Ali Khan Khuwaja

Epilepsy: Public knowledge and attitude in a slum area of Karachi, Pakistan

BACKGROUND Epilepsy is a common but widely misunderstood illness. Consequently, epileptics suffer from considerable stigmatization in society. Since no studies have detailed the misperceptions about epilepsy in our community, it is not possible to provide focused intervention aimed at eliminating this prejudice. PURPOSE To assess the knowledge and attitude regarding epilepsy in an adult population of a Karachi slum area. METHODS A face-to-face interview was conducted on 487 consenting adult non-epileptics (305 males; 182 females) who were conveniently sampled. Chi-square test was employed to calculate the variability in knowledge and attitude with demographic and other variables. RESULTS In all, 12.5% had never heard about epilepsy. Among the rest, 66.7% identified epilepsy as being non-infectious, while 28.2% were unaware of any treatment available for it. Among the other 71.8%, 62.7% were aware of the existence of anti-epileptic drugs. Religious/spiritual treatment was chosen as the most effective treatment by 33.1%. Males were more likely to identify epilepsy as being non-infectious (p=0.02). Nearly 18% of the respondents would not object to their child marrying an epileptic, 69.5% did not want to socially isolate the epileptics, 83.1% said epileptics could receive academic education, 85.6% said they could perform activities of daily life and 62.4% said they could become useful members of the society. Those who considered epilepsy to be infectious were more likely to carry negative attitudes towards epilepsy (p<0.01 with four attitudes). CONCLUSIONS Considerable gaps exist in the communitys knowledge about epilepsy. Some of these may explain the prevalence of negative attitudes towards this ailment.

Gender differences and clustering pattern of behavioural risk factors for chronic non-communicable diseases: community-based study from a developing country

OBJECTIVES This study estimates the burden of behavioural risk factors for chronic non-communicable diseases (CNDs) to evaluate the degree of clustering and the differential of these factors by gender in adults. METHODS In a community-based survey, information was obtained about behavioural risk factors for CNDs among 534 adults in Karachi, Pakistan. Chi-square test and odds ratio (OR) with 95% confidence interval (CI) were calculated to evaluate the differences of these factors by gender. RESULTS Overall, 22.5% of adults had anxiety/depression, 47.8% did not have adequate intake of fruits and vegetables, 60.1% were physically inactive while 49.8% were overweight/obese. More women had anxiety/ depression (OR = 2.1; 95% CI = 1.4-3.1), were physically inactive (OR=2.1; 95% CI = 1.5-3.1) and overweight/ obese (OR= 6.2; 95% CI = 4.3-9.1). On the contrary, greater number of men were found to have inadequate fruit and vegetable consumption (OR = 1.8; 95% CI = 1.3-2.5). Only 1.1% of study subjects had none of the studied risk factors, 16.9% had one while 82% had > or =2 factors. The clustering of these risk factors was significantly higher in women (p<0.001). DISCUSSION This study shows that almost all of the adults in the study had behavioural risk factors for CNDs and clustering of these factors is very common and significantly higher in women. The tendency of clustering risk factors in individuals provides opportunities to address factors with integrated approaches to prevent/delay the onset of CNDs.

Experiences, attitudes and barriers towards research amongst junior faculty of Pakistani medical universities.

BackgroundThe developing world has had limited quality research and in Pakistan, research is still in its infancy. We conducted a study to assess the proportion of junior faculty involved in research to highlight their attitude towards research, and identify the factors associated with their research involvement.MethodsA cross-sectional study was conducted in four medical universities/teaching hospitals in Pakistan, representing private and public sectors. A pre-tested, self-administered questionnaire was used to collect information from 176 junior faculty members of studied universities/hospitals. Logistic regression analysis was used to identify factors related to attitudes and barriers in research among those currently involved in research with those who were not.ResultsOverall, 41.5% of study subjects were currently involved in research. A highly significant factor associated with current research involvement was research training during the post-graduate period (p < 0.001). Other factors associated with current involvement in research were male gender, working in the public sector and previous involvement in research. Overall, a large majority (85.2%) of doctors considered research helpful in their profession and had a positive attitude towards research; nevertheless this positive attitude was more frequently reported by doctors who were currently involved in research compared to those who were not (OR = 4.69; 95% CI = 1.54-14.26). Similarly, a large proportion (83.5%) of doctors considered research difficult to conduct; higher by doctors who were not presently involved in research (OR = 2.74; 95% CI = 1.20-6.22)ConclusionLess than half of the study participants were currently involved in research. Research output may improve if identified barriers are rectified. Further studies are recommended in this area.

The economic costs of diabetes in developing countries: some concerns and recommendations

To the Editor: We read with great interest the recently published article by Esteghamati and colleagues [1] entitled ‘The economic costs of diabetes: a population-based study in Tehran, Iran’. The authors are to be congratulated for their admirable work in measuring the economic burden of diabetes, a disease for which the number of people affected is growing rapidly in developing countries [2]. With reference to the article, we wish to comment on the growing burden of diabetes—especially in the context of developing countries—and then go on to make some recommendations. It is estimated that the total number of people with diabetes globally will rise from 171 million in the year 2000 to more than 366 million in 2030 [2]. Diabetes is a complex metabolic disorder involving many body organs and systems and can devastate the lives of affected individuals. People with diabetes are up to four times more likely to develop cardiovascular diseases, and up to 40 times more likely to require lower limb amputation, than people without diabetes [3]. Furthermore, diabetes is among the leading causes of visual impairment, blindness and kidney failure in adults [3]. Diabetes is the fourth leading cause of death by diseases worldwide; more than one million people died from diabetes in 2005 and almost 80% of these deaths occurred in lowand middle-income countries [3, 4]. Due to the premature disability, morbidity and mortality associated with diabetes, diabetes is one of the most costly diseases to manage [5, 6]. This burden is even more of a problem in developing countries where diabetes and associated cardiovascular diseases develop at earlier ages and with greater severity [7]. The majority of people with diabetes in developing countries are below 64 years of age, whereas in developed countries most are in older age groups [2]. This early onset of diabetes in the more economically productive years of life leads to a devastating extra burden of cost in developing countries. This not only puts extra pressure on individuals, but affects families, society, and the healthcare system of the country. Esteghamati and colleagues [1] determined the annual economic cost of individuals with diabetes in Iran. They reported significantly higher direct and indirect costs of diabetes compared with the control group. Moreover, the authors identified medications and devices as the most expensive component of direct costs. These results are consistent with other researchers’ findings and estimates from developing countries [5, 6]. Nevertheless, we are concerned that these results may underestimate the economic cost of diabetes in Iran. However, some of the methods used by Esteghamati and colleagues [1] are either imprecise or misleading. First, the control group includes people with hypertension and A. K. Khuwaja (*) Department of Family Medicine, Aga Khan University, Karachi 74880, Pakistan e-mail: ali.khuwaja@aku.edu

Effectiveness of counseling for anxiety and depression in mothers of children ages 0-30 months by community workers in Karachi, Pakistan: a quasi experimental study

BackgroundThe prevalence of anxiety/depression is quite high during the perinatal period but unfortunately its detection and treatment have been less than satisfactory. Moreover, many women are reluctant to take pharmacotherapy for fear of excretion of drugs into their breast milk. This study assesses the effectiveness of counseling from minimally trained community health workers in reducing anxiety/depression, the rate of recurrence and the interval preceding recurrence in women during first two and a half years after childbirth.MethodsIn a quasi-experimental study, community women from two under-privileged communities were trained in data gathering, teaching healthy child-rearing practices, basic counseling skills, and screening for anxiety/depression by using an indigenously developed questionnaire, the Aga Khan University Anxiety and Depression Scale (AKUADS). The diagnosis was further confirmed by a clinical psychologist using DSM IV criteria. After obtaining consent, 420 women were screened and 102 were identified as having anxiety/depression. Screening was carried out after 1, 2, 6, 12, 18, 24 and 30 months of a live birth. Only 62 out of 102 agreed to be counseled and received eight weekly sessions. AKUADS was re-administered at 4 weeks and 8 weeks after the beginning of counseling; this was followed by the clinical psychologists interview for confirmation of response. After recovery, screening was continued every 3 months for detection of recurrence throughout the study period. Out of the women who had declined counseling 12 agreed to retake AKUADS after 4 and 8 weeks of diagnosis. Independent samples t-test, chi-square test, Repeated Measures ANOVA and Kaplan Meier technique were used for the analysis.ResultsA significant decline in level of anxiety/depression was found in both the counseled and the non-counseled groups at 4 and 8 weeks (p-value < 0.001) but the counseled group fared better than the non-counseled for recovery, reduction in the rate of recurrence and increase in the duration before relapse.ConclusionsAs our results cannot be generalized; further studies need to be carried out, to assess the benefit of incorporating minimal counseling skills in the training of community health workers.

Factors Associated with Helicobacter Pylori Infection, Results from a Developing Country-Pakistan

BACKGROUND It is known that blood group antigens are related to the development of peptic ulcer and gastric carcinoma. Infections due to H. pylori are most widespread among the developing regions due to poor standard of public health. This study sought to determine the association of H. pylori with ABO blood groups, age, gender, and smoking status among inpatients at a public sector hospital in Karachi. MATERIALS AND METHODS A cross-sectional study was conducted at endoscopy suite at a public sector hospital in Karachi in the year 2011. All the symptomatic patients coming for upper GIT endoscopy were included in this study. RESULTS Biopsy for histopathology was taken from 93 patients, with an age range from 15-65 years. Age group of 15 to 20 years was found to be associated with H. pylori infection but without significance (p-value 0.83). In all, 36 (38.7%) turned out to be H. pylori positive with a significant male preponderance (p=0.04). Distribution of ABO blood groups in H. pylori positive group were A=31.4%, B=15.4%, AB=25.0% and O=53.7%, with a statistically significant link for blood group O (p=0.05) . Rhesus factor was also compared but significant relationship was evident (p-value 0.73). CONCLUSIONS This study demonstrated that H. pylori infection can be related to ABO blood group, middle age persons and male gender. People of blood group O are more prone to develop infection related gastritis, ulcers, and even perforations, so they should be more cautious against transmission of the bacterium.

Factors related to knowledge and perception of women about smoking: a cross sectional study from a developing country.

BackgroundSmoking rates among women are currently low, but they are the fastest growing segment of cigarette smoking population in developing countries. We aimed to assess the knowledge and perceptions towards smoking and to identify the factors related with level of knowledge and perceptions among adult women in urban slums.MethodsThis was a cross sectional study conducted on 250 adult (≥18 years of age) women attending primary care clinics in three slums of Karachi, Pakistan. A pre-tested and structured, interviewer administered questionnaire was used for data collection. Factors associated with level of understanding about smoking were analyzed with chi-square test.ResultsMost of the women knew that smoking has adverse effects on women and childrens health but the knowledge of specific health effects was limited. About one third of the women knew that active smoking can cause lung disease, but only a small percentage (7%) knew that it could lead to heart disease. None of the women were aware that smoking contributes to infertility and osteoporosis. A small proportion of women were aware that smoking can lead to low birth weight (7%), congenital anomalies (5%) and less than 1% of women knew that it contributes to pregnancy loss, still birth and preterm delivery. The understanding of passive smoking affecting childrens lung was low (20%) and a similar proportion voiced concern about the bad influence of maternal smoking on children. Educated women had better knowledge of health effects of smoking. Education was associated with having better knowledge about effects on women health in general (p = 0.02) and specific effects like lung (p = 0.03) and reproductive health effects (p < 0.001). Education was also associated with knowledge regarding effects on fetus (p < 0.001) and children (p < 0.005). Although most of the women disliked being around smokers, more than one third thought that smoking decreases boredom (39%), tension (38%) and also helps to relax (40%). A large proportion (48%) of women had the misconception that smoking helps to reduce weight.ConclusionsThis study reveals that women are aware of the general ill effects of smoking but fail to identify smoking to be associated with female maladies particularly those who were illiterate and had lower levels of education. Understanding and attitudes needs to be improved by increasing health awareness and education of women in these urban communities with special emphasis on the effects of smoking on womens health.

Noncommunicable diseases and injuries: action needed in South Asia too.

We read with great interest the essay by Perel et al. [1] on noncommunicable diseases (NCDs) and injuries in Latin America and the Caribbean (LAC) countries. The authors are to be congratulated for their excellent description of the epidemic of NCDs and injuries in the LAC region. We wish to comment on this growing epidemic of NCDs with reference to South Asian (SA) countries, where the situation is comparable to the LAC region. South Asia, which has one quarter of the worlds population, is experiencing a rapid epidemiological transition similar to the LAC countries. The rising epidemic of NCDs in the SA region is fuelled by demographic ageing and globalization resulting in changing lifestyle, eating habits, and working patterns with less physical activity. In 2000, 44% of the burden of disease in this region measured in disability-adjusted life years (DALYs) lost was attributed to NCDs [2], and these figures are expected to rise. Yet this growing epidemic is a neglected health issue in these countries to a greater extent. Cardiovascular diseases are the major contributors to premature mortality and morbidity in the SA region. The prevalence of diabetes has risen more rapidly in South Asia than in any region of the world. By the year 2030, India will have the highest number of persons with diabetes (79.4 million) [3]; similar trends are also projected for other SA countries. Overall, prevalence of hypertension among Pakistani adults (greater than or equal to 15 years) is about 19% [4], and this is likely to be the pattern in other SA countries. In South Asia, one third of the adult population is classified as obese and the trend is also increasing in SA children [5,6]. Large numbers of South Asians use tobacco in various forms: it is estimated that up to 65% of all men use tobacco in some form [7]. Tobacco use is responsible for approximately half of the tumors in males [8]. South Asians have one of the highest rates of oral cancers reported worldwide, and the rates are still increasing [7,8]. Due to the lack of reliable data and under-reporting of injuries, it is difficult to estimate their prevalence and future projections; nevertheless, the burden is substantially high enough to be one of the major health concerns in South Asia. In Sri Lanka alone, a smaller SA country, road traffic injuries result in 2,000 deaths and 14,000 injuries each year [9]. NCDs are expensive diseases to manage, and SA countries, which already have poor health and economic indicators, cannot afford this emerging costly epidemic. South Asians have a tendency to develop cardiovascular diseases at relatively earlier ages compared to other parts of the world, resulting in the highest potential of loss of productive life years. For a low-income Indian family with an adult with diabetes, as much as 25% of family income may be devoted to diabetes care [10]. Like the LAC region [1], SA countries have social and cultural disparities and inequalities. People of higher socioeconomic status and men who are the major economic contributors of their families are usually able to access the best available health-care facilities. As in LAC countries, South Asians of lower socioeconomic levels have the highest prevalence of mental health problems. The SA countries are well-equipped with highly qualified human resources and have common culture and languages, which can enhance more meaningful research, but are often unable to produce significant levels of quality research due to lack of funding and financial resources. With some exceptions, much of the research on NCDs has been descriptive or observation and on a small scale. Hence, the generalizability of existing research for the whole region is questionable and translating this research into practice is also difficult. Keeping in mind the frightening scenario of NCDs in SA countries, the best option to tackle the epidemic is to take earlier action through comprehensive, multifaceted, and multicultural preventive and interventional strategies. There is also a need for more population-based local research on NCDs, with more collaboration and networking. These all require innovation, funding, political will, and health partnership between individuals, communities, clinicians, public health practitioners, nongovernmental agencies, policy makers and governments of the SA region.

Preventable Lifestyle Risk Factors for Non-Communicable Diseases in the Pakistan Adolescents Schools Study 1 (PASS-1)

Objectives The rising burden of preventable risk factors for non-communicable diseases (NCDs) among adolescents is a major public health challenge worldwide. We identified the preventable risk factors for NCDs in adolescents. Methods In a school-based study, pre-tested structured questionnaires were completed by 414 adolescents (14 to 17 years) at six schools in three cities in Pakistan. The chi-squared test and adjusted odds ratio (aOR) with 95% confidence interval (CI) were calculated in a multinomial logistic regression analysis. Results Over 80% of the adolescents had unhealthy diets, and 54% were physically inactive. Most adolescents were exposed to passive smoking, and 14% were also current smokers. More than one-third of participants chewed betel nut, and one-quarter used oral tobacco. More girls were physically inactive (OR, 4.07; 95% CI, 2.69 to 6.17), whereas a greater proportion of boys were current smokers (OR, 2.17; 95% CI, 1.19 to 3.91), exposed to passive smoking (OR, 2.57; 95% CI, 1.72 to 3.83), and using betel nut (OR, 2.03; 95% CI, 1.34 to 3.06). Only 3.1% of the participants were without any preventable lifestyle risk factor for NCDs, and over 80% had ≥2 factors. Co-existence of risk factors was independently associated with fathers being blue-collar workers (aOR, 3.57; 95% CI, 1.07 to 11.92) and parents not treating their child fairly (aOR, 5.05; 95% CI, 1.29 to 19.78). Conclusions Most of the adolescents studied had preventable risk factors for NCDs. These results warrant comprehensive and integrated interventions to prevent lifestyle risk factors, and parents are front-line stakeholders.

Factors associated with intimate partner violence against women in a mega city of South-Asia: multi-centre cross-sectional study.

OBJECTIVES. To assess the proportion of women subjected to intimate partner violence and the associated factors, and to identify the attitudes of women towards the use of violence by their husbands. DESIGN. Cross-sectional study. SETTING. Family practice clinics at a teaching hospital in Karachi, Pakistan. PARTICIPANTS. A total of 520 women aged between 16 and 60 years were consecutively approached to participate in the study and interviewed by trained data collectors. Overall, 401 completed questionnaires were available for analysis. Multivariate logistic regression analysis was used to identify the association of various factors of interest. RESULTS. In all, 35% of the women reported being physically abused by their husbands in the last 12 months. Multivariate analysis showed that experiences of violence were independently associated with womens illiteracy (adjusted odds ratio=5.9; 95% confidence interval, 1.8-19.6), husbands illiteracy (3.9; 1.4-10.7), smoking habit of husbands (3.3; 1.9-5.8), and substance use (3.1; 1.7-5.7). CONCLUSION. It is imperative that intimate partner violence be considered a major public health concern. It can be prevented through comprehensive, multifaceted, and integrated approaches. The role of education is greatly emphasised in changing the perspectives of individuals and societies against intimate partner violence.