Slums Of Karachi Research Articles

Uncovering the causes and socio-demographic constructs of stillbirths and neonatal deaths in an urban slum of Karachi.

Neonatal deaths and stillbirths are significant public health concerns in Pakistan, with an estimated stillbirth rate of 43 per 1,000 births and a neonatal mortality rate of 46 deaths per 1,000 live births. Limited access to obstetric care, poor health seeking behaviors and lack of quality healthcare are the leading root causes for stillbirths and neonatal deaths. Rehri Goth, a coastal slum in Karachi, faces even greater challenges due to extreme poverty, and inadequate infrastructure. This study aims to investigate the causes and pathways leading to stillbirths and neonatal deaths in Rehri Goth to develop effective maternal and child health interventions. A mixed-method cohort study was nested with the implementation of large maternal, neonatal and child health program, captured all stillbirths and neonatal death during the period of May 2014 till June 2018. The Verbal and Social Autopsy (VASA) tool (WHO 2016) was used to collect primary data from all death events to determine the causes as well as the pathways. Interviews were conducted both retrospectively and prospectively with mothers and caregivers. Two trained physicians reviewed the VASA form and the medical records (if available) and coded the cause of death blinded to each other. Descriptive analysis was used to categorize stillbirth and neonatal mortality data into high- and low-mortality clusters, followed by chi-square tests to explore associations between categories, and concluded with a qualitative analysis. Out of 421 events captured, complete VASA interviews were conducted for 317 cases. The leading causes of antepartum stillbirths were pregnancy-induced hypertension (22.4%) and maternal infections (13.4%), while obstructed labor was the primary cause of intrapartum stillbirths (38.3%). Neonatal deaths were primarily caused by perinatal asphyxia (36.1%) and preterm birth complications (27.8%). The qualitative analysis on a subset of 40 death events showed that health system (62.5%) and community factors (37.5%) contributing to adverse outcomes, such as delayed referrals, poor triage systems, suboptimal quality of care, and delayed care-seeking behaviors. The study provides an opportunity to understand the causes of stillbirths and neonatal deaths in one of the impoverished slums of Karachi. The data segregation by clusters as well as triangulation with qualitative analysis highlight the needs of evidence-based strategies for maternal and child health interventions in disadvantaged communities.

Evaluation of oral health among people with multimorbidity in the marginalized population of Karachi, Pakistan: A multicenter cross-sectional study

BackgroundOral health is linked to physical and mental well-being. Oral disease is common among poor and socioeconomically disadvantaged people in developing and industrialized countries. ObjectivesThis study assessed the oral health disease burden among people with multimorbidity in marginalized populations. MethodsThis cross-sectional study was conducted across 16 locations in the slums of Karachi, Pakistan, to assess oral health disease problems among adults aged 18 to 70 with comorbidity or multimorbidity. The questionnaire covered the socioethnic, demographic, and disease status of people with oral health status. Data analyses were performed using SAS version 9.4. ResultsOf the 16 designated slum locations, 870 individuals were considered for oral health screening. Gingivitis was highly prevalent, 29% among slum dwellers with multimorbidity of diabetes, hepatitis, and hypertension. Dandasa was widely used as a tooth-cleansing agent in 35% of the study population. By contrast, 45.4% of people showed unsatisfactory oral hygiene conditions. Pathan ethnicity showed the highest prevalence (i.e., 29.8% of dental problems with disease multimorbidity in 26.8% of Baldia Town residents of Karachi). Of the 870 individuals, the highest frequency of dental problems was found in the age group of 18–38 years (28–42.9%) and among female participants (53.8%). ConclusionThere is an urgent need for the global enhancement of public health programs, specifically focusing on implementing effective strategies to prevent oral illnesses, promote oral health, and address other chronic diseases in basic healthcare settings. Enhancing oral health poses significant difficulties, especially in less developed nations.

Unveiling Barriers to the Modern Contraceptive Uptake in the Urban Slums of Karachi: Perceptions, Attitude, and Accessibility.

Background Modern contraception plays a vital role in family planning and preventing unintended pregnancies. However, its uptake remains limited in many developing countries, including Pakistan. This study aimed to evaluate the barriers to modern contraception and identify strategies to enhance its adoption in the urban slums of Karachi. Methods A multi-site, cross-sectional study was conducted in 38 slum areas of Karachi, Pakistan. Women aged 15-49 years were interviewed using a comprehensive questionnaire. The questionnaire covered socio-ethnic and economic demographics, knowledge and perceptions of modern contraception, accessibility, affordability, attitudes, and usage. Data analysis was performed using the Statistical Package for Social Sciences (SPSS)version 24 (IBM SPSS Statistics, Armonk, NY). Results The majority of the respondents identified as Pathan ethnicity (49%), and the age range was predominantly from 23 to 34 years (45.5%). A high proportion of participants demonstrated satisfactory knowledge of contraceptives (87.6%). However, a significant portion perceived contraception or family planning to be in conflict with religious beliefs (84%). Many women expressed a desire for more children (56%) and had concerns about contraceptive side effects (78%). A notable proportion of women reported that their spouses forbade the use of contraceptives (12%). Among the surveyed population, the most widely used contraceptives were injections among women (15.5%) and condoms among their male partners (12%). Conclusion Despite sufficient knowledge and accessibility, considerable barriers exist in the uptake of modern contraception in the urban slums of Karachi, Pakistan. These barriers include religious conflicts, cultural norms, concerns about side effects, spousal disapproval, and desires for larger families.

Prevalence of Mental Disorders Among Patients with Multimorbidity Visiting Primary Care Settings in Slums of Karachi, Pakistan.

Anxiety and depression often exacerbate multimorbidity conditions, leading to increased disability rates among affected individuals. The study aimed to assess the mental health status of individuals with multimorbidity belonging to the marginalized population of Karachi, Pakistan. Specifically, the prevalence of anxiety and depression was investigated. A multicenter cross-sectional study was conducted between July 2022 and June 2023 in 10 primary healthcare clinics located in 4 peri-urban areas of Karachi. A total of 9331 participants were included in the study. The Patient Health Questionnaire 4 (PHQ-4), Generalized Anxiety Disorder 7 (GAD-7), and Patient Health Questionnaire 9 (PHQ-9) were used to assess symptoms of anxiety and depression. The data collected were analyzed using the statistical analysis system (SAS) version 9.4. Among the study participants, 2894 (31%) were men and 5534 (59.3%) were women. The prevalence of moderate to severe anxiety was 31% among men and 59.3% among women. The age group between 41 and 60 years exhibited the highest rates of moderate to severe anxiety, 19.3% as evaluated by GAD-7 and 34.6% by PHQ-9. The Pathan ethnic group had the highest prevalence of anxiety (11%) and depression (28.3%) in the neighborhoods. Unemployed participants showed moderate to severe anxiety in 21.3% of the cases and moderate to severe depression in 25.5% of the cases. The study revealed a significant cooccurrence of anxiety and depression among individuals with multimorbidity in the marginalized population of Karachi, Pakistan. Furthermore, the presence of anxiety symptoms in multimorbidity patients with depression indicates a more unfavorable health state. It is essential to explore the implementation of screening measures and therapeutic interventions for comorbid anxiety and depression in this population to improve clinical outcomes.

Methodology for Robust Revalidation of the CHERG VASA Tool to Investigate Under-5 Deaths in Karachi Slums: A Mixed Methods Approach

Objectives: This methodology paper outlines a mixed-methods study design to: (i) further validate the Child Health Epidemiology Reference Group (CHERG) Verbal-Social Autopsy (VASA) tool quantitatively on a larger representative sample in Karachi, (ii) gather qualitative feedback from users, and (iii) refine the tool accordingly to optimize its use investigating under-5 mortality in urban Pakistan.
 Methods: An explanatory sequential mixed methods design will be applied to revalidate the CHERG VASA tool in 7 districts of Karachi. The quantitative arm will validate the tool through analysis of data from under-5 deaths identified via stratified random sampling. Validation techniques will include assessment of criterion validity against hospital records, content validity, construct validity, reliability analysis. This will be followed by a qualitative component with cognitive interviews and focus group discussions with respondents to illicit feedback on user experiences with the tool. Qualitative data will undergo framework analysis. Tool refinement will occur integrating both quantitative and qualitative findings.
 Discussion: Combining robust statistical validation from a substantial representative sample with in-depth qualitative insights on tool design and functionality will lead to an enhanced context-specific instrument to reliably investigate determinants of under-5 mortality in the slums of Karachi, Pakistan’s largest city.
 Keywords: verbal autopsy, social autopsy, validity, reliability, scale validation, mixed-methods

A Community-Based Survey Exploring the Determinants of Invalid, Delayed, and Missed Immunization in Children of Urban Slums of Karachi, Pakistan

In children, the global burden of vaccines-preventable diseases (VPDs) and deaths can be averted by adopting timely immunization practices. Administering immunization to a child within 28 or 30 days of the designated immunization date is referred to as timely immunization. Besides timely immunization, immunization non-compliance (invalid or delayed or missed immunization) increases the risk of various forms of VPDs and death in children, particularly living in urban slums. This study was designed to examine the immunization practices and to measure the determinants of immunization non-compliance in children living in urban slums of Karachi, Pakistan. A community-based retrospective cohort was carried out from October-2018- to August-2019 in six different urban slums of Karachi. Immunization status of children aged less than 2 years was assessed by reviewing their vaccination card. Children from each slum were approached via 30x7 multistage stratified cluster sampling technique. Data of each child was analyzed descriptively and inferentially using statistical software, i.e., Jamovi version 1.2.25. The practice of timely immunization was observed in approximately half of children, i.e., 49.8% (n=457). The immunization rate at birth (first-visit) was 100%, of which 95.7% were timely immunized. Following the second immunization visit, a sharp decline in the immunization rate, including timely immunization rate was observed. Lack of knowledge, childhood illnesses, lack of interest, and vaccines unavailability were the main reasons of immunization non-compliance. However, an increase in paternal education was significantly associated with decreasing the odds of immunization non-compliance. A decrease in the practice of timely immunization is replaced by either invalid and/or delayed and/or missed immunization practices. Thus, timely immunization is crucial for preventing infectious diseases and promoting the health of a child.

Social determinants of low uptake of childhood vaccination in high-risk squatter settlements in Karachi, Pakistan – A step towards addressing vaccine inequity in urban slums

BackgroundRoutine vaccination has remained historically low in major urban pockets of Pakistan, and now lags behind rural vaccination rates. Grossly insufficient publicly funded primary healthcare infrastructure, heterogeneous mix of providers and multi-ethnicity of populations pose challenges in the delivery of essential health services. This paper ascertains factors associated with uptake of routine childhood vaccination, using Pentavalent-3 vaccine, as a proxy indicator for completion of age-appropriate vaccines in urban slums of Karachi, at high risk of Polio and vaccine preventable disease outbreaks. MethodsData was drawn from baseline assessment of an urban immunization delivery pilot project in urban slums of Karachi, Pakistan. The study sample comprised of 2,097 households with children aged 4–12 months, sampled through a cross-sectional cluster survey, applying a structured questionnaire. Multivariable logistic regression was used to determine the association between Penta-3 vaccination, as the outcome variable, and predictor variables including socio-demographic characteristics and healthcare access factors. ResultsThe findings showed that the likelihood of being immunized with Penta-3 was higher for non-Pashtun ethnicity [adjusted odds ratio (aOR) 1.69; 95% CI 1.33–2.14], children of educated mothers, secondary or higher [aOR 2.95, 95% CI 2.34–3.71], and those whose fathers were formally employed (aOR 1.53; 95% CI 1.19–1.97). No association was seen by gender of child [aOR 0.89; 95% CI 0.73–1.08], and place of new born delivery [aOR 1.01; 95% CI 0.83–1.24]. ConclusionPockets of critically low under-vaccinations within the urban slums of Karachi are associated with Pashtun ethnicity, distance to the vaccination centre, lack of mothers’ education and lack of stable family income as in the case of unemployed and daily wage-earning fathers. Recognition of these factors is required in designing contextually appropriate strategies to address vaccine inequity in urban settings.

Feasibility of a peer-supported, WhatsApp-assisted, lifestyle modification intervention for weight reduction among adults in an urban slum of Karachi, Pakistan: a mixed-methods, single-group, pretest–post-test, quasi-experimental study

ObjectivesThis pilot study assessed whether a peer-supported, WhatsApp-assisted lifestyle modification intervention for weight reduction is feasible to execute a definitive trial.DesignA mixed-methods, single group, pretest and post-test, quasi-experimental study.SettingAzam Basti,...

Is a sedentary lifestyle a leading causal factor of obesity and distress in type 2 diabetes? A cross-sectional study in low-socioeconomic areas of Karachi, Pakistan

BackgroundWorldwide, the burden of diabetes with obesity as comorbidity has intensely increased. Even though sedentary behaviour is not favourable for a healthy lifestyle, some people still live a sedentary lifestyle....

Barriers to childhood vaccination in urban slums of Pakistan.

The urban slums of Pakistan continue to record low childhood vaccination coverage. It is therefore vital to understand the demand-side barriers to childhood vaccination in the slums to determine the required demand-generation interventions. To document the demand-side barriers related to childhood vaccination in urban slums of Pakistan and recommend appropriate demand-generation interventions. We investigated the demand-side barriers to childhood vaccination in 4 urban slums of Karachi, Pakistan, and disseminated the findings to the Expanded Program on Immunization and their partners. Using the findings, we made recommendations for collaborations with the various partners and for the design of demand-generation interventions to address the barriers. We then expanded the scope of the original research through a mapping exercise that gathered information on the vaccination-related research and interventions of the partners and used the information gathered to create a portfolio of activities. We present the demand-side barriers from the original research and the portfolio of demand-generation interventions. The original research showed that 412 (49.0%) children aged 12-23 months, from 840 households, were fully vaccinated. Reasons given for not receiving the recommended vaccinations were mainly related to the fear of side effects, social and religious influences, lack of awareness, and misconceptions about vaccine administration. The mapping of activities revealed 47 initiatives that aimed to generate demand for childhood vaccination in the urban slums of Pakistan. Several stakeholders involved in childhood vaccination in the urban slums of Pakistan act independently, operating programmes that are disconnected. There is a need for better coordination and integration of the childhood vaccination interventions by these partners to achieve the goal of universal vaccination coverage.

Self-esteem levels in school-going adolescents across the slums of Karachi, Pakistan: a cross-sectional analysis

IntroductionFor individuals to live their lives and integrate into society, self-esteem is an essential feeling. Self-esteem development depends on the environment in which children are nurtured. Assessment techniques using questionnaires include Rosenberg's self-esteem scale.ObjectiveThe study aimed to assess the self-esteem of school-going adolescents in slum areas.MethodologyThis school-based cross-sectional study was conducted in three understudied slum areas of Karachi, Pakistan. A standardized scale, the Rosenberg Self-esteem Scale (RSES), and a pre-tested demographic scale was used to assess the impact of gender, weight, academic performance, tuition, and parent's education level along with parent's strictness on the self-esteem of the understudied population of adolescents aged between 11 and 19 years included in the study. Parent consent was obtained before visiting the schools.FindingsAs per the collected data on self-esteem, among 539 school-going adolescents, 232 (43%) were male and 307 (57%) were female. Most students, 324 (60%), were in the 14–16 age range. Parents' education status and strictness towards their children, academic performance, and adolescent body mass index (BMI) influenced self-esteem levels.ConclusionThe study found that age, parent's education, parent's strictness, BMI, and academic performance were linked to the levels of self-esteem in the target population regardless of gender. Children's surroundings play an imperative role in developing lower or higher self-esteem in children. Assessing adolescent's self-esteem can be a useful way to build strong self-confident youngster and also beneficial to treatment for those with psychosomatic complaints in their growing age.

Depression and suicidal ideation among individuals with type-2 diabetes mellitus, a cross-sectional study from an urban slum area of Karachi, Pakistan.

Suicidal thoughts and depression are associated with patients with diabetes, especially patients with low socioeconomic backgrounds and prolonged illness. We aimed to estimate suicidal thoughts and depression among patients with type 2 diabetes (T2D) in the slums of Karachi. This cross-sectional study was conducted across 38 locations in the slums of Karachi to understand depression, suicidal thoughts, and other supporting factors of depression associated with T2D. The three-item Oslo Social Support Scale, the Patient Health Questionnaire-9 (PHQ-9) scale, and the Ask Suicide Screening Questions were used to screen the patients. A total of 504 study participants were interviewed, with a response rate of 98%. The prevalence of depression among patients with diabetes was 30.83%, and suicidal ideation was 20.39%. In the final multivariate analysis, being socioeconomically poor, physically disabled, and having poor social support were independent predictors of depression. Diabetes, low socioeconomic level, a lack of social support, and physical disability were all linked to depression. Therefore, trained health providers should conduct an early depression-focused routine screening for patients with diabetes.

Respiratory Diseases' Burden in children and adolescents of marginalized population: A retrospective study in slum area of Karachi, Pakistan.

Worldwide, the burden of respiratory disease has dramatically increased, endangering public health. To our knowledge, there have been no reported cases of respiratory illness among children and adolescents living in the slums of Karachi, Pakistan. This study aimed to assess the burden of respiratory disease in marginalized slum populations and the factors causing such an increase in disease burden. This study was conducted in 35 slums of Karachi, Pakistan, to determine the prevalence of respiratory disease in children and adolescents. Data on pneumonia, bronchitis, bronchiolitis, tuberculosis, and asthma from August 2019 to July 2022 were analyzed and inferences were drawn. Among the studied diseases, pneumonia was more prevalent among females (39,864, 44.9%), followed by males (19,006, 21.4%). Most of the children (59,988, 67.6%) were aged 1-5 years. In addition, of those diagnosed with pneumonia, 50,348 (56.8%) were from the same age group. Furthermore, bronchiolitis was found among 10,830 (12.2%) children aged 5-9 years. The majority (46,906, 52.9%) of the studied population belonged to the Pathan ethnicity, followed by Sindhi (21,522, 24.2%), and most of them (84,330, 95.1%) were of a lower socioeconomic status. This study found that pneumonia is the most common respiratory disease followed by bronchiolitis in children and adolescents in a marginalized slum population of Karachi, Pakistan. Both pneumonia and bronchiolitis have seasonal variations in their occurrence.

Gutka consumption and dietary partialities explaining anemia in women of a coastal slum of Karachi, Pakistan: A mixed-method study.

Limited literature is available on the dietary pattern and its consequences on health of women living in coastal slums of Karachi, Pakistan. The study employed a mixed-method approach where concurrent quantitative and qualitative assessments were carried out. An analytical cross-sectional survey was conducted to collect information on demographic, household, obstetrics characteristics, and dietary pattern of married women of reproductive age (MWRA). Blood samples were collected to identify the hemoglobin level to determine anemia. For the qualitative component, focus group discussions were carried out with women and in-depth interviews with shopkeepers to understand the availability of food items at household level and in local markets respectively. In addition, observational visits were carried out at different points in time to the local market to document the availability of iron-rich foods for the community. The overall prevalence of anemia in sample population was 68.0%. Women with no formal education (AOR: 2.93 95% CI: 1.90-4.52), who consumed gutka (AOR: 2.84 95% CI: 1.81-4.46), did not eat red meat (AOR: 1.68 95% CI: 1.06-2.65), and only had seafood (AOR: 4.56 95% CI: 1.38-15.02) were more likely to be anemic as compared to their counterparts. Qualitative data revealed that any kind of meat and fruits were beyond the reach of community people due to non-affordable cost. A high percentage of women used a locally produced recreational substance known as gutka which gives them a feeling of wellbeing and suppresses hunger. In our study population, lack of access to diversity of food items, illiteracy, and use of gutka are the statistically significant factors which are associated with anemia in married women of this coastal slum area. The lack of demand for diversity in food is related to poverty and preference of spending money on gutka.

Exploring the beliefs and experiences with regard to COVID-19 vaccine hesitancy and acceptance in a slum of Karachi, Pakistan.

The COVID-19-related misinformation and vaccine hesitancy is a widespread global concern and a recognized public health problem in Pakistan. The current research sought to explore the beliefs and experiences with regard to COVID-19, including vaccine hesitancy and acceptance, in a slum of Karachi, Pakistan. This study used an interpretivist epistemological approach for data collection and employed in-depth interviews (IDIs) and focus group discussions (FGDs) to explore the themes of interest. IDIs and FDGs were conducted in the local language (Pashtu) and Urdu, using semi-structured interview guides. A hybrid thematic analysis approach (use of both inductive and deductive coding) was used to analyze the data. We identified two key themes: the first related to vaccine hesitancy and refusal and included the role of personal belief systems, vaccine mistrust and public perceptions in hesitancy; the second related to vaccine acceptance and included knowledge and awareness about the vaccine and trusted sources of information. Religious beliefs and cultural norms influenced attitudes toward COVID-19 and vaccination. This study also found that awareness about the COVID-19 vaccine in this sample was influenced by sex, educational status and socioeconomic status. Participants with good health literacy and those from healthcare backgrounds were more likely to share views that indicated vaccine acceptance. The findings of this study are being used to co-design a comprehensive intervention to dispel COVID-19 misinformation and vaccine hesitancy across a range of stakeholders such as youths, community leaders, family members, faith leaders, schools and community-based local organizations in Pakistan.

A Survey Exploring Reasons behind Immunization Refusal among the Parents and Caregivers of Children under Two Years Living in Urban Slums of Karachi, Pakistan.

This study assesses the experiences of parents/caregivers regarding the refusal to childhood immunization. A cross-sectional study was conducted among the parents/caregivers of children under two years old from January 2019 to June 2019 who were residents of either Pathan Colony or Orangi Town, Karachi. In this study, the data collectors targeted parents/caregivers of 440 households who showed a refusal mark “R” in the Expanded Program of Immunization (EPI) H-chalking system. These households were approached using a 30 × 7 multistage-stratified-cluster random sampling technique and were interviewed using a structured questionnaire. The study sample produced two different types of refusals: true refusal (absence) and potential refusal (presence), based on the absence and presence of a vaccination card at the time of the survey. Multivariate logistic regression was used to analyze the data using Jamovi (V-1.6.13). A total of 230 households consented to participate in this study, of which 141 (61.3%) represented true refusals, while 89 (38.7%) represented potential refusals. More than half of the participants from both groups complained about fever and pain at the injection site following immunization. The use of alternative medicines and a history of adverse events following immunization (AEFI) were associated with increasing the odds of immunization refusals by four-to-five fold. However, advanced paternal age, a long distance to the clinic, a lack of trust in government, and the influence of community/religious leaders were associated with lower immunization refusal odds. Thus, an unawareness about self-limiting vaccine-related adverse events, the use of alternative medicines, and an increased concern about the safety and efficacy of vaccines were found to be barriers to immunization, which can be improved by increasing public awareness through media campaigns and policy reform.

Knowledge and Practices on the Prevention and Management of Diarrhea in Children Under-2 Years Among Women Dwelling in Urban Slums of Karachi, Pakistan

BackgroundDiarrhea is the second leading cause of death especially among children. The age-proportionate mortality of diarrheal disease in infants under 2 years is 72%, among children under 5 years of age. Children living in urban slums are more prone to develop diarrhea. Although the disease can be prevented by many simple cost-effective interventions, i.e. proper sanitation and hygiene, appropriate feeding, and timely vaccination, poverty and lack of basic life amenities often potentiate diarrhea mortality. Gadap town is the largest town of Karachi with a deprived health system. This study aims to assess pediatric diarrhea prevalence and related knowledge-practice gaps in the slums of Gadap Town, Karachi, Pakistan.MethodA community-based cross-sectional study was conducted from November 2016 to May 2017 among mothers of children under 2 years, who were residents of Gadap Town, Karachi, Pakistan. The participants were approached by a multistage sampling method. A validated dichotomous questionnaire, piloted on 40 participants, translated into local language Urdu was used for data collection and the data was analyzed by SPSS® version 20.0.Results51.8% (n = 199) of participants were aged between 25 and 34 years. Among all participants, 68% (n = 261) had primary level education or less, compared to 4.7% (n = 18) of women who had graduate-level education. The mean number of children per woman was 2.52 ± 1.62. Self-reported pediatric diarrhea incidence was 72.1% (n = 277). More than half (55.2% n = 149) of participants reported frequent diarrhea episodes during the 2nd year of their child’s life. In this survey, we found the knowledge of women regarding diarrhea management and how to reduce diarrhea morbidity to be inadequate (p > 0.05). However, many women reported appropriate practices which can significantly reduce diarrhea morbidity (p < 0.05).ConclusionWhile the knowledge among women on preventive measures for pediatric diarrhea was insufficient, the translation of the right knowledge into appropriate practices showed promising outcomes for reducing diarrhea morbidity. An integrated approach for improving feeding, sanitation, and hygiene practices along with continuous health education could curtail the burden of diarrhea among infants living in urban slums.

Nutritional support and prophylaxis of azithromycin for pregnant women to improve birth outcomes in peri-urban slums of Karachi, Pakistan\u2014a protocol of multi-arm assessor-blinded randomized controlled trial (Mumta PW trial)

BackgroundMaternal undernutrition is critical in the etiology of poor perinatal outcomes and accounts for 20% of small-for-gestational-age (SGA) births. High levels of food insecurity, antenatal undernourishment, and childhood undernutrition necessitate the supplementation of fortified balanced energy protein (BEP) during pregnancy in low-income settings especially with scarce literature available in this subject. Hence, this paper extensively covers the protocol of such a trial conducted in an urban slum of Karachi, Pakistan.MethodsThe trial is community-based, open-labelled, four-arm, and randomized controlled that will include parallel group assignments with a 1:1:1:1 allocation ratio in low-income squatter settlements in urban Karachi, Pakistan. All pregnant women (PW), if identified between > 8 and < 19 weeks of gestation based on ultrasound, will be offered routine antenatal care (ANC) counseling and voluntary participation in the trial after written informed consent. A total number of 1836 PW will be enrolled with informed consent and randomly allocated to one of the four arms receiving: (1) ANC counseling only (control group), (2) ANC counseling plus BEP supplement (intervention arm 1), (3) ANC counseling plus BEP supplement plus 2 doses azithromycin (intervention arm 2), or (4) ANC counseling plus BEP supplement plus daily single dose of nicotinamide and choline (intervention arm 3).Trial registrationClinicalTrials.govNCT04012177. Registered on July 9, 2019.

Unveiling and addressing implementation barriers to routine immunization in the peri-urban slums of Karachi, Pakistan: a mixed-methods study

BackgroundGreat disparities in immunization coverage exist in Pakistan between urban and rural areas. However, coverage estimates for large peri-urban slums in Sindh are largely unknown and implementation challenges remain unexplored. This study explores key supply- and demand-side immunization barriers in peri-urban slums, as well as strategies to address them. It also assesses immunization coverage in the target slums.MethodsConducted in four peri-urban slums in Karachi, this mixed-methods study consists of a baseline cross-sectional coverage survey of a representative sample of 840 caregivers of children aged 12–23 months, and 155 in-depth interviews (IDIs) through purposive sampling of respondents (caregivers, community influencers and immunization staff). After identifying the barriers, a further six IDIs were then conducted with immunization policy-makers and policy influencers to determine strategies to address these barriers, resulting in the development of an original validated implementation framework for immunization in peri-urban slums. A thematic analysis approach was applied to qualitative data.ResultsThe survey revealed 49% of children were fully vaccinated, 43% were partially vaccinated and 8% were unvaccinated. Demand-side immunization barriers included household barriers, lack of knowledge and awareness, misconceptions and fears regarding vaccines and social and religious barriers. Supply-side barriers included underperformance of staff, inefficient utilization of funds, unreliable immunization and household data and interference of polio campaigns with immunization. The implementation framework’s policy recommendations to address these barriers include: (1) improved human resource management; (2) staff training on counselling; (3) re-allocation of funds towards incentives, outreach, salaries and infrastructure; (4) a digital platform integrating birth registry and vaccination tracking systems for monitoring and reporting by frontline staff; (5) use of digital platform for immunization targets and generating dose reminders; and (6) mutual sharing of resources and data between the immunization, Lady Health Worker and polio programmes for improved coverage.ConclusionsThe implementation framework is underpinned by the study of uncharted immunization barriers in complex peri-urban slums, and can be used by implementers in Pakistan and other developing countries to improve immunization programmes in limited-resource settings, with possible application at a larger scale. In particular, a digital platform integrating vaccination tracking and birth registry data can be expanded for nationwide use.

Does watching violent electronic and social media content lead to increased levels of aggression? A survey among adolescents in an urban slum of metropolitan Karachi

Increased levels of aggression and desensitization of adolescents has been witnessed as a result of exposure to violent social/electronic media content. It is imperative for policymakers to study such behavioral outcomes in order to make sound policies regarding media literacy. The objective of the study therefore was to assess relationship between violent electronic/social media exposure and level of aggression. A cross sectional study was conducted among adolescents aged 9-19 years in peri-urban slum of Karachi. Content-based Media Exposure scale and Buss and Perry questionnaire, internationally validated tools were used to collect data. Level of aggression was the main outcome variable which was analyzed. Four hundred and twenty-two adolescents participated in the survey. Usage of television was significantly higher in the younger age group whereas the effect of watching violent content among the adolescents varied. It was observed that 153 (36.3%) respondents felt stressed and 24 (5.7%) felt aggressive after watching violent content on electronic and social media. The contents showing people who fight (39.6±5.6, p-value<0.05), who steal (39.5±7.5, p-value=<0.05) and destroyed someone else's belongings (40.6±7.6, p-value=<0.05) had a significant effect on the level of aggression. Regression analysis predicted a strong positive association of exposure of violent content with level of aggression (β=0.43). The usage of violent content on social and electronic media was popular among adolescents, and produced negative effects on the behavior of adolescents. Measures should be taken to introduce media literacy of the children in Pakistan, especially in the peri-urban slums.