Debra Nanan

Evaluation of a water, sanitation, and hygiene education intervention on diarrhoea in northern Pakistan

OBJECTIVE Inadequate water and sanitation services adversely affect the health and socioeconomic development of communities. The Water and Sanitation Extension Programme (WASEP) project, undertaken in selected villages in northern Pakistan between 1997 and 2001, was designed to deliver an integrated package of activities to improve potable water supply at village and household levels, sanitation facilities and their use, and awareness and practices about hygiene behaviour. METHODS A case-control study was conducted during July-September 2001 to evaluate whether, after selected confounders were controlled for, children aged <6 years with diarrhoea were more or less likely to reside in villages that participated in the project than in villages that did not participate. Descriptive and logistic regression analyses were performed. FINDINGS Children not living in WASEP villages had a 33% higher adjusted odds ratio for having diarrhoea than children living in WASEP villages (adjusted odds ratio, 1.331; P<0.049). Boys had 25% lower odds of having diarrhoea than girls (adjusted odds ratio, 0.748; P<0.049). A 2.6% decrease was found in the odds of diarrhoea for every yearly increase in the mothers age (adjusted odds ratio, 0.974; P<0.044) and a 1.4% decrease for every monthly increase in the childs age (adjusted odds ratio, 0.986; P<0.001). CONCLUSIONS The findings in this study may help refine the approach to future water, sanitation, and hygiene initiatives in northern Pakistan. The integrated approach taken by WASEP, which incorporates engineering solutions with appropriate education to maximize facility usage and improve hygiene practices, is a useful example of how desired health benefits can be obtained from projects of this type.

Assessing obesity and overweight in a high mountain Pakistani population.

Objectives  To estimate the prevalence of obesity and overweight among adults in a high mountain rural population of Pakistan, and to determine the correlates of excess body weight.

HEALTH STATUS OF THE PAKISTANI POPULATION

It was encouraging to see the report by Pappas et al. on the health status of the Pakistani population.1 However, the results presented in Tables 1 and 2 of their article may underestimate the potential burden of noncommunicable diseases in Pakistan, in particular that of overweight and obesity. The authors use body mass index (BMI) values of ≥25 and ≥30 to define overweight and obesity, respectively. Current recommendations for the Asia-Pacific region2 define adult overweight at BMI ≥23 and obesity at BMI ≥25. There is growing support for the use of lower BMI cutoffs for Asians, especially given their propensity to abdominal obesity.3, 4 If BMI ≥25 is used to define obesity, a different picture emerges from the National Health Survey of Pakistan. Table 1 would indicate obesity prevalence rates as follows for adults aged 25 to 64 years, moving from low to middle to high socioeconomic status (and rounding to the nearest whole number): for rural areas, 9%, 15%, and 27%; for urban areas, 21%, 27%, and 42%. These figures are alarmingly high for rural and urban areas but especially for urban areas. In Table 2, the authors compare the prevalence of overweight for adults aged 25 to 64 years in the United States and Pakistan. While BMI ≥25 may be a good indicator of overweight in the US context, BMI ≥23 may be a better indicator for Pakistanis. If so, Table 2 would indicate a prevalence of obesity in Pakistan for the age group 25 to 64 at 13% for males and 23% for females. These figures are closer to obesity prevalence rates for US adults 20 years and older, especially for females (20% for males, 22% for females).5 Also, use of BMI ≥23 for overweight would reclassify a proportion of the adult Pakistani population as overweight that was previously considered normal weight. This implies that the health burden from overweight and obesity in Pakistan is currently underestimated. Nonetheless, the authors have demonstrated, and the revised analysis given above emphasizes, that Pakistan is a country in transition, facing a double burden of disease. As Akhter and Pappas rightly point out in their editorial, the forces of globalization influence health.6 How well countries like Pakistan adjust to changes brought on by increasing industrialization and urbanization will depend to some extent on the level of support it receives from local and international bodies, but also on an internal examination of its priorities.

A conversation on health in Canada: revisiting universality and the centrality of primary healthcare.

In 2006, British Columbia launched a public consultation on how to strengthen the health system. We report on the processes and the inputs and views submitted and examine the perceived importance of universality and primary healthcare (PHC). Public response revealed strong support for the Canada Health Act, which upholds 5 principles: public administration, comprehensiveness, universality, portability, and accessibility, and also a need for the system to be more open to innovation. It recognized that keys to improving population health and efficiency gains within the health system lie within the scope of PHC and that prevention, demand management, and self-management are all part of PHC.