Pakistani Women Research Articles

An Evaluation of Obstetric Characteristics and Contraceptive Use Among Refugee Women.

BackgroundThis study aimed to assess the obstetric characteristics of refugee women and evaluate their knowledge and usage of contraception methods.MethodologyThis retrospective, cross-sectional study included 400 married refugee women aged 18-49 years who presented to the Foreigners Outpatient Clinic between 2018 and 2020. In the Foreigners Outpatient Clinic, a health worker filled in a 23-question form for all refugee women to obtain their obstetric history and information regarding contraception methods. The 23-item form comprised 11 questions about the sociodemographic characteristics of refugee women, seven questions about their obstetric history, and five questions about their knowledge and attitudes about contraception methods. Statistical analyses were performed using the data obtained from these forms filed in the outpatient clinic. Descriptive data were presented as frequency, percentage distribution, mean, and standard deviation.ResultsThe average age of the participants was 31.36 ± 8.36 years, with 52.8% of the participants being Afghan women. Overall, 70% of participants were either only literate, learned to read and write without ever going to school, or were primary school graduates. Moreover, 61.1% of refugee women aged ≤18 years at the time of first birth were Somali, Sudanese, and Saudi Arabian nationals, significantly outnumbering other refugee women (p = 0.03). The rate of having ≥three children among Pakistani participants was 90.0%, which was statistically significantly higher (p = 0.04). The proportion of Afghan women who received counseling on family planning was lower (p = 0.04). There was no statistically significant difference between refugee women’s knowledge of using a contraception method (p = 0.09). As a contraception method, the most significant use of injection was by refugee women from Somalia, Sudan, and Saudi Arabia (p = 0.03); tubal ligation was used by Afghan women (p = 0.01); and implanted by Pakistani women (p = 0.01). No difference was found in the use of condoms, pills, and intrauterine devices.ConclusionsOn evaluating the obstetric characteristics of refugee women, it was determined that the number of pregnancies and the rate of giving first birth at the age of 18 and under were high. On the other hand, there was no difference between refugee women regarding condom and pill use; however, it was observed that the rate of using these methods at some point in their lives was high. Hence, it can be concluded that immigration seriously affects women’s reproductive health, makes it difficult to obtain protection methods, and paves the way for having unplanned and large numbers of children.

Overcoming barriers to cervical cancer screening in a developing country like Pakistan.

Cervical cancer is the second most prevalent cancer in Pakistani women of the reproductive age group (15-44 years), while in women of all ages, it ranks as the third most common. It is estimated that around 20 women are found to have cervical cancer per day, ranking Pakistan in the top 10 countries with the highest cancer-related mortality rates. [1] In 2020 alone, cervical cancer took the lives of 341, 831 women, 90% of whom belonged to developing countries including Pakistan. In the same year, it affected 604, 127 women, from which only 12% were from regions like the North America and Europe, while the remaining belonged to the developing world. [2] This startling disparity can be attributed to the introduction of pap smears in the developing world, like the United States and the United Kingdom, which saw >70% decline in cervical cancer mortality since screening through Pap smears was initiated in these countries. [3]. In Pakistan, several studies have shown that women of the reproductive age group lack basic awareness regarding cervical cancer and screening via Pap smears. A survey on 873 women between 18-28 years found 70.1% of the participants were completely unaware of cancer. [4] A more extensive study consisting of 1070 women between ages 21-30 years found that only 2.2% of their study's population was able to identify the symptoms and risk factors for cervical cancer, while Pap smear was recognized as a screening test by only 2.5% of the same. The Pap smear uptake in this population was 2%. [5]. This lack of knowledge regarding screening can be credited to several factors such as the low educational status of developing countries, little information communicated by the healthcare workers, and the insufficient knowledge of preventive measures amongst them. Other screening barriers include misconceptions about testing guidelines, the socioeconomic status of low-income families, lack of access to testing facilities, personal reluctance due to embarrassment, and family trends of not getting tested due to cultural taboos. [5]. It is crucial to overcome the aforementioned obstacles in order to ensure early screening and treatment of precancerous lesions in women. ---Continue

Factors Affecting Age of Onset of Menopause

Background: Menopause is a natural process, occurring in women that marks the end of fertility among women. It is characterized by a cessation of menstruation, decline in ovarian activity and disturbances in periods along with vaginal dryness, mood swings and hot flashes. The age of menopause ranges in between 40 to 55 years. Although there are many factors affecting the age of menopause onset like metabolic syndrome, cytotoxic drugs, but there is no general agreement on them.
 Objectives: To explore the factors affecting age of onset of menopause among Pakistani women.
 Methodology: This cross-sectional-observation study was conducted on 139 women (aged at or above 40 years) presenting to the Outpatient Department of Obstetrics – Gynecology at Jinnah Medical College Hospital, Karachi – Pakistan from Nov 2020 to May 2021. Data was collected using a structured interview-based questionnaire containing inquiries pertaining to basic biodata, sociodemographic details, menstrual history, and probable factors affecting age of onset of menopause. Chi-square test was applied to check the association between the different factors and age of menopause.
 Results: The mean age of the participants was found to be 43.23 ± 4.11 SD years, while the mean age of onset of menopause was recorded to be 49.21 ± 3.83 SD years. The associations between the marital status, body mass index, use of OCP and socio-economic factors with age of onset of menopause, were found to be statistically significant.
 Conclusion: Menopausal age not only reflects the end of fertility era but also of aging as well. Age of menopause significantly effects physical and psychological health of women and is considered as a very important event in women’s lives. Controllable factors like obesity, tobacco use, use of OCP plays a significant role in age of onset of natural menopause.

Women as Agents of Change: Exploring Women Leaders' Resistance and Shaping of Gender Ideologies in Pakistan.

Despite a growing focus on processes to promote gender equity, women remain significantly underrepresented in leadership positions in the Global South. In the present study we focus on the role of familial experiences in shaping and contesting gender ideologies of Pakistani women in the workplace. We specifically examine the reciprocal ways in which women leaders and their family members shape each other’s gender ideologies regarding the workplace. Data collected and analyzed for this study were semi-structured interviews with eight women in positions of leadership in Lahore, Pakistan, and interviews with one family members of each of the women leaders (thus 16 interviews total). Using thematic narrative analysis, we identified three thematic phases: learning gender expectations, resistance, and familial transformation. These phases reflect the progression of developing, resisting, and influencing individual and familial gender ideologies. We document the manifestation of these phases in three specific domains: education, marriage and motherhood, and the workplace. We then discuss how these findings contribute to understanding the experiences of women leaders and perceptions of their family members regarding women’s role in the workplace. Findings from our research provide novel insights into the ways globalization and capitalism continue to shape the socio-cultural context for women leaders in the Global South.

Mediated Scandals and Blame Game: Hina Rabbani Khar, the First Pakistani Woman F..

Using media framing as the guiding lens and drawing on the insights from qualitative content analysis, this study explores Hina Rabbani Khar, Pakistan’s first female foreign minister’s mediated scandal, gendered portrayals, and their potential impact on the audience. The data comprises 59 news stories, articles, and broadcasts from different channels collected during the first 16 months of her tenure. Results show that the media seldom focused on political agenda; instead jeopardized Khar’s position, profiled her to be in illicit relationships with Bilawal Bhutto Zardari that eclipsed her political achievements. For the international media has been way ahead of the national media, their preferences of sustaining gender polarities,therefore, transcend geographical boundaries. Change in the media’s approach of the women politicians’ coverage (especially those elevated to higher political positions) is, thus, desirable for confirming equitable media portrayals and accepting their position as equal to men in politics.

Sociodemographics of Formal and Informal Sector Women Workers of Pakistan and a Comparison of their Perceived and Practiced Autonomy

The majority of Pakistani women are employed in the informal sector of the economy, devoid of protection, safety, and employment benefits, which prevents them from having autonomy. In this study, we aimed to identify (i) the differences in socio-demographic characteristics of formal versus informal sector women workers and (ii) compare the perceived and practised autonomy between the two groups. We used a convenience sample of 150 women, half each from the informal and formal sectors of the economy, specifically the teaching sector. We were able to find through mean analysis that women from the informal sector have higher autonomy. We also found that informal sector women workers in the country are impoverished, illiterate, non-Muslims, living in underdeveloped areas, and have no property ownership. There is a critical need to support policy for transfer to formal sector employment and to develop interventions to improve autonomy in working women.

Stress Induced Menstrual Cycle Irregularities AMIDST the Pandemic

Background: The global pandemic of the coronavirus disease 2019 (COVID-19) has yielded a variety of stressors (psychosocial) for the population, particularly women. The elevated stress may not only affect the wellbeing and health (physical and mental) of women, but also the reproductive status and menstrual cyclicity.
 Objective: To determine the plausibility and mechanism via which stress (emanating from the COVID-19 pandemic) has impacted women's menstrual cyclicity.
 Methodology: This descriptive, cross-sectional study was conducted from Sept 2020 to August 2021 upon a randomly selected sample of 1450 Pakistani women (aged 18 to 40 years). The data was collected using an online questionnaire containing enquiries pertaining to basic biodata, sociodemographic details, lifestyle patterns, medical & reproductive history, and stress score measured via the COVID-19 Stress Scales (CSS). The data obtained, was analyzed using SPSS v. 21.0.
 Results: Among the females, 741 reported regular menstrual cycles, while the remaining 709 reported a disturbed menstrual cyclicity. The commonest changes included early or late start of the cycle (227), more aggravated menstrual symptoms (e.g., cramping, discharge and low back pain) (205), and menorrhagia (277). Individuals with aggravated symptoms of ill-timed cycles scored higher (cumulatively as average scores) on the CSS compared to their counterparts (p < 0.05).
 Conclusion: After careful consideration of the results, it can be concluded that a significant association exists between the stress (emanating from the COVID-19 pandemic) and menstrual irregularity (p < 0.05). Stress relief may help alleviate menstrual irregularities in the current scenario.

Damsels in distress: gender and negative place branding

This article provides a historical perspective on how institutionalized articulations of gender in visual news narratives may contribute towards the erosion of a country’s soft power potential. It analyses thirty years of photographic coverage given by an elite western publication, Time magazine to women from two countries with problematic place brands: Iran and Pakistan. This study documents how iterative longitudinal patterns of visual grammar contribute towards the layered marginalization of women within narratives. Women are much less visible in terms of image frequency, with selective value placed on certain kinds of female subjects across the decades, choices often shaped by stereotypes as well as foreign policy preferences. For Iranian women, the visual discourse empowers women resisting conservative forces, and valorizes trailblazers redefining the public space. For Pakistani women, a narrative showcasing political activism devolves into one highlighting victims/activists in the context of gender-based discrimination. The choice of ‘valuable’ bodies in both instances, expressed with the help of quantifiable semiotic trends in camera angles, shot and gaze, is imbued with indirect judgment of the political leadership and cultural and socio-political systems of the countries themselves. In both cases, the overall narrative is of a system pre-disposed to oppress women, thus negatively juxtaposing the ‘people’ aspect of the Anholt Nation Brand Index against the elements of governance, culture and heritage, to the overall detriment of both place brands.

Urinary Incontinence in Pakistani Women: Impact on Quality of Life and Treatment-Seeking Behavior

Objectives: To determine the prevalence of urinary incontinence and assess its impact on these women’s quality of life and treatment-seeking behaviour

Exploring Women Entrepreneurship Prospects, Challenges, and Barriers in Pakistan

This study aims to explore challenges, prospects, and barriers for young graduate Pakistani women entrepreneurs. The article is qualitative, and the scholars used the case study research method. Researchers conducted semi-structured interviews with young graduate female entrepreneurs and analyzed using Gioia methodology. This study explored that the women entrepreneurs used E-business platforms (e.g., social media marketing) as a tool for promoting their innovative business ideas. Current research documents challenges, barriers, opportunities, and support available to Pakistani women entrepreneurs in light of the experiences of the young graduate female entrepreneurs. Further, this article is vital in terms of exclusive methodology, scarcely studies population, contextual value, theoretical advancement by exploring new themes and practical implications. The present paper portrays implications for policymakers to eradicate barriers, address the challenges, and provide opportunities to females by delivering entrepreneurial training and funding opportunities.

Social reproduction and gender beliefs of ethnic minority women

AbstractResearch suggests that ethnic minority women in employment negotiate more than one culture and grapple with beliefs that stem from a bi‐cultural experience. Research also contends that gender is at the center of social reproduction and the production of labor and social reproduction is invariably linked. However, how is social reproduction at work, and how gender beliefs influence social reproduction and work‐life choices amongst highly educated, employed, second‐generation ethnic minority women, deserves in‐depth attention. Contributing to the intersection of social reproduction and diversity research, the present paper offers two life stories of highly educated second‐generation British Pakistani women and examines in‐depth the role of two cultures on gender beliefs and the influence of those gender beliefs on social reproduction and work‐life choices. Drawing on Ridgeway and Correll's (2004) work on gender beliefs, we extend their work by focusing on two cultures (the host country and the country of ethnic origin). While the literature has generally focused on issues of social reproduction across generations, our study also takes into account the contours of social reproduction across cultures. Our findings reveal the mechanisms of social reproduction, the push and pull of two cultures in the creation of gender beliefs within one person, the fluidity and fixity of gender beliefs, and the ways these are negotiated while the individual contributes toward social reproduction and makes work‐life choices.

Antimicrobial Resistance Pattern in E. coli Isolated from Placental Tissues of Pregnant Women in Low-Socioeconomic Setting of Pakistan.

Infections during pregnancy can culminate in adverse pregnancy outcomes, including preterm birth (PTB). Pakistan is among the top ten nations with high PTB-associated neonatal mortality rates, where access to prenatal as well as neonatal care is only afforded by the privileged few. Societal stigma further discourages women seeking healthcare for minor infections. Microbial pathogens associated with genitourinary infections can lead to gestational complications culminating in earlier onset of labor. In this study, association of Escherichia coli (E. coli) with PTB in Pakistani women of low-socioeconomic status is examined. 57 paired vaginal swabs and placenta samples from mothers with full term and preterm deliveries were collected and processed for isolation and molecular characterization of extraintestinal pathogenic E. coli (ExPEC). ExPEC isolated from vaginal swabs and placenta showed phylotype B2 being most prevalent (Vagina n = 3 (9), 33%) (Placenta n = 4 (12), 33%) in preterm cases followed by phylotype B1 (Vagina n = 2 (9), 22%) (Placenta n = 3 (12), 25%) and untypeable strains. Antibiotic susceptibility profiling showed a large percentage of resistant isolates to multiple antibiotics, including carbapenem and included extended-spectrum beta-lactamase (ESBL) producers. Our study is the first to report different phylotypes of E. coli from placental tissues in preterm deliveries which may be a cause for concern for maternal and neonatal health. ExPEC from vaginal swabs and placental of females delivering preterm shows the pathogenic phylotype B2 dominance with a large percentage of isolates resistant to multiple antibiotics, including carbapenem and included ESBL producers. The placental isolates may indicate ascending infection from vagina or urinary tract which may lead to preterm birth.

Japan resumes active recommendations of HPV vaccine after 8·5 years of suspension.

On Nov 26, 2021, the Ministry of Health, Labour, and Welfare of Japan officially issued an announcement to resume active recommendations of the human papillomavirus (HPV) vaccine, which had been suspended since June, 2013. 1 Ministry of Health, Labour, and Welfare of JapanFuture response to regular vaccinations related to human papillomavirus infection (Notice of Director of Health). https://www.mhlw.go.jp/content/000875155.pdfDate: Nov 26, 2021 Date accessed: January 8, 2022 Google Scholar The new announcement now clearly advises municipalities to recommend the vaccine in accordance with Article 8 of the National Immunization Law, which includes sending notifications and vouchers individually to the target population (ie, girls aged 12–16 years). 1 Ministry of Health, Labour, and Welfare of JapanFuture response to regular vaccinations related to human papillomavirus infection (Notice of Director of Health). https://www.mhlw.go.jp/content/000875155.pdfDate: Nov 26, 2021 Date accessed: January 8, 2022 Google Scholar Municipalities are expected to restart such active recommendations from April, 2022. Has Pakistan failed to roll back HPV?We read with interest the Comment by Rei Haruyama and colleagues,1 and applaud Japan for resuming active recommendations of the human papillomavirus (HPV) vaccine. Given that HPV is most commonly transmitted through sexual contact, Pakistan—where sexual norms differ from European countries—is susceptible to HPV-associated cancers. In Pakistan, where sexual education is a controversial topic, any discussion of sexual activities is considered to be a social taboo. Each year, around 5008 Pakistani women are diagnosed with cervical cancer, with 3197 reported deaths, making it the second most common malignancy in women aged 15–44 years. Full-Text PDF

Assessment of 1 α-Hydroxylase in Vitamin D- Deficient Premenopausal Pakistani Females

ABSTRACT Background: 25-hydroxyvitamin D-1-α-hydroxylase is a key enzyme for conversion of 25-(OH)-D to 1,25-(OH)2-D and is extra renally produced in various tissues. The objective of the study was to determine the levels of enzyme 1-α-hydroxylase in response to supplementation with vitamin D in premenopausal women. Methods: This single-arm pre-post interventional study, included premenopausal females (n=82) and their 1-α hydroxylase levels were measured from peripheral blood. Vitamin D supplements were given and vitamin D levels and α-1 hydroxylase levels were measured through ELISA. The serum vitamin D levels below 30ng/ml (75nmol/L), were considered vitamin D deficient. The correlation between serum vitamin D levels and 1-α-OHase levels was determined using Spearman’s Rank Correlation test, Wessa P Spearman Rank Correlation in Free Statistics Software. Relationships between variables were done through paired t-test and p<0.05 was considered significant. Results: The levels of 1-α (OH)ase varied in response to supplementation, with most values observed between 10-20ng/ml. The average increase in serum vitamin D and 1-α-(OH)ase levels was 9.49ng/mL and 4.66ng/mL respectively. In total 50(60.9%) samples revealed a decrease in 1-α (OH)ase levels, and 32(39.1%) samples increased. Data analysis showed t (84) = 1.214, p=0.228 for serum 1- α (OH)ase. For post-supplementation the results showed no association between (rs = 0.04982, p = 0.65671) the two variables. Conclusion: Serum levels of 1-α-hydroxylase in premenopausal Pakistani females indicated variation when vitamin D was supplemented, highlighting a non-linear relationship. This shows involvement of other unknown factors in Vitamin D metabolism, which requires to be investigated in future research. Keywords: Biopsy; Inflammation; Hydroxylase.

Changing patterns of son preference and fertility in Pakistan

AbstractUsing data from two representative Demographic and Health Surveys, we examine the change in son preference over the past three decades and its effects on Pakistani women's fertility. We analyse a number of indicators and employ different empirical methods to come up with strong and persistent evidence for both the revealed and stated preference for sons. This disproportionate preference for boys is visible in increasing desired sex ratio and worsening sex ratio at last birth. Reliance over differential birth stopping has significantly increased over time as couples are more likely to stop childbearing once the desired number of boys is achieved.

Factors Contributing For Breast Cancer In Pakistan

Breast cancer is the most common malignancy among women around the Globe. Asian countries have highest ratio of breast cancer. About 60 % cases from Asian countries due to lack of health care facilities and awareness about breast cancer in general population. Classification based on age, stage of disease, location of development and family history. Breast cell tumor due to gene mutation prognosis the disease into malignancies. Symptoms may appear in early stage or late stages of disease.Material and method:The literature review was conducted through different sources such as Google scholars, PubMed, MEDLINE and data base. The key words was used breast cancer incidence in Pakistan, prevalence of breast cancer, causes of breast cancer in Pakistan. Only those studies was selected published during the period of 2010 to 2020 and published in English.Results:From this literature review, following factors has been identified, effecting on breast cancer development. Lack of knowledge about breast cancer development. Lack of health care facilities in rural areas, family history and economic problems.Conclusion:Pakistani women are unaware of breast cancer knowledge. Low health care budget, early identification of disease, family history of breast cancer are major contributing factors of breast cancer.

“Passing the baton”: legacy and leadership in convent schools in India and the Islamic Republic of Pakistan

ABSTRACTThis article examines the historical backdrop to the involvement of teaching Sisters in convent schooling for girls in India and the Islamic Republic of Pakistan, since the late nineteenth century. It then explores how, as a consequence of a range of social changes, leadership in convent schools has changed in both countries, across the twentieth century. The Irish Sisters who founded and established these schools commenced “passing the baton” of convent school leadership to Indian and Pakistani women. The article draws on interviews to examine ways in which successive generations of women in the study refer to the legacy of the past, and the issue of women in education leadership.

Patriarchy as an Assemblage: Qandeel Baloch, Male Domination and Feminist Publics in Pakistan

This article contributes to recent debates about nuancing the idea of ‘patriarchy’ by drawing on Deleuze and Guattari’s notion of assemblage. It provides an account of patriarchy as a contingent yet persistent effect of human and material interactions wherein some molar forces aggregate and territorialise social relations around specific notions of womanhood, while molecular flows evade them. The particular set of interactions that this paper considers are configured through and around Qandeel Baloch, a social media celebrity from Pakistan, who was asphyxiated by her brother in 2016. In life, Baloch evaded several normative boundaries prescribed for middle-class Pakistani women. Riding the wave of social media expansion and an attentive youthful audience, she monetised male lust by transforming her body into a commodity, challenged self-appointed arbiters of religion, and mocked politicians. In death, she has been re-territorialised by mainstream media to conform to the social codes that bolster male domination. At the same time, she has been de-territorialised by feminist collectives that have produced their own normativity (or molarity) by erasing Baloch’s ambiguities and pronouncing her a feminist icon. Examining patriarchy as an assemblage of forces directs our attention to such heterogenous, even contradictory, movements wherein some pathways—male domination—are more heavily trafficked than others.

Breast cancer diagnostic delays in pakistan: a looming epidemic threat

Breast cancer is a major contributing factor to the mortality and morbidity burden among the female population in Asia. In 2020, a total of 1.2 million newly diagnosed breast cancer cases and an estimated 3.5 million deaths due to breast cancer were reported in Asia (International Agency for Research on Cancer, 2020a). In particular, Pakistan notably reported the highest proportion of breast cancer cases in Asia. Research estimates that one out of nine women in Pakistan is at a high risk of suffering from breast cancer in their lifetime. The constant growth in breast cancer rates in Pakistan indicates that breast cancer is rapidly reaching epidemic proportions and poses an urgent challenge to Pakistan's public health system. Due to system-level and patient-level delay factors, Pakistani women often seek medical care for breast carcinoma at an advanced stage of the disease, whereby survival chances are minimal. The key to mitigating the breast cancer burden in Pakistan is to foster early detection programs among Pakistani women. This review aims to examine the root causes of delayed detection of breast cancer in Pakistani women, emphasize the pivotal role of early detection in individuals' and populations' health promotion, and highlight nursing implications in promoting breast cancer early detection programs. A comprehensive literature search was conducted in databases including CINAHL, Google Scholar, and Scopus. The review consists of articles from 2005 to 2020 published in the English language only. Furthermore, the study also highlights the need for context-specific and culturally sensitive early breast cancer detection programs to potentially reduce barriers in the uptake of screening services among Pakistani women.

Time for themselves: Perceptions of physical activity among first and second-generation Pakistani women living in the Raval, Barcelona.

Objectives:Pakistani women experience higher-than-average rates of certain chronic diseases, including diseases related to sedentary lifestyles. The aim of this study is to explore how first and second-generation Pakistani women living in the Raval, Barcelona, conceive of physical activity, and their barriers and facilitators around participating in physical activity, with the goal of increasing physical activity in this group.Methods:Qualitative research with an intersectional approach. Nine informal interviews with key community informants were conducted from November 2018 to January 2019 to gain background on the topic, using snowball sampling. Eleven individual interviews were conducted from February to June 2019. Seven were with Pakistani women having lived, or currently living, in the neighborhood of the Raval, Barcelona. Four additional interviews were conducted with non-Pakistani women key community informants who have worked extensively with this community. Thematic content analysis was carried out using ATLAS.ti.Results:First-generation Pakistani women generally did not have physical activity present in their daily lives, but by most accounts wished to. Areas that shed light on this included the following: limited economic opportunities and associated living conditions, barriers to social integration, health concepts and access to information, and cultural norms and related gender roles. For the first-generation, gender-related divisions of labor as well as the absence of the concept of self-care were particularly relevant barriers to their participation in physical activity. The experience of immigration-related grief emerged as a transversal theme which overlapped with multiple areas. While both generations expressed a need for the separation of genders during physical activity—as per their cultural interpretation of Islam—the lack of such spaces was highlighted as a principal barrier in physical activity among the second generation.Conclusion:These findings shed light on distinct elements that exert influence in Pakistani women immigrants’ participation in physical activity—among them: social and living conditions, access to public space, and gender-related work distribution and cultural norms—which are in turn influenced by first or second-generation immigration status. Considering the specific needs of both groups when proposing politics and health programs to encourage physical activity is paramount in order to successfully partner with these populations.