Assad Hafeez

Job satisfaction among public health professionals working in public sector: a cross sectional study from Pakistan

BackgroundJob satisfaction largely determines the productivity and efficiency of human resource for health. It literally depicts the extent to which professionals like or dislike their jobs. Job satisfaction is said to be linked with the employee’s work environment, job responsibilities and powers and time pressure; the determinants which affect employee’s organizational commitment and consequently the quality of services. The objective of the study was to determine the level of and factors influencing job satisfaction among public health professionals in the public sector.MethodsThis was a cross sectional study conducted in Islamabad, Pakistan. Sample size was universal including 73 public health professionals, with postgraduate qualifications and working in government departments of Islamabad. A validated structured questionnaire was used to collect data from April to October 2011.ResultsOverall satisfaction rate was 41% only, while 45% were somewhat satisfied and 14% of professionals highly dissatisfied with their jobs. For those who were not satisfied, working environment, job description and time pressure were the major causes. Other factors influencing the level of satisfaction were low salaries, lack of training opportunities, improper supervision and inadequate financial rewards.ConclusionOur study documented a relatively low level of overall satisfaction among workers in public sector health care organizations. Considering the factors responsible for this state of affairs, urgent and concrete strategies must be developed to address the concerns of public health professionals as they represent a highly sensitive domain of health system of Pakistan. Improving the overall work environment, review of job descriptions and better remuneration might bring about a positive change.

Knowledge and communication needs assessment of community health workers in a developing country: a qualitative study

BackgroundPrimary health care is a set of health services that can meet the needs of the developing world. Community health workers act as a bridge between health system and community in providing this care. Appropriate knowledge and communication skills of the workers are key to their confidence and elementary for the success of the system. We conducted this study to document the perceptions of these workers on their knowledge and communication needs, image building through mass media and mechanisms for continued education.MethodsFocus group discussions were held with health workers and their supervisors belonging to all the four provinces of the country and the Azad Jammu & Kashmir region. Self-response questionnaires were also used to obtain information on questions regarding their continued education.ResultsAbout four fifths of the respondents described their communication skills as moderately sufficient and wanted improvement. Knowledge on emerging health issues was insufficient and the respondents showed willingness to participate in their continued education. Media campaigns were successful in building the image of health workers as a credible source of health information.ConclusionA continued process should be ensured to provide opportunities to health workers to update their knowledge, sharpen communication skills and bring credibility to their persona as health educators.

Integrating maternal psychosocial well-being into a child-development intervention: the five-pillars approach

Maternal psychosocial well‐being (MPW) is a wide‐ranging concept that encompasses the psychological (e.g., mental health, distress, anxiety, depression, coping, problem solving) and social (e.g., family and community support, empowerment, culture) aspects of motherhood. Evidence‐based MPW interventions that can be integrated into large‐scale maternal and child health programs have not been developed. Building on several years of research in Pakistan, we developed and integrated a cognitive behavioral therapy–based MPW intervention (the five‐pillars approach) into a child nutrition and development program. Following formative research with community health workers (CHWs; n = 40) and families (n = 37), CHWs were trained in (1) empathic listening, (2) family engagement, (3) guided discovery using pictures, (4) behavioral activation, and (5) problem solving. A qualitative feasibility study in one area demonstrated that CHWs were able to apply these skills effectively to their work, and the approach was found to be useful by CHWs, mothers, and their families. The success of the approach can be attributed to (1) mothers being the central focus of the intervention, (2) using local CHWs whom the mothers trust, (3) simplified training and regular supervision, and (4) an approach that facilitates, not adds, to the CHWs’ work.

Cognitive-Behavioral Counseling for Exclusive Breastfeeding in Rural Pediatrics: A Cluster RCT

OBJECTIVE: To test the effectiveness of cognitive-behavioral counseling on the rate and duration of exclusive breastfeeding (EBF) during the first 6 months of an infant’s life compared with routine counseling. METHODS: A single blind cluster-randomized controlled trial was undertaken in 40 Union Councils of a rural district in the northwest province of Pakistan between May 2009 and April 2010. By simple unmatched randomization, 20 Union Councils were each allocated to intervention and control arms. Two hundred twenty-four third trimester pregnant women in the intervention and 228 third trimester pregnant women in the control arm were enrolled and followed-up biweekly until 6 months postpartum. Analyses were by intention to treat. Mothers in the intervention group received 7 sessions of cognitive-behavioral counseling from antenatal to 6 months postpartum, whereas the control group received an equal number of routine sessions. Proportion of mothers exclusively breastfeeding at 6 months postpartum and duration of EBF through these 6 months was assessed. RESULTS: At 6 months postpartum, 59.6% of mothers in the intervention arm and 28.6% in the control arm were exclusively breastfeeding. This translates into a 60% reduced risk of stopping exclusively breastfeeding during the first 6 months (adjusted hazard ratio, 0.40 [95% confidence interval: 0.27–0.60], P < .001). Mothers in the intervention group were half as likely to use prelacteal feeds with their infants (adjusted relative risk, 0.51 [95% confidence interval: 0.34–0.78]). CONCLUSIONS: Compared with routine counseling, cognitive-behavioral counseling significantly prolonged the duration of EBF, doubling the rates of EBF at 6 months postpartum.

Medical education and research in Pakistan

2234 www.thelancet.com Vol 381 June 29, 2013 The construction of health facilities, establishment of medical schools, and recruitment of health workers in the public sector have been important aspects of a popular political agenda in Pakistan, especially for elected governments. According to offi cial reports, the number of medical graduates has increased from 500 in 1947 to 171 450 in 2012 and the number of medical colleges has increased from two to 88, respectively. The total budget of the Pakistan Medical Research Council (PMRC) has increased 2·5 times between the fi scal years 2007–08 and 2011–12; and the number of health research publications has increased 7·5 times between 2001 and 2011 (fi gure). These increases give the illusion that the number of doctors in Pakistan who are capable and competent of providing needed clinical services to the population is adequate; that there is an increase in the number of research publications about health issues suggesting that we have skilled researchers; and that funding for health research by the government has gone up over the years. The truth is not so auspicious. Over recent years the real increase in the number of medical graduates Medical education and research in Pakistan health system and improving health outcomes for the country’s most vulnerable citizens. The Lancet Pakistan Series further shows the knowledge and public health capability in Pakistan, and clearly points the way to health reform, particularly in the postdevolution scenario. But tough questions remain. Will the commitment and generosity of communities throughout Pakistan be mobilised to address the most devastating day-to-day public health disaster the country faces? Will policy makers use experience of disasters to expand health-care services in diffi cult-toreach areas? Will political resolve be galvanised, reforms implemented, and resources made available? Pakistan has shown some public health success in response to natural disasters and humanitarian emergencies. The lessons and opportunities must be applied to the health system to prevent the continued death of more than 400 000 children and 12 000 women each year.

Integrating health care for mothers and children in refugee camps and at district level.

Health care for mothers and children is inadequate in most refugee situations and in poorly resourced countries. The authors argue that, as well as providing primary (home based) care for basic health care, there is a need to integrate primary care with adequately functioning hospital based care for a healthcare system to succeed In poorly resourced countries, a failure to link primary (home based) care effectively to that available in the local government run general hospitals is common. Communication between home based care and hospital based care is rare. The extremely poor services available in many district hospitals1 deter families from taking their relatives there for treatment. The patients, supported by their families, would rather die at home than in an ineffective, poorly resourced, and often grossly unhygienic and unwelcoming hospital. There are often no effective links between the primary and hospital care facilities. If the sickest patients detected by primary health workers have nowhere to go, the system fails those most in need. Equally, both home based and hospital based care need to be individually functioning adequately as well as being integrated, and a poverty of services in either sector results in a failing healthcare system. A similar situation exists in camps for refugees, where the prime objective of humanitarian aid during emergencies (often of long standing when caused by armed conflict) is to prevent mortality through the delivery of primary health care and other basic services such as shelter, nutrition, water, sanitation, and protection. The public health doctors who largely control and direct the funds for primary health care, for sound reasons, regard this as the most cost effective approach. However, this form of aid does not address aspects of mortality and morbidity due to acute and serious medical, obstetric, and surgical problems or to chronic diseases …

Crisis in the Swat Valley of Pakistan: need for international action

Since July, 2008, an armed confl ict between the Taliban and the security forces in the districts of Buner, Swat, and Dir in the Northwest Frontier Province of Pakistan has resulted in a large-scale migration of civilians. In the past 2 months, fi ghting has escalated and 1·96 million have so far been registered as displaced. The numbers are expected to rise further. About 232 000 people are living in 23 camps established by the Pakistan Government. Of 112 975 people living in the Jalozai camp, there are around 2000 pregnant women. Because of the culture of Parda (privacy for women), they have to spend most of their time inside the tents. Intense heat and lack of privacy are some of the pressing urgent problems for this population. There is an increasing prevalence of watery diarrhoeal diseases related to the inadequate water and sanitation facilities, which could become worse with the approaching monsoon. WHO has established a disease early warning system network in 162 sites from where the incidence of a cluster of notifi able diseases is regularly collected and immediate outbreak control measures enacted as necessary. The recent polio immunisation campaign has vaccinated about 1·8 million children from the key hosting districts, and vitamin A capsules have been admin i stered to the target age-groups. Yet the camps house less than 20% of those displaced. Without counting the great costs to themselves, families in the local community are looking after more than 1·73 million people, in accordance with the local tradition of hospitality. Most displaced people have been accommodated within family homes; others are in schools, mosques, and other community buildings. To assist in maintaining the cultural issues with regard to women, many host families have made structural changes to their compounds. Although a proportion of host families are related to or friends of the displaced people, many have welcomed strangers. There is a great need for effi cient essential health care, both during this relief operation and on the return of this population to their homes. Assistance is required in ensuring the sustained provision of essential drugs, medical supplies, equipment for hospitals and health centres, as well as ambulances for referral. Additionally, there is a need for expansion of human resources, especially female health workers who can improve maternal and child health-care services. There is a need to construct safer water and sanitation facilities as well as “women friendly” places. The early detection of potential disease outbreaks and their eff ective control, as well as the provision of mental health and psychosocial support, are essential. In the meantime, substantial support is required to the host families, necessitating a scaling up of the service delivery capacity of local hospitals and health centres. Pakistan represents a playing fi eld on which major international issues such as those arising from the actions of other countries in Afghanistan are creating tragic consequences for the civilian population. It is imperative that Pakistan is given urgent assistance to help the displaced people to return in safety and also to have available when they do adequate health care to help them restart their lives in a secure and supportive environment. The communities in the Northwest Frontier Province that have been helping their displaced compatriots cannot continue to do so for much longer without tensions developing. This emergency, although currently having its maximum toll on the people of Pakistan, could have major repercussions on global peace if not adequately handled by the international community.

A randomized controlled trial comparing Pentazocine and Chamomilla recutita for labor pain relief

BACKGROUND Traditional birth attendants in Pakistan sometimes use a homeopathic remedy, Chamomilla for labor pain relief. Our study compares this homeopathic remedy for pain relief in labor with a commonly used parenteral analgesic in a hospital setting. No systematic study has been conducted previously to study the effect of chamomile, which may be affordable and available in community settings. METHODS A double blind randomized controlled trial was carried out at Islamic International Medical College Trust. Ninety-nine normal pregnant women were randomly assigned into three groups. Each group received one of the three trial drugs; Chamomile, Pentazocine or placebo. The efficacy of labor analgesia was assessed by using Visual Analogue Scale (VAS) for pain intensity. Indicators of maternal and child health were recorded as were adverse effects of the drugs. RESULTS Mean pain scores in the three groups were calculated and compared. The difference in mean VAS scores in Pentazocine and Chamomilla recutita group as compared with placebo was not statistically significant. No significant adverse effects were noticed in any group except slight headache and dizziness in three parturients in Pentazocine group. CONCLUSION Neither Pentazocine, or Chamomilla recutita offer substantial analgesia during labor.

Impact of essential surgical skills with an emphasis on emergency maternal, neonatal and child health training on the practice of doctors: A cluster randomised controlled trial in Pakistan

INTRODUCTION Majority of studies on evaluation of emergency management courses have focused on outcomes such as knowledge and skills demonstrated in non-clinical or traditional testing manner. Such surrogate outcomes may not necessarily reflect vital changes in practice. The aim of this study was to determine if and to what extent, specific training in the management of life threatening emergencies resulted in an increased in compliance with established care guidelines of doctors working in the emergency departments of public sector hospitals in Pakistan. METHODS A cluster randomised controlled trial was conducted in three districts hospitals in three cities (Khairpur, Vehari and Peshawar) of Pakistan. Thirty-six doctors, 18 in intervention (trained in ESS-EMNCH training) and 18 in control (untrained), were enrolled and 248 life threatening emergency events, 124 in each group, were observed for the correct use of the Airway, Breathing, Circulation (ABC) structured approach. The outcome measure was structured approach defined a priori. Data was analysed by using STATA software. RESULTS At individual level, 79 (63.7%) life threatening episodes were managed according to the structured approach in the intervention group and 46 (37.1%) were managed according to the structured approach in controls (OR 2.98, 95%CI 1.78-4.99, p-value=0.0001). At cluster level, the mean percentage (95% CI) of the structured approach used by doctors in the intervention group [62.9% (50.4-75.3%)], was significantly higher than those in the control group, [36.3% (26.3-46.4)] (p-value=0.001). CONCLUSIONS 5-day training of ESS-EMNCH significantly increased the compliance with established care guidelines of doctors during their management of life threatening emergency episodes in the public sector hospitals in Pakistan.

What can Pakistan do to address maternal and child health over the next decade

Pakistan faces huge challenges in meeting its international obligations and agreed Millennium Development Goal targets for reducing maternal and child mortality. While there have been reductions in maternal and under-5 child mortality, overall rates are barely above secular trends and neonatal mortality has not reduced much. Progress in addressing basic determinants, such as poverty, undernutrition, safe water, and sound sanitary conditions as well as female education, is unsatisfactory and, not surprisingly, population growth hampers economic growth and development across the country. The devolution of health to the provinces has created challenges as well as opportunities for action. This paper presents a range of actions needed for change within the health and social sectors, including primary care, social determinants, strategies to reach the unreached, and accountability.