Amir Nawaz Khan

One size does not fit all: local determinants of measles vaccination in four districts of Pakistan

BackgroundRates of childhood vaccination in Pakistan remain low.There is continuing debate about the role of consumer and service factors in determining levels of vaccination in developing countries.MethodsIn a stratified random cluster sample of census enumeration areas across four districts in Pakistan, household interviews about vaccination of children and potentially related factors with 10,423 mothers of 14,542 children preceded discussion of findings in separate male and female focus groups. Logistic regression analyses helped to clarify local determinants of measles vaccination.ResultsAcross the four districts, from 17% to 61% of mothers had formal education and 50% to 86% of children aged 12-23 months had received measles vaccination. Children were more likely to receive measles vaccination if the household was less vulnerable, if their mother had any formal education, if she knew at least one vaccine preventable disease, and if she had not heard of any bad effects of vaccination. Discussing vaccinations in the family was strongly associated with vaccination. In rural areas, living within 5 km of a vaccination facility or in a community visited by a vaccination team were associated with vaccination, as was the mother receiving information about vaccinations from a visiting lady health worker. Focus groups confirmed personal and service delivery obstacles to vaccination, in particular cost and poor access to vaccination services. Despite common factors, the pattern of variables related to measles vaccination differed between and within districts.ConclusionsVaccination coverage varies from district to district in Pakistan and between urban and rural areas in any district. Common factors are associated with vaccination, but their relative importance varies between locations. Good local information about vaccination rates and associated variables is important to allow effective and equitable planning of services.

Barriers to Disclosing and Reporting Violence Among Women in Pakistan: Findings From a National Household Survey and Focus Group Discussions

Worldwide, many women who experience domestic violence keep their experience secret. Few report to official bodies. In a national survey of abuse against women in Pakistan, we examined factors related to disclosure: women who had experienced physical violence telling someone about it. In focus groups, we explored why women do not report domestic violence. Nearly one third of the 23,430 women interviewed had experienced physical violence. Only 35% of them had told anyone about it, almost always someone within their own family. Several personal and family factors were associated with disclosure. Having discussed the issue and feeling empowered to discuss violence were consistent associations. Of the 7,895 women who had suffered physical violence, only 14 had reported the matter to the police. Female focus groups said women who report violence risk their reputation and bring dishonor to the family; women fear reporting violence because it may exacerbate the problem and may lead to separation or divorce and loss of their children. Focus groups of men and women were skeptical about community leaders, councilors, and religious leaders supporting reporting of violence. They suggested setting up local groups where abused women could seek help and advice. There are strong disincentives to reporting violence in Pakistan, which are well known to women. Until better systems for reporting and dealing with reported cases are in place, domestic violence will continue to be a hidden scourge here and elsewhere.

Male responsibility and maternal morbidity: a cross-sectional study in two Nigerian states

BackgroundNigeria continues to have high rates of maternal morbidity and mortality. This is partly associated with lack of adequate obstetric care, partly with high risks in pregnancy, including heavy work. We examined actionable risk factors and underlying determinants at community level in Bauchi and Cross River States of Nigeria, including several related to male responsibility in pregnancy.MethodIn 2009, field teams visited a stratified (urban/rural) last stage random sample of 180 enumeration areas drawn from the most recent censuses in each of Bauchi and Cross River states. A structured questionnaire administered in face-to-face interviews with women aged 15-49 years documented education, income, recent birth history, knowledge and attitudes related to safe birth, and deliveries in the last three years. Closed questions covered female genital mutilation, intimate partner violence (IPV) in the last year, IPV during the last pregnancy, work during the last pregnancy, and support during pregnancy. The outcome was complications in pregnancy and delivery (eclampsia, sepsis, bleeding) among survivors of childbirth in the last three years. We adjusted bivariate and multivariate analysis for clustering.FindingsThe most consistent and prominent of 28 candidate risk factors and underlying determinants for non-fatal maternal morbidity was intimate partner violence (IPV) during pregnancy (ORa 2.15, 95%CIca 1.43-3.24 in Bauchi and ORa 1.5, 95%CI 1.20-2.03 in Cross River). Other spouse-related factors in the multivariate model included not discussing pregnancy with the spouse and, independently, IPV in the last year. Shortage of food in the last week was a factor in both Bauchi (ORa 1.66, 95%CIca 1.22-2.26) and Cross River (ORa 1.32, 95%CIca 1.15-1.53). Female genital mutilation was a factor among less well to do Bauchi women (ORa 2.1, 95%CIca 1.39-3.17) and all Cross River women (ORa 1.23, 95%CIca 1.1-1.5).InterpretationEnhancing clinical protocols and skills can only benefit women in Nigeria and elsewhere. But the violence women experience throughout their lives – genital mutilation, domestic violence, and steep power gradients – is accentuated through pregnancy and childbirth, when women are most vulnerable. IPV especially in pregnancy, womens fear of husbands or partners and not discussing pregnancy are all within mens capacity to change.

Analysis of 2010-flood causes, nature and magnitude in the Khyber Pakhtunkhwa, Pakistan

This article attempts to analyse the nature, magnitude and causes of 2010 disastrous flood that seriously affected the province of Khyber Pakhtunkhwa (KPK), Pakistan. Pakistan is famous for its summer floods, but the flood of 2010 is considered to be the century’s worst. It has broken all the previous records in terms of discharge, damages and amount of rainfall occurred. Most of the meteorological stations have received rainfall above normal. Data for this study were collected both from primary and secondary sources. A total 150 questionnaires were filled in from the flood victims. However, secondary data were obtained from the Pakistan Meteorology Department, Flood Forecasting and Warning Centre, Federal Flood Commission, Provincial Disaster Management Authority, National Disaster Management Authority, Surface Water Hydrology Department and Provincial Irrigation and Drainage Authority. The analysis reveals that heavy and prolonged rainfall for four consecutive days (27–30 July) was the major cause of 2010-flood. In addition to this, the development of unusual low pressure zone over the northern Pakistan, aggradations of river bed, rapid deforestation, ponding back of river by motorway, blocking of bridges by tree trunks and subsequent bursting of temporary dams have played their role in causing the disastrous flood in almost all the rivers of KPK. This has inflicted terrible damages to human lives, standing crops, housing, infrastructure and other properties.

Collecting Reliable Information About Violence Against Women Safely in Household Interviews Experience From a Large-Scale National Survey in South Asia

This article describes the first national survey of violence against women in Pakistan from 2001 to 2004 covering 23,430 women. The survey took account of methodological and ethical recommendations, ensuring privacy of interviews through one person interviewing the mother-in-law while another interviewed the eligible woman privately. The training module for interviewers focused on empathy with respondents, notably increasing disclosure rates. Only 3% of women declined to participate, and 1% were not permitted to participate. Among women who disclosed physical violence, only one third had previously told anyone. Surveys of violence against women in Pakistan not using methods to minimize underreporting could seriously underestimate prevalence.

Does contracting of health care in Afghanistan work? Public and service-users' perceptions and experience

BackgroundIn rebuilding devastated health services, the government of Afghanistan has provided access to basic services mainly by contracting with non-government organisations (NGOs), and more recently the Strengthening Mechanism (SM) of contracting with Provincial Health Offices. Community-based information about the publics views and experience of health services is scarce.MethodsField teams visited households in a stratified random sample of 30 communities in two districts in Kabul province, with health services mainly provided either by an NGO or through the SM and administered a questionnaire about household views, use, and experience of health services, including payments for services and corruption. They later discussed the findings with separate community focus groups of men and women. We calculated weighted frequencies of views and experience of services and multivariate analysis examined the related factors.ResultsThe survey covered 3283 households including 2845 recent health service users. Some 42% of households in the SM district and 57% in the NGO district rated available health services as good. Some 63% of households in the SM district (adjacent to Kabul) and 93% in the NGO district ordinarily used government health facilities. Service users rated private facilities more positively than government facilities. Government service users were more satisfied in urban facilities, if the household head was not educated, if they had enough food in the last week, and if they waited less than 30 minutes. Many households were unwilling to comment on corruption in health services; 15% in the SM district and 26% in the NGO district reported having been asked for an unofficial payment. Despite a policy of free services, one in seven users paid for treatment in government facilities, and three in four paid for medicine outside the facilities. Focus groups confirmed people knew payments were unofficial; they were afraid to talk about corruption.ConclusionsHouseholds used government health services but preferred private services. The experience of service users was similar in the SM and NGO districts. People made unofficial payments in government facilities, whether SM or NGO run. Tackling corruption in health services is an important part of anti-corruption measures in Afghanistan.

Analysis of landslide causes and associated damages in the Kashmir Himalayas of Pakistan

Abstract This article deals with the analysis of landslide causes and associated damages in the Kashmir Himalayas of Pakistan. The present study is based on Muzaffarabad, which lies in the lesser Himalayas. Geologically, the Kashmir Himalaya is the young and most dynamic system in the world. In Muzaffarabad, mostly, people live on the fragile mountain slopes, and therefore, they are highly vulnerable to the risk of landslides. To achieve the objectives of the study, data were collected both from primary and secondary sources. Primary data were obtained through intensive field work and human perception survey, while secondary data were obtained from the related line agencies. The analysis reveals that in the study area, immature geology, active seismic zone, wide range of temperature and seasonal rain are the major physical factors, whereas human interventions on the fragile slopes are intensifying factors which in effect contribute to the landslide incidence. As a result, the adverse impacts on housing, sources of livelihood earnings and human casualties are escalating day-by-day. There are several implementing agencies which are responsible for reducing the risk of landsliding. So far, these agencies have not reduced the landslide damages rather their intensity and frequency have been increased especially after 2005 Kashmir earthquake.

Understanding whose births get registered: a cross sectional study in Bauchi and Cross River states, Nigeria

BackgroundIt is a recognized child right to acquire a name and a nationality, and birth registration may be necessary to allow access to services, but the level of birth registration is low in Nigeria. A household survey about management of childhood illnesses provided an opportunity to examine actionable determinants of birth registration of children in Bauchi and Cross River states of Nigeria.MethodsTrained field teams visited households in a stratified random cluster sample of 90 enumeration areas in each state. They administered a questionnaire to women 14–49 years old which included questions about birth registration of their children 0–47 months old and about socio-economic and other factors potentially related to birth registration, including education of the parents, poverty (food sufficiency), marital status of the mother, maternal antenatal care and place of delivery of the last pregnancy. Bivariate then multivariate analysis examined associations with birth registration. Facilitators later conducted separate male and female focus group discussions in the same 90 communities in each state, discussing the reasons for the findings about levels of birth registration.ResultsNearly half (45%) of 8602 children in Cross River State and only a fifth (19%) of 9837 in Bauchi State had birth certificates (seen or unseen). In both states, children whose mothers attended antenatal care and who delivered in a government health facility in their last pregnancy were more likely to have a birth certificate, as were children of more educated parents, from less poor households, and from urban communities. Focus group discussions revealed that many people did not know about birth certificates or where to get them, and parents were discouraged from getting birth certificates because of the unofficial payments involved.ConclusionThere are low levels of birth registration in Bauchi and Cross River states, particularly among disadvantaged households. As a result of this study, both states have planned interventions to increase birth registration, including closer collaboration between the National Population Commissions and state health services.

Devolution and public perceptions and experience of health services in Pakistan: linked cross sectional surveys in 2002 and 2004

BackgroundThe government of Pakistan introduced devolution in 2001. Responsibility for delivery of most health services passed from provincial to district governments. Two national surveys examined public opinions, use, and experience of health services in 2001 and 2004, to assess the impact of devolution on these services from the point of view of the public.MethodsA stratified random cluster sample drawn in 2001 and revisited in 2004 included households in all districts. Field teams administered a questionnaire covering views about available health services, use of government and private health services, and experience and satisfaction with the service. Focus groups in each community discussed reasons behind the findings, and district nazims (elected mayors) and administrators commented about implementation of devolution. Multivariate analysis, with an adjustment for clustering, examined changes over time, and associations with use and satisfaction with services in 2004.ResultsFew of 57,321 households interviewed in 2002 were satisfied with available government health services (23%), with a similar satisfaction (27%) among 53,960 households in 2004. Less households used government health services in 2004 (24%) than in 2002 (29%); the decrease was significant in the most populous province. In 2004, households were more likely to use government services if they were satisfied with the services, poorer, or less educated. The majority of users of government health services were satisfied; the increase from 63% to 67% between 2002 and 2004 was significant in two provinces. Satisfaction in 2004 was higher among users of private services (87%) or private unqualified practitioners (78%). Users of government services who received all medicines from the facility or who were given an explanation of their condition were more likely to be satisfied. Focus groups explained that people avoid government health services particularly because of bad treatment from staff, and unavailable or poor quality medicines. District nazims and administrators cited problems with implementation of devolution, especially with transfer of funds.ConclusionsUnder devolution, the public did not experience improved government health services, but devolution was not fully implemented as intended. An ongoing social audit process could provide a basis for local and national accountability of health services.

Prognostic parameters of luminal A and luminal B intrinsic breast cancer subtypes of Pakistani patients

BackgroundPrognosis of breast cancer and success of therapeutic interventions largely rely on the clinico-pathologic and biological characteristics of the tumor and vary due to the heterogeneous nature of breast cancers. The aim of this study was to determine the frequency and prognostic parameters of luminal breast cancers in our population to devise targeted and personalized therapeutic regimens tailored to the needs of the loco-regional population.MethodsA retrospective cross-sectional study including 1951 cases of primary breast cancer treated at Liaquat National Hospital Karachi was conducted during the year 2011–2016. The clinico-pathologic characteristics were observed and semiquantitative immunohistochemical analysis was performed to study the luminal subtypes A and B. The cross-tabulated statistics of the observed characteristics were performed between the two subtypes. The significance level of each characteristic was estimated utilizing the chi-square test.ResultsLuminal cancers comprised 62.7% of the total number of cases diagnosed with breast cancers in the study period. Out of these 1224 cases of luminal cancers, 845 cases (69%) were luminal B, while 379 (31%) cases were of luminal A. Luminal B cancers were significantly more common in younger age groups as compared to luminal A cancers. Comparison of the two subtypes of luminal breast cancers revealed significant differences. Luminal B cancers were associated with higher grade (26% grade III in luminal B compared to 8% in luminal A), micropapillary histology, and high frequency of nodal metastasis (54 vs. 43%).ConclusionsLuminal B comprised the most frequent subtype of breast cancer in our study and they were found more constantly in a younger age group. Moreover, they were associated with adverse clinico-histologic parameters like higher grade and nodal metastasis. Therefore, we suggest that, despite lack of widespread availability of molecular studies in our setup, IHC-based typing should be done in every case of breast cancer to individualize therapy.