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 Pakistan Journal of Public Health, 2016 ( September )

Vol 6, No.3 (September) 2016

Original Articles
ASSESSMENT OF INFECTION CONTROL: KNOWLEDGE AND COMPLIANCE
AMONG DENTAL UNDERGRADUATE STUDENTS AT NISHTAR INSTITUTE OF
DENTISTRY, MULTAN
Amna Maqbool, Katrina A. Ronis ........................................................................................................ 01

ASSESMENT OF THE COMMUNITY, KNOWLEDGE, ATTITUDE AND PRACTICE

REGARDING PILES OF GARBAGE AROUND UC – 9 GULSHAN-E-IQBAL TOWN
DISTRICT EAST KARACHI
Saeeda Shaikh, Rukhsana Khan, Karim Bux...................................................................................... 07

EVALUATING THE EFFECTIVENESS OF FIRST AID TRAINING COURSE ON NON-

HEALTHCARE PROFESSIONAL VOLUNTEERS IN ISLAMABAD
Afsar Jan, Gideon Victor.................................................................................................................... 14

CHILD MENTAL HEALTH RESEARCH IN PAKISTAN; MAJOR CHALLENGES AND

PITFALLS: A SYSTEMATIC REVIEW
Tanzil Jamali, Sana Tanzil.................................................................................................................. 18

COMPARISON OF EFFECTIVENESS AND SIDE EFFECTS OF KETAMINE AND

PROPOFOL IN PROCEDURAL SEDATION FOR PATIENTS OF FRACTURE FEMUR
Khawaja Kamal Nasir, Suresh kumar, Yasmeen, Farah...................................................................... 24

A COMPARATIVE STUDY OF MATERNAL PSYCHOSOCIAL PROBLEMS AND

ACADEMIC PERFORMANCE OF CHILDREN INMIGRANT AND NON MIGRANT
FAMILIES OF AJK
Rabia Mushtaq, SeemaGul, Muhammad Tahir Khalily....................................................................... 29

HEALTH CARE WASTE MANAGEMENT IN PAKISTAN: A SITUATION ANALYSIS AND

WAY FORWARD
Ejaz Ahmad Khan, Syed Muhammad Sabeeh, Muhammad Ashraf Chaudhry, Aashifa Yaqoob,
Saleem M Rana, Ramesh Kumar........................................................................................................ 35

WILLINGNESS AND PERCEPTION ABOUT BLOOD DONATION IN RESIDENTS OF

RAWALPINDI CITY
Abida Sultana, Bushra Anwar, Madiha Shafi, Muneeba Faisal ........................................................... 44

OUT OF POCKET SPENDING FOR HEPATITIS C PATIENT’S TREATMENT AT

DISTRICT HEAD QUARTER HOSPITAL BADIN, SINDH
Zubair Ahmed Laghari, Assad Hafeez................................................................................................ 49

ASSESSMENT OF WORKLOAD PRESSURE AND OPTIMAL STAFFING NEED OF

NURSING STAFF FOR INPATIENT SERVICES AT FGH ISLAMABAD.
Mir Hassan Bullo, Katrina A. Ronis...................................................................................................... 54

DEPARTMENT OF OMMISSION AND ERROR................................................................ 59

 Dr. Saima Hamid,

Pakistan Journal of Public Health

Dr Ejaz Ahmad Khan, Associate Professor, Health Services Academy, Islamabad

Dr Shahzad Ali Khan, Associate Professor, Health Services Academy, Islamabad
Dr Babar Tasneem Shaikh
Associate Professor, Health Services Academy, Islamabad

Managing Editors
Pakistan Journal of Public Health, 2016 ( September )
Pakistan Journal of Public Health, 2016 ( September )
Pakistan Journal of Public Health, 2016 ( September )
Pakistan Journal of Public Health, 2016 ( September )

Managing Editors
 Pakistan Journal of Public Health, 2016 ( September )

Pak J Public Health Vol. 6, No. 3, 2016 Original Article

ASSESSMENT OF INFECTION CONTROL: KNOWLEDGE AND COMPLIANCE AMONG DENTAL

UNDERGRADUATE STUDENTS AT NISHTAR INSTITUTE OF DENTISTRY, MULTAN

Amna Maqbool1, Katrina A. Ronis2

Amna Maqbool, BDS, EMSPH Student at Health Services Academy, Islamabad. 2Dr. Katrina A. Ronis, MPHC DrPH,
Associate Professor, Health Systems & Policy Department, Health Services Academy, Islamabad. Corresponding
Author Details: Amna Maqbool, Email id: aminahmaqbool20@gmail.com, Cell no: 03347049191

Abstract

Background: Dental Professionals are vulnerable to infectious diseases in their working environment due to
repeated exposure to a variety of microorganisms present in blood and saliva. Dental students who are learning new
techniques are at a higher risk of acquiring and spreading infections, which requires stringent implementation and
compliance with infection control guidelines. This study aimed to gain greater insight and understanding regarding
the knowledge and practices of dental students to improve compliance to infection control guidelines and therefore
enhance the quality of care in undergraduate dentistry training.
Methods: In this cross sectional study (with a quantitative approach) convenience sampling was utilized at a public
teaching hospital in Multan. One hundred and two (n= 102) students, (50 from 3rd year and 52 students from 4th
year) completed a self administered questionnaire comprised of 4 sections regarding socio demographic data,
immunization status and past history of exposure, knowledge and attitude regarding infection control precautions
and adherence to infection control practices. Data was analyzed with SPSS 20 and significance level was set at P<
0.05.
Results: Knowledge regarding the spread of infections and infection control was good and the majority of the
students agreed that standard guidelines and additional precautionary measures need to be adopted. While the
majority of students (70.6%) had been vaccinated against hepatitis, less than half of them had completed 3 doses of
vaccination and only 18.6% have been assessed for anti-HBV. Most of the dental students reported that they were
not satisfied with infection control training at their institute. Practice of using of Personal Protective Equipment
(56.9%) was lagging behind the awareness (77.5%) regarding barrier techniques.
Conclusion: Although the students had good knowledge regarding infection control, the compliance and practice
levels regarding the same were relatively low. Such findings highlight the need of continued infection control
education. Compliance with infection control guidelines can be made better by refreshing and upgrading students'
knowledge through seminars or lectures on standard infection control guidelines each academic year.
Key Words: Dental students, dental safety practices, public teaching hospital, infection control guidelines.

Introduction: secretions and injury with a syringe needle. Indirect

Human oral cavity is a very good environment for the
growth and transmission of a variety of micro-
organisms(1).Hence these microbes are a continuous
threat for cross infection in dentistry. The transmission of
infection can occur easily in everyday practice so
protection from cross infection in the dental environment
is a critical feature of dental practice. Dental health care
workers including dental students are at high risk of
exposure to cross infection with blood borne microbes
such as hepatitis B virus (HBV) and hepatitis C virus
(HCV), human immunodeficiency virus (HIV) and
Mycobacterium tuberculosis, streptococci and other
viruses and bacteria that inhabit the oral cavity and the
respiratory tract(2). Infection transmission in the dental
environment can occur through several routes i.e.
directly through contact with blood, saliva or other
contact with contaminated instruments, dental
equipment and environmental surfaces or contact with
airborne contaminants in either droplet splash or
aerosols of oral and respiratory fluids.
Infection Control is defined as “The control
measures taken by health care personnel in reducing
the risks of transmission of infectious agents to patients
and health care providers”(3). In dentistry, it is a three
way transmission i.e. diseases may be transmitted from
patient-to-patient, dentist to patient, and patient to
dentist, when effective infection control measures are
not being followed.
In 1980s, after AIDS infection epidemic,
infection control gained much interest especially in
dentistry and forced the dental health workers to take
strict measures since reports of infectivity of six patients

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 Pakistan Journal of Public Health, 2016 ( September )
by dentists were common(4). In 2008, 4.7 million people
with HIV were reported in Asia, with 350,000 who
became newly infected Similarly, Hep B and C infections
have become a dilemma of public health and a leading
cause of morbidity and mortality, predominantly in
developing countries. Globally, 2 billion people (about
1/3rd of the world's population) have been infected by
HBV, of these, 75% are Asians(6). Worldwide,
approximately 100 million individuals are chronically
infected with HCV(7). In Pakistan, the prevalence of
Hepatitis B surface antigen (HBsAg) and anti-hepatitis C
virus (HCV) of 2.5% and 4.8%, respectively, reporting an
infection rate of 7.6% in the general population(8). The
prevalence of Hep B in health care providers of Pakistan
according to a survey is 3.25% ± 1.202%(9). It has been
found that dental health care providers are thrice more
liable than the general population to contract hepatitis
B(10). Based on these statistical figures, Pakistan is
classified as a region of 'intermediate risk” towards
Hepatitis B by WHO(11).
Infection Control in Dental Education: Direct
involvement with patients during treatment as part of
their clinical training places dental students at risk of
exposure to pathogens. As majority of the carriers of
infectious diseases cannot be identified, implementation
of standard precautions in dental colleges is the best
way to avoid cross infection(12). Dental institutes are
supposed to be responsible for providing proper
infection control precautions, adequate training of dental
students for their personal protection as well as the
security of patients, and the establishment of harmless
working environment(13). It must also provide the
faculty, dental staff and students with enough protection
against blood borne microbes so that they might provide
routine treatment to hepatitis B carriers, HBV and HCV
positive patients, diagnosed AIDS patients, and patients
with other infectious diseases.
In 1987, the Centers for Disease Control and
Prevention (CDC) in the United States recommended
universal precautions to protect patients and Dental
Health Care Worker (DHCW) from transmitting
infections to each other(14). In 1996, the term Standard
precaution was defined. Every patient must be
considered as possibly infectious, and the guidelines of
infection control should be followed by the dental
practitioner and dental staff according to the CDC
before, during and after care for all patients and for all
types of treatment(15). Standard Precautions that must
be applied to all patients include Hand washing,
Protective barriers i.e. personal protective equipment
(Use of Gloves, Face masks, Protective eye wear,
Rubber dam, Gowns/ Aprons), Routine patient
evaluation, Management of healthcare waste, Correct
handling and disposal of needles and sharps, Effective
cleaning, decontamination and sterilization of
equipment, instruments and environment. Additional
Precautions are for certain 'at risk' patients,
transmission based precautions which are necessary to
prevent potential spread of certain diseases (e.g., TB,
influenza) that are transmitted through air, droplet, or
contact transmission(16). The objectives of this study
were to assess the level of knowledge and to determine
the infection control practices and compliance of dental
undergrad students with CDC infection control
guidelines.
Methodology:
The study sample was drawn from Nishtar Institute of
Dentistry, the only public sector tertiary care dental
hospital in Multan. Convenience sampling technique
was used. All the undergraduate dental students in their
clinical years (3rd year and 4th year) enrolled during the
year 2015-16 academic year who were present on the
days of the survey were included (n= 107: 3rd yr=55 &
4th yr=57); no attempt was made to further invite the
students absent during the survey days. A verbal
consent was taken and the study participants were
asked to fill the questionnaires in their classrooms after
the lectures which were collected immediately after
completion on the same day. It took 2 days to access all
the students, one day for 3rd year and the second day
for 4th year data collection.
A structured, self administered questionnaire
was used as the data collection tool. The questionnaire
was presented in four sections i.e. Socio-demographic
Data, Knowledge assessment regarding Immunization
status and Past history of exposure, Knowledge and
attitude regarding infection control procedures,
Assessment of infection control practices of dental
students according to CDC guidelines. The approval for
this study was taken from the Institutional Review Board
(IRB) of Health Services Academy, Islamabad. A pilot
study was conducted on a random sample of students
(n=5) that was not included in the study to ensure that
the questions were clear and relevant; and to test the
feasibility and applicability of the tools. The
questionnaire was modified according to the feedback
obtained.
All the data was entered and analyzed by SPSS
version 20. Descriptive statistics included reporting of
means and standard deviations for the quantitative
variables like age and frequencies and percentage were
calculated for categorical variables. Chi-square test was
applied to compare the outcomes with respect to gender
and year of education. P-values less than 0.05 was
considered statistically significant.
Results:
From a total of 107 study participants, 50 3rd
year and 52 4th year students returned the completed
questionnaire (n= 102) with a response rate of 95%;
There were more female students with a male to female
ratio of 1:3 (29%:70.6%). Mean age of study participants
was 21.57 ± 1.439 years, ranging from 18 to 25 years.
There was an equal distribution of 3rd year and 4th year
students (49% vs. 51%) respectively.
a) Immunization Status and past history of
exposure:
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 Pakistan Journal of Public Health, 2016 ( September )
Needle Stick Injury: Sixty percent (60%) of the study
participants had a positive needle stick injury. Dental
Probe injury was most common in 3rd year students as
compared to 4th year students who had 37% of injury by
syringe needles. Among females, dental probe 56.8%
and among males, syringe needle 68.8% was the most
common type of injury.
Blood Splashes to eyes, nose or mouth:
Approximately Fifty Eight percent (57.7%) of 4th year
students had reported blood splashes to eyes, nose or
mouth and 30% of 3rd year students experienced it with
a significant difference between both years with P
value= 0.02
Hepatitis B immunization: Vaccination was done by
71.3% of study participants with a significant difference
between 3rd year and 4th year students (66% vs. 76.5%,
P = 0.04).
Figure 1: Stratification of Hep B immunization with
respect to Educational year
Post Immunization test: Thirty percent (30%) of 3rd year
students were tested for post HBV immunization
serology as compared to 4th year 7.7% with a
statistically significant difference of P = 0.003.
Figure 2: Stratification of post immunization test with
respect to education level
b) Knowledge and attitude Assessment
regarding Infection Control:
Knowledge of respondents regarding spread of
infections and infection control guidelines were good
and majority of the students i.e. 96% agreed to the
special precautionary measures to be adopted while
treating Hep B, C, AIDS and potentially infectious
patients. More than 93% of the students agreed to the
fact that standard precautions should be followed for
every patient. Bending needles before disposal was
considered necessary by 86.3% of the students with a
statistically significant difference between male and
female students (p = 0.003).Out of 97% of respondents
who agreed that sterilization is necessary, only 77.5%
students reported that autoclave is the best way of
achieving sterilization. There was found a statistically
significant difference between 3rd year and 4th year
students (p= 0.003) 27.7% of 3rd year students reported
chemical methods and 6.4% mentioned boiling to be the
best method of doing sterilization.
In response to the question whether they had
lectures or clinical demonstrations regarding infection
control during their undergraduate program, 55.9% in
majority said that yes they had a few lectures.40.2%
mentioned they never had any lecture or training, and a
minority (6.9%) told that they had more than just a few
lectures with statistically significant result to year of
education (p=0.02).
Around 50% of the students who reported that
infection control training in their institute was not
adequate , 23.5% were disappointed with the fact that
there was no proper infection control training in their
college, and 25% mentioned that due to burden of
patients, shortage of time, resource deficiencies and
stress of completion of their quota, the infection control
training is not done properly.
b) Assessment of Infection control practices:
Hand jewellery and accessories were always removed
before starting a procedure in 63.7% of students.
Female students were always more conscious in these
practices 70.8% as compared to male students 46.7%.
(p= 0.03).
Majority of the students (88.3%) always washed
their hands before and after the dental procedure with a
statistically significant difference between male and
female students. (p= 0.009). The practice of taking
medical history prior to start the procedure was good
(82%). A significantly higher percentage of 4th year
students 61.5% showed a positive attitude towards the
treatment of patient with infectious diseases as
compared to only 36% of 3rd year (p=0.03 ),while
majority of female students mind treating such patients.
(p=0.00).
3
 Pakistan Journal of Public Health, 2016 ( September )

Table 1- Assessment of Infection control practices:

By Year of Study By Gender Total

3rd year 4th year P Male Female P %

Variable N (%) N (%) Value N (%) N (%) value
1) Use of PPE*
§ Always 30(60%) 28(53.8%) 15(50%) 43(59.7%) 56.9%
§ Sometimes 19(38%) 20(38.5%) 0.39 14(46.7%) 25(34.7%) 0.50 38.2%
§ Never 1(2%) 4(7.7%) 1(3.3%) 4(5.6%) 4.9%
2a) Use of Gloves
§ Always 41(82%) 49(94.2%) 24(80%) 66(91.7%) 88.2%
§ Sometimes 9(18%) 2(3.8%) 0.04 5(16.7%) 6(8.3%) 0.12 10.8%
§ Never 0 1(1.9%) 1(3.3%) 0 1%
2b) Use of face mask
§ Always 24(48%) 23(44.2%) 15(50%) 32(44.4%) 46.1%
§ Sometimes 23(46%) 25(48.1%) 0.90 15(50%) 33(45.8%) 0.20 47.1%
§ Never 3(6%) 4(7.7%) 0 7(9.7%) 6.9%
2c) Use of eyewear
§ Always 7(14%) 4(7.7%) 6(20%) 5(6.9%) 10.8%
§ Sometimes 21(42%) 10(19.2%) 0.01 7(23.3%) 24(33.3%) 0.13 30.4%
§ Never 22(44%) 38(73.1%) 17(56.7%) 43(59.7%) 58.8%
2d) Use of face shield
§ Always 2(4%) 1(1.9%) 2(6.7%) 1(1.4%) 2.9%
§ Sometimes 14(28%) 5(9.6%) 0.04 4(13.3%) 15(20.8%) 0.26 18.6%
§ Never 34(68%) 46(88.5%) 24(80%) 56(77.8%) 78.4%
2e) Use of aprons/
gown 11(22%) 2(3.8%) 4(13.3%) 9(12.5%) 12.7%
§ Always 8(16%) 9(17.3%) 7(23.3%) 10(13.9%) 0.48 16.7%
§ Sometimes 31(62%) 41(78.8%) 0.02 19(63.3%) 53(73.6%) 70.6%
§ Never
3) Changing mask
btw patients
§ Always 23(46.9%) 24(47.1%) 17(58.6%) 30(42.3%) 46.1%
§ Sometimes 21(42.9%) 18(35.3%) 0.50 7(34.1%) 32(45.1%) 0.15 38.2%
§ Never 5(10.2%) 9(17.6%) 5(17.2%) 9(12.7%) 13.7%
3a) If never,
§ Personal 0 3(33.3%) 0 3(33.3%) 2.9%
choice 0.14 0.14
§ Lack of 5(100%) 6(66.7%) 5(100%) 6(66.7%) 10.8%
resources

Regarding overall use of PPE, students' practices were
poor with only 56% who always used PPE. Nearly all
students always wore gloves with overall percentage of
88% with a statistically significant difference (p= 0.04)
between 3rd year and 4th year. Very poor practices were
seen regarding use of eye wear, face shield and aprons
with majority of the study participants reporting that they
never use such protective barriers.
Discussion:
Dental undergraduate students will become dental
health care workers in future, and they will be serving
oral health care to the public later on. Whatever infection
control procedures they learn during their graduation
and the training they acquire while working at the clinical
departments in their institute, they will practice the same
infection control for the rest of their lives. Overall, the
students in the present study had a good knowledge
regarding infection control, but compliance with the
recommended infection control guidelines, especially
use of PPE was not adequate.
Complete Hep B immunization is one of the best medical
treatments to avoid transmission of infections during

4
 Pakistan Journal of Public Health, 2016 ( September )
dental procedures(17). The study indicated that only
70.6% of the students were vaccinated against Hep B
which is much less than the rates reported by other
studies in Brazil (90.8%), Canada (100%), and UAE
(95.8%)(18) but much higher than that reported by Singh
et al.in a Dental School, Central India,(19) where only
38% of students were found to be vaccinated in spite of
the fact that Hep B immunization was mandatory before
the admission in college.
It is important to highlight that vaccination rates
among dental health care professionals vary
significantly worldwide and have been reported to vary
from 33% to 97%(20-22). The data from Nishtar Institute
of Dentistry revealed an improved outcome regarding
hepatitis B vaccination status of dental undergraduate
and graduate students in contrast to a survey conducted
in Pakistan 10 years ago(23). Notably, less than half
(46.1%) of the vaccinated students had completed the
recommended 3 doses of vaccination. This percentage
is very low as compared with findings by Alavian et al.
(24) and Kramer et al.(25) The majority of the dental
institutions include vaccinations of Hepatitis B, tetanus
and MMR as an obligatory part of their admission
process for undergrad students and staff as well which in
turn leaves the fact unsolved about the low vaccination
rate in this study.
The efficacy of HBV vaccination can only be
judged when a post immunization test is performed.
Only 18.6% of students who were vaccinated reported
post-HBV immunization serology, which is comparable
to the results from other studies. In a survey by De
Souza et al.he found that out of 90.8% dental students
were vaccinated, only 27.5% had done post-HBV test.
In the current study, approximately 60% of the
undergrad students reported with needle stick injuries.
This value is very high as compared to the 30.5%
reported in a similar study with dental students in
Brazil(26).
The practice of standard precautions especially
use of PPE is considered to be the best prevention
strategy against occupational transmission of infections
in health care settings. In this study, although the
compliance level for the use of gloves was good
(88.2%), similar to previous research done in Canada,
Iran, UK, UAE, and Brazil,(27-28) the frequency of face
mask, protective eyewear, face shield and apron use
was very unsatisfactory at NID. Moreover 60% of the
students reported of blood splashes to eyes, nose and
mouth which is relatable to low compliance with the use
of PPE. Dental undergraduate students must be
encouraged to wear face masks and a protective
eyewear equipment to reduce the likelihood of
transmission of airborne infections.
The difference with respect to gender for
majority of the infection control procedures was
statistically significant but to a lesser extent, still the
female students were more compliant to Infection
control guidelines than males like precious studies(29)
Year of education showed influence on knowledge and
some of the infection control practices. The results are
consistent with the fact that knowledge is increasing with
higher year of education and more clinical training.
Conclusion:
In general, the undergraduate students at Nishtar
Institute of Dentistry had an acceptable attitude and
level of knowledge regarding infection control guidelines
but the findings revealed poor compliance with some of
the recommended IC practices specially use of PPE.
This inconsistency between knowledge and attitude
with practices was reported by students largely due to
lack of resources, burden of patients, stress of quota
completion, insufficient provision of PPE, carelessness
and a lack of proper Infection control training and
supervision in all departments. It is imperative to transfer
the acquired knowledge into routine daily practices in
order to create a healthy environment for both the
practitioner and the patient.
Recommendations:
Infection control department and committee for keeping
minutes and reports and to enable the students to follow
strict IC measures in all clinical departments. Hospital
authorities must arrange proper provision of PPEs to the
doctors, dental students and staff for self-protection and
for the patients. Mandatory post immunization
screening test of students before exposure to clinical
practice thereby assuring 100% coverage by hepatitis B
vaccination of students.
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c o n t r o l p r a c t i c e s . J D e n t E d u c . 2 0 11
Dec;75(12):1627-34.
25) Kramer A, Meyer G, Ertzinger S, Kietz K, Schrader
O, Martiny H. Multicenter study on the realization
of selected hygiene measures in 331 dental
practices. Hyg Med. 2008;33(3):64-73.
26) de Souza RA, Namen FM, Galan J Jr, Vieira C,
Sedano HO. Infection control measures among
senior dental students in Rio de Janeiro State,
Brazil. J Public Health Dent. 2006;66(4):282-4.
DOI: 10.1111/j.1752-7325.2006.tb04084.
27) Rahman B, Abraham SB, Alsalami AM, Alkhaja FE,
Najem SI. Attitudes and practices of infection
control among senior dental students at college of
dentistry, university of Sharjah in the United Arab
Emirates. Eur J Dent 2013;7 Suppl 1:S15-9.
28) McCarthy GM, Britton JE. A survey of final-year
dental, medical and nursing students:
Occupational injuries and infection control. J Can
Dent Assoc 2000;66(10):561.
29) Ogden GR, Bahrami M, Sivarajasingam V, Phillips
G. Dental students' knowledge and compliance in
cross infection control procedures at a UK dental
hospital. Oral Dis 1997;3(1):25-30
6
 Pakistan Journal of Public Health, 2016 ( September )

Pak J Public Health Vol. 6, No. 3, 2016 Original Article

ASSESMENT OF THE COMMUNITY, KNOWLEDGE, ATTITUDE AND PRACTICE REGARDING

PILES OF GARBAGE AROUND UC – 9 GULSHAN-E-IQBAL TOWN DISTRICT EAST KARACHI

Saeeda Shaikh1,Rukhsana Khan2, Karim Bux1

1
Public Health Fellows at Health Services Academy Islamabad. 2Faculty of Public Health at Health Services
Academy Islamabad, Corresponding Author: Saeeda Shaikh, Public Health Fellows at Health Services Academy
Islamabad.

Abstract

Background: In the past the people with poor practices , such as burning dumps and polluting incinerators, have left
the negative perceptions of new SWM strategies . In developing countries Uncollected solid waste is still a serious
public health issue in Health data show significantly higher rates of diarrhea and acute respiratory infections for
children living in households where solid waste is dumped or burned in the vicinity, as compared with households in
the same cities that receive a regular waste collection service, to assess the community knowledge, attitude and
practice regarding piles of garbage
Methods: Descriptive cross-sectional study (KAP survey) was conducted. Systemic random sampling method for
selection of participant was used pretested and questionnaire was pretested. Data analysis was done by using MS
Excel and SPSS.
Results: The key findings 98%of the community had knowledge on solid waste management, out of 100
respondents,73% respondents knew the importance of solid waste management 76% know garbage related to
transmission of diseases , 49% expressed that they want to educate their family on garbage at proper place , 58%
expressed that crime, unemployment and cost of living are more important to them than garbage free community
.Regarding the practices 58% respondents dispose of their house hold refuse at nearby trashes,47%
respondents take measures for waste to make safer for health ,69% of children up to 5 years of age were found
sick , among them 33% were sick due to fever, 67% adults remain sick out of which 46% were due to fever.
Conclusion: This study indicates that despite of good knowledge, the community have no concerned with public
health issues that is why they wanted to get training on waste management
Key Words: Solid waste management, environmental degradation, garbage, trashes.

Introduction environmental issues(3). Urbanization, inequality, and

In the area of UC-9 town Gulshan e Iqbal a large number
of sweepers have been deployed by the Municipalities
but their services are irregular and limited, citizen are not
provided with enough rubbish bins and proper disposing
facilities. Waste is either burned in pits or disposed of in
uncontrolled dumps or in the forms of piles of garbage
near the household community living in flats or in
bungalows. Infect the bins are kept at the main roads
and in streets and majority of the households are
habitual of throwing their waste on empty plots or
grounds around their residential area which impact on
the health of people and causes the diseases(1).
In the past the people with poor practices , such
as burning dumps and polluting incinerators, have left
the negative perceptions of new SWM strategies .
therefore to manage the household refuse and educate
the people it is necessary to avoid the negligence and
lack of law to punish sanitary offenders are the major
causes of solid waste management(2). Certain studies
have recommended that the community can get a
benefit if accumulate their social capital with respect to
economic growth; cultural and socio-economic aspects;
policy, governance, and institutional issues; and
international influences have complicated SWM in
developing countries(4).It has been observed that in the
middle ages cities were plastered in an odorous mud,
stagnant water, household waste, animal and human
excrement which created very favorable conditions for
vectors of disease. the Black Death, which struck
Europe in the early 1300s(5). Uncontrolled dumping and
improper waste handling causes a variety of problems,
water, attracting insects and rodents, and increasing
flooding due to blocked managed solid waste poses a
risk to earth and the environment which may result in
safety hazards from fires or explosions.. in Seurat in
India in 1994, due to Uncollected waste and blockage of
the drains causes flood and subsequent spread of
water-borne diseases which resulted in an outbreak of a
plague-like disease affected 1000 and killed 56
people(6). It increases green house gas (GHG)
emissions, which contribute to hazardous climate
change,(7)and also a significant environmental impacts

7
 Pakistan Journal of Public Health, 2016 ( September )
as well. As the waste decomposes, it creates leach ate a
mix of toxic and nontoxic liquids and rainwater which
may get into local water supplies and contaminate the
drinking water. not only globalization impact on waste
management, but also waste management, as a major
environmental activity, impacts globalization In order to
deal this harmful situation there are proactive
approaches for the development of capabilities for the
management of environmental risks(8). In response to
this the Chinese government has been developing
approaches to environmental management, such as
establishing strict environmental regulations,
promoting cleaner production and encouraging ISO
14001 certification(9). This threat of poor waste
management is most prominent in low-income countries
also where waste-collection rates are often below 50 per
cent. The global financial crisis seems to have worsened
the situation, from 30 Organization for Economic
Cooperation and Development (OECD) countries it has
been estimated that a 1% increase in national income
creates a 0.69% increase in municipal solid waste
amount per year(10). According to the Awareness Index
in 1991 the parishes with the most aware persons were
St. Elizabeth (83.3%), Westmoreland (73.8%),
Clarendon (51.1%) and St. Andrew (45.9%). The
parishes with the most unaware persons were Hanover
(68.3%), St. Mary (65.0%), St. Catherine (58.0%), St.
Ann (47.5%) the reason for the high level of awareness
in Portland, St. James, St. Ann and Westmoreland in
1998 might be the activities of strong NGOs
there(11).Factors Influencing Sustainable Waste
Management System:Government Policy, Government
Finances, Waste Characterization, Waste Collection
and Segregation, Household Education, Household
Economics, Municipal Solid Waste Management
(MSWM) Administration, Personnel Education, MWM
Plan, Recycled-Material, Technicalstaff, Availability of
landfills(12). In Pakistan 80% vegetables and fruits are
irrigated through sewerage water which may
contaminates them and harm the population by eating
those vegetables or fruits. Shepherds are in common
practice to bring their animals for grazing grass, small
herbs or vegetation growing around sewerage water
and in some portions of the dumping sites. These may
lead to harm due to potential entry into the food chain.
With time population will increase with more utilization of
pharmaceuticals which will become the part of
environment through the waste(13). Solid waste
management by municipalities as a whole is quite
inefficient as it collects only -69% of the total waste
generated. The rate of waste generation on average
from all type of municipal controlled areas varies
from0.283 kg/capita/day to 0.613 kg/capita/day or from
1.896kg/house/day to 4.29 kg/house/day(14).
Methodology Gulshan-e Iqbal town was
established with new system of local Government on the
14thAugust 2001 under Sindh Local Govt. Ordinance
2001.This town was named in honor of Pakistan's
national poet Allama Muhammad Iqbal. Gulshan-e-
Iqbal literally translates to 'Garden of Iqbal'. Gulshan-e-
Iqbaltown is one of the biggest town of city district Govt.
of Karachi, the town consist of Areas, which were
previously (prior to inception of town) under
Administrative control of DMC, East Dehi Councils, KDA
/ Revenue Schemes, DehGujro, DMC Malir, its
boundaries can be detailed as under Started from
Baloch Colony Shahrah-e-Faisal at one end towards
South. Teen Hatti towards waste along with Liyari River
up to Super Highway towards North end up to
MalirCantt. towards East.1
A Descriptive cross-sectional study (KAP
survey) was conducted.in union council -9 of Gulshan-e-
Iqbal town district east Karachi to assessthe public
knowledge, attitude and practice regarding piles of
garbage under waste managementThe respondents
included all members both genders of the household 18
years above.Systematic random sampling technique
was used for selection of household..The sample size
was 100 represents 150,000 of the total households of
the target town.To ensure homogeneity, the collectors
were instructed to cover the whole study area by
following systematic random sampling method for
selection of participant was used pretested and
questionnaire was pretested. Data analysis was done
by using MS Excel and SPSS. Frequencies and
percentages were calculated for categorical variables
and summary statistics for continuous variables. Tables
and -graphs were used to present the data.
Results: Based on the sample size of 100 the overall
response rate was good with higher percentage of male
respondents as compared to females. The reason for a
higher ratio of male respondents seems to be mainly
cultural, as in their society females are generally not
allowed to interact with outsiders because of prevailing
current law & order situation in city, but by enlarge
culture is advance in this study area. Majority of the
population of urban type having Muslim inmajority,The
community respondents were in age category of 36-
45.When question asked by the community regarding
ethnicity, it was found that majority of the population96%
was Muslim 3% Christian 1% hindu.Among the
respondents it was observed 72% males 28% were
female. The respondents were asked about their level of
education ,Eighty two % were literate 7% not educated
1% religious 97% employed non employed were 3%
among study population Majority of population were
educated, & working class two person in one house
were earning hand Rs.31,000-50,000. Similar results
were shown15 the average of the adults were 4-6 per
house.The respondents about knowledge/ awareness
of waste management seventy-three percentanswered
they know about waste management 73% When the
question asked about who is responsible to clean
surrounding 41% mentioned the area representatives.
8
 Pakistan Journal of Public Health, 2016 ( September )

Knowledge of people regarding waste management

Variables Options Frequency Percentage
Knowledge about solid waste Yes 98 98.0
management?
No 2 2.0
Keep separate dust bins (covered) Yes 62 62.0
reduce the transmission of diseases? No 30 30.0
Don’t know 8 8.0
Knowledge about disease related Yes 37 37.0
improper storage and disposal of waste? No 63 63.0
Reasons of overflow of drains and gutters Garbage 26 26.0
in muhallah? throwing
Shoppers in 59 59.0
drains
Other 7 7.0
No opinion 8 8.0
Responsible to clean surrounding? The individual 13 13.0
themselves
Mohalla 19 19.0
/Committee
Area 41 41.0
representative
Municipality 26 26.0
Others 1 1.0
Have been affected from any disease Yes 29 29.0
caused by waste disposal in the past six No 65 65.0
months?
don’t know 6 6.0
Clean environment is important to Yes 79 79.0
prevent from diseases? No 18 18.0
Don’t know 3 3.0

This study revealed that the need for behavioral and
attitudinal change is essential and effective participation
towards waste disposal, reduction, reuse and recycling.
In this study 98% population having adequate
knowledge of solid waste managemnt. The analysis
indicates that the public has at least some
understanding of the links between solid waste
management practices and environmental health. It is
the prime duty area representative to clean the
surrounding said by community. Major issues effecting

9
 Pakistan Journal of Public Health, 2016 ( September )

Karachi environment were automobile exhaust, sewage environment were Household Garbage, Auto Exhaust
pollution, factories, household garbage. Almost similar and Sewage Pollution.40It's better to save the natural
results were shown inprevious study. In 1991, the three environment by reduction of piles of garbage
factors believed to most negatively impact the Jamaican cleanliness of surrounding & so on garbage.

Table- 2 Attitudes of people regarding waste management

Variables Options Frequency Percentage

Satisfied with performance of Yes 10 10.0

municipality staff? No 33 33.0
5 5.0
Don’t know

Staff not available 52 52.0

Concerned 45 45.0
Concerned about health risk No concerned 47 47.0
related to burning garbage? Don’t know 8 8.0
People throw garbage in the Yes 66 66.0
streets, drain and gully because No 19 19.0
they don’t have any other means
Don’t know 15 15.0
of get rid of disposing of their

garbage?

Piles of garbage related to Yes 76 76.0

transmission of disease No 24 24.0
Which diseases? Diarrhea 20 20.0
Typhoid 5 5.0
Malaria 37 37.0
Hepatitis 7 7.0
Others 7 7.0
No disease 24 24.0
Crime, unemployment and cost of Yes 58 58.0
living are more important than No 32 32.0
garbage free community? Don’t know 10 10.0
Regular collection of garbage is Yes 89 89.0
the only solution to garbage No 3 3.0
problem? Don’t know 8 8.0

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 Pakistan Journal of Public Health, 2016 ( September )

Table -3 Practices of people regarding waste management

Variables Options Frequency Percentage

Use of municipality & services 36 36.0

Use of private contractor 2 2.0

Dumping in nearby trash 58 58.0
How dispose refuse of
household? Others 4 4.0

How is responsible to clean Head of household 58 58.0

house? Daughter/Son 6 6.0
Masi / Sweeper 34 34.0
Others 2 2.0
Where dispose garbage? Dust bin 83 83.0
kuchrakundi 3 3.0
Outside house 11 11.0
Bushes 1 1.0
Other specify 2 2.0
On roadside 0 0
Metal bin 23 23.0

Plastic bin 56 56.0

Oil drum 8 8.0

Where familydeposit waste from
house Bag 5 5.0
Container with cover 1 1.0
Container without Cover 4 4.0
Others 3 3.0
Yes 56 56.0
Collecting garbage into shoppers No 44 44.0
before throwing it into dust bins?
Segregate kachra before Yes 10 10.0
disposal? No 90 90.0

Any exercise for waste disposal to Yes 47 47.0

make safer health? No 49 49.0
Don’t know 4 4.0

Pickup truck open/closed 21 21.0

11
 Pakistan Journal of Public Health, 2016 ( September )
Discussion: Majority of the respondents were of the
view to get training on waste management. They wanted
to learn about throwing of garbage at proper place, and
waste disposal methods. The burning of garbage related
to health risk replied by community (47%) have no
concerned with the issue. This type of study had already
been done in Nigeria where all respondents (100%)
were concerned about the diseases related to improper
waste storage and disposal and only a few (3.3%) were
not concerned about the health-risk related to burning
garbage(16). Its trend in the community throw garbage
in the streets, drains and gullies, majority of people were
of view don't have no other means of get rid of
disposing of their garbage In the case study of Dhaka,
Bangladesh, Iftekhar (2004) found out that over 3,000
tons of household wastes are produced daily and that
less than half of it were collected while the remaining
were left on roadsides, in open drains and nalas(17).It is
pointed out that majority have views regarding Pile of
garbage is related to transmission of diseases malaria &
Diarrhea. The community disposed of their refuse of
households of garbage dump nearby trashes & dispose
of garbage by dustbin. They segregate kachra before
disposal. They have practices of waste transport to final
destination hand carry & this study supported by (Kazi
1999); dumping of wastes at sites increasingly away
from the city center without any provision for transfer
station would become a major financial burden for the
DCC in the coming years. Besides fuel cost, this would
also increase the cost for maintenance and spare parts
for waste-carrying vehicles. Moreover as more hauling
distance would have to be traveled, the possibility of
spillage of solid waste during transportation wills
increase(18).
The findings found support with previous
studies Scott and Willet, 1994(19); McKenzie-Mohr et
al., 1995(20); Bradley et al., 1999(21); Eero et al.,
2001)(22), who has documented some relationship
between some socio-demographic variables such as
sex, age, and education and environmental
behavior/practices. The main source of refuse is
domestic which is in form of food waste, garden waste,
unwanted household materials like plastics, wood and
papers., Mir Aftab (2004)(23) carried out a similar
research in Cape Town on waste collection using the
method of interviewing city officials and collecting waste
data from the city council and concluded that most
refuse generated in urban areas is from households.
Conclusion: This study indicates that despite of good
knowledge, the community have no concerned with
public health issues that is why they wanted to get
training on waste management regarding piles of
garbage & its disposal. Towards the attitude of
community the respondents were used to throw
'garbage into streets, drains, gullis and roads because
they have no other means of get rid of it and they are not
satisfied with performance of municipality staff that are
not performing duties properly It became contributing
factors in the transmission of disease like malaria,
diarrhea which played an important role in relation to
diseases prevalence. . As far as practices are
concerned they were good enough like dispose of
garbage, refuse in nearby trashes, deposits their waste
in plastic bin, collecting of garbage into shoppers before
throwing into dust bins, but do not segregate their house
hold waste before disposal, they exercise for waste
disposal to make safer for health, and transport to final
disposal site by hand carrying.
Refrences.
1. Annual Sector Plan. For Specific Reforms through
Improvements / Rehabilitation and Restructuring
of Solid Waste Management Services (SWM
Sector) of Gulshan-e-Iqbal Town.
2. Abrokwah, K. 1998. “Refuse Management
problems in central Kumasi”.
3. Status Report on Population, human Resource
and Development planning and policy in Ghana
1960 to 1991. National Population Council,
Ashanti Press, Kumasi.Figueroa, M. 1998. “The
community as a resource for solid waste
management”, in E.
4. Boadi, K., Kuitunen, M., Raheem, K., Hanninen,
K., 2005. Urbanization without development:
environmental and health implications in African
cities .Environment, Development and
Sustainability 7 (4), 465–500
5. Louis, G.E., 2004. A historical context of municipal
solid waste management in the United States.
Waste Management & Research 22 (4), 306–322.
6. Gupta SK(2010) Plague-like epidemic in Surat,
India. In Solid Waste Management in the Worlds
Cities (ScheinbergA,Wilson DC and Rodic L
(eds)). Earthscan for UN-Habitat,London, UK, p.
21, box 2.2.
7. United States Environmental Protection
AgencyEPA530-F-02-026d(5306W)Solid Waste
and Emergency Response May
2002www.epa.gov/global warming Indus Journal
of Management & Social Sciences, 5(2):100-105
(Fall 2011).
8. .[file:///C:/Users/hp/Documents/primary and
secondary collection / waste.
9. Frankel Jeffrey A., 2002, “The Environment and
Economic Globalization in Globalization:
What's New, edited by Michael Weinstein, Council
on Foreign Relations
10. Waste management 2030+
11. Espeut, Peter. 1999. Attitudes to the Environment
in Jamaica, 1998. Prepared by the Caribbean
Coastal Area Management Foundation.
12. Troschintez, A. 2005. “Twelve Factors Influencing
Sustainable Recycling of Municipal Solid Waste in
Developing Countries.” Masters of Science in
Environmental Engineering Thesis, Michigan
Technological University. Houghton, Michigan.
13. KhudaBakhsh and Sarfaraz Hassan, waste water
12
 Pakistan Journal of Public Health, 2016 ( September )
use in Pakistan: The cases of Haroonabad and
Faisalabad, International journal of agriculture and
biology 1560-8530/2006/80-3-423-425
14. Brief on Solid Waste Management in Pakistan
National study on privatization of solid waste
management in eight cities of Pakistan, EPMC,
1996.
15. Agbola, T. 1993 “Environmental education in
Nigerian schools”. In Filho .L. (ed) Environmental
Education in the Commonwealth, the
Commonwealth of learning, Vancouver
16. Iearn gen environment-global issues (Wesley high
school Otukpo, Benue state Nigeria)
17. I f t e k h a r, E . ( 2 0 0 4 ) H o u s e h o l d W a s t e
Management. Footsteps59 (1) 10-11
18. Kazi MN (1999). Capacity Building for Primary
Collection in Solid Waste, Citizens Guide for
Dhaka, Environmental and Development
Associates (BDA), Dhaka, in association with
Water, Engineering and Development Centers
(WEDC), Loughborough University, U.K
19. Scott D, Willets FK (1994). Environmental
attitudes and behavior. Environ. Behavior26 (2):
239-261
20. McKenzie-Mohr D, Nemeroff LS, Beers L,
Desamrais S (1995). Determinants of responsible
environmental behavior. J. Social Issues. 51: 139-
156.
21. Bradley CJ ,Waliczek TM, Zajicek JM (1999 ).
Relationship between environmental knowledge
and environmental attitude of high school
students. J. Environ. Edu. 30(3): 17-21.
22. Eero O, Grendstad G, Wollebak D (2001).
Correlates of environmental behaviors: Bringing
back social context. Environ. Behavior. 33: 181-
208
23. Miraftab, F. (2004), Neoliberisation and
Casualization of Public Sector Services: The
Case of Waste Collection in Cape Town, South
Africa. International Journal of Urban and Regional
Research, Vol 28 No. 4, pp 874-892.
13
 Pakistan Journal of Public Health, 2016 ( September )

Pak J Public Health Vol. 6, No. 3, 2016 Original Article

EVALUATING THE EFFECTIVENESS OF FIRST AID TRAINING COURSE ON NON-

HEALTHCARE PROFESSIONAL VOLUNTEERS IN ISLAMABAD

Afsar Jan, Gideon Victor

Shifa College of Nursing Islamabad Pakistan.

Email: shaniuz1975@gmail.com

Abstract

Background: Everybody in the community may face with emergency cases that need first aid applications. The
person who is supposed to save the life and to practice first aid application is the person who is the nearest to the
victim of emergency case. It is thought that training the community on first aid is very beneficial.
Objectives: 1). to assess pre and post knowledge of first aid training course on non-health professional volunteers.
2). to compare pre and post knowledge of first aid training course on non-health professional volunteers.
Methods: A quasi experimental (pre & post) study design was used to compare pre and post knowledge of First Aid
Training Course on non-health professional volunteers. The study population for the study was all the volunteers of
the community center. The sample unit in the study is a single participant. Sample was universal sample, i.e. 43
participants of the session.
Results: The mean age of study participants is 22.3 ±4.30 (min 17, max 39). The gender proportion male (n=25,
58%) and female (n=18, 42%). The highest level of education was graduation following 56% (n=24) and lowest 2%
(n=1).The mean scores of knowledge in pretest is 14.39±3.78, while 21.60±1.13 in posttest with t-value -13.968 at df
=42 and p=value <0.000. The mean scores of skills in pretest is 3.16±1.61, while 22.37±1.91 in posttest with t-value -
44.998 at df =42 and p=value <0.000.
Conclusion: In conclusion, first aid is for everyone, which could save many lives. Knowledge and application of first
aid skills is imperative to perform injury prevention and lifesaving activities. Regular and periodical community based
first aid training programs for first care responders will help to provide care and improve outcomes for injured
persons.
Key words: first aid, volunteers.

Introduction community is ready against emergency cases. Injuries

Natural disasters such as earthquake and erosion, war
and accidents have been causing disabilities and death
of so many people as well as leaving people homeless1.
These cases are still very important problems for human
being, actually never ends, although there are
sophisticated developments in science and
technology(1). According to EERA Special Earthquake
Report, February 2006, the Pakistani government's
official death toll as of October 2005 stood at 100,0002.
Approximately 138,000 were injured and over 3.5 million
rendered homeless. According to government figures,
19,000 children died in the earthquake, most of them in
widespread collapses of school buildings. The
earthquake affected more than 500,000 families(2). The
community as well as state and state institutions must
be ready against emergency cases(3).Only those
communities, which are ready against emergency
cases, can practice effective life saving and first aid
applications. For this reason the capacity of community
on first aid issue can not be underestimated. It is obvious
that training is the most important way to get the
rank among the leading causes of morbidity and
mortality worldwide, and are steadily increasing in
developing countries(3). It is vital to provide first aid to
the victim on time and first aid provider may be any
person who is trained for first aid, even a first aid
provider may be a lay person. Laypersons are an
important factor for saving lives in emergency
situations(4). According to Eisenburger and Safar, Life-
Supporting First-Aid (LSFA) should be part of basic
health education and all persons from the age of 10(4).
Several studies have shown a clear relationship
between the level of first aid training and the quality of
first aid measures provided(5). One important barrier
and main concern of laypersons about giving first aid to
acute ill or injured people is the fear to make
mistakes(6).First aid is the initial assistance or treatment
given at the site of accident to someone who is injured or
suddenly taken ill, before the arrival of ambulance(7). A
first aid provider should be able to assess the situation
quickly and calmly, deal with life threatening conditions
meanwhile protecting him/her self from the danger,

14
 Pakistan Journal of Public Health, 2016 ( September )
obtain medical aid and call an ambulance in case of
serious injury or illness(8).
In view of the above scenario, first aid has a special
importance in Pakistan where earthquake, flood, and
traffic accidents often occur and leave so many
causalities. Although, there are many such training are
given to lay persons but there are limited studies
investigating effectiveness of first aid being provided
and determining the knowledge needs of the community
in Pakistan. The main purpose of this study is to asses
the effectiveness of first aid training in non health
professional volunteers in a community of Islamabad.
Research Hypothesis:
There is difference between pre and post session of
knowledge and skill of first aid training in non health
professionals volunteers.
Research question:
Is there any difference between pre and post session
knowledge and skills of first aid training in non health
professional volunteers?
General Objective:
The general objective of this study is to evaluate the
effectiveness of First Aid Training Course on non health
professional volunteers.
Specific Objectives:
Ÿ To assess pre and post knowledge of First Aid
Training Course on non health professional
volunteers
Ÿ To compare pre and post knowledge of First Aid
Training Course on non health professional
volunteers.
Methodology:
A quasi experimental (pre & post) study design was
used to compare pre and post knowledge of First Aid
Training Course on non health professional volunteers.
Mean score of knowledge in pre test and post test were
calculated and further compared these mean scores of
knowledge between pre and post test to see any
significant difference. Similarly, mean score of skills in
pre test and post test were calculated and further
compared these mean scores of skills between pre and
post test to see any significant difference. The study
period was December 21st-31st 2015 and study setting
was a community centre Islamabad. The study
population for the study was all the volunteers of the
Community centre. The sample unit in the study is a
single participant. Sample was universal sample, i.e. 43
participants of the session selected based on the
following inclusion criteria:
Ÿ Participating in the first aid training session first time
Ÿ At least passed metric
Researchers took data using an evaluation tool to test
pre& post knowledge and skills levels. The instrument
comprised of three parts; in part A the participants will be
about the socio-demographics, part B consists of 23
questions about knowledge of first aid and measured
objectively as yes (if knowledge is accurate)=1, no=0 (if
knowledge is inaccurate). In part C, participants were
assessed for skills of first aid which contained 27 items
as a performa and measured as done appropriately=1,
not done appropriately=0. The validity and reliability of
these tools were tested by pilot study. Using this tool,
before the session, a pre test was taken. Then properly
these participantswere trained by using techniques such
as lecture, role-playing,question- and-answer,
demonstration, and power point presentations. The
trainers wereshowed how to apply first aid techniques
such assplint, bandage, and slide materials on human
mannequins. After the session, using the same tool, post
test was taken.Questionnaire was coded before
entering the data to computer by the researcher. The
sample database was checked by double entry. For data
analysis, the Statistical Package for the Social Sciences
(SPSS version 20) was used. The data was analyzed
using descriptive and inferential statistics. T-dependant
test was applied to see any significant difference
between pre and post mean score of knowledge and
mean score of skills. The results have been presented in
terms of means and standard deviationsand
percentages in tabular and graphical form. Independent
variables of the study are age, sex, and level of
education. Dependent variables were scores of pre and
post test knowledge level and skills about first aid
training.
Ethical Consideration
The study was approved from Shifa International
Hospital's Institutional Review Board and Ethical
Committee; approval reference # 535-384-2015.
Permission from president of the community centreto
carry out the research was also taken.Data was
collected anonymously and written informed
consentwas takenfromstudy participants.
Results
Table-1 Socio-demographic characteristics of
study participants:
Total participants (n=43) n (%)
Age of Participants
Min 17
Max 39
Mode 21
Mean 22
SD 4.30
Gender
Male 25(58%)
Female 18(42%)
Education Status of
Participants
Matric 1(2%)
Intermediate 10(23%)
Graduate 24(56%)
Other 8(19%)
Table 1: The mean age of study participants is 22.3
years with SD 4.30. The minimum age was 17 and
maximum 39 years, and mode is 21years of age. It is
15
 Pakistan Journal of Public Health, 2016 ( September )

clear from the table that proportion of male (n=25, 58%) In table 4.0, t-value -13.968 at df =42 and P-value 0.000
participants was higher than female (n=18, 42%).As clearly depicts that the mean score of knowledge in post
shown in the table, the highest level of education among test is significantly higher than that of pre-test.
the participants was graduation followed by Table 5: Difference between pre and post test scores
intermediate which were 56% (n=24) and 23% (n=10) of Skills
respectively. The lowest level of education was metric
Paired t-value df p-value
which was only 2% (n=1).
Mean score of Knowledge and skills in Pre and Post Differences
test mean SD
The first objective was to assess pre and post
knowledge of First Aid Training Course on non health Mean score of -44.99 42 0.000
professional volunteers. skills in pre
Table 2: Mean score of Knowledge in Pre and Post test- Mean -19.20 2.79
test
score of skills
Mean N Std. Deviation
in post test
Pre knowledge 14.39 43 3.78
In table 5.0, t-value -44.998 at df =42 and P-value 0.000
Post knowledge 21.60 43 1.13 clearly depicts that the mean score of skills in post test is
significantly higher than that of pre-test.
Discussion: This study assessed the pre and post
Table 2 clearly shows the mean scores of knowledge in knowledge and skills of study participants. The study
pre test is 14.39 with standard deviation 3.78, while the demonstrated the minimum age of participants was 17
mean score of knowledge in post test is 21.60 with and maximum 39 years, and mean 22.3 (SD=4.30) and
standard deviation 1.13. gender male (n=25, 58%) participants was higher than
Table 3: Mean score of Skills in Pre and Post test female (n=18, 42%). Regardless of age and gender, first
aid is for every on(9). Including this study other
Mean N Std. Deviation studies(10,1) has the younger age of participants in the
Pre skills 3.16 43 1.61 first aid training. The younger population considered to
participate in live saving activities more actively.
Post skills 22.37 43 1.91 Whereas, one study reported application of first aid in 4-
5 year of age, most of the children involved in the study
were able to apply learnt skills after two months of the
Table 3 clearly shows the mean scores of skills in pre test training(6). While two studies highlighted the role of
is 3.16 with standard deviation 1.61, while the mean older age 65+ years' first aid responders(11,12).
score of skills in post test is 22.37 with standard However, one study reported the older peoples have
deviation 1.91. difficulty performing first aid skills(12). There were
Difference between pre and post test scores of majority of male 58% male, while 42% females in this
Knowledge and Skills study. The higher proportion of male is also consistent in
The second objective of this study was to compare pre a study carried out in India, 75.88% male and 24.12%
and post test scores for knowledge and skills. To fulfill female(3). Male may have assumed their responsibility
this objective the mean scoresof pre test were compared in carrying out lifesaving activities in the communities,
with those of post test separately for both knowledge consequently they participated more in the first aid
and skills. The results are shown in table 4.0-5.0 trainings. Though, one study pointed out the role of
Table 4: Difference between pre and post test scores female (housewives) at the time of disaster as
of Knowledge accidental injuries, which can include anything from falls
Paired t-value df p-value and burns to wounds, often occur at home. In fact, it is
the second most common location of accidental fatal
Differences
injuries(11). Unsurprisingly, first responders are usually
mean SD also from within those same households or immediate
Mean score of -7.20 3.38 -13.96 42 0.000 communities(13). Therefore, during large-scale
disasters, households should be prepared to be self-
knowledge in sufficient until first responders (and relief) can reach the
pre test- Mean affected areas and residents. The highest level of
education among the participants was graduation
score of
followed by intermediate which were 56% (n=24) and
knowledge in 23% (n=10) respectively. The lowest level of education
post test was metric which was only 2% (n=1). Due to significant

16
 Pakistan Journal of Public Health, 2016 ( September )
dispersion in data the educational inferences could not
be made. However, Delavar's study(10) found that there
was a significant difference between education level and
the knowledge score (p= <0.0001). Whereas, Bollig(6)
suggested laypersons are an important factor for saving
lives in emergency situations.The mean score of
knowledge in pretest is 14.39 ± 3.78, while 21.60 ± 1.13
in posttest. This difference clearly reflects the gap in first
aid knowledge. A lack of first-aid knowledge can
increase the risks associated with domestic accidents.
Many emergency services report that parents bring their
child suffering from burns without having cooled the
burnt parts of his body or that parents believe poisoning
can be cured by making their child vomit(14). There is
strong evidence in this data this study's data set that first
aid training has significantly increase the knowledge of
study participants since increase in the knowledge score
7.21 and there is statistically difference (t-value -13.968
at df = 42, p=value <0.000). The importance of first aid
knowledge is emphasized because up to 150,000
people a year could be given a chance to live if more
people knew first aid(15). Second to the knowledge of
first aid is skills application. The mean scores in this
study of skills application in pretest 3.16±1.61, while
22.37±1.91 in post test and two sample t-test
significantly different (t-value -44.998 at df =42 and p=-
value <0.000). There is strong proof in this data set that
first aid training has significantly improved the
application of first aid skills. The studies related to the
first aid showed that consciously and timely first aid
applications lowered mortality ratios significantly. 15-18
percent of deaths as a result of injuries can be prevented
by consciously applied first aid practices(1).
Conclusion: In conclusion, first aid is for everyone,
which could save many lives. Research on blunt trauma
injuries,(16) and injuries from traffic accidents,(17) have
also shown significant improvements in mortality rates
when first aid was applied. Nevertheless, knowledge
and application of first aid skills is imperative to perform
injury prevention and lifesaving activities. Repetition of
training appears to be a significant variable in skill
retention, and hence, strategies for increasing the
repetition of the skills and knowledge should be
explored(18). Regular and periodical community based
first aid training programs for first care responders will
help to provide care and improve outcomes for injured
persons(15). This study has revealed that first aid
training can improve the knowledge and skills
application of first aid, as a result saving many lives and
a source of help at the time of disaster situations.
References
1. Bayraktar N, Çelik SS, Ünlü H, Bulut H. Evaluating
the Effectiveness of a First Aid Training Course on
Drivers. Hacettepe U Faculty Health Sci Nurs J
2009; 47-58. Earthquake Engineering Research
Institute
2. Learning from Earthquakes: The Kashmir
Earthquake of October 8, 2005: Impacts in
Pakistan. EERI Special Earthquake Report 2006
Feb; 1-8.
3. Pallavisarji U, Gururaj G, Girish RN. Practice and
perception of first aid among lay first responders in
a southern district of India. Arch Trauma Res 2013;
1(4): 155-160. DOI: 10.5812/atr.7972
4. Eisenburger P, Safar P: Life supporting first aid
training of the public review and
recommendations. Resusc 1999, 41(1):3-18.
5. Zakariassen E, Andersen JE: First aid for 1Class.
Scand J Trauma Resusc Emerg Med 2004,
12:162-165.
6. Bollig G, Myklebust AG, Østringen K. Effects of first
aid training in the kindergarten - a pilot study.
Scand J Trauma, Resusc Emerg Med 2011;
19(13):2-7.
7. Emergency First Aid. 1st ed. London: Dorling
Kindersley; 1997.
8. Abbas A, Bukhari SI, Ahmed F. Knowledge of first
aid and basic life support amongst medical
students: a comparison between trained and un-
trained students.JPak Med Assoc 2011 June;
61(6):613-6
9. International Federation of Red Cross and Red
Crescent Societies. Law and first aid: Promoting
and protecting life-saving action.Geneva, 2015
10. Delavar MA, Gholami G, Ahmadi L, Moshtaghian
R. Knowledge, attitude and practices of relief
workers regarding first aid measures. JPak Med
Assoc 2012; 62(218):218-221.
11. Ahmed WAM, Salman AO, Arafa KA. Households'
preparedness for first-aid of burns and falls in
Khartoum. Afr J Emergency Med 2014; 4:184–187
http://dx.doi.org/10.1016/j.afjem.2014.07.010
12. Harvey LA, et al. A population-based survey of
knowledge of first aid for burns in New South
Wales. Med J Aust2011;195(8):465-468.
13. Hoon RS. Introduction to First Aid; First aid to the
injured Saint John's Ambulance Association. 1st
ed. 2002.
14. International Federation of Red Cross and Red
Crescent Societies, First aid for a safer future
Updated global edition: Advocacy report 2010.
September 2010.
15. Real First Aid. Duty of care and law. [cited 2016 Jun
1 ] . A v a i l a b l e f r o m
http://www.realfirstaid.co.uk/dutyofcare/
16. Tannvik, T., et al, A systematic literature review on
first aid provided by laypeople to trauma victims,
Acta Anaesthesiol Scand 2012; 56(10):
1222–1227.
17. Arbon P, Haynes J. First aid and Harm
Minimisation for Victims of Road Trauma: A
Population Study – Final Report June 2007. [cited
2 0 1 6 J u n 2 ] , a v a i l a b l e f r o m
http://clicktosave.com.au/wp-
content/uploads/2013/06/Australian_Population_Stu
dy_on_victims_of_Road_Trauma1.pdf
18. Anderson G. CPR and First Aid Skill Retention.
University College of the Fraser Valley. 2008.
17
 Pakistan Journal of Public Health, 2016 ( September )

Pak J Public Health Vol. 6, No. 3, 2016 Original Article

CHILD MENTAL HEALTH RESEARCH IN PAKISTAN; MAJOR CHALLENGES AND PITFALLS: A

SYSTEMATIC REVIEW

Tanzil Jamali1, Sana Tanzil1

1
Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
Corresponding author and reprint request: Dr. Tanzil Jamali, Department of Community Health Sciences,
Aga Khan University, Karachi, Stadium Road P.O Box 3500 Karachi 74800, Phone number: 92-21-486-4857, Email
address: tanzil.jamali@aku.edu

Abstract
Introduction: According to The World Health Report 2001, the prevalence of disabling mental illness among
children and adolescents is 20% worldwide. The estimated burden of psychiatric illness is much higher in developing
countries as compared to developed parts of world reporting a prevalence of 10-12%. Child mental health research
is a neglected area in Pakistan. The aim of this review is to understand the current status of child mental health
research in Pakistan.
Methods: “Pub Med and Pakmedinet database” were searched using key words “child mental health, Pakistan,
research”. A total of 33 articles were retrieved in from selected search engines. Of these, 22 studies excluded due to
(i) did not elaborate child mental health, (ii) elaborate adult mental health. Of 11 studies included, eight studies were
finally selected; directly related to mental health research among children in Pakistan.
Results: Small scale studies have reported the burden of common mental health disorders among children in
Pakistan. However important pitfalls in research methodology of these studies limit the reliability of estimates. The
major challenges faced by child mental health research in Pakistan include lack of recognition about the issue, lack
of validated research tools, dearth of intervention studies and lack of capacity within health system to support child
mental health. The only child mental health research tool validated in Pakistan is Strengths and Difficulties
Questionnaire.
Conclusion: The priority research agendas should emphasize on the development of locally validated research
tools to be used in children, identification of risk factors and tailored interventions for control and prevention of mental
health disorders among children in Pakistan.
Keywords: Child mental health, research, pakistan.

Introduction: of prevention and treatment of mental disorders among

Globally mental health is known to contribute about 30
percent towards the total burden of non-communicable
diseases and more than 70 percent of this burden is
contributed by lower and middle income countries(1).
Currently around 5 percent of children are suffering from
some psychiatric disorders worldwide(2). According to
the WHO`s global statistics, prevalence of disabling
mental illnesses among children and adolescence
attending urban health centers ranges between 20-30%
and 13-18% in rural areas(3). Developing countries
have been reported even higher prevalence rates of
mental health morbidity in children for psychiatric
problems as compared to developed countries(4).
However in many countries mental disorders among
children and adolescent are underreported; whereas
only a small proportion of these children and
adolescents diagnosed with some kind of psychiatric
disorder receive adequate medical care. Lack of
research has resulted in insufficient evidence about the
severity of the issue, its impact and appropriate methods
childhood and adolescence, particularly in developing
countries(5).
Pakistan is one of the countries where child mental
health is a neglected area with limited evidence
regarding the burden of various mental health disorders
among children and adolescents(1). Mental health
research is still an underdeveloped area due to various
reasons including lack of research capacity and
unavailability of child mental health screening tools(2,4).
The unavailability of the locally validated mental health
screening tools for children and adolescents also
hinders the control and prevention strategies at primary
health care level. So far, no national or provincial
estimates are available to report the burden of common
mental health disorders among children and
adolescents, however, few small scale studies have
identified the variable burden of various mental
disorders mostly among school-aged children while
using distinct research tools. A detailed review is
considered necessary to understand the current status

18
 Pakistan Journal of Public Health, 2016 ( September )
of child mental health research in Pakistan and various
child mental health disorders among children in
Pakistan. The identification of research gaps and major
bottle necks in child mental health research in Pakistan
provide the future direction for child mental health
research.
Methods:
Literature was searched to using electronic sources to
access published literature. Pub Med sources and
Pakmedinet were searched using key words “child
mental health, Pakistan, research”. The search was
limited to articles for which full text was available in
English language, which focused any mental health
disorder or issue and included only children and
adolescents up to 19 years of age. A total of 33 published
articles were retrieved from selected search engines
after screening through predefined eligibility criteria.
The pre-defined inclusion criteria included all the studies
which were directly related to mental health research
among children and was conducted in Pakistan.
Of these 22 studies excluded due to (i) did not elaborate
child mental health, (ii) elaborate adult mental health.
Out of 11 studies (3 excluded due to not accessible),
eight studies included in the final analysis, three articles
were related to emotional behavior among children, two
were related to learning disability, one related to
treatment in neuropsychiatry illness, one review article
on issues in child mental health in Pakistan and one
interventional study on child mental health school
program (Figure 1).
Results:
This review has identified the burden, interventions or
strategies for reducing mental health issues based on an
analysis of 8 studies selected on preset criteria (Table 1).
Discussion:
a. Unrecognized burden of child mental health
problems:
The actual burden of common child mental health
disorders in Pakistan is not known due to lack of
research. Small scale studies are available focusing few
of the important mental health issues among children in
Pakistan. Behavioral and emotional problems and
intellectual disabilities are the common child mental
health problems in Pakistan. A cross sectional
community based survey conducted in rural settings of
district Rawalpindi screened children aged (2- 9) years
for cognitive and developmental disability using Ten
Question Screen (TQS). Results revealed that around
24.8 % of study children were screened positive for
learning disabilities 6. In another study conducted
among children of age 5-11 years, around 34% reported
to have emotional or behavioral disorders by their
parents; when assessed using strength and difficulties
questionnaire (SDQ)(7,8). The above mentioned
estimates reflect a high burden of emotional disorders
and learning disabilities among children in Pakistan.
These estimates reflect on the previously reported
estimates, reporting a considerably high burden of
mental retardation among children in Pakistan. It is
reported that in Pakistan rate of severe mental
retardation is 19.0/1,000 children for serious retardation
and 65.3/1,000 children for mild retardation(9).
A mixed methods study was conducted to explore the
current community management of intellectual
disabilities ID in Pakistan. The findings of the study
report that there was a delay of 2.92 years (CI: 1.9, 3.94)
to 4.17 years (CI: 2.34, 6.01) between detection and
care seeking for intellectual disabilities. The study
highlighted the important pit falls related to early
detection and management of intellectual disabilities
among children. Lack of awareness about causation
and availability of treatment for intellectual disabilities
were the main reasons contributing towards increased
morbidity(10). Studies conducted in two major cities of
Pakistan among 2 to 9 year-old children in Karachi and
6-10 years in Lahore have reported the factors
associated with increased risk of mental retardation
among children. The lack of maternal education,
histories of perinatal difficulties, small for gestational
age, neonatal infections, postnatal brain infections, and
traumatic brain injury and malnourishment were
identified as important risk factors for mental retardation
among children.
b. Strategies /intervention in school health
program:
The school based mental health program provides an
opportunity to understand the mental-health problems
among school aged children. World Health Organization
has given a model framework for school mental health
programs(11). The strategies to improve community
awareness of mental health, particularly in areas with
low literacy rates; school mental-health program and are
considered as effective interventions. In Pakistan this
19
 Pakistan Journal of Public Health, 2016 ( September )
can be counted as a missed opportunity. The only
published evidence of school based intervention in
Pakistan is reported from rural settings of Rawalpindi. A
small trial was conducted among secondary school
children to assess the impact of a school mental-health
program on community awareness regarding mental
health problems. The intervention targeted school
children (12-16 years), their parents, friends (who were
not attending school), and neighbors as well. Awareness
regarding mental health was assessed using a 19-item
questionnaire before and after a 4-month program of
mental-health education(12). The pre and post-
intervention scores were compared for the all study
groups. In the study group there was a significant
improvement in the mean scores after the school
program in the schoolchildren, their parents, friends and
neighbors. The school program succeeded in improving
awareness of mental health in schoolchildren and the
community(12). The school program was proven
effective in improving awareness of mental health in
schoolchildren and the community(12).
However, in Pakistan, there is no school based
intervention has been done, however, school-based
interventions has assessed in high income and low and
middle income countries(13,15). The systematic review
on the effects of school-based interventions on mental
health report that, overall, the curriculum might serve as
primary prevention for some students and as secondary
prevention for others. Another meta-analysis of primary
prevention mental health programs for children and
adolescents report programs modifying the school
environment individually focused mental health
promotion efforts. The average participant in primary
prevention program surpasses the performance from
59% to 82% of those in a control group and outcomes
reflect 8% to 46% difference in success rates favoring
prevention groups(15).
c. Validation of the screening tools for child
mental health:
Currently, in Pakistan, there is no system of routine
screening of infants and young children. Screening is
necessary in order to enable early detection and
appropriate intervention, particularly where there are
such high rates of disability(16). A Validation study,
conducted among children aged 5-11years in Karachi,
with the objective to compare CBCL (child behavior
check list) Urdu, with the validated Urdu version of
Strengths and Difficulties Questionnaire (SDQ) used as
“gold standard”. 556 parents filled out both the SDQ and
CBCLUrdu version. The scores from the parent rated
total SDQ scores were highly correlated with the total
CBCL scores (r=0.58). Therefore in Pakistan both
CBCL and SDQ are validated assessment tools for
behavioral problems, used for both clinical and research
purpose(17).
In Pakistan, depression assessment of children and
adolescent is very challenging, owing to the lack of any
validated screening tool(18). Among all the available
psychiatric tools for children and adolescent, only
Strength and Difficulties Questionnaire (SDQ),
(designed to screen emotional and behavioral problems
in children) is validated in Pakistan(17).
d. Challenges faced by Pakistan in Child mental
health:
In Pakistan, mental health is a neglected area and under
recognized as a public health issue(19). Literature is
scarce and mostly focuses of few most common
illnesses including anxiety and depression. Child mental
health is even much more neglected as a priority health
issue owning to a huge burden of diseases secondary to
malnutrition and communicable diseases. The most
common health disorders among children and
adolescents include depression, and learning
disabilities like autism, behavioral disorders including
attention deficit disorders and hyperactivity disorders.
Studies report in Pakistan the prevalence of psychiatric
morbidity among children from community samples
between 10 and 20% (20).
In Pakistan mental health illness is still under dispute as
an area of public health interest due to lack of capacity
within health system and poor commitments from
relevant authorities had resulted in lack of required
development in this health domain. This lack of interest
has resulted in a lack of research, lack of progress in
incorporating mental health as a part of a primary
healthcare and overall under recognition of this
problem. Child mental health is even much more
neglected in Pakistan despite of having a higher burden
of intellectual disabilities and psychiatric illnesses
among children. This negligence has resulted in lack of
awareness among general population, lack of child
mental health services and lack of research related
activities. This higher burden of mental health can also
be attributed to social inequities and can be secondary
to higher burden of mental health disorders among
adults, for example mothers. Research need for child
and adolescent mental health service, to identify priority
areas of child mental health; assess the actual burden of
mental health disorders and effective interventions for
control and prevention of such disorders(21).
Limitations and strengths of the review:
This review included articles from two search engines
only which might have resulted in inclusion of articles
only published in indexed journals only. Furthermore we
didn't include any gray literature from national data
sources. Majority of the studies included in the review
were small scale cross-sectional studies mainly among
school children and hospital / health care facilities with
several shortcomings including study methodology and
limited validity of the findings. However an inherent
limitation of this paper represents severe dearth of
quality evidence on mental health in the country.
However only one community based and one school
based randomize control trial having representative
samples and provide useful evidence for policy makers
in term of improving child's mental health. Nevertheless,
20
 Pakistan Journal of Public Health, 2016 ( September )

Table 1: Articles related to prevalence, general predictors and intervention among children in Pakistan.

s.no Title of article Name of journal Study Study site Key findings
design
1. Comparison of Urdu Journal of the College of Cross- School Scores from the parent
Version of Strengths Physicians and Surgeons sectional children in rated total SDQ scores
and Difficulties Pakistan study Karachi were highly correlated
Questionnaire (SDQ) with the total CBCL
and the Child scores (r=0.589)
Behavior Check List
(CBCL)Amongst
Primary School
Children in Karachi
2. Feasibility study on Journal of Pakistan Cross- Gujar Out of 1789 children,
the use of the Ten Psychiatric Society sectional Khan, 612 (34.2%) screened
Questions Screen by study District positive on TQS; 24.8
Lady Health Workers Rawalpindi % screened positive on
to detect questions on mentally
developmental dull, backward or slow;
disabilities in sitting or walking delay;
Pakistan and reported inability to
learn to do things like
other children
3. A Review of Global Journal of Pakistan Review Pakistan
Issues and Psychiatric Society article
Prevalence of Child
Mental Health
problems:Where
does CAMH stand in
Pakistan?
4. Prevalence of Indian Journal of pediatrics Cross- Karachi In the present study
emotional and sectional prevalence of child
behavioral problems study mental health problems
among primary was higher than
school children in reported in studies from
Karachi, Pakistan – other countries. There
Multi Informant was also a gender
Survey difference in
prevalence; boys had
higher estimates of
behavior/externalizing
problems, whereas
emotional problems
were more common
amongst females
5. Primary care Child: care, health and cross- Punjab, There is considerable
treatment for child development sectional Pakistan variation in treatments
and adolescent survey available for child and
neuropsychiatric adolescent
conditions in remote neuropsychiatric
rural Punjab, disorders in remote
Pakistan rural areas of Punjab, a
large proportion of
which are considered
ineffective by the users
and carers

21
 Pakistan Journal of Public Health, 2016 ( September )

6. Screening for Social Cross- Karachi The prevalence of child

emotional and PsychiatryandPsychiatric sectional mental health problems
behavioral problems Epidemiology study was higher than reported
amongst 5–11-year-old in studies from other
school children in countries. Prevalence
Karachi, Pakistan was higher amongst
children attending
community schools

7. Randomized trial of The lancet Randomize Rawalpindi The school program

impact of school control trial succeeded in improving
mental-health program awareness of mental
inrural Rawalpindi, health in school children
Pakistan and the community. The
schoolchildren were
receptive to the
program and shared
their new understanding
with family, friends, and
neighbors
8. Community Journal of Intellectual Gujar Cross There is significant delay
management of Disability Research Khan, sectional in detection of ID
intellectual disabilities Rawalpindi survey especially in rural setting
in Pakistan: a mixed where more than 70% of
methods study population of Pakistan
resides. This missed
opportunity for
rehabilitation in early
formative years is a
cause of significant
distress for the
caregivers who rarely
receive valid information
about course, prognosis
and what remedial action
to take

this review has its own strengths as it provides a clear interests.

understanding about the current shortfalls in the field of
child mental health research in Pakistan. It also offers an
insight to the available evidence on child mental health
issues in Pakistan and enhance.
Conclusion:
There is an urgent necessity for capacity building
regarding mental health research to evaluate the actual
current situation. Available literature is insufficient to
provide accurate estimates regarding burden of various
child mental health disorders. Specified child mental
health screening tools needs to be developed and
validation of available tools is a huge challenge and
needs vigorous efforts. Recognition of this high amount
of mental health disorders' burden can help in raising
awareness and can make child mental health a priority
issue along with other important child health indicators
at national level.
Competing interests
The authors declare that they have no competing
Authors' contributions
Tanzil Jamali conceived the study and supervised the
article search. Tanzil Jamali and Sana Tanzil drafted and
revised the manuscript.
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10. Mirza I, Tareen A, Davidson LL, Rahman A.
Community management of intellectual disabilities
in Pakistan: a mixed methods study. J Intellect
Disabil Res. .2009;53(6):559-570.
11. Hendren R, Weisen R B, J. O. Mental health
programs in school. Division of Mental Health
1993;WHO/MNH/PSF/93.3 Rev.
12. Rahman A, Mubbashar MH, Gater R, Goldberg D.
Randomised trial of impact of school mental-health
programme in rural Rawalpindi, Pakistan. The
Lancet. 1998;352(9133):1022-1025.
13. Schachter HM, Girardi A, Ly M, Lacroix D. Effects
of school-based interventions on mental health
stigmatization: a systematic review. Child Adolesc
Psychiatry Ment Health. 2008;2(18).
14. Pinfold V, Toulmin H, Thornicroft G, Huxley P,
Farmer P, Graham T. Reducing psychiatric stigma
and discrimination: evaluation of educational
interventions in UK secondary schools. Br J
Psychiatry.2003;182(4):342-346.
15. Durlak JA, Wells AM. Primary prevention mental
health programs for children and adolescents: A
meta-analytic review. Am J Community Psychol.
1997;25(2):115-152.
16. Mirza I, Mehmood T, Tareen A, Davidson L,
Rahman. A. Feasibility study on the use of the Ten
Questions Screen by Lady Health Workers to
detect developmental disabilities in Pakistan. J
Intellectual Disabil Res. 2008;5(2):97.
17. Syed EU, Hussein SA, Azam SI, Khan AG.
Comparison of Urdu version of Strengths and
Difficulties Questionnaire (SDQ) and the Child
Behaviour Check List (CBCL) amongst primary
school children in Karachi.J Coll Physicians Surg
Pak. 2009;19(6):375.
18. Ahmer S, Faruqui RA, Aijaz A. Psychiatric rating
scales in Urdu: a systematic review. BMC
psychiatry. 2007;7(1):59.
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Prevalence of Child Mental Health
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JPPS. 2009;6(1):5.
20. Verhulst FC. The epidemiology of child and

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 Pakistan Journal of Public Health, 2016 ( September )

Pak J Public Health Vol. 6, No. 3, 2016 Original Article

COMPARISON OF EFFECTIVENESS AND SIDE EFFECTS OF KETAMINE AND PROPOFOL IN

PROCEDURAL SEDATION FOR PATIENTS OF FRACTURE FEMUR

Khawaja Kamal Nasir1, Suresh kumar2, Yasmeen3, Farah3

1.Professor, Department of Anesthesiology, Pakistan Institute of Medical Sciences, Islamabad.

2.Assistant Professor, Department of Anesthesiology, Pakistan Institute of Medical Sciences, Islamabad.
3.Assistant Professor, Department of Anesthesiology, Pakistan Institute of Medical Sciences, Islamabad.
4.Assistant Anaesthetist, Department of Anesthesiology, Pakistan Institute of Medical Sciences, Islamabad.

Abstract

Introduction: Procedural sedation has provided an option to undergo emergency surgical procedures with ease
and pain free without taking general anesthesia. The ideal agent for procedural sedation should be safer, easier to
administer, provide adequate amnesia, muscle relaxation and have a rapid onset and offset. Ketamine and propofol
are two procedural sedation agents safely used in children and adults. We conducted a randomized controlled trial to
compare the effectiveness and safety of ketamine and propofol in patients undergoing surgery for fracture femur.
Objective: To compare effectiveness and safety of ketamine and propofol in patients undergoing procedural
sedation for femur fracture
Methodology: A total of 70 patients of fracture femur were enrolled and randomly assigned to receive analgesia with
either propofol or ketamine. This RCT was conducted at the Department of Anaesthesiology, Pakistan Institute of
Medical Sciences, Islamabad from May 2009 to October 2009. Both male and female patients above 15 years of age
who had elective femure fracture were included in the study. The study outcome was measured in terms of
comparison of effectiveness and safety of ketamine with propofol procedural sedation agents in patients of femur
fracture.
Results: Patient age was comparable between the study groups, male gender was dominant in both groups.
Ketamine acted immediately for positioning than propofol (p-value = 0.01). In propofol group the mean topup was
greater 1.0 + 0.84 doses compared to 0.03 + 0.17 doses in the ketamine group. At baseline the systolic blood
pressure and heart rates were comparable between study groups, however, after 5 minutes of intervention it
dropped significantly in propofol group. After 20 minutes mean systolic BP was 109.8 + 10.9 mmHg in propofol
compared to 124.9 + 13.0 mmHg in ketamine group (p-value = <0.001). Similarly, after 20 minutes the mean heart
rate was 87.1 +9.9 per minute in propofol group while it was 93.2 +11.6 in ketamine group and found statistically
significant (p-value = <0.001). Hypotension 5 (14.3%) was found associated with propofol whereas increased heart
rate above 100/min was found prevalent in 4 (11.4%) cases in ketamine group.
Conclusion: Overall both ketamine and propofol are effective drugs for procedural sedation. Ketamine was better in
terms of time taken for positioning. More topups were required in propofol group to maintain the level of sedation.
Systolic blood pressure was better maintained in ketamine group with no incidence of hypotension.
Keywords: Procedural sedation, ketamine, propofol, effectiveness, safety

Introduction: department by non-anaesthesiologists(3).

Procedural sedation in emergency departments and
operation theatre has allowed the patient to undergo
unpleasant and painful procedures without undergoing
full-fledged anaesthesia(1).The ideal agent for
procedural sedation should be safer, easier to
administer, provide adequate amnesia, muscle
relaxation and have a rapid onset and offset. In children
procedural sedation is safe and effective, control of pain,
anxiety and motion, so as to allow the necessary
procedure to be performed and to provide an
appropriate degree of memory loss or decreased
awareness(2). Procedural sedation is also commonly
used in the radiology, gastroentrology and emergency
In this regard propofol, etomide and ketamine have
gained popularity in procedural sedation. Different
studies have reported variable results regarding
success and safety of these drugs. Propofol is a phenol
derivative compound, has rapid onset, short duration of
action and less hangover effects. However, some
haemodynamic changes including change in heart rate
and arterial pressure have been reported(4).
Side effects with propofol though small in numbers, it is
concerning that 17% suffered apnoea or hypoxiawith
propofol, probably reflecting the narrower margin of
safety with this sedation agent4.Many have described
variation in costs of different anesthetic agents(5).

24
 Pakistan Journal of Public Health, 2016 ( September )
Overall the recent literature on propofol has described
increasing use in emergency department for procedural
sedation(5,6,7) with conclusion that propofol is safe and
effective for procedural sedation with high satisfaction of
both patient and physician(9).
Ketamine a dissociative anaesthetic and analgesic
agent also has rapid onset and short duration of action. It
has many advantages in terms of low rate of respiratory
depression and hypotension(2). A recent audit done
revealed 100% procedural success rate with
ketamine(9). Safety was comparable to other agents
with 14.6% of patients given ketamine suffering an
adverse event compared with 15.9% overall. In another
trial, the incidence of adverse events was comparable
between ketamine and midazolam (14.6% vs 15.8%)
r e s p e c t i v e l y, a p n o e a , h y p o x i a , h y p e r t o n i a
and—arguably the most serious adverse events
observed. Hypertonia and hypertension were
associated with ketamine, which reiterates the
importance of careful patient selection to exclude those
with predisposition tohyper tension from ketamine
sedation(9). There were few studies comparing
combination of ketamine with other drugs for PSA,
moreover, very rare studies were found which
exclusively compared ketamine alone with propofol
alone.
The current study was aimed to see the effectiveness
and adverse events of ketamine as compared to
propofol in facilitating the positioning of the patient for
placement for subarachnoid block in patient scheduled
for fixation of fracture femur patients.
Methodology:
Patients and settings:
In this randomized controlled trial a total of 70 patients of
fracture femur were enrolled and randomly assigned to
receive analgesia with either propofol or ketamine. The
study was carried out at the Department of
Anaesthesiology, Pakistan Institute of Medical
Sciences, Islamabad from May 2009 to October 2009.
Both male and female patients above 15 years of age
who had elective femure fracture were included.
Patients who had contraindication to spinal
anaesthesia, had bowel obstruction or gastro
esophageal reflex or had upper air way obstruction,
airway infection, exacerbation of asthma, any
cardiomyopathy, those with head injury, meningitis,
space occupying lesion were excluded from the study.
Patients with hepatic and renal diseases, who had any
psychiatric illness, hypertensive patients and those
having any allergy to ketamine, propofol and bupivicaine
were also excluded from the study.
Data collection and analysis:
The study was approved by the hospital ethical
committee. All patients were selected according to
inclusion criteria and written consent administered at the
time of enrollment. On arrival in operating room patients
were randomly divided in two equal number in two
groups. All patients were monitored by noninvasive
blood pressure, continuous pulse oximeter and
electrocadiography. All patients preloaded with 500 ml
ringer lactate solution before subarchnoid block. After
taking baseline parameters group Propofol were given
0.5mg/kg after estimated weight initial dose followed by
0.25mg/kg top ups if required. Ketamine group received
0.8mg/kg initial dose followed by 0.25mg/kg top ups as
needed. After achieving target after estimated weight
sedation level(3/4) patients were placed in lateral
decubitus position and subarchonoid block was
performed. During procedural sedation patient were
monitored for time taken for positioning, sedation score
and cardio-respiratory instability.
Data was entered and analyzed in SPSS software
version 11.0. Descriptive statistics was applied to
measure frequency and percentages from categorical
variables and mean + standard deviation from numerical
variables. Chi square test was applied to compare
efficacy and side effects between the two study
interventions i.e. ketamine and propofol.
Results:
In this study a total of 70 patients undergoing procedural
sedation for fracture femur were randomly assigned to
propofol and ketamine study groups. In propofol group
the mean + SD age of patients was 45.3 +22.3 years
while in ketamine group it was 41.7 +19.3 years. Overall
70% study cases were above 50 years whereas
remaining 30% were below 50 years of age. Male
gender was dominant in this study, with 29 (82.9%) in
propofol and 31 (88.6%) in ketamine group. The
demographic characteristics were found equally
distributed among study groups (p-value = 0.49). In
propofol group the mean + SD weight of patients was
62.9 + 8.8 kilograms while in ketamine group it was 62.5
+ 10.4 kilograms, thus, found comparable among study
groups. (Table 1)
Ketamine acted immediately after intervention than
propofol for positioning. In propofol majority of the cases
took 5 or more minutes to position, while in contrast in
more than 80% of ketamine group, patients were ready
for positioning within 3-5 minutes. The difference in time
taken for positioning between study groups was
statistically significantly less in ketamine group when
compared with propofol group (p-value = 0.01). The
comparison of topups or more doses of study drugs was
compared between groups. In propofol group the mean
topup was 1.0 + 0.84 doses compared to 0.03 + 0.17
doses in the ketamine group which was also found
statistically significant (p-value = <0.001).Overall both
the study interventions succeeded in gaining positioning
for procedure in all (100.0%) cases. (Table 2)
At baseline the systolic blood pressure was comparable
between study groups, however, after 5 minutes of
intervention it started dropping significantly in the
propofol group when compared with ketamine group.
After 20 minutes of intervention the mean systolic BP
was 109.8 + 10.9 mmHg in propofol group while in
ketamine group it was 124.9 + 13.0 mmHg and this
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 Pakistan Journal of Public Health, 2016 ( September )

difference between study groups was found statistically Table 3: Comparison of systolic blood pressure,
significant (p-value = <0.001). Similarly, the heart rate heart rate and oxygen saturation after intervention
was also comparable at baseline between the study between the two study groups
groups. However, 5 minutes after intervention it
Propofol Ketamine
remained stable in propofol group but rose drastically in
the ketamine group, and the difference in mean heart group Group p-value
rates was found significant. After initial raise the heart (n = 35) (n = 35)
rate started normalizing in the ketamine group as (Mean + SD) (Mean + SD)
observed between 10 and 15 minutes. After 20 minutes
Systolic blood
of intervention the mean heart rate was 87.1 +9.9 per
minute in propofol group while it was 93.2 +11.6 in pressure
ketamine group and was found statistically significant At baseline 125.5 + 12.8 125.8 + 11.7 0.92
(p-value = <0.001). The mean oxygen saturation was
found comparable between the two study interventions At 5 min 113.2 + 12.1 128.6 + 13.6 <0.001
and no statistical difference was observed. (Table 3) At 10 min 110.1 + 12.1 133.7 + 25.6 <0.001
The complications after intervention in terms of
hypotension and deranged heart rate were also At 15 min 112.7 + 12.7 129.6 + 13.2 <0.001
recorded. In propofol group 5 (14.3%) patients
At 20 min 109.8 + 10.9 124.9 + 13.0 <0.001
developed hypotension compared to none in ketamine
group (p-value = 0.05). Similarly, in ketamine group 4 Heart rate
(11.4%) patients had heart rate above 100/min after
intervention compared to none of patients in propofol At baseline 92.0 + 10.8 90.1 + 13.5 0.52
group. (Table 4) At 5 min 89.1 + 9.3 102.6 + 12.4 <0.001
Ta b l e 1 : C o m p a r i s o n o f d e m o g r a p h i c
characteristics between the two study At 10 min 87.6 + 8.6 100.3 + 11.8 <0.001
Propofol group Ketamine Group At 15 min 87.7 + 8.4 97.4 + 10.6 <0.001
(n = 35) (n = 35) p-value
At 20 min 87.1 + 9.9 93.2 + 11.6 <0.001
Age (yrs)
Mean + SD 45.3 + 22.3 41.7 + 19.3 0.46 Oxygen

Sex saturation

Male 29 (82.9%) 31 (88.6%) 0.49 At baseline 97.6 + 1.4 97.3 + 1.6 0.43

Female 6 (17.1%) 4 (11.4%) At 5 min 95.4 + 1.9 95.3 + 2.3 0.91

Weight (kg)
At 10 min 95.1 + 2.1 95.5 + 2.1 0.46
Mean + SD 62.9 + 8.8 62.5 + 10.4 0.88
At 15 min 95.7 + 2.0 96.2 + 1.9 0.36

At 20 min 96.2 + 1.7 96.6 + 1.7 0.35

Table 2: Comparison of time taken for position
between the two study groups
Table 4: Comparison of complications between the
Propofol group Ketamine
two study groups
(n = 35) Group p-value
Propofol group Ketamine Group
(n = 35)
(n = 35) (n = 35) p-value
Time taken for
position (min) 0.01 Hypotension 5 (14.3%) 0 (0.0%) 0.05

3.1 to 4 8 (22.9%) 22 (62.8%) Heart rate 0 (0.0%) 0 (0.0%) -

4.1 to 5 5 (14.3%) 7 (20.0%) below 60/min
5.1 to 6 12 (34.3%) 6 (17.2%) Heart rate 0 (0.0%) 4 (11.4%) 0.11
6.1 to 7 2 (5.7%) 0 (0.0%) above 100/min
7.1 or above 8 (22.9%) 0 (0.0%) Desaturation 0 (0.0%) 0 (0.0%) -
Topup doses
required 1.0 + 0.84 0.03 + 0.17 <0.001
Mean + SD

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 Pakistan Journal of Public Health, 2016 ( September )
Discussion:
Procedural sedation and analgesia (PSA) has provided
an opportunity to patients to easily undergo unpleasant
and painful procedures that could have otherwise
required general anesthesia1.Many PSA agents like
propofol, etomidate, midazolam, fentanyl and ketamine
have been successfully utilized, but there are concerns
among anesthesiologists regarding safety and
complications during intervention of these agents10. We
conducted a randomized controlled trial in which
propofol was compared with ketamine as a procedural
sedation agent in terms of effectiveness and side effects
in patients with fracture femur undergoing subarachnoid
block. A total of 35 cases were enrolled in each study
group.
Our results showed that ketamine takes less time for
positioning, it does not require an additional dose or a
topup and there are very few side effects from it. The
current study observed that ketamine was more
successful in maintaining blood pressure during the
phase of sedation however, propofol has shown a good
maintenance of heart rate while a few cases in ketamine
group had heart rate risen to 100 per minute or more.
Oxygen saturation was similar in both study groups i.e.
propofol and ketamine groups.
Previous reports on propofol and midazolam reveal that
the latter lack activity that is undesirable to patient
movement which may occur during the block when
these drugs are used alone, however, large dosage can
ensure patient immobility. The use of narcotic as
analgesic supplements increases the risk of respiratory
depression. In this regards ketamine provides analgesia
without respiratory depression(11). However, other side
effects such like hypertension and psychomimetic
emergence reactions, limit its use as a sole drug(12,13).
Many previous reports have demonstrated the
successful use of propofol in children undergoing
oncology procedures by both pediatric intensivists and
anesthesiologist outside the operating room in a
controlled setting(10,14,15). Despite advantages
propofol has cardiopulmonary depressant effects when
used alone. Recent studies have revealed that the
addition of low-dose ketamine to propofol has
counteract effects on cardiorespiratory depression that
occurs when propofol is used alone, whereas propofol
decreases the psychotomimetic and nauseant effects of
ketamine(16,17).
Our study although compared two different drugs having
different mechanism of action and side effects, the aim
was to see the efficacy of the two drugs regarding
procedural sedation and not for adverse effects of the
drugs. Our indicators for efficacy used were RSS,
hemodynamics. Only in the regards the efficacy
depended upon observation of hemodynamics and
RSS.
Ketamine belongs to phencyclidine group and can be
given I/M as well as I/V injections. Topup injection can
only be given if verbal contact established. The dose
used for procedural sedation was 0.8 mg/kg18. On the
other hand propofol belongs to phenol group. It can only
be given I/V it is rapidly acting and act by depressing the
CNS. Top up injection can be given if required. It was
used in a dose of 0.5 mg/kg in the current study(19).
All the study patients were bed bound and immobilized
for variable duration. Their estimated weights were
taken and dosages were adjusted accordingly. This was
the methodology employed in all the patients in both
groups and error in the judgment of the weight was
applied to all patients.
Though the assumed study hypothesis was that
propofol is better than ketamine for procedural sedation
in patients with fracture femur in terms of efficacy and
complications, this was slightly rejected by our study
results as ketamine proved to be better option for control
of blood pressure, time taken for positioning and topups
required.
In this study oxygen saturation was maintained within
normal range after both interventions and none of the
patients required airway patency and ventilation. Frey K
and colleagues also reported a similar trend where none
of their study patients required airway support when
induced sedation with ketamine and propofol in
combination. They concluded that ketamine and
propofol combination provided a faster onset and
improved quality of sedation compared with propofol
alone11. Another study also reported that ketamine
preserved airway patency and airway muscle tone in
doses of 1 mg / kg administered intravenously in 27 to 74
year old men(20). Other investigators have also
suggested that combination of ketamine and propofol
preserve hemodynamics well during procedural
sedation(1,21).
There were no limitations of the study except for small
sample size which was mainly due to the short duration
of study. Moreover, there were numerous advantages of
this study. There are very few reports on the comparison
of ketamine and propofol alone and the current study
was one of the very few trials done so far. Keeping in
mind the critical and emergency situations during
surgeries and different procedures this report helped in
determining the efficacy and safety of both drugs and
could show a way forward to intensivists and
anesthesiologists in the appropriate and timely
management of sedation and recovery.
Conclusion:
It can be concluded that overall both ketamine and
propofol are effective drugs for procedural sedation.
Ketamine was better in terms of time taken for
positioning as compared to propofol. Topups were
required in propofol group to maintain the level of
sedation required for as per operational definitions. As
far as hemodynamics are concerned blood pressure
was better maintained in ketamine group with no
incidence of hypotension whereas heart rate was better
maintained with propofol with lesser rate of tachycardia.
It can be suggested that combination of propofol and
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 Pakistan Journal of Public Health, 2016 ( September )
ketamine may be tried to rectify the issues of
hemodynamic changes during procedural sedation.
References:
1. Ghadami Yazdi A, Ayatollahi V, Hashemi A,
Behdad SH, Ghadami Yazdi E. Effect of two
different concentrations of propofol and ketamine
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lumbar puncture or bone marrow aspiration.
Iranian J Pediatr Hematol Oncol 2013; 3: 187-192.
2. Borker A, Ambulkar I, Gopal R, Advani SH. Safe
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hematology-Oncology Unit. Indian Pediatrics
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3. Minai FN, Siddiqui KM, Qureshi R. Sedation –
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4. Pandit JJ. Intravenous anesthetic agents. Anesth
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5. 12Hohl CM, Nosyk B, Sadatsafavi M, Anis AH. A
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6. 9Zed PJ, Abu-Laban RB, Chan WW, Harrison DW.
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CJEM 2007;9(6):421-7.
7. 10Weaver CS, Hauter WE, Brizendine EJ, Cordell
WH. Emergency department procedural sedation
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8. 11Hohl CM, Sadatsafavi M, Nosyk B, Anis AH.
Safety and clinical effectiveness of midazolam
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9. 8Vardy JM, Dignon N, Mukherjee N, Sami DM,
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the emergency department. Emerg Med J 2008;
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10. Wheeler DS, Vaux KK, Ponaman ML, Poss BW.
The safe and effective use of propofol sedation in
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11. Frey K, Sukhani R, Pawlowski J, Pappas AL,
Mikat-Stevens M, Slogoff S. Propofol vs propofol-
ketamine sedation for retrobulbar nerve block:
Comparison of sedation quality, intraocular
pressure changes and recovery profiles. Anesth
Analg 1999; 89: 317-21
12. Sener S, Eken C, Schultz CH, Serinken M,
Ozsarac M. Ketamine with and without midazolam
for emergency department sedation in adults: a
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57:109–14
13. Green SM, Sherwin TS. Incidence and severity of
recovery agitation after ketamine sedation in
young adults. Am J Emerg Med.2005; 23:142–4
14. Hertzog JH, Dalton HJ, Anderson BD, Shad AT,
Gootenberg JE, Hauser GJ. Prospective
evaluation of propofol anaesthesia in the
paediatric intensive care unit for elective oncology
procedures in ambulatory and hospitalized
children. Paediatrics 2000; 106: 742-7.
15. Jayabose S, Levendoglu-Tugal O, Giamelli J,
Grodin W, Cohn M, Sandoval C, et al. Intravenous
anaesthesia with propofol for painful procedures in
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16. Mortero RF, Clark LD, Tolan MM, Metz RJ, Tsueda
K, Sheppard RA. The effects of small-dose
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Lafosse JM, Nguye I et al. Propofol to facilitate
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 Pakistan Journal of Public Health, 2016 ( September )

Pak J Public Health Vol. 6, No. 3, 2016 Original Article

A COMPARATIVE STUDY OF MATERNAL PSYCHOSOCIAL PROBLEMS AND ACADEMIC

PERFORMANCE OF CHILDREN INMIGRANT AND NON MIGRANT FAMILIES OF AJK

RabiaMushtaq1, SeemaGul2, Muhammad Tahir Khalily3

1
Lecturer Department of Psychology, International Islamic University, Islamabad, Pakistan, 2Associate Professor
Department of Psychology, International Islamic University, Islamabad, Pakistan, 3Dr. Muhammad TahirKhalily:
Professor Department of Psychology, International Islamic University, Islamabad, Pakistan, Corresponding Author,
Ms. Rabia Mushtaq, Lecturer, Department of Psychology, International Islamic University Islamabad Pakistan, Cell:
0333-5687368, E mail: rabia.mushtaq@iiu.edu.pk

Abstract

Background: Overseas migration of family head brings a change in roles of left behind family members. Left behind
members including wives and children suffer at psychological, social, emotional and academic level in the absence
of their husbands/fathers.
Objectives: The present study aimed at measuring the maternal psychosocial problems and academic
performance of children in migrant and non migrant families of Azad State of Jammu & Kashmir. Age wise difference
in academic performance of left behind children was also measured by dividing them into two groups of younger age
(6-12 years) and older age (12-18 years) children. Among left behind children gender differences on their academic
performance were also measured.
Method: Sample of 800 individuals including 400 mothers(n=400) and 400 children (n=400)was selected through
purposive convenient sampling technique from two districts (Sudhnotti & Poonch) of Azad State of Jammu &
Kashmir. Age range of children was from 6 to 18 years. Data of present study was collected from the mothers by
using instruments, Psychosocial Problems Scale (PSPS) and demographic information sheet. Data was analyzed
through SPSS 21 version. Test and Pearson Chi square analysis were used for measuring group differences.
Results: Findings of the present study indicated that children in migrant families having mothers with more
psychosocial problems showed less academic performance as compared to children in non migrant families having
mothers with less psychosocial problems. Younger left behind children (age range from 6-12 years) showed good
academic performance as compared to older children (12-18 years).Female left behind children over all showed
good academic performance as compared to male left behind children.
Conclusion: Study found high prevalence of psychosocial problems among left behind wives and resultant poor
academic performance of their children.
Keywords: Psychological problems, migration, academics

Introduction: To examine the impact of migration on emotional

Migration has been playing the role of a key contributor
in the global process of change. During migration people
move from one place to another with the objectives of
living there permanently or for relatively shorter period of
time(1).Remittance-led migration causes traumatic
separation of husbands and wives, children and
parents, formulating transnational households. In
addition to this suffering, separation caused by
migration and its accompanying sense of uncertainty
have significant consequences for the future wellbeing
of transnational family members(2).Studies on left
behind families (children and wives) of overseas
migrants indicated their psychosocial problems in the
form of additional responsibilities, anxiety, loneliness &
psychological problems, poor academic performance,
children behavioural and emotional problems(3,4).
wellness of family members remaining in the country of
origin, study conducted in Mexican families indicated
depressive symptoms and feelings of separation among
close family members more specifically among their
spouses and children(5).
Migration grounds a lot of problems forleft
behind families most importantly for their wives in the
form of personal, psychological, managerial, social and
children discipline related. For investigating the
problems faced by left behind wives,a study was
conducted in Kangra District of Himachal Pradesh. The
study found their problems in the form of feelings of
anxiety because of communication gap with their
husbands; problems in children upbringing and work
overload(6).
A longitudinal survey was conducted in

29
 Pakistan Journal of Public Health, 2016 ( September )
Indonesia between 1993-2007 regarding psychosocial
consequences of out migration and it has been shown
that spouses left behind are more vulnerable to stress
related illnesses i.e. hypertension and depression 7.
Studies conducted in Uk, China and India indicated that
majority of the wives report loneliness, emotional
disturbance and lack of guidance for their children(8).
Migration of only husbands to some other places for
earning money, have a considerable effect on their left
behind wives and children. International migration of
parent or a family member can have either positive or
negative effects on left behind family members,
including non migrant children also. On one hand
remittances relax the household budget constraints and
in result increase child schooling, child health, and
corresponding decrease in child labor(9,11). However
parental absence from the home can have a negative
impact on their child's outcomes, which may outweigh
the positive effects of their remittances. In line with these
findings, in Albania negative impact on school
attendance for left behind children(LBC) has also been
explored(12).
Despite the fact that family and children can
enjoy the economic advantages because of remittances
sent by migrant, LBC pay the price of separation with
negative consequence on their psychological well
being, which is going to influence their development,
behaviour and education(13,15). Psychosocial
problems including behavioural, emotional and
educational problems are more common in adolescents
and they cause severe disturbance in performing their
every day functioning(16).In Romania Impact of
Parental economic migration on children psychosocial
and academic outcomes indicated poor academic
performance of their children(17).
In Mexico evidence for gender based
educational attainment differences were revealed.
Because of parental migration girls showed significantly
increased educational achievement, however
probability of boys completing junior high school was
low. Similarly in developing countries both boys and girls
presented academic difficulties in case where care
giversmigrated. Income effect dominantly appeared in
developing countries, where for girls, remittances (by
easing family budget constraints) opened up greater
education opportunities. As girls are more likely to be
deprived of educational investments when family
finances are constrained. However for older boys this
income effect was over comed by having other
alternatives to education (particularly in the form of their
own migration) which drove boys away from school(18).
Findings of a qualitative study conducted in Mexico
indicated that left behind adolescents often become
migrants themselves. As migration appears as a way out
of poverty and adolescents are more prone to drop out
from school(19). Migration caused negative effects for
Mexican older children because of increased
housework for female children and migration of male
children(20).
Pakistan is one of the major country who gets its
major income from international migration(21).
However little attention is given to the effect of economic
migration on the left behind families. As people move out
but their family remains there in their home land. That is
why family unity suffers a lot when the left behind
families do not accompany labor migrants(22).
Studies conducted in Pakistan with the aim of
investigating the impact of out migration reported both
the positive and negative impact son left behind families.
Along with positive monetary outcomes the negative
outcomes of over seas migration indicated i.e. lack of
parental control over children, burden in controlling male
children, psychological disturbances in personality of
left behind children, drug addiction among family
members, problems in arrangement of their sons and
daughters marriages(23,26).
Large number of male members of the study
population of Sudhanotti & Poonch districts of Azad
State of Jammu & Kashmir move abroad because of
their economic problems, their families have been
suffering in their absence. Study highlighted that on one
side savings of people became many fold higher,
expenditure on their basic needs, preference to educate
their children in private schools, purchase of commercial
plots/vehicles, construction and renovation of their
houses , spending on ceremonies and luxury items
increased due to emigration of their family heads. While
on the other side some negative impacts have been
reported including psychological disorders in women,
insecurity feelings and children drop out from
school(27).
Results of the study can be utilized for better
understanding the role of overseas migration of
husbands/fathers on psychosocial problems of their left
behind wives and its impact on the school performance
of their left behind children. Considering children and
their educational attainments as the future of any nation,
practical measures can be taken in light of findings of the
present study for saving the future of the State of Azad
Jammu & Kashmir.
Method: Individual contacts with mothers of both left
behind children and children who were living with their
both parents from Poonch & Sudhanotti districsts of
AJ&K were made for the purpose of data collection.
Prior consent of the mothers was taken before data
collection in the form of their written agreement for
taking part in the present study. Data of the present
study was gathered by making use of Psycho social
Problems Scale and demographic information sheet,
which was completed by mothers of children in migrant
and non migrant families. Present research employed
comparative study design to measure maternal
psychosocial problems and academic performance of
children in migrant and non migrant families of AJ&K. A
total sample of Sample of 800 individuals including 400
mothers(n=400) and 400 children (n=400)was selected
30
 Pakistan Journal of Public Health, 2016 ( September )

through purposive convenient sampling technique from school going boys n=100 & school going girls n=100).
two districts (Sudhnotti & Poonch) of Azad State of Psychosocial Problem Scale (PSPS) comprised of 60
Jammu & Kashmir. The sample of 400 mothers was items, was used for the measurement of maternal
divided into two groups, first group comprised of 200 left psychosocial problems.
behind wives/mothers (n =200) of over seas migrants Results: For calculating the difference of mothers of
and 200 wives/mothers (n =200) living with their migrant and non migrant families t test was computed.
husbands. The sample of 400 children was also divided The results of (Table 1)indicate significant mean
into two groups, first group comprised of 200 left behind differences on maternal psychosocial problems t(398) =
children (n=200) of overseas migrants (including school 86.85, p< .001. The findings show that mothers of
going boys, n= 100 & school going girls, n=100) and migrant families have significantly more psychosocial
second group was also comprised of 200 children of non problems (M = 2.39.62, p <.001) as compared to
migrant parents that served as a control group (including mothers of non migrant families (M = 96.67, p<.001).
Table 1: Mean, Standard deviation and t-values for psychosocial problems of mothers in migrant and non migrant
families (N=400)
Mothers ofMigrant Mothers ofNon 95% CI
Families(n = 200) Migrant Families (n
= 200)
variables M SD M SD t(398) LL UL Cohen’s d
Psychosocial 239.62 21.30 96.67 9.38 86.85*** 139.71 146.18 8.68
problems
***p < .001

Table 2 indicates significant differences on academic have significant difference on their academic
grades of children in migrant and non migrant families χ2 performance with respect to their age rangesχ2 (4,
(2, N=400) =7.88, p< .05. Left behind children in migrant N=200) =16.66, p< .01.Younger left behind children over
families having mothers with more psychosocial all secured high academic grades (M = 76, p < .01) as
problems have shown less academic performance on compared to older left behind children (M = 60, p < .01).
high (M = 132, p < .05), average (M = 42, p < .05)and low Older left behind children got more average grades (M =
grades (M = 26, p < .05) as compared to children good 34, p < .01) as compared to younger left behind
academic performance on high (M = 142, p < .05), children(M = 11, p < .01). Similarly on low grades,
average (M = 48, p < .05) and low grades (M = 10, p < younger left behind children's ratio was less(M = 5, p <
.05) in non migrant families having mothers with less .01) as compared to older left behind children (M = 13, p
psychosocial problems. < .01).
Table 2: Pearson Chi square showing difference on Table 3: Pearson Chi square showing difference of left
Academic grades ofLeft behind Children of migrant behind children on their Academic Performance with
families with mothers having more psychosocial respect to their ages (N=200)
problems& Children of non migrant families with Child Age
mothers having less psychosocial problems (N=400)
Child grade 6-12 years 12-18 years χ2
Child grades
High 76 60 16.66**
Mothers Families High Average Low χ2
% 63% 73.3%
Grades Grades Grades
Average 11 34
Mothers in Migrant
families 132 42 % 20.7% 24.1%
26 7.88*
% 137% 45% Low 5 13
18%
% 8.3% 9.6%
Mothers in Non 142 48 10
Migrant families *p < .05
137% 45% 18%
%
Table 4 indicates that child gender have over all highly
*p < .05 significant difference on their academic performance χ2
(198, N=200) =29.1, p< .05. Female children over all
Findings of the Table 3 indicate that left behind children scored significantly higher on academic grades (M = 47,

31
 Pakistan Journal of Public Health, 2016 ( September )
p < .05) as compared to male left behind children (M =
22, p < .05) on academic grades with the range of 90-
100%. Female children also scored higher (M = 40, p <
.05) as compared to male left behind children (M = 37, p
< .05) on academic grades with the range of 80-90%.
Male left behind children scored significantly higher (M =
26, p < .05) as compared to female left behind children
(M = 7, p < .05) on academic grades with the range of 70-
Table 4: Pearson Chi square showing difference between male and female left behind children on their Academic
Performance (N=200)
Child grade
Gender 90-100% 80-90% 70-80% 60-70%
Male 22 37 26
% 22.0% 37.0% 26.0%
Female 47 40 7 2
% 47.0% 40.0% 7.0%
*p < .05
Discussion
Findings of the present study indicated that large
number of left behind wives were having more
psychosocial problems as compared to wives (mothers)
who were living with their husbands. Results of the
present study are in line with a prior study conducted
with aim of investigating the psychosocial problems of
left behind families of migrants in rural area of Pakistan,
which showed that 36% of wives reported psychological
strain/loneliness/emotional distance, 32% reported
burden for having new responsibilities(caring children
and domestic affairs), 32% of left behind children were
lacking guidance in education and other co-curricular
activities because of lack of inspiration and social
environment(24).
It was also studied in China that in situations
where husbands migrate away for getting jobs, the left-
behind wives have to take responsibilities of hard work,
i.e. growing farm crops, household responsibilities, and
looking after their elders at home. These additional
responsibilities, along with raising their children and a
sparse sex life, are causing left-behind rural wives more
psychological stress and negative effects on their
mental health(28). Present study found significant
difference between academic performance of left
behind children of over seas migrants and children living
with both parents and these findings are similar with
results of a study conducted on samples of children of
internal migrants, children of international migrants and
children of non migrant parents of Mexica and
Indonesia, which found that children of international
migrants were worse off on educational achievement as
compared to the children of non migrant parents(29).
In the present study older children showed poor
academic performance as compared to younger
children, these findings are in line with a study
80%. On academic grades with range from 60-70% both
male and female left behind children scored equally (M =
2, p < .05). Only male children scored (M = 9, p < .05) on
academic grades with range from 50-60%. While On
academic grades with range below 50% both male and
female left behind children scored equally (M = 4, p <
.05).
50 -60% Below 50 χ2
2 9 4 29.11*
2.0% 9.0% 4.0%
0 4
2.0% 0.0% 4.0%
conducted in China where internal migration showed
negative relationship with enrollment in high
schools(30). Research has identified two age groups of
left behind children more vulnerable to poor educational
outcomes in Caribbea. The first age group comprised of
LBC with age range from 11- 13 years, who were at the
transition stage from primary to secondary level. LBC
during these ages (11-13 years) were involved in fighting
and dropping out from school because of coping
difficulties or because of taking care of their younger
siblings. The second age group comprised of LBC with
age range from 14- 18 years, who were assumed to take
the role of parent/s in their absence and also because of
lack of that support, which child headed Caribbean
families receive(31).
Present study also aimed at measuring the gender wise
academic performance of left behind children of
overseas migrants. Findings of the study overall
indicated significantly high academic performance of left
behind female children. These findings are in line with
already existing literature related to effects of over seas
migration on left behind children education. To study the
impact of migration on children education, Pakistan
Rural Household survey was conducted in Rural area of
Pakistan including 16 districts covering 2531
households from 143 villages of four provinces. Survey
results indicated that drop out rate of girls in migrant
household was low as compared to non migrant
households(32). This can be one of the factor for overall
good academic performance of left behind female
children of over seas migrants in the present study.
Findings of a study conducted in Pakistan showed that
from sample of three hundred wives, 60% reported non
satisfactory academic performance of their male
children, while 64% wives reported that their daughter
had fulfilled their expectations. Findings also showed
32
 Pakistan Journal of Public Health, 2016 ( September )
strong association between father migration and drop
out of male children from the schools and colleges(24).
Present study has implications as majority of male
population of Poonch & Sudhanotti districts of Azad
Jammu & Kashmir have migrated abroad, strong need
was felt by the researcher while working on the present
study to have actual figures and number of persons who
moved to foreign countries from these two districts.
Overseas migrants send a large amount of remittances
to their host country, so their sacrifices must be
acknowledged by the host country policy makers for
providing, quality education and access to mental and
physical health care to their left behind families.
Mother's responsibilities and her role become significant
in absence of father. Results of the study can be useful
for devising health policies in public hospitals also for
assuring the mental health facilities for left behind
families. This research intends to provide basic data to
the researchers who are interested in this area and the
present findings will give them base line information to
develop further hypotheses in this regard. Being a
developing country findings of the research can be
helpful to address this challenging issue by devising a
policy framework enabling health protection of left
behind family members while promoting migration for
country's economic development.
Conclusion
The findings of the study suggest that migration
influence should be studied not only in terms of socio
economic process including remittances, but also as a
psychosocial process due to family disruption and
changing roles of left behind family members. Over all
findings of the study indicted the high prevalence of
psychosocial problems among left behind wives and
resultant poor academic performance of their children.
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 Pakistan Journal of Public Health, 2016 ( September )

Pak J Public Health Vol. 6, No. 3, 2016 Original Article

HEALTH CARE WASTE MANAGEMENT IN PAKISTAN: A SITUATION ANALYSIS AND WAY

FORWARD

Ejaz Ahmad Khan*1,Syed Muhammad Sabeeh2, Muhammad Ashraf Chaudhry3, Aashifa Yaqoob4, Saleem M
Rana5, Ramesh Kumar6

*1
Associate Professor and Head Epidemiology, Biostatistics and Environmental Health, Health Services
Academy,Islamabad, Pakistan. 2Managing Consultant (Quality, Accreditation & Business Development) Team Lead: EMR
Project Institute of Sleep Medicine & Research (MD & Ohio Networks), Towson, Maryland 21286,USA, 3Senior Lecturer,
Community Medicine Allama Iqbal Medical College, Lahore, Pakistan, 4Biostatistician,National TB control programme,
Ministry of National Health Services, Regulation and Coordination, Islamabad, Pakistan. 5Consultant, Contech
International Health Consultants, Lahore, Pakistan, 6Assistant Professor, Health Services Academy, Islamabad, Pakistan
*Corresponding Author:Dr Ejaz Ahmad Khan, Associate Professor Health Services Academy, Tel: +92-51-9255592, email:
ejaz@hsa.edu.pk

Abstract

Background: Almost all the developing countries face issues in Healthcare Waste Management, compromising
quality of healthcare delivery
Methods: In order to assess the Healthcare Waste Management system and practices in public and private
hospitals of Pakistan, semi-structured questionnaire sand in-depth interviews in one tertiary, two secondary, and
four first level care hospitals were employed.
Results: Healthcare Waste Management systems were only found in the tertiary hospitals where colored bins,
dedicated trolleys, Personal Protective Equipment, temporary and central storage areas were found.
Key words: Hospital, Healthcare, Waste Management, Practices,

Introduction done on injection practices in Oman showed lack of

Among almost all the developing countries, Healthcare
Waste Management (HCWM) is still an issue, which is
compromising healthcare delivery quality. The first step
towards implementation of a sound HCWM system in a
country is presence of its robust policy and plan for
implementation of HCWM, which is found absent among
some of the developing world . In Bangladesh even
when the policy framework for HCWM was absent,
efforts were continuously in place to emphasize over
proper handling of the medical waste and upon
continued trainings of the healthcare staff in handling of
medical waste . Within Eastern Mediterranean Region
Office (EMRO) of the World Health Organization
(WHO), during 2009, a study revealed that in Egypt,
inappropriate segregation, collection, storage, lack of
financial and human resource, and in adequate disposal
of the waste resulted in poor HCWM in the country. The
study also indicated an absence of any liquid waste
management and proper incineration of the hazardous
waste in Egypt . However, in some areas of EMRO
countries (Jordan), partial liquid waste management
and incineration has been documented. Nonetheless,
lack of proper segregation practices was yet a problem
within their system. The study revealed the need for
training and capacity building programs of all employees
involved in the medical waste management .A survey
healthcare waste management by looking at proxy
indicators for injection practices . Apart from the EMRO
region, within South Asia itself, China has shown some
improvements in HCWM .A situation analysis of HCWM
practices in Istanbul, Turkey, also came-up with results
showing improper handling of the medical or healthcare
waste .In view of the evidence, the existing regulations
were modified for better management of the healthcare
waste. .
A well-planned and well-implemented program
may result in well-segregated and pollution free
management of the healthcare waste . Bangla deshhas
assessed its HCW production and stepped towards
development of national policy and implementation of a
national action plan for HCWM .Iran has been another
example in the region which showed similar patterns
and poor practices of healthcare waste management
and recommendations made for the remedial actions. .
Some of the other countries have highlighted proper
budget allocation support in addition to development of
concrete policies, laws and to adopt newer technologies
in HCWM .
Pakistan needs a comprehensive description
and analysis of the situation and to formulate a
comprehensive healthcare waste management plan for
the country. Therefore, we planned this study to have a

35
 Pakistan Journal of Public Health, 2016 ( September )
comprehensive understanding of HCWM being done in
the country.
Methods
The objective of the survey was to assess existing
HCWM systems and practices including packaging and
labeling, collection, temporary storage, internal
transport and central storage, and to chalk out the final
disposal methods The survey was conducted in a one-
month period of time during 2009. The structured
questionnaire was used to collect the information from
all the four provinces, Kashmir and capital territory area.
Data was collected from a purposive sample of all levels
of healthcare facilities. Sample size was estimated on an
average Hepatitis sero-prevalence of 4.5%, and by
using the formula given below by Open Epi software:
Sample size:n = [DEFF*Np (1-p)]/ [(d2/Z21-α/2*(N-1)
+p*(1-p)]
The total sample size calculated was 67
healthcare facilities with 14 healthcare facilities in each
region (one tertiary care, two secondary care and four
primary care levels, seven facilities in each of public and
private healthcare setup) were recruited for all five
regions cumulating to 78 healthcare facilities in total
(10% increase in sample size was done to cover any
non-response). The provincial coordinators were
identified, who were senior managers and nominated by
the respective governments, lead the data collection
process. The principal author also visited hospitals and
policy makers to validate current on-site and off-site
practices and costing of the procedures. This
information was collected through a semi structured
questionnaire (annexed) and mainly the in depth
interviews were used. The data was cleaned and
entered on SPSS for analysis. Frequencies were
generated against the variables of interest for
descriptive analysis and associations were looked into
by using the Chi-square. Results were interpreted in
order to compare with other studies and making final
recommendations.
Results
Descriptive Analysis
Among the total of 78 visited healthcare facilities all over
the country, 28 % were large hospitals (more than 100
beds). Ten percent (10%) were the medium-sized
hospitals (50-100 bedded) and 23 % were small health
care facilities (< 50 beds). Thirty four percent (34%) were
only having Out Patient Departments (OPDs). Out of
those, 24% were tertiary care hospitals and 27% were
secondary care hospitals. Forty one percent (41%) were
categorized as primary level care facilities.
Thirty percent (30%) of these hospitals were
having HCWM Teams or Infection Control Teams (at
some places). Forty onepercent (41%) had the
guidelines or internal rules for the HCWM with them,
while only 27% were having any plan for HCWM. Among
those 27%, only 12% were practicing the program for
weighing the HCW. Twenty three percent (23%) were
having regular training programs on the HCWM, and the
same percentage received training on HCWM.Two-third
of the staff among those HCFs was aware about the
hazards of the HCW and its associated risk factors.
Routine health surveillance for the staff was available in
only 22% of the facilities. One-third of the facilities were
having reporting system for an incident, and almost the
same percentage of the facilities was having post
exposure procedures, in both public and private sectors.
About Nineteen percent (19%) of over all of these
hospitals were not having any kind of segregation. In
27% percent, sharps were being segregated and among
those, 21% of the infectious waste other than the sharps
was being segregated. Rest, radioactive,
pharmaceutical, anatomical and chemical wastes were
being separated in a range of 3 to 11%. About half of the
HCFsimplemented separate containers for infectious
and non-infectious waste. Out of these, around one-
third of the containers were properly labeled or color
coded. On an aggregate, proper labeling and color
coding among wards and operation theaters was found
to be around 31%. For OPDs, only one percent of
containers had proper labeling and coding.In some
places, there were different types of containers, other
than described above, were being used in the health
care facilities. Half of the facilities were using plastic
containers (usuallyplaced beside the patient beds in
wards) for collection of sharps. Only 5% of the HCFs
used yellow color coded bins for sharps. Rest were
either throwing them in ordinary waste bins (28%) or
collecting them in card boards (5%).More than two-
thirds of the facilities were destroying syringe needles.
Less than a quarter of the facilities were not using any
type of sharp waste management.
Regarding the overall segregated waste, More
than one-third were either using plastic boxes, or the
waste bins, and 6% were using containers made of
steel. About a quarter were not using any kind of
containers for segregating the HCW. Dedicated trolleys
for internal transportation of the HCW bags were
present only in 37% of the facilities. In about half of the
HCFs, the waste handlers were provided with any type
of protective material and clothing. In just one-third of
the facilities, infectious waste from laboratories was
being segregated. About two-third of the sampled
hospitals had no record of the daily waste generation as
they were not quantifying in terms of weighing the HCW
being produced.
Temporary and central storage areas were
present in half of the health facilities. Less than one-third
of the facilities with temporary storage facilities were
segregating infectious waste from non-infectious waste.
The practice was not much different from the ones for
central storage areas where one-third of the facilities
were also segregating the waste in both the general and
the hazardous waste categories. The central storage
areas, in 35% of the facilities, were having closed doors
and 27% were having a ceiling. Thirty percent (30%)
were washed periodically and only 6% were found
36
 Pakistan Journal of Public Health, 2016 ( September )

refrigerated. Forty one percent (41%) had an easy waste water treatment. Most of the patients (77%) were
access to them. using toilets at the HCFs where the sewerage system in
For onsite transportation, more than one- most of the instances (55%) led to open water source. In
thirdwasusing trolleys and two wheel bin containers (just a small number of facilities (19%) went through the
a quarter of facilities).In half of the cases, municipality wastewater treatment plants, and even lesser (8%)
vehicles were executing off-site transportation of the discharged into the septic tanks.
waste. Dedicated vehicles were present only in 18% of We understand that the Hospital Waste
the facilities. Regarding the onsite treatment, no Management Rules 2005 are in place in the country.
treatment was being performed in most of the facilities However, when we assessed their inaction at the
(60%). Waste was being burnt in open air in 17% of the provincial levels, majority (80%) had no implementation
facilities, and in incinerators among 18% of the facilities. of the rules. Rest had scattered code of conduct.
Chemical disinfection was the least (1%) employed Similarly, most (78%) had no local or provincial plan for
method of the onsite treatments. Two-third of the management of HCW. Majority (77%) had no inspection
facilities was sending their waste, either treated or not- system on HCWM in the hospitals. Financial mechanism
treated, to the municipal dumping sites for the final for HCWM in the most of the HCFs (73%) was found
disposal. Mostly, the bags containing the HCW were non-existent. Mostly (84%), operational cost was not
being thrown without proper burial (33%) or being buried being met, and the recovery mechanism depended on
along with the municipal waste (36%). Only a small self income-generation programmes and/or was
number of the facilities (11%) were keeping records of partially funded by the controlling health department.
the arrangements of waste disposal. Inferential Analysis (Table 1).
We also explored the situation of sanitation and
Table 1: A Single Chambered Incinerator posing Harm to the Environment, B Central Storage Area before Final
Incineration, CHospital Waste being Sparingly Mixed and Taken away along with the General Waste,DUn-cut
Syringe Found in the Bed Side Basket of the Patient, E Single-chambered Incinerator posing threat to local vicinity
FSame Incinerator with short chimney and lack of scrubbers

Table 1: Numbers and percentages of variables for Health Care Waste Management
Variable Number Percentage
Type of Healthcare facility
Public 33 45.2
Private 29 39.7
Charity/trust 6 8.2
Categories of HCF
Large 21 28.8
Medium 6 8.2
Small 18 24.7
OPD only 25 34.2
Level of Care
Tertiary 18 24.7
Secondary 17 23.3
Primary 26 35.6
Presence of HCWM/Infection Control Team
Yes 23 31.5
No 44 60.3
Guidelines/Internal Rules for Management of HCW
Yes 30 41.1
No 43 58.9
Plan for Management of HCW
Yes 20 27.4
No 53 72.6
Internal Programme for Weighing the HCW
Yes 9 12.3
No 64 87.7
Awareness about management of the HCW and associated risks
Yes 50 68.5
No 23 31.5

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 Pakistan Journal of Public Health, 2016 ( September )

Presence of a training programme on HCWM

Yes 17 23.3
No 56 76.7
Trainings received
Yes 18 24.7
No 55 75.3
Post-exposure procedures
Yes 25 34.2
No 48 65.8
Routine health surveillance of the staff
Yes 16 21.9
No 57 78.1
Reporting system
Yes 16 21.9
No 57 78.1
Properly labeled/color coded containers
Yes 22 30.1
No 51 69.9
Labeled containers for infectious and non-infectious waste
Wards 3 4.1
Operation theaters 6 8.2
OPDs 1 1.4
Wards + Operation Theaters 23 31.5
Do not know* 19 26.0
Not applicable 21 28.8
Highly infectious lab waste segregated
Yes 21 28.8
No 43
Not applicable 5
Treatment for the syringe needles
Yes 55 75.3
No 18 245.7
Types of containers for sharps
Plastic box 32 43.8
Yellow colour coded 4 5.5
Waste bin 20 27.4
Card boards 6 8.2
Not applicable 11 15.1
Type of container for segregated waste
Plastic box 26 35.6
Waste bins 26 35.6
Steel 5 6.8
Not applicable 16 21.9
Dedicated trolleys/wheeled containers
Yes 29 39.8
No 44 60.2
Waste-handlers provided with PPEs
Yes 33 45.2
No 40 54.8
Temporary storage areas in wards
Yes 34 46.6
No 39 53.4
Central storage areas
Yes 33 45.2
No 40 54.8

38
 Pakistan Journal of Public Health, 2016 ( September )

Separate hazardous and general HCW in temporary storage areas in wards

Yes 21 28.8
No 52 71.2

Separate hazardous and general HCW in central storage areas

Yes 23 31.5
No 50 68.5
Central storage facility with closed doors
Yes 24 32.9
No 49 67.1
Central storage facility with ceiling
Yes 19 26.0
No 54 74.0
Central storage facility washed periodically
Yes 20 27.4
No 45 61.6
Not applicable 8 11.0
Central storage facility refrigerated
Yes 4 5.5
No 69 94.5
Easily accessible
Yes 29 39.7
No 41 56.2
HCW onsite transportation
Carts 6 8.2
Trolleys 25 34.2
Two wheel bin containers 17 23.3
Plastic bags 8 11.0
Trolleys plus two wheel bin 1 1.4
containers
Sweepers 2 2.7
Buckets 5 6.8
Not applicable 9 12.1
HCW offsite transportation
Dedicated vehicles 13 17.8
Animal carts 2 2.7
Municipality vehicles 35 47.9
Plastic bags 5 6.8
Others 7 9.6
Not applicable 11 15.1
Onsite treatment facility
None 47 64.3
Open fire 11 15.1
Incinerator 12 16.4
Chemical disinfection 1 1.4
Others 2 2.7

39
 Pakistan Journal of Public Health, 2016 ( September )

The healthcare waste was not managed properly and in c e n t r a l s t o r a g e a r e a s ( p = 0 . 0 1 4 , C I : 0 . 0 11 -

accordance with the rules despite of presence of HCWM
teams at the tertiary care hospitals. The teams were
almost absent at the secondary and primary health care
levels. (p=0.001, CI: 0.000-0.001, p=0.003, CI: 0.001-
0.004). Separate bins for infectious and non-infectious
waste could be found at some of the tertiary care
hospitals only (p=0.049, CI: 0.043-0.054). Similarly,
dedicated trolleys for HCW were available in most of the
tertiary care hospitals and the waste handlers were
provided with the Personal Protective Equipment (PPE)
(p=0.000, CI: 0.000-0.000,p=0.004, CI: 0.002-0.006).
Tertiary care hospitals also had temporary storage and
0.016,p=0.000, CI: 0.000-0.000). The central storage
facilities easily accessible had proper door and were
washed regularly (p=0.000, CI: 0.000-0.001,p=0.000,
CI: 0.000-0.000 and p=0.000, CI:0.000-0.000).
Regarding the awareness of the healthcare staff
about HCWM, the staffs at all levels of healthcares
werewell-aware of the healthcare waste management
(p=0.020, CI: 0.016-0.024). In case of any exposure of
the staffs to the infected waste, post-exposure treatment
was usually available at the tertiary and the secondary
level but not at the primary level (p=0.004, CI: 0.003-
0.006)(Table 2).

Table 2. Cross-tabulation between Level of the Health Care Facility Level and HCWM Indicator

Confidence Interval
Chi-
Indicator df Lower Upper P-value
square
bound bound
Presence of HCWM or Infection 12.102 2 0.001 0.004 0.003
Control Team by level of care*
Rules/internal guidelines for HCWM 14.853 2 0.000 0.001 0.001
by level of care
Plan for HCWM by level of care 10.268 2 0.005 0.009 0.007
Programme for weighing the 11.500 4 0.007 0.012 0.009
generated HC waste by level of care
Awareness of HCWM according to 8.138 2 0.016 0.024 0.020
level of care
Presence of a training programme by 12.817 2 0.000 0.002 0.001
level of care
Received training on HCWM by level 17.345 8 0.002 0.005 0.003
of care
Presence of post-exposure SoPs for 10.940 2 0.003 0.006 0.004
Healthcare Staff by level of care
Routine surveillance for Healthcare 12.514 2 0.001 0.004 0.002
Staff by level of care
Reporting system for any HCW 15.789 4 0.000 0.001 0.001
emergency by level of care
Presence of separate bins for 6.414 2 0.043 0.054 0.049
infectious and non-infectious wastes
by level of care
Dedicated trolleys for transportation of 22.994 2 0.000 0.000 0.000
HCW by level of care
Waste handlers provided with 11.032 2 0.002 0.006 0.004
protective clothing/materials
Temporary storage areas in wards by 8.802 2 0.011 0.016 0.014
level of care
Presence of central hospital storage 18.855 2 0.000 0.000 0.000
areas by level of care
Central storage facility with door by 20.692 2 0.000 0.000 0.000
level of care
Central storage facility washed 17.555 2 0.000 0.000 0.000
periodically by level of care
Central storage facility easy 14.175 2 0.000 0.001 0.000
accessibility by level of care

40
 Pakistan Journal of Public Health, 2016 ( September )
Results from the in-depth interviews
The members of the Federal team visited the hospitals,
private HCWM projects and the policy
makers/implementers from the provinces. The following
situation was observed and the in-depth interviews with
the concerned authorities came up with the more insight
of the prevailing situation in the country.
The Health Departments pointed out that
despite of the awareness programmes on Health Care
Waste Management in the healthcare establishments,
no serious steps were taken to address the issue.
Trainings of the staff did take place, however there was
no follow-up on impact of the trainings. Due to non-
availability of budget dedicated to the HCWM, neither
the necessary equipment nor the regular activities of
trainings on the equipment could be conducted.
Wherever onsite treatment facility such as incinerator
was available, lack of segregation would surface as
soon as there was a breakdown of incinerator. However,
the financial authorities within the health departments
and at the finance department level expressed their
commitments to fund the HCWM initiatives and make
them sustainable. Generally they supported the option
of a centralized facility (integrated HCWM) that may
cater a number of hospitals loads and is environmentally
friendly. Environment Protection Agency showed
willingness to implement the law but faced problems due
to non-cooperation of the stakeholders. The option to
use Public –Private Partnership in achieving the better
HCWM in the country was also supported by some of the
respondents.
There is absolutely no mechanism to allocate
budget for HCWM in the hospitals among the public
sector organizations. The practices were not found in
accordance with the prescribed procedures. There is not
much concept of disinfection before disposing off.
Literally, engineered landfills were absent and ashes
were also buried sometimes near the water sources.
There was also no treatment for the chemical waste,
observed. Coordination between the health department
and the municipality lacked at all levels. Incinerators
were found installed but were either of not of proper
standards or were not working and being operated
optimally. No monitoring mechanism was also found
existing.
As a result of visit to all public sector teaching
hospitals and private sector hospital, it was observed
that HWM Program was partially implemented. Among
teaching hospitals, there were lapses visible from
segregation till on-site treatment. Off-site disposal
facilities were also presenting a disappointing picture.
Incinerators' capacity and daily waste generation from
teaching hospitals did not match the equation.
Operational difficulties remain a regular constraint as
there were no funds available to address maintenance
issues. Regular training and the staff commitment was
lacking in majority of hospitals.
Discussion
In Pakistan, the HCWM suffers due to non-
implementation of the HCWM rules. The country lacks a
comprehensive national HCWM implementation plan.
There was either no healthcare/medical waste
management team notified or if it is formed, it remains
non-functional. The HCWM activities lack budget
allocation, which is absolutely fundamental for
implementation of HCWM rules, was found absent in all
of the cases. There is no robust recording system of the
generated waste from the hospitals. Hence, there were
no proper reporting mechanisms. Trainings do play a
vital role in creating awareness for proper medical waste
management among the healthcare staff but it needs to
be strengthen and frequently done.
Within South Asia, regardless of basic
prerequisites being in place, planning and implementing
proper HCWM is yet to be seen. Studies from
neighboring countries support results from our study.
Sing K etal., and Patel, A.D., have argued similar
observations in their study in India. Shinee, E etal., have
recommended need of implementation plan in their
context of Mangolia. Overall implementation plans,
mechanisms and teams to implement those plans within
hospitals are either missing or non-operational. Studies
from Kanclerski, K., and Goren, S., give examples how
some of rapidly developing or developed countries in the
Europe have seriously realized the importance of having
medical waste teams and are in the process of
developing a robust system .
Budget allocation is usually the blood line for any
healthcare intervention. Our study has identified this
crucial gap in all the hospitals surveyed during the study
period through qualitative discourse. A recent study by
Ananth, A.P. etal., has strongly recommended budget
allocation as one of the most important measures for a
successful HCWM implementation plan. Studies from
other developing countries, as reported by Al-Emad,
A.A., clearly attributed budgetary constraints to lack of
necessary equipment for HCWM, and absent training
programmes for the healthcare workers .
Our study has also indentified that there was no
proper record of the HCW generated in the hospitals.
Without proper record of the HCW, plans for HCWM are
difficult to implement. Almuneef, M., has identified such
measures as pre-requisites for effective waste
management procedures .
According to our study, training of the
Healthcare Workers has an impact on better
management of the HCW. Poor knowledge and skills of
the healthcare providers not only exposes themselves
to the risk of injury but becomes a threat of infectious
disease spread for the community at large . Taghipour,
H., has documented that initiation of a training
programme for HCWM, in addition to other necessary
measures of HCWM, should reducesubstantial
amounts of the HCW. Patil, A.D., also came up with the
similar recommendations. Abdulla, F., identified need for
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 Pakistan Journal of Public Health, 2016 ( September )
trainings for healthcare staff in a High Income Country
(HIC) of the EMRO region .
Conclusions
Healthcare waste management is not following the
prescribed protocols and procedures. A robust national
action plan is required to address this degrading
situation of HCWM. On an urgent basis, a separate
budget head need to be created for the specific activities
of HCWM and for implementation of the rules among the
hospitals.
Acknowledgments
We are deeply grateful to the World Health
Organization, Health Services Academy, Provincial
Health Departments, coordinators, and data collectors
and analysis team for their support and work with us.
We declare that the study was carried out under
the ethical approval of the academy with close
coordination with the WHO. We also declare that we
have no conflict of interest.
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 Pakistan Journal of Public Health, 2016 ( September )

A B

C D

E F

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 Pakistan Journal of Public Health, 2016 ( September )

Pak J Public Health Vol. 6, No. 3, 2016 Original Article

WILLINGNESS AND PERCEPTION ABOUT BLOOD DONATION IN RESIDENTS OF

RAWALPINDI CITY
1
Abida Sultana, 2Bushra Anwar, 3Madiha Shafi, 4Muneeba Faisal

1
Professor, Department of Community Medicine, Rawalpindi Medical College, Rawalpindi, University of Health Sciences,
Lahore, Pakistan, 2Postgraduate Trainee(FCPS), Department of Community Medicine, Rawalpindi Medical College,
Rawalpindi, University of Health Sciences, Lahore, Pakistan, 3Demonstrator and Postgraduate Trainee(MCPS),
Department of Community Medicine, Rawalpindi, Medical College, Rawalpindi, University of Health Sciences, Lahore,
Pakistan, 4Postgraduate Trainee(FCPS), Department of Community Medicine, Rawalpindi Medical College, Rawalpindi,
University of Health Sciences, Lahore, Pakistan,Correspondence: Bushra Anwar, Postgraduate Trainee(FCPS),
Department of Community, Medicine, Rawalpindi Medical College, Rawalpindi, University of Health Sciences, Lahore,
Pakistan, Email address: bushra.anwar@live.com

Abstract

Background: Blood has always held mysterious fascination for all and is considered to be the living force of our
body. It is estimated that donation by 1% of the population (10 per 1000 population) is generally the minimum needed
to meet a nation's most basic requirements for blood. All around the world that there is serious mismatch between
demand and availability of blood. Lack of knowledge and facilities, fear, religious, socioeconomic and cultural
factors, influence willingness of people to donate blood.
Objective: To assess the willingness to donate blood voluntarily to blood bank, and perception about blood donation
of residents of Rawalpindi. Also to find percentage of residents of Rawalpindi who had ever donated blood.
Study design: A cross-sectional survey done in Rawalpindi city, in duration of one month. Subjects and methods: A
cross-sectional survey was done on residents of Rawalpindi in a period of one month, May 2015. 119 study subjects
were surveyed using close-ended questionnaire. The questions asked were about their age, gender, education,
occupation, willingness to donate blood and perception about blood donation in terms of social obligation and effect
on health. Willingness and perception was compared in relation to age, gender, education and occupation of
subjects.
Results: 70% people were willing to donate blood voluntarily to blood bank. But 36.1% had donated blood
previously in life. Majority persons (82.35%) perceived it as a beneficial thing for health and 91.6% considered it a
social obligation. 81.5% respondents said that there are no bad effects of blood. More males and young respondents
were seen to be willing for blood donation.
Conclusion: Many people were willing to donate blood regarding it a social obligation and for helping others but
some of them had practically donated blood due to fears of anemia and weakness mostly.
Keywords: blood donation, willingness, perception

Introduction population were collected. The average number of blood

Each second of every day all around the world people
belonging to different age groups and various fields of
life need blood transfusion. Over a million blood units
are collected from donors every year; nevertheless,
many more millions still need to be collected to meet the
global demand and ensure sufficient and timely
provision of blood(1). Blood has always held mysterious
fascination for all and is considered to be the living force
of our body. It is estimated that donation by 1% of the
population (10 per 1000 population) is generally the
minimum needed to meet a nation's most basic
requirements for blood. The average donation rate in
developed countries is 38.1 donations/1000 population
(range 4.92–68.01); and in developing countries an
average 2.3 (range 0.40–7.46) donations per 1000
donations per 1,000 populations is 12 times higher in
high income countries than in low-income countries(2).
In Pakistan more than 1.5 million pints of blood are
collected each year. Among them about 65% is from
replacement donors, 25% from volunteer donors and
about 10% from professional donors . Infact, the World
Health Organization and the council of Europe
recommend that(3) blood should be collected only from
voluntary, unpaid repeat donors who can assist blood
bank to manage blood supply and schedule transfusion
smoothly(4). It is observed all around the world that
there is serious mismatch between demand and
availability of blood .Lack of knowledge, fear, facilities,
religious , socioeconomic and cultural factors,
convenience and the quality of service are common

44
 Pakistan Journal of Public Health, 2016 ( September )

factors in people’s decisions on whether to donate blood Results:

repeatedly on a voluntary basis resulting in limited In our study, majority people were of age 15-25 years
number of voluntary donors(4). Altruism, social (48%). Proportion of males was 45.3% and of females
responsibility, peer influence, access to health was 54.6% as shown in figure 1 and 2. 30% people were
communication, and knowledge about importance of related to medical profession and rest were non-
blood donation are mentioned as some of medical.
the factors that motivate individuals to donate blood.
Transmission of values to generations(5) among family
members practicing donation and the influence of active
blood donors on others are also noted(6). Similar
studies have been done at international, national and
local levels. A study of Saudi Arabia discussed the
perceptions about voluntary blood donations among the
supportive service employees of a rural tertiary care
Hospital. A qualitative study conducted in Rawalpindi (7)
explained the reasons for people donating and not
donating blood voluntarily in Pakistan. Reasons found
were lack of information, low altruism, lack of trust in Figure 1: Age groups in years (n=119)
functioning blood banks, poor quality of blood bank
services, fear of diagnosis of disease like HIV, hepatitis
during screening and blood deficiency after donating
blood(8). Keeping in view the importance of donation
and transfusion, our study was conducted to determine
the willingness and perceptions about blood donation in
Rawalpindi City. This will help public health authorities to
design health education programs to dispel the myths
and to inspire the general public to come forward for this
noble cause.
Subjects And Methods:
This study was conducted in the month of May 2015, in Figure 2: Gender distribution (n=119)
the city of Rawalpindi. 119 study subjects were selected
using non-probability convenience sampling. Inclusion Results about questions asked about willingness show
criteria was that person should be resident of Rawalpindi that 70% people were willing to donate blood voluntarily
and more than 15 years of age. They were approached to blood bank (shown in table 1). But 36.1% had donated
in colleges, workplaces and markets. Data was blood previously in life. Majority persons (82.35%)
collected by researchers using questionnaires, which perceived it as a beneficial thing for health and 91.6%
were filled by them after interviewing the respondents. considered it a social obligation.
Questionnaire was semi-structured and in English Table 1: Variables noted for willingness and perception
language. Questions were related to age, gender, about blood donation with responses ‘yes’ and ‘no’
education, occupation and their willingness and
perception about blood donation. Interviewers were
trained before taking data and meanings of words
relevant to variables in questionnaire were cleared, so
that a common perception of words is maintained
among the interviewers. Prior permission was taken
verbally from study subjects and confidentiality of
patients was assured. They were asked whether they
had ever donated blood in life or were they willing to
donate blood in future. Reasons were asked for their
willingness or non-willingness in close ended questions.
They were asked what bad effects they know of blood
donation and whether they perceived it as a social
obligation and beneficial thing for health. These
variables of perception and willingness were compared
in relation to age, gender, education and occupation and
were tested for statistical significance using chi-square
test. Statistical analysis was done using SPSS Version
21.

45
 Pakistan Journal of Public Health, 2016 ( September )
81.5% respondents said that there are no bad effects of
blood donation as shown in figure 4. However, 14.5%
said that blood donation causes physical weakness,
1.68% said obesity and 2.52% said iron deficiency
occurs from blood donation.
Figure 4: Bad effects on health (n=119)
Among the 69 willing persons, only 24.6% people were
willing to donate blood voluntarily as aroutine to blood
bank as shown in figure 5. But many respondents
(52.2%) claimed that they would donate blood in need of
their relatives as well as non-relatives. 21.7% were
willing to donate blood only to their close relatives in
need.
Figure 5: when to donate blood (n=69 willing persons)
60 out of 69 persons who were willing to donate blood
(87%) said that they wanted to donate blood to help
others. 5% wanted it for health benefits, 4% motivated
by religious reasons and only 2.8% said they want
money in return as shown in figure6.
Figure 6: Motivating Factors of willing persons (n=69)
Among the 50 non-willing persons, 32% said that they
don’t donate blood by fear of physical weakness and
10% were afraid of needle prick. Other factors for not
donating blood were medical problems such as, anemia
in 28%, hepatitis C in 8% respondents, old age in 8%
respondents, diabetes in 6% and asthma in 2%
respondents (shown in figure 7).
Figure 7: Demotivating Factors of non-willing persons
(n=50)
Willingness was observed to be better in young age
groups (67% willingness in 15-25 year age persons) as
compared to old persons (25% in 55 years and above
age) as shown in table 2. There was a significant relation
found between age and willingness of blood donation
using chi-square test.
Table 2: Willingness to donate blood and age (p-value
less than 0.05 is considered statistically significant)
Willingness to donate blood was compared among
males and females and different age groups as shown in
table 3. More males were seen to be willing for blood
donation and had donated blood previously. There was
a significant relation between gender and history of
previous blood donation (p-value< 0.05).
Table 3: Willingness to donate blood and history of
previous blood donation comapared in both gender (p-
value less than 0.05 is considered statistically
significant)
A small percentage of females had donated blood
previously and main reasons observed were anemia in
20% and fear of weakness in 17% females. Willingness
to donate blood was compared among different
46
 Pakistan Journal of Public Health, 2016 ( September )
education groups and was found to be better in
undergraduates (72.2% willing) as compared to
Table 4: Willingness to donate blood and education (p-value<0.05 is statistically significant)
Main reasons told by graduates for being non-willing for
blood donation were feeling of weakness in 30.4%,
anemia in 21.7%, and fear of prick in 17.4%. Persons
related to medical profession were more willing to
donate blood (72.2%) as compared to non-medical
personnel (51.8% willing) as shown in table 5. This result
was statistically significant as p value is <0.05.
Table 5: Willingness to donate blood and occupation (p-
value< 0.05 is statistically significant)
Discussion
Our study showed that only 36.1% people had donated
blood voluntarily to blood banks and 57.9% were willing
to donate blood in future whereas a survey conducted in
Austria showed that 66% public donated blood in their
life. This less percentage of willingness in our 9
population may be because in our setup there is no
system of motivating people for welfare of society.
In our study, it was found that more males (59.3%) had
donated blood than females (16.9%). This is similar to a
study done in Israel where among blood donors,
proportion of males was more (98.3%) than females
(1.7%). Same results were found in a study of Saudi
Arabia where 10 blood donation in males was 66% and
in females 13.3%. This may be because generally 11
females are more conscious of their health and afraid of
weakness. Females of our study were willing but
practically few of them donated as 20% of our females
had anemia, which may be true as blood should not be
donated with hemoglobin of 12.5 or lower. 12 Our study
showed that young people were more willing to donate
blood than older ones with the percentages being 67.2%
and 25% respectively. This is similar to results of a study
of Bostwana; the percentage was found to be highest
graduates (35.1% willing) as shown in table 4. This
result was significant as p-value was less than 0.05.
(80.7%) in young age group 21-30years whereas lowest
(48.8%) in 51years and above. The low percentage of
willing elderly 13 individuals in our study can be
attributed to the fact that old people are afraid of
becoming weak upon donation. Reasons mostly
observed for non-willingness of blood donation in our
study population were fear of weakness in 32% and
anemia in 28%. However in a survey of Chennai, India
main reasons for not donating blood were pain of needle
prick in 55%, which in our study was told 14 by only 10%
respondents. In our study 91.6% people considered
blood donation a social obligation, just similar to a study
conducted in Saudi Arabia where 91% subjects took
blood donation as a religious and social duty. This may
be due to our common religious beliefs of helping
society.
In our study only 2.85% individuals were willing to onate
blood for financial gains while according to a study
conducted in Congo, 12.6% subjects wanted to donate
blood in return of money. Also, in a Saudi Arabian study,
91% subjects rejected the idea of taking money in 16
exchange for blood but out of these 63% approved the
idea of accepting a token gift from the recipients. 15 In
our study we observed that illiterates were mostly willing
to donate blood and the graduates were the least willing
persons (% willing). This is similar to a study of Karachi
where it was noted that blood donation decreases as
education level increases as there was 8% willingness
in matric-pass respondents as compared to 34% in
illiterates.17
Conclusion
In our study, willingness to donate blood was found in
majority of people with intention of helping others, but
few of them had donated blood, mostly due to fear of
anemia and weakness. Most of the people perceived it
as a social obligation and a beneficial thing for health.
Recommendations
Misconceptions and myths related to blood transfusion
should be cleared by health education and counseling.
People should be guided about eligibility criteria for
blood transfusion. Public record of blood donors should
be available on internet with their address and phone
47
 Pakistan Journal of Public Health, 2016 ( September )

numbers so that people who need blood can contact 13 Pule PI, Rachaba B, Magafu MGMD, Habte D.
them. Blood transfusion services especially sterilization Factors Associated with Intention to Donate Blood:
procedures should be improved. Donors should be Sociodemographic and Past Experience
facilitated during blood donation process by providing Variables. Journal of Blood Transfusion. J Blood
them a friendly and pleasant environment so that they Transfus. doi:10.1155/2014/571678.
are encouraged. Appreciation and incentives should be 14 Uma S, Arun R, Arumugam P. The knowledge,
given to blood donors e.g. by giving certificates or attitude and practice towards blood donation
providing some other free medical services, so that among voluntary blood donors in chennai, India. J
more people are motivated for donating blood. Clin Diagn Res. 2013;7(6):1043-6.
References 15 AbdelGader AG, Osman AM, Al Gahtani FH,
1 Malik MR, Majid S, Laghari MS. Determinants of Farghali MN, Ramadan AH, Al-Momen AKM.
blood donation behaviour of general public in Attitude to blood donation in Saudi Arabia. Asian J
Pakistan. Pak J Med Health Sci. Transfus Sci. 2011; 5(2):121-6.
2010;4(1):137–42. 16 Kabinda JM, Miyanga SA, Ramazani SY, Dramaix
2 World Health Organization. Blood safety and MW. Assessment of Knowledge, Attitude and
availability. Fact sheet N°279. Updated June 2014. Practice of the General Population of Bukavu in the
3 Asif N, Kokhar N, Ilahi F. Seroprevalence of HBV, Democratic Republic of Congo on Blood Donation
HCV and HIV infection among voluntary non and Blood Transfusion. SciRes. 2014;6(18).2525-
remunerated and replacement donors in Northern 34.
Pakistan.Pak J Med Sci 2004;20(1):24-8 17 Malik MR, Majid S, Laghari MS. Determinants of
4 Alfouzan N. knowledge, attitude and motivations Blood Donation Behaviour of General Public in
towards blood donation among king abdul aziz Pakistan. Pak J Med Health Sci. Apr-Jun
medical city population. International journal of 2010;4(2):137-42.
family medicine. 2014; Article ID 539670, volume
2014: 8 pages.
5 N. Zaller, K. E. Nelson, P. Ness, G. Wen, X. Bai,
and H. Shan, “Knowledge, attitude and practice
survey regarding blood donation in a Northwestern
Chinese city,” Transfusion Medicine, vol. 15, no. 4,
pp. 277–286, 2005.
6 A. H. Misje, V. Bosnes, O. Gåsdal, and H. E. Heier,
“Motivation, recruitment and retention of voluntary
non-remunerated blood donors: a survey-based
questionnaire study,” Vox Sanguinis, vol. 89, no. 4,
pp. 236–244, 2005.
7 Baig M, Habib H, Haji A, Alsharief F, Noor A, Makki
R. Knowledge, misconceptions and motivations
towards blood donation among university students
in Saudi Arabia. Pak J Med Sci. 2013;29(6).
8 Zubia Mumtaz,Promoting Voluntary Blood
donations in Pakistan; meanings of Blood,
Bleeding and Blood donation.Sept 27 th 2009,Pg
5,22,23
9 Blood donation and blood transfusions. Survey.
Belgium: European Commission, Health and
Consumers; 2010.
10 Das K, Geetanjali, Sachdev S, Kaur B, Singh CI,
Nongbri D. knowledge, attitude and practices of
blood donors towards blood donation. J Postgrad
Med. 2014;48(3):123-7.
11 Abolfotouh MA, Al-Assiri MH, Al-Omani M, Al Johar
A, Al Hakbani A, Alaskar AS. Public awareness of
blood donation in Central Saudi Arabia. Int J Gen
Med. 2014 ;12(7):401-10.
12 Food and Drug Administration. Requirements for
Human Blood and Blood Components Intended for
Transfusion or for Further Manufacturing Use.
Federal Register. 2007;72(216):63426.

48
 Pakistan Journal of Public Health, 2016 ( September )

Pak J Public Health Vol. 6, No. 3, 2016 Original Article

OUT OF POCKET SPENDING FOR HEPATITIS C PATIENT’S TREATMENT AT DISTRICT HEAD

QUARTER HOSPITAL BADIN, SINDH

Zubair Ahmed Laghari1, Assad Hafeez2

Corresponding author: MSPH Fellow, Health Services Academy / Planning Officer, Department of Health, Government of
Sindh. Email: msphs14zubair@hsa.edu.pk
2.Professor and Dean/Executive Director, Health Services Academy, Islamabad

Abstract
Introduction: Developing countries account for 84 percent of global population and 90 percent of the global disease
burden, but only 12 percent of global health spending, Hepatitis is among top ten diseases which are costing the
people more in Pakistan at present and in country more than 61% of expenditure for seeking treatment comes
through households own pocket.
Objectives: Objectives of the study were to calculate the out of pocket spending for hepatitis C treatment at
government health facility of district head quarter hospital Badin and to look into the issues which are faced by
patients in order to get the treatment for hepatitis C disease.
Material and Methods: A cross sectional survey was conducted from hepatitis C patients who were in their last two
months of treatment, a pre structured and translated questionnaire was developed in order to interview the
participants, interviewed patients were 103, Data analyses was done on SPSS version 20.0
Results: Study calculated that at average every patient has spent the cost of Pakistani Rupees (PKR).14564 and
major issues were non availability of medicine, transportation as centers were centralized and delay for getting
reports of diagnostic tests (PCR) which took maximum six months and minimum three months for receiving the
reports for the treatment of hepatitis C if government facility is used.
Conclusion: Study concludes that at average every patient has to pay Rs.14564 for getting treatment of disease
from government facility and major issues are non availability of medicines, transport and delay in receiving reports
as patients has to wait for six months in case of maximum time taken for collecting his PCR test results if he prefers to
use government laboratory for the purpose.
Key Words: Health expenditure, infectious disease, government health facilities

Introduction than neighboring countries where India (0.66%), Nepal

Developing countries account for 84 percent of global
population and 90 percent of the global disease burden,
but only 12 percent of global health spending. The
poorest countries bear an even higher share of the
burden of disease and injury, yet they have the fewest
resources for financing health services. Direct
payments for seeking health care are believed to be
most reliable source for reducing the service provision
impact globally but these direct payments can cause
high and unfair distribution of household's payments in
total health expenditures.
Viral Hepatitis is a global public health problem affecting
millions of people worldwide by causing disability and
death; around 500 million people are affected or
chronically affected with hepatitis B virus (HBV) or
hepatitis C virus (HCV), and approximately 1 million
people die each year due to causes of hepatitis (2.7% all
deaths) most commonly due to liver diseases,
prevalence of hepatitis C infection is very high in
Pakistan (4.7%), varying from 0.4% to 33.7% indicating
pockets of infection, the frequency is significantly higher
(1.0%), Myanmar (2.5%), Iran (0.87%), China (1%) and
Afghanistan (1.1%)-.
In Pakistan more than 10 million people are living with
hepatitis C virus along with high morbidity and mortality,
blood transfusion, reuse of needles for ear and nose
piercing, reuse of syringes, injecting drug users,
tattooing, shaving from barbers, unsterilized dental and
surgical instruments, unsafe sex, quackery and vertical
transmission (from infected mother to child during labor
process) are being the major source of disease
transmission in general population.
According to Chief Minister's Initiative for Hepatitis
Control Programs Sindh in the province estimated more
than 3 million people are affected by any viral infection of
hepatitis and program has about 79 sanctioned
sites/treatment centers for treating the disease
throughout province, through these centers about
74,43,869 people are vaccinated till to date from
beginning of the program. At the treatment center of
Badin (the target centre) total 334 patients were under
treatment, 1811 patients had completed treatment and

49
 Pakistan Journal of Public Health, 2016 ( September )

24 new patients registered as on December of 2014. Marital status

Program aim to target 33,30,000 general population and
100,000 school going children to vaccinate against
Unmarried 4 3.9
hepatitis B, along with 150,000 population for hepatitis C
treatment and to establish ELISA screening facilities at Married 98 95.1
taluka level.
widow/divorced 1 1
Hepatitis is among top ten diseases which are costing
the people more in the country at present, and when Educational Status
analyzed the funding sources by financing sources and
financing agents it is clearly mentioned that top most
Illiterate 69 67
funding source for treatment in the country is
households own payments which are labeled as Out Of Primary 13 12.6
Pocket Spending (OOPS)
Matriculation 16 15.5
Methods
We conducted this cross sectional study including 125 of Intermediate 5 4.9
hepatitis C patients being treated for their diseases, and
being followed for the last two months of the course of Residential Background
the treatment. We could achieve 82% of our sample size
due to less registered patients at the facilityand due to Urban 11 10.7
four drop outs at the last moments. We used an adopted
Rural 92 89.3
structured questionnaire, which was pre-tested. The tool
covered socio-demographic, economic, expenditure Profession/Occupation
incurred by the patient for diagnosis and treatment; and
issues faced by the patients during treatment. . After
private employee 1 1
cleaning the data, it was analyzed using SPSS 20.0
version for descriptive and analytical analyses. not employee 2 1.9
This study was approved by the Internal Review Board
Farmer 31 30.1
(IRB) of the Health Services Academy. Further approval
and consents from the Medical Superintendent and shop keeper 8 7.8
patients respectively were sought for data collection and
House wife 38 36.9
filling in the questionnaires. . Strict anonymity and
confidentiality was maintained for participants as only Other 23 22.3
codes were used instead of original names of the
Monthly Income
participants.
Results
Descriptive 0 1 1
Table 1: Socio Demographic characteristics
Undocumented 37 35.9
Socio Demographic <5000 8 7.8
Frequency Percentage
character 5001-10000 33 32

10001-20000 7 6.8
Age
20001-30000 12 11.7
30001-40000 2 1.9
18-25 16 15.5
>40000 3 2.9
26-35 44 42.7
Expenditure
36-45 33 32

46-55 10 9.7
Dependent 39 37.9
Gender
<5000 4 3.9

5001-10000 34 33
Male 61 59.2

Female 42 40.8
Expenditure
The below graph shows the different heads of

50
 Pakistan Journal of Public Health, 2016 ( September )
expenditures which incurred for receiving the treatment
of hepatitis C by the patient at government run facility,
three major heads of high expenditure which patients
had to bear for treatment were medicine, PCR tests and
traveling cost for collection of HCV injections, these cost
are very high for the patients as 39.8% of the patients
had income less than Rs. 10,000 per month.
Figure : Expenditure during Hepatitis treatment
Note: Additional tests: blood CP&ESR, Liver
Functioning Test (LFT), Ultra Sound Abdomen and
Random Blood Sugar (RBS). Traveling Cost: this cost is
only for PCR and additional tests. Total Transport: this
cost is for traveling for receiving injections from
treatment centre every fortnightly.
Issues faced by patients
PCR test issue
The evidence from our study shows that in average the
expenditure for PCR test incurred for two tests (as one is
required before the start of treatment and one is after
completion of the course) is Rs. 4763which is one of the
major cause due to which Out of Pocket Spending is
high in the country. Although diagnostic facility is
available in government system but problem is delay as
our study points out that a patient has to wait for
maximum six months and minimum three months if
he/she utilizes the services of government that is why
about 79.6% participants used private lab facilities for
PCR test.
Medicine Issue
The leading cause for OOPS for hepatitis C disease is
due to medicine as almost all the participants were
prescribed with medicines by the doctors at hepatitis
treatment centre of DHQH Badin and all of the
participants bought medicines with their own resources
as medicines were not provided by government run
hospital at DHQH Badin (which is supposed to provide
the medicines free of cost to the patients), in result
OOPS is high in government setup for hepatitis
treatment.
Transport
Our study finding shows that transportation cost for the
purpose of collecting the treatment injections from
hepatitis treatment centre every fortnightly is Rs. 2529
as 56.3% participants used public transport and 35.9%
used private vehicle which may be a taxi or personally
owned vehicle in most cases which was motor cycle, this
was also a big issue as treatment collection points were
centralized at certain identified government health
facilities if program is more expended at lower level this
cost can be cut down.
Delay in receiving reports
As most of the patients were using the partial method of
diagnostic tests in which they used private labs for
conducting PCR tests therefore there was no delay for
receiving the reports as 79.6% patients responded that
they have received the reports of the tests within a
month. But problem lies with government sector where
remaining 20.4% patients went for PCR test who could
not afford the cost for private lab and used government
facility for PCR and had waited for more than a month for
receiving reports of their tests.
Time taken from diagnosed to treatment
It was found that those patients who had used private
labs for tests were able to receive treatment injection
within a month period but those who had tests from
government laboratory had to wait for maximum six
months (3.9%) and minimum for three months (7.8%)
this long time taken for reports is the major contributing
factor of under utilization of government laboratories for
the diagnostic tests like PCR.
Discussion
This study was designed with two main objectives one
was to collect the data for out of pocket expenditures
incurred on the treatment of Hepatitis C and second was
to look into the issues which were faced by the patients
during the process of getting treatment at hepatitis
treatment centre which in our study was district head
quarter hospital Badin.
The general procedure for treatment which was adopted
at government facilities in particular for the disease of
hepatitis C was that every patient has to undergo some
diagnostic test the major test among all was PCR test
which showed the viral load in a patient and every
patient has to conduct two PCR test one before start
after screened positive and confirmed through ELISA for
hepatitis C and second after completion of the treatment
course in order to check the response of virus after
treatment, in this study we calculated the traveling cost
for conducting diagnostic tests which a patient has to
bear for conducting treatment as our study patients were
still under treatment so we did get the traveling cost for
first PCR test and multiplied that cost with two as we
assumed that patients will use the same lab for second
test too and our study calculated that patients had paid
at average Rs.557 only for conducting the PCR test
before and after the treatment. Whereas, same
procedure was adopted for the PCR test itself as most of
the patients had used private laboratory facility for PCR
test except 20.4% patients who used government facility
for PCR test, average cost incurred for PCR test in our
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 Pakistan Journal of Public Health, 2016 ( September )
study was Rs.4763 for both before and after tests. In a
policy developing article writers conclude that the major
hurdles are high cost of treatment and the affordable and
reliable diagnostic tests so is the case in our study where
government setup has yet to develop the trust building in
public.
Our study findings revealed that at average every
patient has to bear Rs.5954 for medicine which patient
has to take during the treatment for entire course period,
we questioned every patient for cost of medicine for
fifteen days as they were collecting the injections for
every fifteen days from hospital and then multiplied that
amount with 12 visits which every patient has to make for
completion of the treatment course. There were some
patients who replied that they are unable to buy the
medicine all the time. Study conducted in Thailand
focused on the objective of to estimate the cost for the
management of chronic hepatitis C and related
morbidities finds that the largest portion of cost for all
cohorts was of medication. The study concludes that
hepatitis C is a very costly disease in Thailand, whereas
one Canadian study concludes that many patients
experienced difficulties in paying for concomitant
medications; patients think that at time of prescribing
physicians should take into account patient's
affordability for medicine.
Findings of this research showed that at average the
cost for transport from the home of patient to the facility
for collecting the injection for treatment of hepatitis C
was Rs. 2529, this was the third highest cost for the
patients after cost for PCR and cost of medicine,
patients used to cover huge distance in hectic means of
public transport for collecting the injections from facility
as these hepatitis treatment centers are centralized in
the province. A Korean study states that traffic costs
went up by 1.3 times from KRW 5.5 billion in 2004 to 7
billion in 2008, although this study has been conducted
on aggregated national level whereas our study has just
focused on micro level where only one treatment centre
has been focused but increasing trends of transportation
costs shows the burden of payments on patients.
Rs. 14564 has been paid at average by every patient for
getting the services of treatment for the disease of
hepatitis C from government health facility where
treatment is meant to be free of cost for the general
population provided by the government of Sindh under
the name of Chief Minister's initiative for the control of
hepatitis in Sindh. Korean study has also showed the
increasing trend in OOPS by 1.8 times from year 2004 to
2008 , and same paying difficulties has been observed in
USA where a study tried to see the financial stress and
medical debt that how people managed that,
participants spoke of difficulty in paying of their
household bills due to their medical bills. In order to pay
their medical bills participants commonly compromised
their other basic needs like heating, transportation and
food.
Whereas, major issues which are faced by the patients
are non provision of medicine from hospital, traveling
cost for injections and delay in receiving reports from
government provided diagnostic laboratories which is
the leading factor for patients to opt for private labs for
the purpose of PCR test and low utilization of
government provided facility, at maximum patients
waited for six months for collection of their PCR test
reports and start of their treatment course. These all
factors are making situation more worsening and leads
towards more Out of Pocket Spending for the patients
Conclusion
Our study concludes that at average every patient has to
pay Rs.14564 (in average for traveling Rs.2529, for
diagnostic tests Rs.4763 and for medicine Rs.5954) for
getting treatment of disease from government facility
and some issues which are faced by patients which are
also leading factors for increasing the OOPS are non
availability of medicines, transport cost due to
centralization of the hepatitis clinics and delay in
receiving reports as patient has to wait for six months in
case of maximum time taken for collecting his PCR test
results if he prefers to use government laboratory for the
purpose. Study was focused to measure direct medical
and non medical costs and opens the doors for further
research in the field and scope can also be increased to
measure the indirect cost too.
Reference
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2 Abolhallaje et al. Determinants of Catastrophic
Health Expenditure in Iran. Iranian J Public Health.
2013;42(1): 155-160
3 WHO. Prevention and Control of Viral Hepatitis
infection: Framework for Global Action.2012
4 Umar M et al. Hepatitis C in Pakistan: A Review of
Available Data. Hepat Max. 2010; 10(3): 205-214
5 Attaullah et al. Hepatitis C virus genotypes in
P a k i s t a n : A S y s t e m i c R e v i e w. Vi r o l o g y
Journal.2011;8:433
6 Waheed Y et al. Hepatitis C virus in Pakistan: A
Systematic review of Prevalence, Genotypes and
Risk Factors. World J Gastroentesole. 2009.
7;15(45): 5647-5653
7 Chief Minister's Initiative for Hepatitis Control
Program Sindh. www.hpcp.com.pk
8 Pakistan Bureau of Statistics GoP. Pakistan
National Health Accounts 2011-12. Islamabad
9 Suthar AB, Harries AD (2015). A Public Health
Approach to Hepatitis C Control in Low and Middle
Income Countries. PLoS Med 12(3): e 1001795.
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10 Thongsawat S, Piratvisuth T, Pramoolsinsap C,
Chutaputti A, Tanwandee T, Thongsuk D.
Resource Utilization and Medical Costs of Chronic
Hepatitis C in Thailand: A Heavy but Manageable
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 Pakistan Journal of Public Health, 2016 ( September )

Economic Burden. ELSEVIER (value in health

regional). 2014; 3 C: 12-18
11 ChiranjeevSaniyal. Coping Strategies Adopted by
Patients Infected with Hepatitis C Virus who are
Facing Medication costs. CJHP. 2011; 64(2): 131-
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of Liver Disease in Korea. Korean J Hepatol.
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 Pakistan Journal of Public Health, 2016 ( September )

Pak J Public Health Vol. 6, No. 3, 2016 Original Article

ASSESSMENT OF WORKLOAD PRESSURE AND OPTIMAL STAFFING NEED OF NURSING

STAFF FOR INPATIENT SERVICES AT FGH ISLAMABAD.

Mir Hassan Bullo, Katrina A. Ronis

Author: Mir M Hassan Bullo Deputy Director Admin FGH (MSPH 2014-15), Dr. Katrina. A. Ronis (Associate
Professor) Health Services Academy Islamabad.

Abstract
Background: Human Resource Management in the health sector is one of the most important building blocks of the
World Health Organisation's “Health Systems”. Managing and balancing the health work force equitably in the
hospital and other health care facilities is important to deliver quality health care. Within a Pakistani context the
challenge is primarily with the public sector hospitals where staff shortages lead to higher workload pressure
especially among nursing staff.
Hospital nurse staffing and their working conditions is a major concern due to the effect it can have on patient safety
and quality of care. This study generated evidence to provide base line data for future nurse staffing need for the
inpatient services of the Federal General Hospital (FGH) Chak Shahzad Islamabad.
Methods: Workload Indictor of Staffing Need (WISN) methodology was used to determine the workload pressure
and optimal staffing need for nurses. In this cross sectional study all the activities of 23 nurses were enlisted through
a spread sheet and questionnaires were used to document the time required to execute each nursing activity
according to the Nursing Staff and an expert group in this study. The expert group in this study consisted of 1.Nursing
Superintendent of the hospital, 2 Deputy Registrar of PNC, 3 Senior Nurse from N.I.H.
Results: The main findings revealed a mean age of 30 ± 0.739 years for the Nursing Staff. There was a maximum
shortage of 12 nurses for the Accident and Emergency department with 67% higher workload pressure.
Conclusion: The five indoor departments of the FGH require an additional 25 Nursing Staff to manage the 53%
workload pressure.
Key Words: Health Systems, Hospital, Patient Safety, Workforce, Pakistan, Fatigue Syndrome.

Introduction due to four factors: 1.Increase demand of nurses,(2).

Workload Indicator of Staffing Need (WISN) is an
analytical operational tool developed by P.J Shipp in
1998 to estimate staff requirement in strategic planning
for health work force worldwide [01].
It calculates the required number of health workers per
cadre against current workload of a facility. It determines
the workload pressure of a specific cadre & its results
help to identify an increase in current staff or to transfer
existing staff(1).
Pakistan has been categorized as one of the 57
countries that are facing a health workforce crisis, below
the threshold level defined by World Health
Organization (WHO) to deliver essential health services.
A Pakistani Government report revealed that nationally
the country needs 60,000 extra nurses(2,3).
Workload pressure increases with the shortage of
Nursing Staff on those who are already working in the
health sector. This work load pressure can result in a
fatigue syndrome or what is referred to as “burn out” of
staff which can lead to poor performance and hence
poor health care delivery(4).
Nursing staff are facing enormous workload pressure
Improper distribution of nurses(3): Improper work
distribution and 4. Reduced staffing & increasing over
time(5).
A broad array of research on this topic has found an
association between lower nurse staffing levels and
higher rates of some adverse patient outcomes. Most of
the studies examined nurse staffing levels and adverse
occurrences in the hospital setting, including in-hospital
deaths and nonfatal adverse outcomes such as
nosocomial infections, pressure ulcers, or falls(5,6).
Globally many studies have been undertaken to
estimate staffing need & to measure workload pressure
however WHO's Workload Indicator of Staffing Need
has been identified as the most appropriate tool to
estimate workload pressure & staffing need. WISN
methodology has been used in countries such as Egypt,
Oman, Sudan, Bahrain, Turkey, Indonesia, South Africa,
Hong Kong, New Guinea, Sri Lanka, Kenya, Tanzania,
Mozambique and Uganda. All the latter countries and
their respective hospitals had improved health services
and gained beneficial outcomes by applying the WISN
methodology(7).

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 Pakistan Journal of Public Health, 2016 ( September )
Regionally the literature revealed that Workload
Indicator of Staffing Need (WISN) HRM tool has been
successfully utilized in India, China, and Bangladesh. At
a national level here in Pakistan there was a study
performed in Benazir Bhutto Hospital Rawalpindi and
the Holy Family Hospital that revealed a shortage of staff
against an existing workload [07, 08].
The Federal General Hospital Islamabad is a 200 beds
secondary care hospital, established in February 2012.
FGH is the only public sector hospital serving the rural
community of Islamabad. FGH is providing indoor,
outdoor & diagnostic services not only to the catchment
population but also to the people of adjoining areas of
Punjab, Khyber Pakhtoon Khuwoon & Azad Jamo
Kashmir. This recently established hospital is providing
round the clock health services to the community within
its limited resources. The turnover of patients has
increased from 23,157 in the year 2012 to 84,142 in the
year 2013 showing a threefold increase in the year of
2014 to 112928 and the staff is coping with the
increased work load pressure as with the same number
of staff initially recruited [09].
Over burden of work was the constant complaint of
Nursing Staff working in FGH. To stream line the
workload on nurses & to generate evidence, the senior
management of FGH agreed to apply the WISN tool with
the Nursing Staff of the inpatient department.
The rationale for using WISN is that it is a health work
force planning tool to calculate the required number of
staff against an existing workload. The WISN method is
simple to operate & technically acceptable to health
managers. It is realistic in providing practical targets for
budgeting & resource allocation [07].
Methodology:
A cross-sectional study with a quantitative approach and
a WISN methodology was utilized. Study participants
included Nursing Staff working in the inpatient
departments of the FGH. Total number of Nursing Staff
(from the concerned departments) and an expert group
were included in the sample size as per WIISN
specification. In this study there were twenty three
(N=23) Nursing Staff and three (N= 3) members of an
expert group to identify the activity standards. Ethical
approval was granted by the Ethical Review Committee
of the Health Services Academy, Islamabad. Written
consent was obtained from the study participants. Data
was obtained from the hospital annual statistics and
collated for analysis (i.e. secondary data analysis);
Interviews with the Nursing staff and expert group were
performed; Activities of all nurses of inpatient
departments were listed on spread sheets. Data was
entered in templates of the tool and analyzed manually
through WISN methodology. Workload pressure and
staffing need were calculated as an outcome of the
process.
Results:
Minimum work experience of nursing staff in FGH was
four years, while maximum was 13 years over all. Mean
work experience was 7.08 ± 0.52 years. The standard
deviation for experience was 2.50.
Figure 1: Graph showing Working experience of
Nursing Staff
On “X” axis total number of 23 nurses has been given
and on” Y” axis work experience of Nursing Staff in years
along with their ages has been shown.
FGH is providing inpatient health care services in five
main departments 1. Accident & Emergency, 2.
Obstetrics & Gynaecology, 3. General Surgery, 4.
General Medicine, 5.Operation Theatre. WISN Human
Resource Health Management (HRHM) tool was
applied stepwise with the Nursing Staff of each
department providing inpatient health care services.
Staffing Need: It is shown in the results of the study that
there was a genuine shortage of Nursing Staff in
inpatient units of Federal General Hospital Islamabad.
In the final estimate maximum shortage of Nursing Staff
with high workload pressure was appeared in the
Accident & Emergency department in which 12 nurses
were deficient to cope up with the workload.
While second in the list was Obstetrics & Gynaecology
department where the shortage of 06 nurses to manage
the workload of inpatient services. Operation Theatre of
FGH was lacking 03 nurses to handle workload
pressure efficiently. The estimated shortage for General
Surgery inpatient was 2 nurses and for General
Medicine inpatient was 01 nurse only. Hence there was
extreme need of 25 nurses to cope up with the overall
workload pressure in FGH Islamabad. A total of 48
nurses was needed in all 3 shifts to provide good quality
inpatient health care services. The WISN ratio for all five
inpatient departments of FGH was 0.47 and the overall
workload pressure was 53%. Table 1 provides a
summary of the data.
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 Pakistan Journal of Public Health, 2016 ( September )

Table 1: Nursing Staff Needs (Inpatient Services at FGH)

Workforce Requirements
Indoor Units Current Needed No. Shortage Workforce WISN Workload
No. of of Staff Problem Ratio Pressure
Staff As %
Emergency & 06 18 12 Shortage 0.33 67%
Accident
(E & A)
Department
Obs. & Gynae 05 12 07 Shortage 0.41 59%
Inpatient
Operation 03 06 03 Shortage 0. 50 50%
Theatre
G. Surgery 05 07 02 Shortage 0.71 29%
Inpatient
G. Medicine 04 05 01 Shortage 0.80 20%
Inpatient
Over All 23 48 25 Shortage 0.47 53%

Two different measures have been obtained while
analysing the WISN result: (i) variance between existing
and required number of staff, and (ii) the WISN ratio
(existing staff divided by required staff). The WISN ratio
is a proximate degree for the everyday workload burden
on the staff.
Workload Pressure: According to the result Of WISN (A
& E) department was declared as area for serious
concern because it had 67% highest workload pressure
& secondly the nurses of OBs & Gynaecology
department were facing 59% workload pressure. In the
Operation Theatre it was 50% workload pressure on
Nursing Staff. Respectively the workload pressure on
the Nursing Staff of G Surgery department was 29%.
Eventually workload pressure on the Nursing Staff of G
Medicine department was 20% but comparatively less
than other units.

Figure 2: Work Load Pressure on Nursing Staff (Inpatient Departments)

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 Pakistan Journal of Public Health, 2016 ( September )
Discussion:
In this study the main activities of Nursing Staff and
variety of services provided by them in inpatient
departments of FGH were analysed. WISN HR
management tool was utilized to study the HR
management problems, different activities and workload
on the nursing staff. Only inpatient health care services
were examined in this study because hospital
management committee was interested to apply this tool
on the Nursing Staff of inpatient departments. The main
reason behind that verdict was constant complain of
nurses about workload pressure and for improving
inpatient health care services at FGH.
The WISN Study in 2006 was performed on the Nursing
Staff of Burkina Faso Referral Hospitals but the findings
in that study were quite different from this study
conducted in Federal General Hospital. Over staffing
was found that in some wards of Burkina Faso Referral
Hospitals in that study while in FGH it was only shortage
of Nursing Staff in every inpatient department [10]. The
same type of WISN study in 2006 was carried out in
Locar hospital Uganda, the situation of staff and
workload pressure were quit balanced in that study, no
over or under staffing found [11]. The services indicators
were found comparatively better in Locar hospital than
FGH according to study. WISN study of Namibia, WISN
software was used at the country level for data entry and
data analysis. They faced different technical problems
regarding software and previous year statistical record
[12]. In Federal General Hospital manual calculation
method was applied rather than WISN software. The
principle findings of WISN study for Namibia was staff
shortage and staff inequity but the study in the Federal
General Hospital indicated overall shortage of Nursing
Staff as well as inappropriate utilization.
Inappropriate use of available staff: The problem of skill
mix was identified in this study at FGH Islamabad
Pakistan. In Accident & Emergency department where
the maximum workload pressure was found, the
dressers and dispensers were performing the duties of
qualified nurses due to acute shortage of staff. For
example some dressers or dispensers were assisting
the doctor in catheterization and intravenous (I.V.)
medication in the emergency room which is the duty of a
qualified and trained nurse. The Study participants
revealed that the skill mix in this way resulted into the
increased chances of infection [13].
In the obstetrics and Gynaecology ward of the hospital
where the second highest workload pressure was found,
the LHVs were performing the duties in place of qualified
nurses which were resulting into the poor quality health
services. Similarly in the OT, the technicians were
performing the duties in place of trained and qualified
nurses, which were increasing the risk of infection and
compromised quality care [13].
Limitations of WISN study: A big weakness of the WISN
study is that it relay comprehensively upon the
accurateness of the workload records. Obtained data for
annual workload should be 100% correct, So that any
impreciseness in provided statistics can have effect on
the validity of the concern study. However the data
provided from the inpatient departments was cross
checked with data available in the statistics office the
hospital. So it was concluded that acquired data was
quite reliable [01].
The previous year workload data is always been used in
the WISN methodology to determine staffing need for
present year. In this way it creates a possible source of
error that acquired staffing need would be of previous
year. However this is not so upsetting since hospital
workloads do not varies significantly from one year to
next year. To avoid this most fresh workload data is
always been utilized that could be acquired from the
health facility [01].
Conclusion:
According to the findings of the study it was very clear
that Nursing Staff working in inpatient department were
facing high workload pressure and it was much difficult
to meet with professional standards while providing
services. The five indoor departments of the FGH
require an additional 25 Nursing Staff to manage the
53% workload pressure.
The Socio-demographic characteristics study of
Nursing Staff disclosed that the majority of nurses were
less experienced and were lacking specialization in
different areas. Minimum work experience of Nursing
Staff in FGH was four years, while mean work
experience was 7.08 ± 0.52 years overall.
Recommendations:
There are three main recommendations for Hospital
Management at FGH: 1. Undertake a WISN
assessment on all the departments 2. Consider re-
distribution of current Nursing Staff based on WISN
data. 3. Recruitment of new Nursing staff.
It is also recommended that Federal & Provincial
Ministries of Health in Pakistan should take advantage
of the WISN tool to assess staffing requirements and
where necessary improve the quality of nursing care by
initially addressing non-nursing tasks i.e. the allocation
of these tasks to suitable hospital employees. This
would be a first step in reducing some of the workload
pressure on highly qualified Nursing Staff in particular
departments.
Main References:
1. Shipp P. Workload indicators of staffing needs
(WISN): a manual for implementation,1998; WHO,
Geneva
2. WHO. List of 57 countries facing Human
Resources for Health crisis. 2006; Available at:
http://www.who.int/workforcealliance/countries/57
crisiscountries.pdf. Accessed on Feb 18 2015.
3. Journal of pioneering medical sciences. Nursing
shortage in Pakistan human resource
management. 2014; 4(3) 123-129.
57
 Pakistan Journal of Public Health, 2016 ( September )

4. Aiken LH, Clarke SP, Sloane DM, Sochaiski J,

Silber JH. Hospital nurse staffing and patient
mortality, nurse burnout and job dissatisfaction.
Journal American Medical Association (JAMA).
October 23/30, 2002; vol. 288, no. 16
5. Sean P, Nancy E. Patient Safety and Quality: An
Evidence-Based Handbook for Nurses: 2010;
2(1) 45-48.
6. Jack N, Peter B, Soeren M, Maureen S, Katya Z.
Nurse-Staffing levels And the Quality of Care in
Hospitals. The New England Journal of Medicine
May 30, 2002; 346(22): 1715-1719.
7. HRH resource center. WISN: workforce planning
tool with unexpected motivational benefits. 2011.
8. Ejaz Sahu workload indicator of staffing need at
Holy Family Hospital RWP 2010, Accessed 2015
H.S.A library.
9. Admin FGH annual statistics year wise report book
2014 no 4 - 9.
10. Antarou L, Séni K, Valéry R. Nursing and midwife
staffing needs in maternity wards in Burkina Faso
referral hospitals. Human Resources for Health.
2014; 12(Suppl 1):13-18
11. John F, Grace N. Using the Workload Indicator of
Staffing Needs (WISN) Methodology to Assess
Work Pressure among the Nursing Staff of Lacor
Hospital. Health Policy and Development 2008;
6(1): 1-5.
12. Pamela A, Riitta L, Norbert F. applying the
workload indicators of staffing need (WISN)
method in Namibia: challenges and implications
for human resources for health policy. Bio Med
Central 2013; 11(64): 2-8.
13. Buchan J, Ball J, May FO. Skill mix in the health
workforce: determining skill mix in the health work
force: guidelines for managers and health
professionals 2000. Evidence and Information for
Policy Department of Organization of Health
Services Delivery World Health Organization
Geneva 2000; pp. 1-9.
14. Hurst K et al. calculating staffing requirements.
Nursing Management (Harrow), 2008; 15: 26-31
15. Grace F Angela Angela M F. Workload and the
nurse faculty shortage: Implications for policy and
research. Nursing Outlook 15 January 2011; 59(5):
259-265.

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 Pakistan Journal of Public Health, 2016 ( September )

DEPARTMENT OF OMMISSION AND ERROR

Article "Assessment of Weaning Practices among working mothers of Islamabad" issued in

PJPH's June 2016; the author's name Ali Khan Jabeen should be read as Ali Khan.

59
 Vol 6, No.3 (September) 2016

Original Articles
ASSESSMENT OF INFECTION CONTROL: KNOWLEDGE AND COMPLIANCE
AMONG DENTAL UNDERGRADUATE STUDENTS AT NISHTAR INSTITUTE OF
DENTISTRY, MULTAN
Amna Maqbool, Katrina A. Ronis ........................................................................................................ 01

ASSESMENT OF THE COMMUNITY, KNOWLEDGE, ATTITUDE AND PRACTICE

REGARDING PILES OF GARBAGE AROUND UC – 9 GULSHAN-E-IQBAL TOWN
DISTRICT EAST KARACHI
Saeeda Shaikh, Rukhsana Khan, Karim Bux...................................................................................... 07

EVALUATING THE EFFECTIVENESS OF FIRST AID TRAINING COURSE ON NON-

HEALTHCARE PROFESSIONAL VOLUNTEERS IN ISLAMABAD
Afsar Jan, Gideon Victor.................................................................................................................... 14

CHILD MENTAL HEALTH RESEARCH IN PAKISTAN; MAJOR CHALLENGES AND

PITFALLS: A SYSTEMATIC REVIEW
Tanzil Jamali, Sana Tanzil.................................................................................................................. 18

COMPARISON OF EFFECTIVENESS AND SIDE EFFECTS OF KETAMINE AND

PROPOFOL IN PROCEDURAL SEDATION FOR PATIENTS OF FRACTURE FEMUR
Khawaja Kamal Nasir, Suresh kumar, Yasmeen, Farah...................................................................... 24

A COMPARATIVE STUDY OF MATERNAL PSYCHOSOCIAL PROBLEMS AND

ACADEMIC PERFORMANCE OF CHILDREN INMIGRANT AND NON MIGRANT
FAMILIES OF AJK
Rabia Mushtaq, SeemaGul, Muhammad Tahir Khalily....................................................................... 29

HEALTH CARE WASTE MANAGEMENT IN PAKISTAN: A SITUATION ANALYSIS AND

WAY FORWARD
Ejaz Ahmad Khan, Syed Muhammad Sabeeh, Muhammad Ashraf Chaudhry, Aashifa Yaqoob,
Saleem M Rana, Ramesh Kumar........................................................................................................ 35

WILLINGNESS AND PERCEPTION ABOUT BLOOD DONATION IN RESIDENTS OF

RAWALPINDI CITY
Abida Sultana, Bushra Anwar, Madiha Shafi, Muneeba Faisal ........................................................... 44

OUT OF POCKET SPENDING FOR HEPATITIS C PATIENT’S TREATMENT AT

DISTRICT HEAD QUARTER HOSPITAL BADIN, SINDH
Zubair Ahmed Laghari, Assad Hafeez................................................................................................ 49

ASSESSMENT OF WORKLOAD PRESSURE AND OPTIMAL STAFFING NEED OF

NURSING STAFF FOR INPATIENT SERVICES AT FGH ISLAMABAD.
Mir Hassan Bullo, Katrina A. Ronis...................................................................................................... 54

“DEPARTMENT OF OMMISSION AND ERROR” 59