT

Background: Severe mental illness (SMI) presents a major challenge worldwide, affecting approximately 5–8% of the world’s population. It causes significant distress to affected people, families and wider communities, generating high costs through loss of productivity and ongoing healthcare use. Over 75% of patients with psychosis receive inadequate care and experience a negative financial impact and reduced quality of life (QoL). It is therefore a priority to reduce the treatment gap by providing low-cost, effective interventions for people with psychosis. Our research project, PIECEs, is designed to explore, adapt and test a low-cost, approach (DIALOG+) that makes use of existing resources to improve community-based care for patients with psychosis. The research will be conducted in two urban sites: Karachi, Pakistan and Chennai, India. DIALOG+ is a novel, technology-assisted and resource-oriented intervention, based on QoL research, concepts of patient-centred communication, IT developments and solution-focused therapy. However, the approach has not been rigorously tested within India and Pakistan. Our randomised controlled trial (RCT) aims to test the effectiveness and cost-effectiveness of DIALOG+ in improving the QoL and clinical outcomes for individuals with long-term psychosis being treated in the community in India and Pakistan. Methods: To assess the acceptability, feasibility, and cost effectiveness of DIALOG+, we will conduct a cluster RCT with 210 patients and 14 clinicians in each country. The intervention will be used during a routine interaction between a clinician and a patient. It consists of a patient-centred assessment (the DIALOG scale) whereby the clinician invites the patient to rate their satisfaction with different life domains and treatment aspects, which forms the active control group. The intervention group will follow this up with a four-step solution-focused approach to identify the patient’s resources and develop solutions to deal with the patient's concerns (DIALOG+). Discussion: If shown to be effective DIALOG+ has the potential to improve community-based care and the QoL for millions of people within India and Pakistan who experience psychosis. Trial registration: The trial was registered prospectively on the ISRCTN Registry: ISRCTN13022816 on 9 February 2022

Ray of hope: opportunities for reducing unsafe abortions!

Unsafe abortion is one of the leading causes of maternal mortality and morbidity which impede the nation in achieving the targets of MDG 5. In the developing world, it is estimated that 13% of all maternal deaths are due to unsafe abortions. Despite having certain liberty in the law and religion, Pakistan has a relatively high prevalence of unsafe abortion. Poverty, unintended pregnancies, ineffective use of contraceptive methods and unawareness about the law are the root causes for the rise in the number of women seeking abortions. Nonetheless, with all these opening points of having permission in the law and religion could direct us that if we just follow them we can reduce the number of unsafe and illegal abortions.Therefore, there is a strong interventions would be required in health and legal aspects, which would decrease maternal mortality and morbidity

Exploring the Feasibility of Integrating Mental Health into a Family Planning Program in low-resource settings

Introduction: Mental health challenges remain a pressing issue, underscored by the glaring gap between the elevated demand and the scarce resources. Research has highlighted the effectiveness of integrating mental health services with primary care services, particularly in low-resource settings

Exploring biomedical and traditional care pathways for people with psychosis in Karachi, Pakistan.

Peer reviewed: TrueAcknowledgements: This research was aided by contributions from the field team at IRD. Field Supervisors Irfan Ali and Maryam Bibi helped to coordinate and recruit participants overall, and Asim Khan connected the researchers to faith healers in Karachi.BACKGROUND: Psychosis is known to have an adverse impact on an individual's quality of life, social and occupational functioning. A lack of treatment options for psychotic disorders such as schizophrenia contributes to adverse outcomes for individuals. A significant proportion of people with psychosis consult both formal and traditional routes of care. This warrants a need to explore perceptions around treatment options provided by diverse care providers, as the identification of avenues for support can improve psychiatric, alternative treatment and social outcomes. METHODS: Focus groups discussions (FGDs) and in-depth interviews (IDIs) were used. Interactive Research and Development (IRD) research staff conducted 20 IDIs and 2 FGDs to obtain information about the perspectives, treatment pathways and experiences of individuals with psychosis, their caregivers, and service providers. Questions for clinician care providers and faith healers revolved around perceptions of psychosis, service users' background, subject knowledge and treatment, feedback and referral mechanisms, and promotion of services. A thematic analysis was used to analyze the interviews and coding was conducted on NVivo. RESULTS: The results were categorized into five themes: perception of psychosis, experience of seeking/receiving care, assessment and diagnosis methods, promotion of services, and living with psychosis. Across service providers and patients, there was a wide variety of causes attributed to psychosis, and an overall lack of awareness regarding severe mental health conditions from both formal and informal care-providers. Biomedical treatment received mixed reviews, while some reported it as beneficial, the limited number of institutes and clinicians to cater for patients, stigma within society and care providers, the burden of caregiving, and misinformation from faith healers were all significant barriers to treatment. CONCLUSION: The results highlight the use of traditional healing practices for psychosis in Pakistan, which, coupled with inadequate referral mechanisms, present an opportunity to bridge the treatment gap between clinical and traditional healing practices through integration of treatment within community structures and systems. Better awareness of psychosis and its treatment methods, alongside interventions that reduce stigma could help facilitate help-seeking behavior and reduce the burden of caregiving