Kausar S Khan

Participatory action research as the approach for women’s empowerment

Women’s empowerment is recognized as an imperative for achieving women’s rights, health and development. The achievement of women’s empowerment as an end goal or even initiation of the process necessitates usage of approaches that promote participation and incite action. The Community Health Sciences Department (CHS) of Aga Khan University Karachi that is part of a five-component study (including four Asian countries) titled ‘Women’s Empowerment in Muslim Contexts’ (WEMC), used the participatory action research approach for women’s empowerment. Work with communities entailed reflection, analysis and action not only to create knowledge but for education, development of consciousness and mobilization for action. We adapted the participatory rural appraisal (PRA) tools to explore women’s perceptions and reflections on their existent situation and aspired needs with respect to empowerment, community’s overall health, mental health, reproductive health, daily work load, access to resources, participation in decision-making and violence against women. Our experience emerged as a five-step model of participatory action research for women’s empowerment that included steps of field inquiry, analysis for action, advocacy training, policy dialogue and tracking action for change. Reflections on this model can serve as a learning instrument for those engaged with community based work and social transformation.

A source of strength and empowerment? An exploration of the influence of disabled children on the lives of their mothers in Karachi, Pakistan

Purpose. Previous literature has highlighted marginalisation and stigma of children with disabilities in developing countries, but few studies have explored the central care-giving environment and the relationship of the mother and her child with disabilities in this context. A group of women caring for children with disabilities in a low income community in Karachi, Pakistan was identified for the study. The aims were: (1) to explore the influence children with disabilities have on the daily lives of their mothers, (2) to describe the factors which influence the care-giving capacity of mothers. Method. A participatory qualitative research design was implemented. A womens group of caregivers of children with disabilities was formed. Several different tools were used during the course of the group meetings to facilitate discussion including social mapping. A thematic analysis of issues around care-giving and the relationship between the mother and her child with disabilities was conducted. Results. In a society where women may experience restrictions in freedom of movement and decision making, caring for a child with disabilities enabled women to move beyond traditional boundaries in seeking health and education services for their children. However, the gain in empowerment was counter-acted by a lack of care-giving support, a lack of appropriate services for health, rehabilitation and education of children with disabilities and stigma creating anxiety and stress for women. Conclusion. While children with disabilities do have some positive effects on the lives of their mothers, there are many more factors which create anxiety for this group of mothers (including a lack of care-giving support and stigma). Community-based rehabilitation strategies should consider the care-giving environment of children with disabilities and shift from a child only to family focus. Interventions which support, empower and strengthen the capacity of mothers are essential for the well being of their children with disabilities.

Bridging the gap of knowledge and action: A case for participatory action research (PAR)

What is the purpose of knowledge? Is it an end product only, or a means for action for change? Who is expected to take action – the researcher, research subjects, both, or some unknown others who may come across the knowledge produced? The larger question then is: is it health research, or research for health, equity and development? This article raises these concerns in context of a study conducted in Pakistan entitled Women’s Empowerment in Muslim Contexts (WEMC). This article argues that participatory action research (PAR) provides a bridge to the separation of knowledge and action. It proposes, especially, in resource poor countries, combining health research with Paolo Freire’s view of participation and change; and sees action by research participants as an outcome of the development of their critical consciousness.

Gender: shaping personality, lives and health of women in Pakistan

BackgroundGender norms determine the status of Pakistani women that influence their life including health. In Pakistan, the relationship between gender norms and health of women is crucial yet complex demanding further analysis. This paper: determines the reasons for reiteration of gender roles; describes the societal processes and mechanisms that reproduce and reinforce them; and identifies their repercussions on women’s personality, lives and health especially reproductive health.MethodsAs part of a six-country study titled ‘Women’s Empowerment in Muslim Contexts’, semi-structured group discussions (n = 30) were conducted with women (n = 250) who were selected through snowballing from different age, ethnic and socio-economic categories. Discussion guidelines were used to collect participant’s perceptions about Pakistani women’s: characteristics, powers, aspirations, needs and responsibilities; circumstances these women live in such as opportunities, constraints and risks; and influence of these circumstances on their personality, lifestyle and health.ResultsThe society studied has constructed a ‘Model’ for women that consider them ‘Objects’ without rights and autonomy. Women’s subordination, a prerequisite to ensure compliance to the constructed model, is maintained through allocation of lesser resources, restrictions on mobility, seclusion norms and even violence in cases of resistance. The model determines women’s traits and responsibilities, and establishes parameters for what is legitimate for women, and these have implications for their personality, lifestyle and health, including their reproductive behaviours.ConclusionThere is a strong link between women’s autonomy, rights, and health. This demands a gender sensitive and a, right-based approach towards health. In addition to service delivery interventions, strategies are required to counter factors influencing health status and restricting access to and utilization of services. Improvement in women’s health is bound to have positive influences on their children and wider family’s health, education and livelihood; and in turn on a society’s health and economy.

Epidemiology and Ethics: The People's Perspective

To a Western audience the terms “people” and “people’s perspective” could appear somewhat perplexing. Technically, every person belongs to the class of “people”; hence, to talk of “people’s perspective” seems to make an artificial division within one monolithic group. This ostensibly artificial division reflects a reality that necessitates it. In a Third World context, the term “people” has a fairly distinct connotation. It is not just a majority which is governed by a system that gives all people a minimal quality of life and allows them a meaningful participation in the political process. In a Third World context “people” are a “mass”-a faceless body of massive energy to be manipulated and kept domesticated in the interest of the powerelite.’ It is a power-bloc that is threatening as well as inescapable. Often it is also the source of identity for the power-elite, and a means to justify its own power. In the name of the masses the power-blocs fight, only to exploit and suppress the masses-a frequent term for referring to people. Thus, the term “people” is like a dividing-line that separates different world views which do not live in peaceful co-existence but are locked into a battle for survival. In this struggle one world is potentially powerful but actually powerless; the other is potentially weak but actually made powerful by the structures of oppression and by the global alliances that help sustain these structures, and thereby the under-development of people’s world, Thus, to evoke people’s perspective is to acknowledge a phenomenon peculiar to most Third World societies. And to understand people’s perspective one will need to understand people’s world as they experience it. People in the Third World countries are said to live in a world that is called “under-developed.’’ It is important to note that people are not under-developed; it’s the world which they inhabit that is under-developed; and people’s role in under-development if any, is less than that of other forces. And it is also important to note that the world they inhabit is not homogenous, though people in their own socio-cultural grouping do have a certain homogeneity. But their homogeneity, though a source of strength because of the tradition on which it is founded, is fragile in the face of adversity. And their adversary is not always visible like the old colonial masters; as a matter of fact, it often appears very intimate-in the form of changed values, and frustrations in the face of a collapsed social sector; and it is also amorphous for it is the whole system that makes and keeps the Third World under-developed. Hence it is important to look at the nature and working of underdevelopment, and the relationships between the power-elite and the people. This paper does not propose to analyze the socioeconomic and political system of Third World countries. It will merely attempt to first describe certain general patterns that constitute the dynamics of under-development, and then will try to locate the question of epidemiology and ethics within it. Ethical issues and ethical principles as they are discussed and applied in the North, cannot be mechanically transplanted in the South. Their relevance in the South has to be reviewed in the context of the dynamics of under-development; the existential realities of the people of the Third World countries; and the relationship between people and the power elites of their societies. The epidemiologists of these countries belong to the minority elite, and their perception of the poor and their role as researchers needs to be seen within the context of the state of the overall health system of their country. In this paper, the term Third World countries is used in a general way, whereas the actual description and analysis of the situation reflects more directly the situation in Pakistan. It is being assumed that the analysis is general enough to be representative of societies that appear trapped in poverty, with disproportionate expenditure on arms, with civil and military bureaucracies, where there is politi-

Schools of public health in low and middle-income countries: an imperative investment for improving the health of populations?

BackgroundPublic health has multicultural origins. By the close of the nineteenth century, Schools of Public Health (SPHs) began to emerge in western countries in response to major contemporary public health challenges. The Flexner Report (1910) emphasized the centrality of preventive medicine, sanitation, and public health measures in health professional education. The Alma Ata Declaration on Primary Health Care (PHC) in 1978 was a critical milestone, especially for low and middle-income countries (LMICs), conceptualizing a close working relationship between PHC and public health measures. The Commission on Social Determinants of Health (2005–2008) strengthened the case for SPHs in LMICs as key stakeholders in efforts to reduce global health inequities. This scoping review groups text into public health challenges faced by LMICs and the role of SPHs in addressing these challenges.Main textThe challenges faced by LMICs include rapid urbanization, environmental degradation, unfair terms of global trade, limited capacity for equitable growth, mass displacements associated with conflicts and natural disasters, and universal health coverage. Poor governance and externally imposed donor policies and agendas, further strain the fragile health systems of LMICs faced with epidemiological transition. Moreover barriers to education and research imposed by limited resources, political and economic instability, and unbalanced partnerships additionally aggravate the crisis. To address these contextual challenges effectively, SPHs are offering broad based health professional education, conducting multidisciplinary population based research and fostering collaborative partnerships. SPHs are also looked upon as the key drivers to achieve sustainable development goals (SDGs).ConclusionSPHs in LMICs can contribute to overcoming several public health challenges being faced by LMICs, including achieving SDGs. Most importantly they can develop cadres of competent and well-motivated public health professionals: educators, practitioners and researchers who ask questions that address fundamental health determinants, seek solutions as agents of change within their mandates, provide specific services and serve as advocates for multilevel partnerships. Funding support, human resources, and agency are unfortunately often limited or curtailed in LMICs, and this requires constructive collaboration between LMICs and counterpart institutions from high income countries.

How we developed a bioethics theme in an undergraduate medical curriculum

The 5-year undergraduate medical curriculum at Aga Khan University integrates basic sciences with clinical and community health sciences. Multimodal strategies of teaching and learning, with an emphasis on problem-based learning, are utilized to equip students with knowledge, skills, behaviours, attitudes and values necessary for a high-calibre medical graduate. Bioethics teaching was introduced in the medical curriculum in 1988 and has since undergone several changes. In 2009, a multidisciplinary voluntary group began review of undergraduate bioethics teaching and invested over 350 man-hours in curricular revision. This involved formulating terminal objectives, delineating specific objectives and identifying instructional methodologies and assessment strategies appropriate for the contents of each objective. Innovative strategies were specially devised to work within the time constraints of the existing medical curriculum and importantly, to increase student interest and engagement. The new bioethics curriculum is designed to be comprehensive and robust, and strives to develop graduates who, in addition to being technically skilled and competent, are well-versed in the history and philosophy of ethics and bioethics and are ethical in their thinking and practice, especially in the context of a developing country like Pakistan where health indicators are among the worst in the region, and clinical practices are not effectively regulated to ensure quality of care.

Stretching the boundaries of medical education: A case of medical college embracing humanities and social sciences in medical education

Objective: Aga Khan University, a private medical college, had a vision of producing physicians who are not only scientifically competent, but also socially sensitive, the latter by exposure of medical students to a broad-based curriculum. The objective of this study was to identify the genesis of broad-based education and its integration into the undergraduate medical education program as the Humanities and Social Sciences (HASS) course. Methods: A qualitative methodology was used for this study. Sources of data included document review and in-depth key informant interviews. Nvivo software was utilized to extract themes. Results: The study revealed the process of operationalization of the institutional vision to produce competent and culturally sensitive physicians. The delay in the establishment of the Faculty of Arts and Sciences, which was expected to take a lead role in the delivery of a broad-based education, led to the development of an innovative HASS course in the medical curriculum. The study also identified availability of faculty and resistance from students as challenges faced in the implementation and evolution of HASS. Conclusions: The description of the journey and viability of integration of HASS into the medical curriculum offers a model to medical colleges seeking ways to produce socially sensitive physicians.

Social and Societal Context of Women’s Mental Health, What Women Want, What They Get: Gap Analysis in Pakistan of Mental Health Services, Polices and Research

Introduction: The burden of mental illness is increasing in Pakistan as political instability, violence and terrorism beset the country. Mental health in Pakistan can be examined from three perspectives—services, research and policy. Services are provided in major public sector hospitals and some private institutions. Trained health professionals including psychiatrists and clinical psychologists are limited, and people often access faith healers for mental illnesses. Research on mental health is also being conducted, the focus being on the clinical aspects of mental health. Public health initiatives in Pakistan are yet to develop disease prevention and health promotion programmes. Intervention studies on the social context of women’s mental health are scarce. There is a mental health policy and a mental health Ordinance, Pakistan’s National health policy documents do not integrate mental health as a priority area. Women’s mental health, in contrast, is well recognized as an issue, but no national or provincial programme is to be found.

GENDER TRAINING IN PAKISTAN: AN ANALYSIS FOR WAY FORWARD

Cancer in general in Albania is an increasing problem and cervical cancer is the third most common gynecologic cancer among all women. Refer to European Code Against cancer an important action for women to help to prevent cervical cancer is to take part in organised cancer screening programmes. The study aims to identify in women health beliefs about cervical cancer. This is a transversal and analytical study with a sample of 210 healthy women from Vlora city with different socio-economic and educational levels. A selfadministered questionnaire that assesses the health beliefs components about cervical cancer was the data collection instrument. The results highlighted low risk perception relative to cervical cancer. Most of women believe that cervical cancer as dangerous as all the other cancers and uncertainties about the chances to recover from it exist among them. Misunderstandings and high sensitivity relate to cervical screening. Relationship between perceived benefits, emotional, economic barriers and Pap test uptake was found. Large numbers of women never screened. The results indicated that to improve the womens attitudes to health, to encourage adherence to cervical screening and to avoid misconceptions due to lack of information conversations with health operators and the designing of effective prevention strategies based on health beliefs are fundamental.