Vol. 5, No. 2 June 2015 - Health Services Academy

Vol. 5, No. 2 June 2015

2015

Pakistan Journal of Public Health, 2015 ( June )

Vol 5, No.2 (June) 2015

Original Articles JOB SATISFACTION AND MOTIVATION AMONG CLINICIANS AND HEALTH MANAGERS WORKING IN PUBLIC SECTOR OF FEDERALLY ADMINISTERED TRIBAL AREAS OF PAKISTAN Qayum M, Qamar W, Khan HM, Sawal SH, Basharat S, Ali A, Shaq N, Ali I, Pervaiz N, Afridi A, Ahmad F, Qayum F......................................................................................................................................................... 01

CASE STUDY; LOW HIV TRANSMISSION OF HIV INFECTED MEN TO THEIR SPOUSES IN MALE DOMINATING SOCIETY Ahmed M, Gul T, Shah SA............................................................................................................................... 07

KNOWLEDGE, ATTITUDE AND PRACTICE OF PESTICIDES HANDLERS IN PAKISTAN Ahmad A, Chattha IA, Raheem A, Yasmeen A................................................................................................ 09

FACTORS RESPONSIBLE FOR NON-COMPLIANCE OF TIMELY ADMINISTRATION OF BCG VACCINE IN DISTRICT JHELUM PAKISTAN Iqbal W, Danish SH, Ahmad F.......................................................................................................................... 13

PREVALENCE OF MYTHS RELATED TO HEALTH AMONG ARMED FORCES OFFICERS AND THEIR FAMILIES IN PESHAWAR GARRISON Iqbal S, Mughal NI, Ejaz H, Khan IA............................................................................................................... 19

Review Article TITLE: NUTRITIONAL STATUS OF PAKISTAN'S ELDERLY POPULATION: A COMPARATIVE REVIEW WITH LOW TO MIDDLE INCOME COUNTRIES Ahmad AMR, Ronis KA.................................................................................................................................. 22

Dr. Saima Hamid,

Managing Editors

Dr. Mariyam Sarfraz





Dr. Saima Hamid


Pak J Public Health Vol. 5, No. 2, 2015

JOB SATISFACTION AND MOTIVATION AMONG CLINICIANS AND HEALTH MANAGERS WORKING IN PUBLIC SECTOR OF FEDERALLY ADMINISTERED TRIBAL AREAS OF PAKISTAN Mehran Qayum1, Wajiha Qamar2, Hassan Mehmood Khan3, Shafa Haider Sawal4, Sarah Basharat5, Anwar Ali6, Nighat Shaq7, Ibrar Ali8, Nadia Pervaiz9, Anisa Afridi10, Fayaz Ahmad11, Fatima Qayum12 1,3,4

Deutsche Gesellschaft fuer Internationale Zusammenarbeit (GIZ) GmbH Peshawar Pakistan, 2,7Sardar Begum Dental College, Gandhara University Peshawar Pakistan, 5Health Service Academy Islamabad Pakistan, 6,11Health Sector Reforms Unit (HSRU) Federally Administered Tribal Areas (FATA) Secretariat, 8Mardan Medical Complex Pakistan, 9Merlin International, Pakistan. 10Directorate of Health Services Federally Administered Tribal Areas (FATA) Secretariat, 12Rural Health Center (RHC), Dewana Baba - Buner Khyber Pakhtunkhwa - Pakistan, (Correspondence to Qayum M: [email protected].) Abstract Objective: Federally Administered Tribal Areas of Pakistan remains an unsafe place to live with failure of governance and rise of war on terror affecting Afghanistan and Pakistan jointly therefore despite of attractive salaries to health staff, they are reluctant to work. The region has the lowest economic and health indicators not just in the country but in the entire continent. The study was conducted with an objective to determine the motivation and job satisfaction among clinician and management staff of health workforce working in Federally Administered Tribal Areas of Pakistan using Minnesota Satisfaction Questionnaire (MSQ). The study also present which cadre of health workforce was motivated in terms of intrinsic and extrinsic satisfaction. Design & Duration of Study: The convenient sampling method was used and the participants were interviewed by trained enumerators in privacy. The study was conducted from March to December 2014. Methods: Fifty two participants from clinical and management health staff of FATA Secretariat were interviewed using the Minnesota Satisfaction Questionnaire (MSQ). Ethical considerations were followed and the objectives of the study were explained to interviewees. Results: More than one third of our study participants were dissatised/ very dissatised with the way the health department policies are put into practice. Almost half of the survey respondents showed their dissatisfaction when asked about salary and amount of work they perform. T test was done to nd difference in satisfaction level of managers and clinicians and results were insignicant. Conclusion: It was found that participants were satised by their supervisor and his competencies but showed dissatisfaction with salary they receive the way health policies are in practice and career advancement strategy. No statistical difference was found between managers and clinicians. Keywords: Satisfaction, motivation, FATA, health work force, clinicians, managers (Pak J Public Health 2015;5(2):1-6 ) Introduction An overview of FATA The Federally Administered Tribal Areas (FATA); a tousled area of 27,224 sq kilometers and home of population around 3.1 million people(1, 2). The territory comprises of six frontier regions and seven tribal agencies which is administratively controlled by Federal Government of Pakistan through political agents and traditionally through tribal elders (1-3). This remains an unsafe place to live with failure of governance and rise of war on terror affecting Afghanistan and Pakistan jointly(4, 5). The region has the lowest economic and health indicators not just in the country but in the entire continent. There overall literacy rate is 17 percent (compared to 43 percent nationally), dipping down to seven percent for women and girls in FATA older than 10 years old (2, 5-8). Beside the literacy rate, other indicator such as infant mortality ( estimated to be as

high as 87 deaths per 1,000 live births) and maternal mortality (over 600 deaths per 100,000 live births) are alarming high(6-8). The region of FATA lags behind in nearly all the socioeconomic indicators when compared with those at national level(5, 7). Furthermore nearly two-thirds of the population lives below the national poverty level; the health system operates 33 hospitals to cover 3 million people and there is one bed in hospitals for every 2,179 people as compared to 1,341 in the rest of Pakistan (6, 8). The doctor to population ratio is 1 to 7,670 and a mere 43% people have access to safe drinking water (2, 5, 7). Access to health services is severely limited although services are offered by private medical practitioner(7, 8). These medical practitioner is usually qualied from Afghanistan and other former Soviet republics who are not recognized by Pakistan(7). Health planning is focused on infrastructure, whereas an equally serious problem exists with respect to the 1


availability of human resources(8). Security is also a concern for those considering taking up employment opportunities in the tribal areas therefore a serious problem exist with the availability of human resources(8). "FATA does not have its own health workforce and all public employees are part of the health cadres of the Khyber Pakhtunkhwa province of Pakistan"(8). FATA Sustainable Development Plan 2007-2015 shows that majority of health facilities are not occupied by medical practitioners(8). A report shows that on paper 72 specialists, 495 medical ofcers, 62 female doctors and 209 nurses are available to serve the ve million people of FATA, but in reality it's hard to nd a single one(9). The situation is further compounded by out migration of people who have moved to settled areas. Health professionals are not safe in providing healthcare services in FATA which led to unwillingness of women healthcare professionals to work in militancy hit areas (9). Despite of attractive salaries to female health services, they are reluctant to work because of security concerns(9). Retention of human resource for health in fragile state is a concern across the globe especially when health staff is the target of violence, abduction, disconnected from social and professional support system, faced with scarce resources(10, 11). Therefore understanding what motivates them provides an insight how to maintain retain staff and offer essential health care during difcult times and in unsettled areas(10). Such a working environment can weigh heavily on a person, impacting their ability to perform with devotion and to be motivated to give their best to their work. The Impact WHO dened health worker as all people engaged in actions with the primary intent of enhancing health(12, 13). A health worker plays a vital role in determining the quality of care and increases the morale of its staff vice versa. S/he is assumingly having both managerial and leadership responsibilities. The satisfaction of health workers and their motivation in work is vital for organization to achieve its objectives. Studies show that job satisfaction is associated with reduced absenteeism and turnover rates; with increasing job satisfaction workers show commitment(14). Similarly the commitment of worker is enhanced when he feels motivated and is satised with his job. The link between job satisfaction and job motivation is illustrated by commitment of the worker to his job. Motivation is nonetheless not measurable but can be inferred from a person's behavior. It begins with an intrinsic need leading to a contemplation process that guides a person decision to satisfy them by appropriate behavior and follow a course of action, this appropriate behavior may result an incentive or reward which strengthens the behavior further(14). Motivation could be intrinsic; internal desire of an employee to achieve something

e.g. respect, loyalty or extrinsic which depends on environmental factors such as any tangible incentives, bonus etc. The Theories of Motivation There are several theories of motivation that inuences human resource and management of an organization. They attempt to explain why people behave in a certain way and how to get best from them. Frederick Herzberg in 1959 carried out a survey on motivation in American industry which led to development of "MotivationHygiene" or "Two-factor" theory(6). He theorized that intrinsic factors in job contribute to job satisfaction and motivation and the extrinsic factors are associated with job dissatisfaction(15). He called the intrinsic factors as "Motivational factors" while the extrinsic factors in job as "Hygiene factors", both of them are totally different from one another(15). He was of the opinion that removing the dissatisers doesn't always lead to satisfaction. Hygiene factors if adequate will help in preventing dissatisfaction while motivational factors increases job satisfaction and leads to motivation. The hygiene and motivational factors both contribute to motivation but in different ways. Hygiene factors has a denite end and once they are fullled they cease to be motivating, however the motivators do not have no end point and continue to generate a source of long lasting energy and drive(16, 17). An increase in salary (hygiene factor) will temporarily "tick off" the worker but after some time when the positive feeling has been dissolved and is not sufcient enough to bring the desired motivation sought by the employers. Hertzberg made an important contribution in changing the employer's attitude and making them believe that the two factors are notmutually-exclusive and both the needs has to be fullled in order to increase the satisfaction and engagement of their employees(16). Rationale & Objective The level of job satisfaction among healthcare managers working in FATA in Pakistan using a robust instrument as not been assessed prior to this. This study presents the motivation and job satisfaction of clinical and management staff of health working in Federally Administered Tribal Areas of Pakistan using the Minnesota Satisfaction Questionnaire (MSQ). This study also presents which cadre of health personnel is more motivated in terms of extrinsic and intrinsic motivation in tribal areas of. Methods Since the development of Job Diagnostic Inventory (JDI) signicant attention has been given to job satisfaction(18). The instrument focused on ve variables of jobs satisfaction which includes supervision, promotion, pay, coworkers and promotion

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opportunities(18). Based on Hertzberg theory of motivation (MSQ) was developed which unlike JDI was divided has intrinsic and extrinsic satisfaction factors(18). The MSQ provides more specic information on the aspects of a job that an individual nds rewarding than do more general measures of job satisfaction. It is useful in exploring client vocational needs, in counseling follow-up studies, and in generating information about the enforcers in jobs. According to manual of MSQ "the MSQ is an instrument that measures job satisfaction with several different aspects of the work environment"(19). The different aspects of work environment refers to intrinsic and extrinsic factor which can be assumed as motivator and hygiene factor in Herzberg's theory of motivation(19). The MSQ has a longer and shorter version which is used to measure the job satisfaction based on Hertzberg's Two Theory of Motivation(18). A descriptive cross sectional study was conducted on clinical and management staff of FATA health Secretariat. The short version of MSQ was used because it is used previously in similar settings and is easy to use and understand. A demographic sheet was included which was focusing on the place of residence, years of schooling complete, designation, trainings, marital status and number of years in the related eld. Fifty two participants from clinical and management staff working under FATA Health Secretariat were selected in the study. The convenient sampling method was used and the participants were interviewed by trained enumerators in privacy. The study was conducted from March December 2014. Ethical considerations were followed. Informed consent was taken verbally and in writing from the participants. The objectives of the study were explained and they were informed that they had the right to call off the interview at any point of time without any reason. The MSQ short form has a high reliability coefcient ranging from 0.87 to 0.92. The extrinsic median reliability is 0.8 (20). Data was entered in SPSS version 17 and was cross checked again for errors. Descriptive and Analytical S were performed to nd difference in satisfaction level of managers and clinicians.

majority of the participants working in tribal areas of Pakistan were legal residents (domicile) of FATA (n=40). Male to female ratio of our study was (45:7). Only 9.6 percent (n=5) of the survey participants were single. Different domains of health cadres were interviewed. Table 1: Items and their level of satisfaction based on MSQ

As evident in Table 1, more than eighty percent of our survey respondents agreed (satised / very satised) that they are busy all the time, 67.3 % (n=35) were satised with the way their boss handles employees while 78.8% (n=41) were either satised or very satised with competencies of supervisor in decision making. On the other hand the survey highlighted some negative ndings as well, more than one third of our study population was dissatised/ very dissatised with the way the health department policies are put into practice. Almost half of the survey respondents showed their dissatisfaction when asked about salary and amount of work they perform. Similarly 30.7% (n=16) were not happy with working condition while 34.7% (n=18) showed their dissatisfaction/ strong dissatisfaction when questioned about advancement in job. Figure 1: Satisfaction level of managers and clinicians working in FATA

Results The rst part of questionnaire was seeking information about demographic information while the second part refers to intrinsic and extrinsic factors (MSQ) that can lead to job satisfaction. The intrinsic factors can also be considered as motivators while extrinsic factors can be assumed as hygiene factors of Hertzberg's theory of motivation. Each question was assessed on Likert scales of ve (1= Very Dissatised to 5=Very Satised). A total of 65 questionnaires were administered but only 52 returned back (Response Rate= 80 %). A demographic sheet was attached and it was found that

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For the purpose of analysis the participants (Figure 1) of the study were grouped into management and clinicians. We found based on our survey that clinicians were more motivated in terms of intrinsic satisfaction (motivating factors) and extrinsic satisfaction (satisfying factors) than managers. T test was carried out between them. The critical t value 2.00 is greater than t-value -0.922 therefore the difference of jobs satisfaction between the managers and clinicians is not signicant (P-value=0.36). (Table 2) Table 2: Comparison of job satisfaction between two sample groups

Discussion Our ndings suggested that with regards to job satisfaction the health workers and managers were least satised with the way health department policies are put into practice, salary and working hours were alarming. Similar study was done in 2011 in health centers of Vientiane capital and Bolikhamsai province where the health workers were generally satised with their jobs except salary and the main factors that correlate with their overall job satisfaction were conict resolution at work, organizational structure and relationship with other employees(21). FATA is a conict zone so the impoverishing medical expenditures are more as compared to settled area of Pakistan. Low remuneration have adverse effects on the delivery of health services which could be one of the reason Pakistan is lagging on its progress to achieve Millennium Development Goals. Studies shows that erosion of pay is one of the factor associated with absenteeism, informal fee and brain drain(22). The health workers and teachers which are poorly paid often look for other means of income as a coping strategy e.g. private practice, informal payments and in countries like DRC and Yemen in rural areas lack of nancial incentives leads to unlled positions(22). Similarly career and job advancement is considered one of the important elements of job satisfaction but our ndings show that 34.7% (n=18) were not satised with the current status of job advancement. Literature review shows that people working in health sector should be frequently refreshed and trained on health capacity building as it increases

the self-esteem, builds condence and improves the quality of care(23). The health service providers are commonly described as being intrinsically motivated and are quoted as professionalism, esteem and caring(24). The motivation differs from person to person e.g. a physician may be motivated by holding responsibilities while another factor could be a motivating factor for an auxiliary staff(14). Monetary incentives such as bonuses been considered important in the motivation of employees but according to growing number of studies conducted on motivation and satisfaction intrinsic motivation is a stronger success factor (25). Professor Bard Kuvaas and Anders Dysvik conducted a study on more than eleven thousand respondents from hundred organization found that loyalty and accomplishment are associated with intrinsic motivation of an employee(25). Dr. Mark Friedberg, the study's lead author and a natural scientist at RAND in a press release in 2013 said "Many things affect physician professional satisfaction, but a common theme is that physicians describe feeling stressed and unhappy when they see barriers preventing them from providing quality care"(26). Surprisingly we found that despite of working in a conict region the clinicians were more intrinsically and extrinsically satised than managers. The difference in satisfaction could be attributed to the fact that clinicians are working in tribal areas of Pakistan having an extra source of income through private practice in the evening. Conclusion Participants acknowledged that their activities keep them busy all day, were satised with the competencies and the way their supervisor handles them. It was found that participants were not happy with the way health policies are put into practice, salary was a dissatisfying factor identied by most followed by no structure for career advancement. There was no difference in job satisfaction among managers and clinicians, however difference in male and female health managers and clinicians was found in terms of satisfaction and motivation. Further research in the area is needed. Suggestions/ Recommendations Pakistan is spending 3.2% total expenditure as percentage of GDP on health which is not enough to keep the health workers morale elevated despite of the fact that household spending in Pakistan is 4.95% of their expenditure on health, more than other Asian countries (22, 26). Based on our study we conclude: 1.

2.

FATA Secretariat needs to have its own health work force. Strategies for retaining skilled personnel thereby reducing the push factors needs to be developed. An employee recognition programme is a good

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5.

example of motivating employees. Similarly nancial compensation in exchange for work performed in the form of bonus, vacations, pay and other benets like insurance are good examples of extrinsic rewards. Policy formulation necessitates inclusion of suggestions from all levels of FATA Secretariat. Once policies have been formulated continuous monitoring should be done during implementation. People of all cadres ought to have access to such information and know what is expected of them. Perk and privileges for people working in FATA, not only be limited to monetary terms but may also include good living condition, career development, security and providing free education to employee's children. Fostering career satisfaction through career advancement programme could be ensured by developing an organizational framework where health managers have clear understanding regarding their advancement. Similarly a continuous education programme should exist where employees are trained on regular basis.

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13. 14.

Disclaimer: The views expressed in the article reect the personal opinion of the authors, not of their organizations. References 1. CAMP. Understanding FATA: Attitudes Towards Governance, Religion & Society in Pakistan's Federally Administered Tribal Areas. 2010 16th April, 2014]; Available from: http://www.understandingfata.org/about-u -fata.php. 2. Orakzai AMJ. Situation in FATA: Causes, consequences and the way forward. Policy Perspectives 2009; 6(1). 3. Mohsin ZR. The Crisis of Internally Displaced Persons (IDPs) in the Federally Administered Tribal Areas of Pakistan and their Impact on Pashtun Women. 4. Shinwari NA. Understanding FATA" Attitudes Towards Governance, Religion & Society in Pakistan's Federally Administered Tribal Areas 2010. 5. Nawaz S. FATA - A most dangerous place. Meeting the challenge of militancy and terror in the Federally Administered Tribal Areas of Pakistan, in Why FATA is the way it is 2009. 6. International A. As if Hell fell on me, 2010. 7. P r o g r a m m e F B H . H e a l t h i n FATA . 0 9 September 2014]; Available from: http://www.fatabhp.com/fata-Insight/health-in -fata.asp.

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FATA CS. FATA Sustainable Development Plan 2007-2015. Yusufzai A. FATA, KP women's health care suffers from militancy. Female healthcare workers stop working in militancy-hit areas. 2010 09 September, 2014]; Available from: http://centralasiaonline.com/en_GB /articles/caii/features/pakistan/2010/11/06/feat ure-01. Namakula J and Witter S. Living through conict and post conict: experiences of health workers in northern Uganda and lessons for people-centered health system. Health Policy and Planning, 2014; 29. Bonenberger M, et al. The effects of health worker motivation and job satisfaction on turnover intention in Ghana: a cross-sectional study. Human Resources For Health, 2014; 12(43). Jensen N. The Health Worker Crisis: an analysis of the issues and main international responses. Health Poverty Action 2013. World Health Organization. Working together for health, 2006. Qayum M,Sawal SH, Khan HM. Motivating employees through incentives: productive or a counterproductive strategy. Journal of Pakistan Medical Association 2014; 64(5): 567-70. Net MBA. Herzberg's Motivation-Hygiene Theory (Two Factor Theory). 28 April, 2014]; Available from: http://www.netmba.com/mgmt /ob/motivation/herzberg/. Linder JR. Understanding employee motivation. Journal of Extension 1998; 36(3). Herzberg F. One More Time: How Do You Motivate Employees? Harvard Business Review, 1987. Hyun S. Re-examination of Herzberg's Two -Factor Theory of Motivation in the Korean Army Food service Operation, Iowa State University, Ames Iowa 2009. Weiss DJ. Manual of the Minnesota satisfaction questionnaire1967: [Minneapolis (Minn.)] : University of Minnesota, Industrial Relations Center, 1967. Nerison HA. A descriptive study of job satisfaction among Vocational Rehabilitation counselors in a Midwestern state, in Vocational Rehabilitation1999, The Graduate College, University of Wisconsin-Stout. Khamlub S, et al. Job satisfaction of health -care workers at health centers in Vientiane capital and Bolikhamsai province, LAO PDR. Nagoya Journal of Medical Sciences 2013; 75: 233-241.

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UNICEF, Social and economic policy working briefs, in Protecting salaries of frontline teachers and health workers.2010. Kumar R, et al. Job satisfaction among public health professionals working in public sector: a cross sectional study from Pakistan. Human Resource for Health 2013; 11(2). Brock JM, Lange A, Leonard KL. Generosity norms and intrinsic motivation in health care provision: Evidence from the laboratory and the eld, 2012. Stranden AL. Motivated employees equal satised customers. 2014. Mills RJ. Quality of Patient Care Drives Physician Satisfaction; Doctors Have Concerns About Electronic Health Records, Study Finds, American Medical Association 2013.

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CASE STUDY; LOW HIV TRANSMISSION OF HIV INFECTED MEN TO THEIR SPOUSES IN MALE DOMINATING SOCIETY Manzoor Ahmed1, Tahira Gul2, Sharaf Ali Shah3 1,2,3

Bridge Consultation Foundation, Karachi (Correspondence to Ahmed M: [email protected])

Abstract Background: A substantial number HIV infection occur in the stable discordant relationship. Men invariably remain index cases. One of the objectives of the community home-based care (CHBC) program at Karachi Pakistan is to prevent HIV transmission from HIV infected men to uninfected wives. Methods: This project is implemented by the Bridge Consultants Foundation under the grant of Global Fund to ght AIDS, Tuberculosis, and Malaria (GFATM) since May 2012. Under this project, 339 HIV infected individuals (men and women) were registered from 22nd May 2012 to 30th June 2014. Results: 110 discordant couples were identied wherein men were the index cases. The wives of index cases underwent periodic voluntary counseling and testing (VCT) every three months, condom distribution, risk reduction counseling, and ART treatment to index cases. After follow up of two years, only two wives were found HIV seropositive and the remaining (108) remained seronegative. As a result of VCT, around 98% of the wives of index men were prevented from acquiring HIV infection. Keywords: HIV, male, case study, transmission. (Pak J Public Health 2015;5(2): 7-8)

Background Tremendous progress has been made in prevention and control of HIV infection globally. Yet, new HIV infections continue to occur. There are 2.1 million people newly infected globally (1). Most of the new infections however occurred within the context of discordant relationships (2). The annual risk of infection for a partner of a HIV infected person is about 10% (3). Heterosexual transmission remains the leading cause of HIV infection in adult men and women (4). A man is thought to be a case in most relationship (5). HIV serodiscordant couples are at risk of sexual transmission of HIV between infected and uninfected partner. The rate of serodiscordancy in couples underscores the fact the risk behaviors of men put their spouses (wives) at risk of infection. They are an important source of new HIV infection (6). Patel SN & Hennink M et al described in their study in Gujrat India that approximately 40% of new HIV infection occur among married women (7). Women are biologically and socially more vulnerable to HIV infection as compared to men. In Pakistan's patriarchal society, men dominate the sexual decisions. The strong patriarchal culture greatly limits the ability of women to negotiate sexual behavior with husbands. This makes them more vulnerable to acquire

HIV infection. Most of women reported with HIV infection in Pakistan are married and have probably acquired HIV infection from their husbands. Bridge Consultants Foundation (BCF) has been implementing the community home-based care (CHBC) program for HIV infected and affected people under the round 9 grant of Global Fund to ght against AIDS, Tuberculosis and Malaria (GFATM) since May 2012 in Karachi, Pakistan. One of the objectives of the program is prevention of HIV transmission from an infected partner to their uninfected spouses (wives). The services provided in the program include regular voluntary counseling and testing (VCT), condom distribution, risk reduction counseling to couples, ARV treatment for PLHIV, adherence counseling to therapy, and social services. We describe our experience on prevention of HIV transmission from HIV infected partner to their spouses. Methods A retrospective analysis of the records of HIV infected men and women registered with community homebased care (CHBC) program from 22nd May 2012 to 30th June 2014.The medical history of the clients was documented. From all men and women registered 7


clients, married couples living with their spouses (wives) were identied. Their spouses were aware of their husband's HIV status. Then spouses were offered voluntary counseling and testing (VCT) periodically. The HIV positive clients were referred to ARV treatment center. The HIV negative spouses underwent regular VCT every three months for about 2 years to identify HIV seroconversion. Besides VCT to seronegative spouses, counseling for the consistent and correct use of condoms were performed, condoms were distributed to them, and other social services. Results There were 339 men and women registered with CHBC program in Karachi Pakistan from 22nd May 2012 to 30th June 2014. Among them, 129 married and ten ever married HIV positive men; nineteen married and twelve ever married females. One hundred and ten couples were found serodiscordant (husband HIV positive while wife HIV negative) and 19 couples were seroconcordant (both husband and wife HIV positive). From serodiscordant couples, two wives become HIV positive after follow-up of two years while 108 wives remained HIV negative at the end of two years of the program. Discussion Main ndings of present study in which we found two wives became HIV seropositive and 108 wives were HIV seronegative, and index cases were all men. Reviewing the two Chinese studies that had showed the comparable results. Of which, one study showed HIV incidence of 2.5 per 100 person-years was found, while another was over three years revealed 2.14, 1.5, and 0.90 per 100 person-years in 2008, 2009, and 2010 respectively. Kumarasamay N et al (2010) documented the incidence of HIV infection among initially seronegative partner was 6.52 per 100 personyears. It is suggested that couple based interventions are crucial in preventing HIV transmission to seronegative spouse (wives). Therefore, these patients may be motivated for consistent and correct use of condoms, encourage spouses (wives) undergo regular voluntary counseling and testing (VCT), and those married index cases must be placed on HAART at the very earliest in order to arrive at undetectable HIV viral titer.

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sub-Saharan Africa: a systematic review and meta-analysis; Lancet Infect Dis 2010; 10: 770 77. Hugonnet S, Mosha F, Todd J, et al. Incidence of HIV infection in stable relationship: a retrospective study of 1802 couples in Mwanza region, Tanzania; J Acquir Immune Dec Syndr 2002; 30: 73 - 80. Jones D, Kashy D, Chitalu N, Kankasa C, Mumbi M, Cook R, Weiss S. Risk reduction among HIV-seroconcordant and discordant couples: the Zambia NOW2 Intervention; AIDS Patient Care STDS 2014; 28 (8): 433 - 41. IBID report. Wang L, Wang L, Smith MK, Li MM, Ming S, Lu J, C a o W H , H e W S , Z h o u J P, Wa n g N . Heterosexual transmission of HIV and related risk factors among discordant couples in Henan Province China; Chin Med J (Engl) 2013; 126 (19); 3694 - 700. Patel SN, Wingood GM, Kosambiya JK, McCarty F, Windle M, Yount K, Hennink M. Individual and interpersonal characteristics that inuence male-dominated sexual decision -making and inconsistent condom use among married HIV serodiscordant couples in Gujarat, India: results from the positive Jeevan Saathi study; AIDS Behav 2014; 18(10):1970-80.

References 1. UNAIDS, Global Report: UNAIDS Report on the Global AIDS Epidemic 2013, Joint United Nations Programme on HIV/AIDS (UNAIDS), Geneva, Switzerland 2013. 2. Eyawo O, Walque D, Ford N, Gakii G, Lester RT, and Mill EJ. HIV status in discordant couples in

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KNOWLEDGE, ATTITUDE AND PRACTICE OF PESTICIDES HANDLERS IN PAKISTAN Aftab Ahmad1, Intsar Ahmad Chattha2, Asif Raheem3, Aneela Yasmeen4 1,2,3,4

National Academy of Young Scientists (NAYS), University of the Punjab, Quaid- i- Azam Campus, Lahore, Pakistan, (Correspondence to: Ahmad A [email protected])

Abstract Background: Pesticides and insecticides are very toxic by design and they are used world over to protect the crops from insects. Although, they are good for better crops production but they have serious effects on environment and human health. Exposure to pesticides and insecticides is one of the most important occupational health risks in developing countries, like Pakistan. Methods: A survey was designed to know the awareness level about insecticides and pesticides toxicity and spray procedure in Punjab, Pakistan. Results: Majority of respondents was from village, in the age group of 25-34, with spray experience of 0-5 years and did not have any formal education. Mostly learned about spray procedure themselves or from family and friends and none of them had training from government institutes. Most of the respondents did not use any protection equipment's and also had different health problems during spray process. They also reported deaths due to acute poisoning of spray personals. Conclusion: The results clearly indicate that there is great need to aware people about toxicity of pesticides and insecticides as well as educate them about personal, family and environmental protection. Government and nongovernment organizations as well as print and electronic media can play an important role in this regards. There is need of urgent steps to stop acute and chronic poisoning of poor pesticide handlers and make this profession safer. Keywords: Pesticide, spray, farmers, health problems, Pakistan. (Pak J Public Health 2015;5(2):9-12 )

Introduction Pesticides are benecial as they protect crops and preserve food and materials. Pesticide and insecticides are very toxic by design, they are biocides, designed to kill, reduce and repel unwanted objects like insects, weeds, rodents and fungi etc. Pesticides act upon biological system and enzymes of pests and this mode of action is similar to system and enzymes in human beings; therefore exposure of insecticides and pesticides poses a risk to human health. In addition, they have devastating effect on environment(1,2). There are three major routes of entry for pesticides; contamination of the skin, lungs and the gut. The public health issue of pesticide exposure is further complicated by the presence of impurities in so-called "inert-ingredients" such as solvents, wetting agents and emulsiers. Exposure to pesticides is one of the most important occupational risks among farmers in developing countries (3-5) Pakistan is an agricultural country with population of about 182.1million in 2013 and about 70%

of the population is related to agriculture directly or indirectly. In addition, majority of population live in villages. To increase per acre yield of agri-products, farmer use harmful and costly synthetic pesticides to prevent their crops from attack of pests, which have harmful effect on environment including human being. They cause environmental pollution, pest resistance leads to superbug and accumulation of pesticide residues in the body of animal and human. These pesticides leach down into the soil and pollute ground water which ultimately effect human being and animals by entering the food chain. Farmer attitude is the major factor along with others of pesticide contamination or poisoning in developing countries. There are various factors identied in previous research including incorrect beliefs of farmers about pesticide toxicity, lack of attention to safety precautions, environmental hazards, and the use of faulty and not well maintained spraying equipment's. In addition, lack of proper protection and appropriate clothing during handling and spraying of pesticides is a major health issue(6-10) 9


Awareness among farmers is very important about the risks and consequence of unsafe use of pesticide by arranging seminars, educational programs, trainings and doing research work to identify the extent of problem and notify the areas which required more attentions(6,10-13). By giving better understanding to farmers about the pesticide hazards, we can reduce the intensity of adverse effects of pesticides on farmers and help to protect themselves against these hazards. So rst step, in this regard should be to acquire knowledge to identify the extent of problem by exploring farmer's perception, attitude and knowledge about pesticide handling and pesticide safety and their adverse effect on environment particularly on human beings. In the present work, different parameters have been assessed to investigate the farmer's perceptions, knowledge, and attitude towards pesticides/insecticide use, risk to human health by their extensive use and adaptation of many malpractices during spraying process. Materials and Methods A survey questionnaire was designed to have basic idea about age, education, training and experience of spray persons and also their understanding about poisons and spray process to know the problem faced by the people associated with insecticides and pesticides spray in the elds. All the questions were asked in an interview manner, in local language so people could understand them fully and answer comfortably. The survey was done in district Gujranwala of Punjab Province of Pakistan in the month of July to August 2014 and all the answers were recorded to prepare results. Results Personal Information The people who were involved in spray profession were mostly from village and in the age group of 25-34. Most of them did not have any formal education and majority of them had 0-5 years of spray experience. They either learned themselves or some of their family members guided them about spray while none of them got any training from any government professional or agriculture department (Table 1).

Spray related Answers On asking a question to spray personals that did they ever watched a program or heard any program on TV or radio about insecticide/pesticides toxicity and spray process, all of them replied that they did not watch or hear any such program in their whole life. All of them told that they know that how to protect them self from poison and further added that they take all the measures which they think are necessary to protect. None of respondent ever used any specic mask, glove or special shoes during spray but they told that when poison had very bad smell then they do cover mouth and nose with simple cotton cloth. In addition, all of them told that they do have separate cloths for spray work, so when they have to spray they change cloth and also after spray process, wash them separately from other cloths to protect other cloths from poison and further added that mostly they wash cloth in open water. Most of respondent told that they had one or more health issues during the spray process and allergy was reported to be more common problem among them. In addition, some reported that they become unconscious, other told vomiting and ulcer and less than half of respondents told that they did not get any health problem so far. The respondents who did not have any problem were new in this profession. According to all of them, they think the process that they opt for spray is ne and they do wash their hands with soap and also take bath after the spray process. Among the total 50 respondents, 6 of them also told that they know somebody died after the spray due to acute poisoning while almost half of them reported that they know other people who had health issues during or after spray in the eld. None of the respondent was aware about the potency of the poison which is given on the bottle and they added that they get instruction from owner or agri-shop and accordingly they do spray in the eld. All of the respondent agree that it will be great if government agriculture department arrange training sessions for them so they could better understand the process and could protect themselves, their family and environment from poisons (Table 2). Table 2. Answers to spray related questions

Table 1: Basic information about the pesticide handlers/spray workers

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Discussion Pakistan is an agriculture country with almost 22.45 million hectare area under crops. The agricultural crops are under severe attack of various insects and pests and use of pesticides is common in Pakistan, like many other countries, across the world. The increased use of insecticides in agriculture sector can be estimated from the fact that from last 10 years approximately 30 million tons insecticides are purchased annually. These insecticides are source of hazardous health problems for the farmers(14). According to Pakistan economic survey, 43.7% of labor force in Pakistan is deployed in agriculture sector. The majority of which is expected to be under direct effect of pesticides and insecticides. The survey done in this research was an effort to determine the practices followed by farmers and to get an idea of their knowledge about use of pesticides. The survey was conducted among farmers of various age groups ranging from 15 to 55 years mostly residing in villages. Among these 86% farmers were below 45, the results were in accordance with a study conducted in Ahmednagar (India), where the majority of respondents belong to age group 40 (16). The ndings from this research show that majority of the respondents were literate. 42% of them have secondary school or more education. 9% respondents have passed the middle classes and 10% had the primary education while remaining 30 % were illiterate. The results were in accordance with studies conducted in Bangladesh, Ethiopia and India (16-18). Most respondents have eld experience of around 5 years, whereas some had more experience. These farmers had no proper training; most of them were self-learners or got training from their forefathers conrming the reports already present in literature (18). On the other hand some got training from agri-shops and few from friends. None of them got any training from any government institute. A disappointing fact in the present study was that none of the respondents used masks, gloves or special boots despite of the fact that 100% of them claimed that they knew how to protect themselves. The results were totally in contrast to studies conducted in India (16) where 10% respondents used masks and a good number of them used other safety equipment's like life apron, gloves, goggles and special boots. Neither these results were in accordance to studies conducted in some parts of India (i.e., Ahmednagar, Itarpardesh) (15), Palestine, Bolivia and Cambodia where at least respondents used masks and apron as safety measures (19,20). Something positive observed from research was that 100% respondents wash hands and also take

bath after spray. Also all of them also used separate clothes for spray. The results of similar study in India showed that 100% respondents wash hands and 67.44% take bath after spray (16). The reports of relevant study in kerala showed that 93% respondents took bath after spray of pesticides. The results are also in accordance to reports of similar studies conducted in Bahrain, Bolivia and Cambodia where majority of respondents wash hands after spraying and also in Cambodia and Bolivia majority respondents also took shower afterwards (19-21). The results showed that 66% respondents had an idea of adverse effects of spray, while 54% knew about death or any other illness due to sprays, which is totally in contradiction to study of Neupane 2014 who reported that majority (89.54%) respondents were un aware of poisoning cases and almost 100% were not aware of any death or hazard caused by sprays. Our study revealed that, none of the respondents was trained by any government department regarding precautions during spraying procedures. Also as per results of our survey, 100% respondents were unaware of any media campaign to teach precautionary measure during spray process. As in countries like India, where farmers use precautionary measures like masks, special boots, aprons etc. they do not see hazardous effects frequently. There is strong need to adopt such practices in Pakistan and this can be achieved by collaborative efforts of different stakeholders including government organizations, civil society and media. All farmers reported that they never saw any awareness program via media. Also they never attended any training by any government organization regarding hazardous effects of pesticides and insecticides. There is a strong need to take such initiative at government and private level to make these people aware and protect them from what can be life taking threats for them. There is great need of immediate efforts to protect people, their families and environment from hazardous effects of pesticides and insecticides. Conict of Interest: There is no conict of interest for the present study References 1. International Code of Conduct on the Distribution and Use of Pesticides. Food and Agriculture Organization of the United Nations. 2003. 2. Pesticides in the Diets of Infants and Children | The National Academies Press. The National Academies Press. 1993. 3. Wesseling C, Aragón A, Castillo L, Corriols M, Chaverri F, de la Cruz E, et al. Hazardous pesticides in Central America. Int J Occup

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Environ Health. 2001;7(4):287-94. Konradsen F, van der Hoek W, Cole DC, Hutchinson G, Daisley H, Singh S, et al. Reducing acute poisoning in developing countries--options for restricting the availability of pesticides. Toxicology. 2003;192(2-3):249 -61. Coronado GD, Thompson B, Strong L, Grifth WC, Islas I. Agricultural task and exposure to organophosphate pesticides among farmworkers. Environ Health Perspect. 2004;112(2):142-7. Sosan MB, Akingbohungbe AE. Occupational insecticide exposure and perception of safety measures among cacao farmers in southwestern Nigeria. Arch Environ Occup Health 2009; 64(3):185-93. Plianbangchang P, Jetiyanon K, Wittaya -Areekul S. Pesticide use patterns among small -scale farmers: a case study from Phitsanulok, Thailand. Southeast Asian J Trop Med Public Health 2009; 40(2):401-10. Chalermphol J, Shivakoti GP. Pesticide Use and Prevention Practices of Tangerine Growers in Northern Thailand. J Agric Educ Ext. Taylor & Francis Group 2009;15(1):21-38. Hurtig AK, San Sebastián M, Soto A, Shingre A, Zambrano D, Guerrero W. Pesticide use among farmers in the Amazon basin of Ecuador. Arch Environ Health 2003;58(4):223-8. Damalas CA, Georgiou EB, Theodorou MG. Pesticide use and safety practices among Greek tobacco farmers: a survey. Int J Environ Health Res 2006;16(5):339-48. Oluwole O, Cheke RA. Health and environmental impacts of pesticide use practices: a case study of farmers in Ekiti State, Nigeria. Int J Agric Sustain. Taylor & Francis Group; 2011 Ibitayo OO. Egyptian farmers' attitudes and behaviors regarding agricultural pesticides: implications for pesticide risk communication. Risk Anal 2006;26(4):989-95. Damalas CA, Theodorou MG, Georgiou EB. Attitudes towards pesticide labelling among Greek tobacco farmers. Int J Pest Manag. Taylor & Francis 2006;52(4):269-74. Pakistan Economic Survey 2013-14. Ministry of Finance, Pakistan. 2014. Available from: http://nance.gov.pk/survey_1314.html Singh B, Gupta MK. Pattern of use of personal protective equipments and measures during application of pesticides by agricultural workers in a rural area of Ahmednagar district, India. Indian Journal of Occupational Environmental Medicine 2009; 127-30.

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Neupane D, Jørs E, Brandt L. Pesticide use, erythrocyte acetylcholinesterase level and self -reported acute intoxication symptoms among vegetable farmers in Nepal: a cross-sectional study. Environ Health 2014;13(1):98. Mekonnen Y, Agonar T. Pesticide sprayers knowledge, attitude and practice of pesticide use on agricultural farms of Ethiopia. Occup Med (Lond) 2002;52(6):311-5. Bamberry G, Dunn T, Lamont A, (RIRDC) RIR and DC. A pilot study of the relationship between farmer education and good farm management: a report for the Rural Industries Research and Development Corporation. Rural Industries Research and Development Corporation; 1997; Available from: http://www.voced.edu.au /content/ngv14506. Jors E, Morant RC, Aguilar GC, Huici O, Lander F, Baelum J, et al. Occupational pesticide intoxications among farmers in Bolivia: A cross -sectional study. Environ Health 2006;5:10. Jensen HK, Konradsen F, Jors E, Petersen JH, Dalsgaard A. Pesticide Use and Self-Reported Symptoms of Acute Pesticide Poisoning among Aquatic Farmers in Phnom Penh, Cambodia. J Toxicol 2011; 2011:639814. Al-Haddad SA, Al-Sayyed AS. Pesticide Handlers' Knowledge, Attitude and Practice. Bahrain Med Bull 2013;35(1):1-7.

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FACTORS RESPONSIBLE FOR NON-COMPLIANCE OF TIMELY ADMINISTRATION OF BCG VACCINE IN DISTRICT JHELUM PAKISTAN Waseem Iqbal1, Syed Hasan Danish2,Farah Ahmad3 1

DOH (Headquarters Jhelum), 2 Department of Community Health Sciences, Ziauddin University, Karachi, Assistant Professor, Department of Community Health Sciences, Ziauddin University, Karachi (Correspondence to: Ahmad F [email protected])

3

Abstract Objectives: To assess factors for the non-compliance of BCG administration at appropriate time, primarily. This was also to nd level of awareness of parents regarding the EPI schedule in District Jhelum; to assess timely vaccination with special emphasis on BCG; and to discuss the tangible factors for delay and their remedial measures. Methods: A cross-sectional study was conducted in District Jhelum, over a period of six months, with the target population of all parents having children > 2 years of age. A representative sample of 450 parents having children of less than two years of age was selected. Data was collected through a questionnaire by teams of two members- one male and one female. Data was entered in MS Excel and analysed using SPSS, Version 20. For qualitative analysis, interviews of the key persons of Dist. Jhelum in EPI and their suggestions and recommendations were gathered for the remedy. Results: Out of 450 children under 2 years, 164, i.e. 36.4 %, were vaccinated with BCG during the rst seven days after their birth. Regarding the awareness of parents about EPI 389, i.e. 86.4 %, are aware of EPI. Monthly incomes greater than 20,000 Rupees, 90.8 had their child vaccinated within the rst week. This shows that only 36.4 % were vaccinated during the rst 7 days, while the remaining was vaccinated after the rst week of their life signifying the noteworthy delay in the administration of the vaccine. Regarding the qualitative part of the study, it was revealed that the factors for delayed BCG vaccination were 20dose vile, inadequate resources including logistic, and manpower and inefcient supervising and monitoring. Conclusions: This study concludes that there is a signicant delay in timely vaccination in children even with generally omniscient parents regarding the EPI schedule. Increase in the respective household incomes, educated parents- especially mothers, deliveries in hospitals, outreach vaccination, punctuality of the vaccinator and the mother's 'more than' two antenatal visits are factors that help raise BCG-vaccination rates. Thus the introduction of the single-dose vial, the provision of resources and strict monitoring can help alleviate these concerns. KEY WORDS: EPI, BCG, Vaccine, Timely. (Pak J Public Health 2015;5(2):13-18 )

Introduction Vaccine-preventable diseases are major causes of infant mortality and under-ve mortality. Twenty seven percent deaths in Pakistan among under-ve children are attributed to these vaccine-preventable diseases (1). To combat the rising number of deaths attributed to these diseases, expanded program of immunization was launched by WHO in 1974 that covered six diseases polio, diphtheria, tuberculosis, Pertussis, m e a s l e s a n d t e t a n u s . (http://www.unicef.org/immunization/index_coverage.h tml). In Pakistan EPI was launched in 1978 and covered the six diseases later on three more diseases were added hepatitis, pneumonia and Hib. The global target is to vaccinate 95% of the total infants. If EPI is withdrawn in Pakistan, 1000 children under 5 years of age will die

daily (1). Another signicant performance indicator is timely administration of vaccines (3). Based on guidelines, the schedule followed in Pakistan BCG & OPV0 is given soon after birth followed by Pentavalent and pneumococcal at 6, 10, 14 weeks and Measles at 9 & 15 months with coverage exceeding 95%. BCG prevents 80% of the total children in the world against childhood Tuberculosis (1). The BCG vaccination is a highly cost-effective intervention against Milliary TB & TB Meningitis (2). The effectiveness of BCG is maximum if given soon after birth. Immunogenicity assessed by cytokine signature in culture supernatants from diluted blood sample stimulated that Mycobacterium Tuberculosis showed lower production of most cytokines in infants vaccinated within 1st week after birth than those vaccinated later (5). 13


A study conducted in Guinea-Bissau revealed that only 50% children were fully immunized by the age of one year & 65% at the age of two (6). In 2011, more than 50% of children did not receive DPT3 majority were from India (32%), Nigeria (14%) & Indonesia (7%) (7). According to a study in Kampala, Uganda, only 45.6% children received timely vaccination (8). In East China, in 2011, timely measles coverage was only 47.5% (9). According to 3rd party evaluation in Oct-2013, the overall coverage of Pakistan was 56%. Dist. Jhelum being at the top in Punjab could achieve 85% (4). This was regardless of timely administration, when this factor is of utmost importance. Numerous studies have implicated multifarious factors including cultural issues, decit of supervision of health workers and inappropriate program planning and monitoring (14,16) . Other factors that play a pivotal role include dismal immunization services and religious aspects (17, 18) Studies to assess the timeliness of vaccines have been conducted in other parts of the world yet no appreciable data is available from Pakistan. Therefore we assessed the factors responsible for the non compliance of the timely administration of vaccines with emphasis on BCG vaccines. Material & Methods This cross sectional study was conducted in District Jhelum from June 2014 to November 2014 for time duration of 6 months. Parents of children of less than two years of age were taken as the target population. A total of 450 children were selected through probability cluster sampling technique. Sample size was calculated by using the formula

The sample size was inated to 450 to accommodate non response and incomplete questionnaires.

Out of 54 Union Councils (UC), 9 UCs were selected randomly with a cluster of 50 in each. All parents having children less than two years old and who were permanent residents of District Jhelum were included. Those non-responsive/ absent at the time of the data collection were excluded. The data collection team comprised of two people- one male and one female, who were trained in data collection. Data was collected by using a self administered questionnaire formulated for quantitative analysis. Proforma based interview was conducted and questionnaire was developed in both English and Urdu. Data was then entered in MS Excel. In lieu of errors data was cleaned prior to analysis. P value of 0.05 was taken as signicant. For descriptive statistics frequency and percentages were calculated as entire data was categorical. For qualitative analysis, a separate questionnaire was used for interviewing the key persons of district Jhelum in EPI and their suggestions and recommendations nalized for the corrective measures. Results Out of 450 children under 2 years, 164, i.e. 36.4 %, were vaccinated with BCG during the rst seven days after their birth, while 151 i.e. 33.6 % were given the BCG vaccination between the rst seven to fteen days of their birth. 97, i.e. 21.6 %, were vaccinated with this between the ages of 15 days to 29 days. While 38, i.e. 8.4 % were vaccinated after one month. This shows that only 36.4 % were vaccinated during the rst 7 days, while the remaining bulk (i.e. 63.6 %) was vaccinated after the rst week of their life demonstrating the signicant delay in the administration of the vaccine. (Fig1). When parents' knowledge was assessed regarding expanded program of immunization, majority 86.4% (n=389) were aware of it. Regarding the EPI schedule 59% (n=265) were aware of it and another 41% (n=185) had no knowledge regarding the schedule of the EPI program. While assessing the knowledge about the diseases covered under the EPI programme, 67% (n=302) replied in assent, while 33% (n=148) displayed lack of knowledge. When inquired about the required age for the rst vaccination according to the EPI schedule, 62% (n=279) replied correctly by saying 'at birth'. Whereas for age of last vaccination, 57% (n=255) replied correctly. (Table 1) When factors related to non compliance were assessed, working status of the mothers showed mixed results as out of the total housewives 35.8% ( n=149) had their child vaccinated with BCG within rst 7 days of birth as compared to 44% (n=15) working woman. In the case of the respective household incomes, those with monthly income less than Rs. 20,000, 103 out of 314 (32.8%) had their child

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vaccinated during the rst 7 days, while those earning between Rs. 20,000-50,000 per month, 48/108 (44.4%) had their child vaccinated within rst week, whereas those with wages greater than 50,000 rupees per month, 46.4 % had their child vaccinated within the rst week. (P value 0.036). 59.5 % (n=25) of fathers with an educational status of graduation had their child vaccinated within the rst week. (P value 0.031). Similar results were seen when educational status of mother was assessed, 60% of the graduate mothers had their child vaccinated in the rst week (P value 0.000). When practice versus knowledge was assessed, 52.4% (n=148) of the people aware of the EPI schedule underwent vaccination of their child within the rst week (P value 0.017). Considering the place of delivery, 26.7% (n=16) of the children delivered at home were vaccinated within the rst week, while those delivered at government hospitals, 34 % (n=71) had vaccination within the rst week. Deliveries 42.5% (n=77) that took place in private hospitals 47 % of those delivered at private hospitals underwent vaccination within the rst week. (P value 0.006). When place of vaccination was associated with timeliness, out of the total vaccinated at home 11 % (n=18) were vaccinated within the rst week, those vaccinated at a health facility, 42.1 (n=96) % were vaccinated timely and 47 % (n=77) of those seeking outreach program were vaccinated within the rst week. (P value 0.000). Antenatal visits of mothers came out to be another important factor for non compliance for timely vaccination. When antenatal visits by mothers was less than or equal to 2, only 1.2 % (n=2) had their child timely vaccinated within the rst week. However, 98.8 % (n=162) mothers with more than 2 antenatal visits had their child vaccinated within the rst week. (P value 0.000). When visits by the vaccinator was taken into account for nding association with timeliness, only 20.5% (n=8) children were vaccinated on time where vaccinator visits were irregular as compared to 38% (n=156) children who were vaccinated on time where the visits were every month. (P value 0.001) (Table 2).

Table 1: Knowledge of participants regarding EPI Program

Table 2: Association of age at BCG vaccination with different factors

Figure 1: Age of child at BCG Vaccination

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Discussion The Expanded Programme on Immunization (EPI) is a disease prevention activity aiming at reducing illness, disability and mortality from childhood diseases preventable by immunization. It is a global programme carried out in all countries helped by WHO, UNICEF and further donor agencies. Basically, it includes 9 target diseases: poliomyelitis, neonatal tetanus, measles, diphtheria, pertussis (whooping cough), hepatitis-B, Hib Pneumonia & meningitis, and childhood tuberculosis, as well as pneumococcal pneumonia; these cause numerous illnesses, disabilities and deaths every year27% of deaths in < 5 years age-group are because of vaccine-preventable-diseases e.g. 80% of total children globally are being protected against TB. EPIdiscontinuation can cause 1000 deaths in those less than 5 years old on daily basis. Immunization is most operational and cost effective in eradicating smallpox, lowering worldwide-polio incidence till now by 99% and has gained a vivid reduction in the effects of some targeted diseases. Keeping in mind this goal, the plan began, and continues since 1978 in Pakistan; evaluation is carried out at 2-3 year intervals. Its specic objectives are 95% immunisation coverage, eradicating neonatal tetanus and reducing VPDs morbidity and deaths by 2/3rd by 2015 according to MDG-4, 2000, conrming eradication of poliomyelitis after existing free of it for 3 years and introducing new vaccines in the EPI schedule of pneumococcal in 2011 (1). Our study aimed to assess timeliness. To assess the present situation, especially timely vaccination with BCG, this study was conducted in Jhelum. This vaccine has unswervingly proved to be very effective against meningitis, Milliary and childhood tuberculosis, but its efcacy against pulmonary tuberculosis and other mycobacterial diseases is variable. The overall coverage of vaccination in children at risk was 72.6% (95% condence interval (CI): 66.3 78.0). In Île-de-France, this coverage was 89.8% (95% CI: 81.4 - 94.7), whereas outside this the coverage was (95% CI: 81.4 - 94.7). Children had higher vaccination coverage when aged 13 to 23 months than those with ages from 2 to 12 months, though this difference was merely statistically important outside it, as its p value was less than 0.01 (2). As is the case in our study, though all 450 children were vaccinated with BCG, only 164/450 i.e. 36.4% were vaccinated within the rst week of their birth. Another signicant concern is whether insufcient coverage of vaccination affects TBincidence, e.g. the vaccinated have a low incidence (as is evident from a universal BCG- vaccinediscontinuation in Sweden when coverage was low and TB incidence in foreign-origin children increased fteen-

fold.) thereby proving that proper vaccination corresponds to low TB incidence (2). According to a study conducted in Ghana, when most mothers attended antenatal clinics during pregnancy, maximum (98.8) delivered in hospitals, 85% babies less than 12 months of age and mean distance to arrive at clinics was 30 minutes, the uptake of initial vaccines was generally timely at 87.3% while the lategiven vaccines were to 5.3% of these (administered after time) (3). Timeliness of this vaccination is possible, shown through a study in Kampala Uganda, using methods bent upon improving it specically among the poorest, single and multiparous women plus within mothers not delivering at health facilities (8). This is very much parallel to our study which proved that mothers making more than 2 antenatal visits had a very high, 98.8%, proportion of children vaccinated suitably in accordance with time. Similarly, the higher proportion of timely vaccinated children was of those delivered at hospital facilities. A study in rural Guinea-Bissau, coverage within 12 months was not high, but beyond this age increased. More than half of all children underwent vaccination out of sequence, thus highlighting the need for improved vaccination (6). In another community- based cross-sectional study in Kampala, Uganda, 45.6 % of 821 children received all vaccines during the recommended time ranges (45.6%;95% Cl39.8-51.2), this being lowest for measles (67.5%;95% Cl 60.5- 73.8) and highest for the BCG vaccine(92.7%;95% Cl 88.1-95.6) (8). Our study shows that from those children vaccinated in their rst week, 95.1 % belonged to the vaccinators visiting regularly and 4.9 % were included in the area where the vaccinator was irregular. Thus, improved communication for EPI, as well as the effective implementation of programmed outreach session health facilities are needed to ensure timely vaccine administration (10) According to a Cameroonian health district in the period of Feb. to May 2009, it has been revealed that merely 62% of the immunization sessions were executed properly since transport funds and staffs was limited (11). So, further considerable factors include the accessibility of the to-be-vaccinated populations. Vaccination rates can be enhanced through better service delivery, vaccines- availability, increased involvement of nomadic/rural communities and separate outreach services for the remote areas, e.g.is in Tanzania (12). Interventions based on communities can improve rates through raising community demand for immunisation based on e.g. education and patient reminders; increasing provider opportunities; better

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access to immunisation services and executing all of them together. Manual outreach, tracking and home visits are expensive and require more labour, but can be effective than standard strategies in rural and far-off populations (14). In the expansion of immunisation in Chinese children, considerable advancement has occurred, but discrepancies across different provinces are present owing to information gaps between the supply and demands in rural areas. However, quick developments in mHealth, the mobile health technology, provide exceptional opportunities in improving this situation (13). A Government mediation plan that did consist of recruited village-based community volunteers increased the DPT vaccination in India ageappropriately- a part of a health-sector reform centred at increasing timely vaccination through decentralizing the administration (17). When immunogenicity was examined in Malawi through cytokine signature in culture and then supernatants from the diluted whole blood samples stimulated with M. tuberculosis PPD (using a multiplex bead assay) infants vaccinated within the rst week of their lives showed lesser cytokine-production than those vaccinated later5 -signifying the importance of the time of vaccine delivery. Delayed immunisation is primarily due to staff and vaccine-supplies shortages and disobedience of plans (17). Deliberately delayed vaccines are quite occurring and therefore children, whose parents practice this, may be at a raised risk of being missed out from recommended vaccine doses by the age of 19 months and are even more susceptible to vaccines preventable-diseases. Vaccine suppliers need to develop educational strategies addressing concerns of the parents regarding the safety and effectiveness of vaccines, helping encouraging timely vaccination.18 Our study brings into limelight that a kind of the educational strategies, i.e. EPI-awareness, 90.2 % mothers had their children vaccinated timely. Conclusion This study concludes that there is a signicant delay in administrating the BCG vaccine timely in children even though parents are mostly aware of the EPI schedule. Increase in the respective household incomes does result in a corresponding increase in vaccination. Further to this, when the parents, specically mothers, are educationally qualied- at the very least, graduatedvaccination coverage is comparatively extensive. Vaccination rates are, also, high when most deliveries are in hospitals and through the data it is evident that our primary focuses is on outreach, door-to-door vaccination as when vaccinators are regular the rates are very high-almost all children are vaccinated (even if

not timely) though other practices at hospitals are not very uncommon. Mothers are also very much likely to get their children vaccinated within the recommended limited time if they make more than two antenatal visits. The qualitative part as well concludes that the use of 20dose BCG vial, the lack of sufcient resources and the overall lenient monitoring are important factors contributing to the delay in vaccine administration. So aside from all factors pointing to the above mentioned effects on timely vaccination, the single dose vile should substitute the existing, the resources increased and the monitoring made stricter to alleviate the concerns regarding the delay in vaccine-administration. References 1. website: Extended Program on Immunization (EPI) Heath Department. [Online]Available from:http://health.punjab.govt.pk/[Accessed 20th May 2014] 2. Trunz BB, Fine PEM, Dye CD. Effect of BCG on childhood Tuberculous meningitis and miliary tuberculosis worldwide: A vaccination meta -analysis and assessment of cost-effectiveness. Euro surveillance 2011;16(12). 3. Laryea DO, Abbeyquaye PE, Frimpong E. Timeliness of childhood vaccine uptake among children attending a tertiary health service facility-based immunization clinic in Ghana: BMC Public Health 2014;14(90):14-90. 4. Provinces want to procure measles vaccine (report in DAWN News by Asif CH updated on 24 may 2013). 5. Hur YG, Gorak-Stolinska P, Lalor MK, Mvula H, Floyd S, Raynes J, et al. Factors affecting immunogenicity of BCG in infants, a study in Malawi, The Gambia and the UK. BMC Infect Dis 2014;14(184):14-184. 6. Hornshoj L, Benn CS, Fernandes M, Rodrigues A, Aaby P, Fisker AB. Vaccination coverage and out-of-sequence vaccinations in rural Guinea-Bissau: an observational cohort study. BMJ Open 2012;2(6). 7. Global routine vaccination coverage, 2011.Centers for Disease Control and Prevention. Global routine vaccination coverage, 2011. Centers for Disease Control and Prevention. 2011; 60(44):1520-1522. 8. Babirye JN, Engebretsen IM, Makumbi F, Fadnes LT, Wamani H, Tylleskar T, et al. Timeliness of childhood vaccinations in Kampala Uganda: a community-based cross -sectional study. PLoS One 2012;7(4): 9. Hu Y, Li Q, Luo S, Lou L, Qi X, Xie S. Timeliness vaccination of measles containing vaccine and barriers to vaccination among migrant children in East China. Published online 2013;10(13).

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10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

Ebong CE, Levy P. Impact of the introduction of new vaccines and vaccine wastage rate on the cost-effectiveness of routine EPI: Lessons from a descriptive study in a Cameroonian health district. Cost Eff Resour Alloc 2011;9(1). Veranz A, Gaudart J, Sallah K, Casanova L, Debroise A, Laporte R, Minodier PBCG vaccination: Survey among children less than 5 years of age in an emergency department 2014 ;21(5):454-60. Kruger C, Olsen OE, Mighay E, Ali M. Immunization coverage and its association in rural Tanzanian infants. Rural Remote Health 2013 ;13(4):2457. Chen L, Wang W, Du X, Rao X, Velthoven MH van, Yang R, et al. Effectiveness of a smart phone app on improving immunization of children in rural Sichuan Province, China: study protocol for a paired cluster randomized controlled trial. BMC Public Health 2014 ;14(1):262. Peneiope A, Robert M, Joyce D, Louise M, Han W. Improving immunization timeliness in Aboriginal children through personalized calenders. BMC Public Health 2013 ;13:598. Fadnes LD, Jackson D, Engebretsen IM, Zembe W, Sommerfelt H, Tylleskar T. Vaccination coverage and timeliness in three South African areas : a prospective study. BMC Public Health. 2011;11:404. Greenland KI, Rondy M, Chevez A, Sadozai N, Gasasira A, Abanida EA, et al. Clustered lot quality assurance sampling: a pragmatic tool for timely assessment of vaccination coverage. Bull World Health Organ 2010;88(2):97-103. Prinja S, Gupta M, Singh A, Kumar R. Effectiveness of planning and management interventions for improving age-appropriate immunization in rural India. Public Health Rep 2010;125(4):534-41. Smith PJ, Humiston SG, Parnell T, Vannice KS, Salmon DA. The association between intentional delay of vaccine administration and timely childhood vaccination coverage. Public Health Rep 2010;125(4):534-41. Fonteneau L, Guthmann JP, Collet M, Vilain A, Herbet JB, Levy-Bruhl D. Vaccination coverage estimated based on data found in 24th month health certicates of infants, France, 2004 -2007. Bull Epidemiol Hebd 2010;31-32:329-3. French. Romanus V, Svensson A, Hallander HO. The impact of changing BCG coverage on tuberculosis incidence in Swedish-born children between 1969 and 1989. Tuber Lung Dis 1992;73(3):150-61.

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PREVALENCE OF MYTHS RELATED TO HEALTH AMONG ARMED FORCES OFFICERS AND THEIR FAMILIES IN PESHAWAR GARRISON Sana Iqbal1, Naveed Iqbal Mughal2 ,Hira Ejaz3, Iqbal Ahmad Khan4 1,2,3,4

Sarhad University, Islamabad, Pakistan (Correspondence to: Iqbal S: [email protected])

Abstract Background: Myth is an idea or study that is believed by many people but that is not true. A story that was told in an ancient culture to explain practice, belief, or natural occurrence. The purpose of this study was to nd out various myths prevalent the among Armed Forces Ofcers and their Families in Peshawar Garrison regarding health. Material & Method: The study was conducted in Peshawar Garrison, KPK, Pakistan. Sample size was of 200.Convenient sampling technique was used. A Self-structured questionnaire containing close-ended questions in Urdu and English language was used to obtain knowledge about various Myths related to health. Data Analysis was carried out using SPSS version 17. Results: Most of the respondents were found believers of various myths irrespective of their qualication level. The percentage of individuals believing in myths was 40.7% among the 'Matric to bachelor' category whereas among the respondents having 'Master and Post-graduation' it was 16.66% Among males 38.05% persons were found to have belief in myths as compared to 43.93% of females. Conclusion: The results clearly show that a lot of misconceptions and false beliefs are prevalent in the ofcers and their families. Myths were most common among the respondents in Matric to graduate category depicting their lower educational status. women believe in such mythical stories and beliefs more. Key Words: Myths; Health; Peshawar Garrison. (Pak J Public Health 2015;5(2): 19-21)

Introduction Health is a state of complete physical, mental and social well-being and not merely absence of disease or inrmity. (1) Myth is an idea or story that is believed by many people but that is not true. A story that was told in an ancient culture to explain a practice, belief, or natural occurrence. Mythology can refer either to the collected Myths of a group of people - their body of stories which they tell to explain natural, history and customs - or to the study of such Myths. As a collection of stories, Mythology is an important feature of every culture. No part of world is free from social Myths and Misconceptions related to health even in highly developed countries like U.S.A and U.K, such beliefs and Myths do prevail. In developing and under developed regions like South East Asia and Indo-PAK, these traditional stories and Myths are much more prevalent and common. There are number of old wives tails out there regarding some basic scientic principles. Though most of them were refuted years ago, these rumors just won't go away (2-6). For example, in India, Pakistan and few other countries of South Asia following

myths are common. When you pluck one grey hair, many others grow. If you see something ugly when you are pregnant, your baby will be ugly too. Another most common myth is, if you watch a lunar eclipse during your pregnancy, your baby will have a cleft lip. The present study was conducted to see the prevalence of myths related to health among armed forces ofcers and their families of Peshawar Garrison. Methodology And Material Study population comprised of 200 respondents, both males and females and in an age segments of 18 years and above, among armed Forces Ofcers and their families in Peshawar Garrison. The tool used to observe various myths was a questionnaire comprising of 20 close-ended questions having options "yes", and "no". Questions were regarding the most commonly observed myths related to health. The respondents were given total marks according to the following criteria;

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Results Out of the 200 respondents, (134) 67% were males and (66) 33% were females. Educational status of 194 (97%) respondents was "Above Matric to graduate" level and 6 (3%) respondents was masters and postgraduate. Among the 194 Matric to Graduate category respondents, 40.7% of the total sample size), were found to be believers of myths as compared to 16.86% above Masters and Post Graduate believed in myths. Among the non myth 59.2% of Matric to graduate as to the 83.3% among in post graduate / master level respondents. Among the males, 38.05% were found to be myth believers (having score between 24-34 compared to 43.93% of the female respondents who believed in myths (Fig 1). Fig1: Relationship of headaches with stroke or brain tumor & Heath Care Seeking behavior of respondent.

Discussion Results of this study depict lack of knowledge about health on part of the Peshawar Garrison community. Prevalence of a large number of myths has destroyed the community health. The health and the issues related to health needs special attention through out the life, specially if people are suffering from any health problem they should consult doctors or specialist in concerned eld not the quacks. This behavior has led to the poor Health of the people. Treatment charges are usually far out of range of the common man. Not everyone can afford the treatment costs and consequently they visit Hakeems and Quacks, most of them also lack knowledge regarding the General and dental health and are affected by various myths.

Literacy level and socio - economies status of people play a very important role in development of health sector of a country. Proper education makes an individual more realistic and practical and nobody denies this fact. In our study we see that the percentage of people strongly believing in myths was more among the people who were matric to gradate, depicting their low educational status. Lower level of knowledge regarding health gives way to the myths and their spread from person to person and from one generation to the next. If not stopped these false beliefs will keep on deteriorating the health status of the general population. Conclusion The results clearly show that a lot of misconceptions and false beliefs are prevalent in the ofcers and their families. Myths were most common among the respondents in Matric to graduate category depicting their lower educational status. women believe in such mythical stories and beliefs more. Multidimensional approach is required to clear society from harmful effect of myths. References 1. www.who.int/about/denition/en/print.html. 2. www.merriam-webster.com/dictionary/myth. 3. W i k i p e d i a . o r g / w i k i / m y t h o l o g y. 4. Nasir MZ. Prevalent social myths and taboos related to dental health among general population of Rawalpindi. Dissertation for MPH 2010:4. 5. Myth story examples - your Dictionary. 6. www.iscience.com/health-and -medicine/common-science-myths-most -people-believe. 7. Well.blogs.nytimes.com/2009/06/29/ii-health -myths-that-may-surprise-you/? 8. Tropaion.blogspot.com/2008/08/importance-of -myths-in-ancient-and html? 9. en.wikipedia.org/wiki/mythology. 10. S h a i k h B T. M y t h s , f a l l a c i e s a n d misconceptions: Applying Social Marketing for promoting Appropriate H e a l t h S e e k i n g Behavior in Pakistan. 11. S h a i k h B T. M y t h s , f a l l a c i e s a n d misconceptions: Applying Social Marketing for promoting Appropriate H e a l t h S e e k i n g Behavior in Pakistan. 12. Blogs.JPMSonline.Com/2014/06…/mental -health-in-Pakistan-Myths-and-fact. 13. Myths, fallacies and misconceptions. Applying Social Marketing for promoting Appropriate Health Seeking Behavior in Pakistan. Babar T.Shaikh. 14. Nasir MZ. Prevalent social myths and taboos

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15. 16. 17. 18. 19. 20. 21.

related to dental health among general population of Rawalpindi. Dissertation for MPH 2010:4. www.contact Pakistan.com. Ali S, Sophie R,Imam AM, Khan FI, Ali SF, Shaikh A and Syed Farid-ul-Hasnain. Skeptics.stackexchange.com/is-eating-sh -and-drinking-milk-at-the-same-time-linked with skin diseases? www.jpma.org.pk/full-article-text.php? www.the health site.com/tness/top-10-indian -dieting-myths-busted. Hyperlink reference not valid. style/health/article/seven-diabetes-myths -dispelled. Powe BD, Daniels EC, Finnie R, Thompson A. Perception about Breast Cancer among African American Women.

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Review Article

NUTRITIONAL STATUS OF PAKISTAN'S ELDERLY POPULATION: A COMPARATIVE REVIEW WITH LOW TO MIDDLE INCOME COUNTRIES Abdul Momin Rizwan Ahmad1, Katrina A. Ronis2 Institute of Health & Management Sciences, Islamabad1, Health Services Academy, Islamabad2, (Correspondence to Ahmad AMR: [email protected])

Abstract The main focus to date in Pakistan regarding nutritional status has been with mothers and children under the age of ve. The 2011 National Nutrition Survey for Pakistan acknowledged that the nutritional status of the elderly needs greater attention. Globally the number of people living longer is increasing and their nutritional status is a contributing factor in their quality of life. This review has compared results from Nestle's Mini Nutritional Assessment tool utilised in Pakistan and six other low to middle income countries to ascertain whether elderly are at risk of malnutrition. Review Approach: A comprehensive review of academic publications was performed using the following databases PubMed, the Cochrane Library, Sage, EM Base, Bio Med Central, Science direct, and INASP. Literature that was published from 1997 to 2013 was included in the review and those studies that utilised the Nestle Mini Nutritional Assessment tool where included. Main Findings: Data regarding the elderly and their risk of malnutrition using the Mini Nutritional Assessment tool was obtained from six countries including Pakistan. Iran had the least percentage of elderly at risk of malnutrition (38.7%) and Bangladesh had the highest at 62%. The data from Pakistan revealed 43.3 % at risk of malnutrition. The sample sizes varied from n=102 to n=850 and elderly were assessed from a range of locations e.g. the community and in hospitals. Conclusion: The nutritional status of the elderly varied considerably from country to country and necessitates further research into how the tool is being utilised and conformity regarding where the elderly are accessed. Keywords: Nutritional status, elderly, ageing, developing countries, Mini Nutritional Assessment. (Pak J Public Health 2015;5(2):22-25 )

Introduction Old age is not a disease in itself, but with age comes many diseases especially non-communicable diseases (1). Many elderly suffer from one or more chronic diseases such as diabetes, coronary heart diseases as well as hypertension. The elderly are generally more prone to disabilities such as arthritis and dementia as well as nutritional problems as compared to other population groups. With age, many elderly people also suffer from a decreased appetite or difculty chewing and swallowing reducing their total caloric and nutrient intake (2). In 1990 Asia had 50% of the world's elderly population which is expected to rise to 58% by the year 2025. Since the Asian continent has many developing countries, this has led to an increased focus on the elderly population (3). In Pakistan the main focus on nutritional status has traditionally been with Mothers and children under the age of ve. The rst National Nutrition Survey was conducted in 1985, the second in 2001/2

and the most recent survey published in 2013. The last survey highlighted the need to focus on the elderly.2 Nutritional assessments of the elderly is an important public health screening approach to ascertain those who are malnourished or are at the risk of poor nourishment (4). One screening tool available is the original Mini Nutritional Assessment (MNA) by Nestle which consists of 18 questions however the current version, referred to as the "short form" consists of only 6 questions and streamlines the whole screening process, making it a very practical tool at a grassroots level in public health (5). Body Mass Index (BMI) is also a useful generic tool to ascertain whether an adult is underweight, normal weight, overweight or obese. However it does not provide information about the quality of diet consumed. The normal BMI range is 18 to 25 and is calculated by dividing body weight in kilograms by height in meters squared (body weight kg/height meters) (6).

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Current projections predict that the life expectancy of elderly people living in Pakistan will rise from 66 years to 72 years by the year 2023. According to a WHO report published in 1998 the elderly population of Pakistan constituted 5.6% of the country's total population estimated to increase to 11% by the year 2025.7 This change in the population pyramid is a public health challenge in Pakistan for all levels of health care and social welfare with a focus on the elderly and their nutritional status (7,8). Globally there is also a similar trend with a greater number of elderly living longer in many developed and developing countries. According to the current estimates, the world's elderly population is 605 million and the proportion of elderly people has been rising globally each year.1 By the year 2025 the projected global population of elderly will be approximately 1.2 billion and by 2050, 2 billion.8 Of the current 605 million elderly, 61% live in developing countries and 39% live in developed countries. Over sixty percent (61%) in developing countries is expected to rise to almost 70% by the year 2025. This implies that developing countries will have three fourths of the world's elderly population in a decade requiring substantial resources and health services to provide adequate care and quality nutrition to the population group (9). Nutritional assessment of the elderly is an enormous public health challenge since there are many contributing factors which are not always easy to dene (10). From a new public health perspective, research and development of appropriate interventions needs to be initiated to address the health and well-being of this population group especially their nutritional needs (11). Literature Review: Academic journals' articles written in English were reviewed from 1997 to 2013 utilizing the databases Pub Med, the Cochrane Library, Sage, Excerpta Medica database, Bio Med Central, and Science direct, for relevant publications. Key search words included 'geriatric nutrition', 'older people nutrition', nutrition of older people', 'elderly nutrition', 'nutrition of ageing population' and the 'Nestle Mini Nutritional Assessment'. Inclusion Criteria : Relevant articles from the year 1997 to 2013 were included which utilized MNA tool to determine the nutritional status of the elderly. Exclusion Criteria : The articles which used other methods to determine the nutritional status of the elderly were excluded. Bangladesh: In a rural study malnutrition among elderly (n=850) was assessed utilizing the MNA tool. The main ndings revealed that 26% of the elderly had protein-energy malnutrition while 62% elderly were at the risk of malnutrition. Health disorders were negatively

associated with the nutritional status of the elderly (12). Iran: One hundred and forty (n=140) elderly people living in a residential house in Kermanshah, Western Iran had their nutritional status assessed using the MNA. The study participants included males (n=76) and females (n=64). The MNA revealed that 14.9% were malnourished, 38.7% were at risk of malnutrition while the remaining 46.4% were well nourished. More than half (53.6%) of the elderly were either malnourished or at the risk of malnutrition. The study concluded that there was a need for an intervention to improve the nutritional status of elderly living in residencies (13). Nepal: Research was carried out to determine the level of malnutrition and associated factors among elderly people (n=300) residing in two areas of Pharping. The main ndings from the MNA tool revealed that 31% of the elderly were malnourished, 51% were at the risk of malnutrition and 18% of the elderly had a normal nutritional status (14). The number of elderly has risen over the past decade in Nepal which presents two challenges: free health care for the elderly is not available throughout the country and the current health system does not have the capacity for the expanding number of elderly (14). Pakistan: A mixed method study in the Federal Capital of Pakistan (Islamabad) utilized a face-to face survey i.e. MNA with three hundred elderly people (n = 300) and semistructured face-to-face interviews (n = 9) to provide greater insight into the survey ndings. Of the total sample size (n=300) 52% (n=156) were males and 48% (n=144) were females. The results showed that 48.7% respondents had normal nutritional status while 8% were malnourished. The remaining 43.3% were at risk of malnutrition. Cross tabulation of the socio-demographic variables and the nutritional status of the elderly revealed that there was a statistically signicant relationship between the age of study participants and their nutritional status. There was no statistical signicant between gender, place of residence, education and income of respondents and their nutritional status. When the study participants were asked about their food intake and correct foods to consume, most of them had poor knowledge (15). When nine (n=9) study participants were asked about concerns regarding their food intake and maintaining good health, half of them said that they had no issues whatsoever in terms of food intake and maintaining their health in the old age. When asked about the right foods which an elderly person should consume in the old age in order to maintain good health,

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most of the participants answered that balanced diet is one thing which they should consume in this age. Regarding caring for elderly people, all of the study participants replied that there is a dire need to reduce the tension from their lives which shows that whatever maybe the reason, tension denitely is one of the major causes of early deaths of elderly in Pakistan (15).

In conclusion: There was a range of at risk of malnutrition from almost 4 in 10 elderly to just over 6 in 10 (Iran and Bangladesh respectively) using the MNA. A comparative analysis between countries has its limitations due to the different settings where the elderly were accessed and the different sample sizes.

Democratic Republic of Congo: A cross sectional study with elderly study participants (n=370) utilised both forms of the Nestle nutritional assessment form i.e. short and long version. According to the MNA13.8% elderly were well nourished,57.8% elderly were at the risk of malnutrition while the remaining 28.4% were malnourished (16).

References 1. Katta A, Gopalakrishnan S, Ganeshkumar P, Christopher A, Rajit K, Suresh M. Morbidity pattern and nutritional status of elderly population in rural Tamil Nadu. J IndAcadGeriat 2011; 7:159-62. 2. N a t i o n a l N u t r i t i o n S u r v e y, P a k i s t a n . Agha Khan University, Karachi, Pakistan 2011. 3. Sachdeva R, Grewal S, Kochhar A, Chawla P. Efcacy of nutrition counseling on knowledge, attitudes and practices of urban and rural elderly males. Stud. Home Comm. Sci 2008; 2(1): 65-8. 4. Phillips MB, Foley AL, Barnard R. Isenring EA, Miller MD. Nutritional screening in community -dwelling older adults : a systematic literature review. Asia Pac J Clin Nutr 2010; 19(3): 440 -49. 5. W h a t i s t h e M N A ® h t t p : / / w w w. m n a -elderly.com/[Accessed on March11, 2013 at 3:15 am] 6. About BMI for adults. http://www.cdc.gov /healthyweight/assessing/bmi/adult_bmi /index.html#Interpreted[Accessed on March13, 2013 at 3:15 am] 7. Pakistan's Aging Population. Available at http://tribune.com.pk/story/464108/pakistans -aging-population/ [Accessed on July 24, 2013 at 1:05 am] 8. Elmadbouly MA, AbdElhafezAM. Assessment of nutritional status of hospitalized elderly patients in Makkah Governorate. Pak J Nut 2012;11(10):886-92. 9. Chilima D. Assessing nutritional status and functional ability of older adults in developing countries. Dev in prac 2000; 10(1): 108-13. 10. Ahmed T, Haboubi N. Assessment and management of nutrition in older people and its importance to health. Clinical Inter. in Aging 2010; 5: 207-16. 11. Baum F. The New Public Health. Third edition 2008: Oxford University Press, Melbourne. 12. Kabir ZN, Ferdous T, Cederholm T, Khanam MA, Streateld K, Wahlin A. Mini Nutritional Assessment of rural elderly people in Bangladesh: The impact of demographic, socio -economic and health factors. Public Health Nutr 2006; 9(8): 968-74.

Nigeria: A cross sectional descriptive study was undertaken at a General Outpatient Department of the University College Hospital, Ibadan, with ve hundred (n=500) elderly patients. The MNA tool was utilized and for the assessment of body weight, the variable of Body Mass Index (BMI) was used. The main ndings of this study revealed that 54.1% elderly patients were overweight while 7.8% were under nourished while 11.8% were at the risk of malnourishment (17). Saudi Arabia: A cross-sectional study with over a hundred (n=102) recently hospitalized elderly patients utilized MNA tool. Just over twenty two per cent (22.6%) were malnourished, 57.8% were at risk of malnutrition while 19.6% were well nourished. The main factors associated with malnutrition (p < 0.05) were low BMI, weight loss during the last three months, living independently, taking more than three medications per day as well as the prevalence of neuropsychological problems. The study concluded that malnutrition is a very common problem among the elderly and the MNA screening tool must be performed when elderly are admitted to hospitals to address any nutritional deciencies immediately (8). The summary of seven countries and data related to elderly at risk of malnutrition is mentioned in table 1. Table 1 presents a summary of the seven countries and data related to elderly at risk of malnutrition.

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13.

14. 15.

16.

17.

Pasdar Y, Gharetapeh A, Pashaie T, Alghasi S, Niazi P, Haghnazari L. Nutritional status using multidimensional assessment in Iranian elderly. Behbood J 2011; 15(3): 178-85. Proceedings of the Ageing Nepal. Malnutrition : Elderly people in Nepal; 2012 Sep; Nepal. Ahmad AMR, Ronis KA. A public health nutritional assessment of elderly in Islamabad; A mixed method study. Pakistan Journal of Public Health 2013; 3(4): 2-5. Andre MB, Dumavibhat N, Ngatu NR, Eitoku M, Hirota R, Suganuma N. Mini Nutritional Assessment and functional capacity in community-dwelling elderly in Rural Luozi, Democratic Republic of Congo. Geriat Geron 2013; 13: 35-42. Adebusoye LA, Ajayi IO, Dairo MD, Ogunniyi AO. Factors associated with under-nutrition and overweight in elderly patients presenting at a primary care clinic in Nigeria. S AfrFamPract 2011; 53(4): 355-60.

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Vol 5, No. 2 (June) 2015

Original Articles JOB SATISFACTION AND MOTIVATION AMONG CLINICIANS AND HEALTH MANAGERS WORKING IN PUBLIC SECTOR OF FEDERALLY ADMINISTERED TRIBAL AREAS OF PAKISTAN Qayum M, Qamar W, Khan HM, Sawal SH, Basharat S, Ali A, Shaq N, Ali I, Pervaiz N, Afridi A, Ahmad F, Qayum F......................................................................................................................................................... 01

CASE STUDY; LOW HIV TRANSMISSION OF HIV INFECTED MEN TO THEIR SPOUSES IN MALE DOMINATING SOCIETY Ahmed M, Gul T, Shah SA............................................................................................................................... 07

KNOWLEDGE, ATTITUDE AND PRACTICE OF PESTICIDES HANDLERS IN PAKISTAN Ahmad A, Chattha IA, Raheem A, Yasmeen A................................................................................................ 09

FACTORS RESPONSIBLE FOR NON-COMPLIANCE OF TIMELY ADMINISTRATION OF BCG VACCINE IN DISTRICT JHELUM PAKISTAN Iqbal W, Danish SH, Ahmad F.......................................................................................................................... 13

PREVALENCE OF MYTHS RELATED TO HEALTH AMONG ARMED FORCES OFFICERS AND THEIR FAMILIES IN PESHAWAR GARRISON Iqbal S, Mughal NI, Ejaz H, Khan IA............................................................................................................... 19

Review Article TITLE: NUTRITIONAL STATUS OF PAKISTAN'S ELDERLY POPULATION: A COMPARATIVE REVIEW WITH LOW TO MIDDLE INCOME COUNTRIES Ahmad AMR, Ronis KA.................................................................................................................................. 22