Syed Iqbal Azam

Time to focus child survival programmes on the newborn: assessment of levels and causes of infant mortality in rural Pakistan

OBJECTIVE Population-based surveys were conducted in selected clusters of Pakistans least developed provinces, Balochistan and North-West Frontier Province (NWFP), including the Federally Administered Tribal Areas (FATA), to assess levels and causes of neonatal and postneonatal mortality. METHODS Interviews were conducted in a total of 54 834 households: Balochistan, 20 486; NWFP, 26 175; and FATA, 8173. Trained interviewers administered questionnaires after obtaining verbal informed consent from the respondents. Verbal autopsy interviews were conducted for infant deaths reported for the previous year. FINDINGS The infant mortality rate based on combined data from the different sites was 99.7 per 1000 live births (range 129.0-70.1). The contribution of neonatal deaths to all infant deaths was much higher for NWFP (67.2%), where the overall rate was lowest, than for Balochistan (50.8%) and FATA (56.8%). Around 70% of all neonatal deaths occurred in the early neonatal period. The three main clinical causes of infant deaths were diarrhoea syndrome (21.6%), tetanus (11.7%) and acute respiratory infections (11.6%). In the neonatal period, however, tetanus (18.3%), small size for gestational age or low birth weight (15.3%), and birth injury (12.0%) accounted for nearly half (45.6%) of all deaths, while the contributions of diarrhoea syndrome (5.1%) and acute respiratory infections (6.0%) were less significant (11.1%). Tetanus was the cause of death for 21.7% and 17.1% of all infant deaths in FATA and NWFP respectively. CONCLUSION The results suggest that there should be a shift in child survival programmes to give greater emphasis to maternal and neonatal health, in particular to maternal tetanus immunization, safe delivery and cord care.

Designing a balanced scorecard for a tertiary care hospital in Pakistan: a modified Delphi group exercise

Balanced Scorecards (BSC) are being implemented in high income health settings linking organizational strategies with performance data. At this private university hospital in Pakistan an elaborate information system exists. This study aimed to make best use of available data for better performance management. Applying the modified Delphi technique an expert panel of clinicians and hospital managers reduced a long list of indicators to a manageable size. Indicators from existing documents were evaluated for their importance, scientific soundness, appropriateness to hospitals strategic plan, feasibility and modifiability. Panel members individually rated each indicator on a scale of 1-9 for the above criteria. Median scores were assigned. Of an initial set of 50 indicators, 20 were finally selected to be assigned to the four BSC quadrants. These were financial (n = 4), customer or patient (n = 4), internal business or quality of care (n = 7) and innovation/learning or employee perspectives (n = 5). A need for stringent definitions, international benchmarking and standardized measurement methods was identified. BSC compels individual clinicians and managers to jointly work towards improving performance. This scorecard is now ready to be implemented by this hospital as a performance management tool for monitoring indicators, addressing measurement issues and enabling comparisons with hospitals in other settings.

Gendered Disparities in Quality of Cataract Surgery in a Marginalised Population in Pakistan: The Karachi Marine Fishing Communities Eye and General Health Survey

Background Marine fishing communities are among the most marginalised and hard-to-reach groups and have been largely neglected in health research. We examined the quality of cataract surgery and its determinants, with an emphasis on gender, in marine fishing communities in Karachi, Pakistan, using multiple indicators of performance. Methods and Findings The Karachi Marine Fishing Communities Eye and General Health Survey was a door-to-door, cross-sectional study conducted between March 2009 and April 2010 in fishing communities living on 7 islands and in coastal areas in Keamari, Karachi, located on the Arabian Sea. A population-based sample of 638 adults, aged ≥ 50 years, was studied. A total of 145 eyes (of 97 persons) had undergone cataract surgery in this sample. Cataract surgical outcomes assessed included vision (presenting and best-corrected with a reduced logMAR chart), satisfaction with surgery, astigmatism, and pupil shape. Overall, 65.5% of the operated eyes had some form of visual loss (presenting visual acuity [PVA] < 6/12). 55.2%, 29.0%, and 15.9% of these had good, borderline, and poor visual outcomes based on presenting vision; with best correction, these values were: 68.3 %, 18.6%, and 13.1%, respectively. Of 7 covariates evaluated in the multivariable generalized estimating equations (GEE) analyses, gender was the only significant independent predictor of visual outcome. Women’s eyes were nearly 4.38 times more likely to have suboptimal visual outcome (PVA<6/18) compared with men’s eyes (adjusted odds ratio 4.38, 95% CI 1.96-9.79; P<0.001) after adjusting for the effect of household financial status. A higher proportion of women’s than men’s eyes had an irregular pupil (26.5% vs. 14.8%) or severe/very severe astigmatism (27.5% vs. 18.2%). However, these differences did not reach statistical significance. Overall, more than one fourth (44/144) of cataract surgeries resulted in dissatisfaction. The only significant predictor of satisfaction was visual outcome (P <0.001). Conclusions The quality of cataract surgery in this marginalised population, especially among women, falls well below the WHO recommended standards. Gender disparities, in particular, deserve proactive attention in policy, service delivery, research and evaluation.

Culture and quality care perceptions in a Pakistani hospital

PURPOSE Organizational culture is a determinant for quality improvement. This paper aims to assess organizational culture in a hospital setting, understand its relationship with perceptions about quality of care and identify areas for improvement. DESIGN/METHODOLOGY/APPROACH The paper is based on a cross-sectional survey in a large clinical department that used two validated questionnaires. The first contained 20 items addressing perceptions of cultural typology (64 respondents). The second one assessed staff views on quality improvement implementation (48 faculty) in three domains: leadership, information and analysis and human resource utilization (employee satisfaction). FINDINGS All four cultural types received scoring, from a mean of 17.5 (group), 13.7 (developmental), 31.2 (rational) to 37.2 (hierarchical). The latter was the dominant cultural type. Group (participatory) and developmental (open) culture types had significant positive correlation with optimistic perceptions about leadership (r = 0.48 and 0.55 respectively, p < 0.00). Hierarchical (bureaucratic) culture was significantly negatively correlated with domains; leadership (r = -0.61,p < 0.00), information and analysis (-0.50, p < 0.00) and employee satisfaction (r = -0.55, p < 0.00). Responses reveal a need for leadership to better utilize suggestions for improving quality of care, strengthening the process of information analysis and encouraging reward and recognition for employees. RESEARCH LIMITATIONS/IMPLICATIONS It is likely that, by adopting a participatory and open culture, staff views about organizational leadership will improve and employee satisfaction will be enhanced. This finding has implications for quality care implementation in other hospital settings. ORIGINALITY/VALUE The paper bridges an important gap in the literature by addressing the relationship between culture and quality care perceptions in a Pakistani hospital. As such a new and informative perspective is added.

Prevalence of Byssinosis in Spinning and Textile Workers of Karachi, Pakistan

The authors measured prevalence of byssinosis in spinning and textile workers of Karachi, Pakistan, and examined association of the disease with demographic and environmental factors. This was a cross-sectional study conducted in 3 spinning and textile mills and 3 colonies inhabited by spinning and textile workers. A precoded questionnaire was administered to the workers and followed by physical and clinical examination. Among 362 textile workers, the authors found the prevalence of byssinosis to be 35.6%. Educational status of the workers and section of the mill were significantly associated with prevalence of the disease. The authors conclude that there is a high prevalence of byssinosis in spinning and textile workers of Karachi. Furthermore, low education level and work in the spinning section of the mill appear to contribute significantly to the high prevalence of the disease in Pakistan.

Growth charts of fetal biometry: a longitudinal study

Objective: The aim of this study was to construct reference charts for fetal biometry in Karachi, Pakistan. Methods: This was a prospective longitudinal study involving 1228 women with singleton pregnancies. Biparietal diameter, head circumference, abdominal circumference and femur length were measured repeatedly until delivery. Regression analysis and multilevel modeling was used to construct charts. Results: The mean age of the women in this study was 28.0 years with standard deviation of 4.6. For each gestational age percentiles were calculated and charts were then constructed. Conclusion: Our reference percentiles for fetal biometry measurements are the first of their kind in Karachi, Pakistan. They will not only help us in the diagnosis and management of fetal growth restriction but will provide the basis to develop charts at the national level.

Reasons of refusal and drop out in a follow up study involving primigravidae in Pakistan

Objective. To determine the reasons underlying the refusals to participate and drop outs from a follow up study involving primigravidae. Design. A descriptive study. Methods. Aga Khan University and Aga Khan Hospital for Women, Karachi, jointly initiated a nested case‐control study on primigravidae for determining the predictability of preeclampsia using various biochemical markers in blood. The protocol‐eligible study subjects were counseled along with their accompanying family members to participate in the study. All women recruited in this study were followed up throughout their pregnancy till delivery. Results. One thousand six hundred and sixty‐five primigravidae were identified as the potential study subjects. Out of which, 1,307 (78.5%) consented and 358 (21.5%) refused to participate in the study. The most common reason underlying the refusal was inability to get permission from the family members (n = 84; 34.4%) followed by fear of prick (n = 51; 20.9%). For 114 refusals, either the reason was not mentioned by the counseled women (n = 60) or the data was missing (n = 54). Out of 1,307 women recruited in the research, only 611 (46.7%) women completed the study according to the prescribed protocol. Among the rest, 102 (7.8%) subsequently withdrew from the research, 503 (38.5%) were dropped out, and 91 (7.0%) were lost to follow up. Conclusions. Refusal to participate and drop out from the research program are two significant factors hindering the smooth flow of a study. In Pakistan, the major reason for the refusal by the protocol‐eligible pregnant women for participating in a research program is the unwillingness of the family members.

Dose-response of Cotton Dust Exposure with Lung Function among Textile Workers: MultiTex Study in Karachi, Pakistan

Background: Cotton dust exposure among textile mill workers lead to impaired lung function. However, only few studies have investigated the dose-response relationship between cotton dust and lung function. Objective: To determine the dose-response relationship between cotton dust exposure and lung function among textile workers. Methods: This cross-sectional survey was conducted from January to March 2016 and included 303 adult male textile workers from spinning and weaving sections of 5 mills in Karachi, Pakistan. We collected data through a translated version of the American Thoracic Society respiratory questionnaire (ATS-DLD-78A) and using spirometry. Mill-level airborne cotton dust was measured over an 8–12-hour shift through UCB-PATS (University of California, Berkeley-Particle, and Temperature Monitoring System). Multiple linear regression was used to determine the association between cotton dust exposure and lung function assessed through the 3 indices: forced expiratory volume in the first second (FEV1), forced vital capacity (FVC), and their ratio (FEV1/FVC). Results: The mean age of the workers was 32.5 (SD 10.5) years. The mean spirometry indices expressed in percent predicted values were FEV1 82.6 (SD 14.0); FVC 90.3 (14.7), and FEV1/FVC 94.9 (10.5). The median cotton dust concentration was 0.61 (IQR 0.2 to 1.3) mg/m3. The frequency of respiratory symptoms was 15% for cough, 20% for phlegm, and 20% for wheezing. After adjustment for covariates, every mg/m3 increase in dust concentration was associated with 5.4% decline in FEV1. Conclusion: This study quantifies the exposure-dependent relationship between cotton dust and lung function; which has implications for regulations and standards in the textile industry in Pakistan and similar cotton-processing countries.

Factors Associated With Child Maltreatment Among Children Aged 11 to 17 Years in Community Settings of Karachi, Pakistan, Using Belsky Ecological Framework

Child maltreatment is considered as a global social issue and results as combined effect of parental background, socioeconomic environment, family structure, and child characteristics. The aim of this study was to determine factors associated with child maltreatment among children aged 11 to 17 years in Karachi, Pakistan. A cross-sectional survey of 800 pairs (children ranging from 11 to 17 years old and their parents) was randomly selected from 32 clusters of Karachi, using multistage cluster sampling. A structured questionnaire was adopted from the International Society for the Prevention of Child Abuse and Neglect (International Child Abuse Screening Tool for Parent [ICAST-P] and for Child [ICAST-C]). Multiple linear regression technique was used to assess the association of factors with child maltreatment score, by using STATA software. Our study found that children who always get bullied and mistreated by their siblings are at increased risk of getting maltreatment by parents (adjusted β: 10.78, 95% CI = [8.5, 13.05]).The mean estimated ICAST-C score increases by 9.86 (95% CI = [6.17, 13.55]) for children with exposure of verbal abuse and quarrel within family members. The mean estimated ICAST-C score increases by 5.09 among male children as compared with female children (95% CI = [3.65, 6.52]). Among children whose family always fight with each other and whose parents have exposure to childhood maltreatment, the mean estimated ICAST-C score increases by 22.25 (95% CI = [16.53, 27.98]). This study reflects the potential factors of child maltreatment in Karachi. Our findings provide evidence to raise awareness about child maltreatment.