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Background Women in Pakistan suffer from a high rate of depression. The stress of low-income, illiteracy, exposure to violence and living in a patriarchal society are predisposing vulnerabilities for depression, particularly during and following pregnancy. The resilience of an individual plays a significant role in promoting prenatal mental health, but this has yet to be thoroughly researched. In this article, our objective is to identify the core characteristics of resilience among pregnant women, which will then help us in developing an intervention. Methods The exploratory-descriptive study was conducted over 6 months in five different antenatal hospitals in Sindh, Pakistan. A total of 17 semi-structured interviews were conducted with pregnant women, purposefully selected with heterogeneous characteristics to explore diverse perspectives, while symptoms of depression were quantified by the Edinburgh Postnatal Depression Scale before the interview. Verbatim transcriptions were coded openly and merged into categories and themes. Result A total of six themes emerged from in-depth thematic analysis: 1) purpose of life, 2) dealing with emotions, 3) believing in yourself, 4) optimistic approach, 5) strengthening support and relationship and 6) spirituality and humanity. Women agreed that these characteristics could help them improve their mental health. Conclusion In conclusion, these themes were the core components of pregnant women’s resilience which ultimately could help to promote prenatal mental health. These pave a pathway towards developing culturally and contextually resilience interventions aimed at enhancing mental health of pregnant women which then may improve neonatal and family mental wellbeing.

Perinatal mental health issues in women can lead to a variety of health complications for both mother and child. Building resilience can strengthen coping mechanisms for pregnant women to improve their mental health and protect themselves and their children. The study aims to develop and validate the contextual and cultural appropriateness of the Safe Motherhood-Accessible Resilience Training (SM-ART) intervention for pregnant women in Pakistan. A three-phase approach was used to develop and validate an intervention that promotes resilience in pregnant women. Phase I comprised a needs assessment with stakeholders (pregnant women and key informants) to elicit opinions regarding module content. In Phase II, an intervention to build resilience was developed with the help of a literature review and formative assessment findings, and Phase III involved the validation of the intervention by eight mental health experts. The experts assessed the Content Validity Index (CVI) of the SM-ART intervention on a self-developed checklist. The resultant SM-ART intervention consists of six modules with strong to perfect CVI scores for each of the modules. Qualitative responses endorsed the strengths of the intervention as having innovative and engaging activities, contextual and cultural relevance, and a detailed, comprehensive facilitator guide. SM-ART was successfully developed and validated and is now ready for testing to promote the resilience of pregnant women at risk of perinatal mental illness.

Violence against women (VAW) is a major determinant in the assessment of a women's mental health. Many interventions have addressed strategies to reduce VAW, however, little information is available regarding effectiveness in the local context, particularly the role of men in women's empowerment. In Pakistan, a qualitative approach was undertaken in all four of its provinces to describe the community residents', both men and women, perceptions regarding the acceptability of a proposed life skills building (LSB) intervention involving men's engagement with regards to women's empowerment and VAW. Eighteen focus group discussions were conducted with men and women from locales within each province of Pakistan, averaging 6-10 participants per group. Fourteen key informant interviews were conducted with community stakeholders. The analysis identified three major themes: family life and male engagement, LSB training as an empowerment tool, and operationalization of the proposed LSB intervention. The proposed LSB intervention was well accepted by the participants with a strong urge to engage men in receiving the LSB training sessions. Men's engagement has been identified as an important element to facilitate women's empowerment. Participants suggested that these sessions should be held for two and a half hours per week within the community public spaces. In addition, these sessions should be based on an interactive approach. The focus of these sessions should include ideas surrounding positive relationships and economic skills building. Moreover, men's engagement will help to reduce VAW and improve the mental health of women in a patriarchal country like Pakistan.

Introduction The study aimed to assess resilience and its associated factors in head and neck cancer patients, post-treatment in a low middle income country (LMIC) such as Pakistan. Methods An analytical cross-sectional study was conducted from November 2019 to May 2020 among head and neck cancer patients aged at least 18 years at the largest private tertiary care hospital, in Karachi, Pakistan. Information regarding their resilience scores was collected through Wagnild and Young’s Resilience scale that comprises of 14 items (RS-14). Moreover, depression and anxiety were also assessed via Hospital Anxiety and Depression Scale (HADS) and social support was assessed by Enriched Social Support Instrument (ESSI). Results The data was analyzed by linear regression modeling. Unadjusted and adjusted beta coefficients with 95% CI were reported. A total of 250 head and neck cancer patients were recruited, 79% of them were males. Mean age of the patients was 51.59 years with 93% having high social support and only 8% having severe depression and 3% having severe anxiety. After adjusting for the covariates in multivariable analysis resilience was associated with severe depression (− 17[− 20.98,-12.93]) or borderline depression (− 4[− 8.41,-0.39]), severe anxiety (− 11 [− 17.88,-4.18]), low social support (− 6[− 9.62,-1.71]), having family members of > 6 in the household (− 2[− 4.31,-0.29), smokeless tobacco users post- treatment (10[5.79, 14.45]), and those who underwent tracheotomy (− 4[− 7.67,-0.21]). There was a significant interaction between education and role in the family (decision maker). Conclusion In Pakistan, a South Asian LMIC, collectivist culture prevails, family ties are greatly promoted thus resilience and social support is highly prevalent in head and neck cancer patients resulting in lower prevalence of depression and anxiety. Our study highlights that higher resilience is prevalent among small families less than six members, as the welfare of the individual is prioritized over multiple needs of the family. Formal Education and role in household/decision making power are effect modifiers in our study, demonstrating its protective effect on the mental health of head and neck cancer patients. High resilience scores were reported among current smokeless tobacco users as compared to quitters post treatment. Resilience-building interventions should be formulated to aid head and neck cancer patients to cope with the disease and its sequel.

Objectives This study assessed resilience in brain tumor patients at a tertiary care hospital in Pakistan (a lower-middle-income country; LMIC), and explored its relationship with patients' sociodemographic factors, clinical characteristics, social support, and mental health. Methods A cross-sectional survey was conducted amongst adult (≥18 years) patients with brain tumor at the Aga Khan University Hospital, Pakistan. Resilience was assessed by Wagnild and Young's Resilience Scale,andpatients'psychosocial characteristics by the Hospital Anxiety and Depression Scale and the Enriched Social Support Instrument. Results A total of 250 patients were included (mean age:44 years; 68% males), with majority (97.6%) having high social support and only 4.4% and 2% having symptomatic depression and anxiety, respectively.On multivariable linear regression adjusted for covariates, lower resilience was associated withnot being involved in household decision-making(Adjusted Beta Coefficient: 4.58 [95% Confidence Interval:-7.59,-1.56]), not currently working (-2.80[-4.61,-0.99]), undergoing multiple neurosurgical interventions such as tumor biopsies or resections(-8.64[-13.11,-4.16]), receiving chemotherapy (-5.17[-9.51,-0.83]) or combination adjuvant therapy (-2.91[-5.14,-0.67]), low social support (-7.77[-13.73,1.81]), milddepression (-13.00[-17.00,-8.99]) or symptomatic depression (-19.79[-24.69,-14.89]), and mild anxiety (-4.24[-7.98,-0.50]). Conclusion Our study highlights the function of familial/household role and working status in mediating resilience, and demonstrates the well-known protective effect of resilience for mental health in brain tumor patients in Pakistan, a South-Asian LMIC.These findings are of clinical relevance with regards to the development of culture-specific evidence-based resilience-building interventions that may help patients with brain tumors to cope with the psychological distress of cancer. This article is protected by copyright. All rights reserved.

Background In Pakistan there is a dire need to explore the quality of life in infertile males and females and its undesirable psychological outcomes. This, study aimed to compare the quality of life (QoL) of males and females visiting an infertility centre for treatment and to assess its association with resilience, depression, and other socio-demographic factors. Methods An Analytical Cross-Sectional study was conducted amongst infertile males and females at the Australian Concept Infertility Medical Centre (ACIMC), Karachi, Pakistan. The non-probability (purposive) sampling strategy was used to recruit the participants. The sample size was 668. Data was analysed using STATA version 12. FertiQoL tool, Beck II Depression Inventory Tool and Resilience Scale 14 (RS-14) were used for assessing the quality of life, depression and resilience respectively of infertile patients. Results Total 668 infertile patients, 334 males and 334 females participated in the study. The mean age was 35.53 ± 6.72, among males, and 30.87 ± 6.12 among females. The mean resilience scores were significantly higher among males, (77.64 ± 8.56), as compared to females (76.19 ± 8.69) (95% CI; − 2.757, − 0.1347). However, a significantly higher proportion of females were depressed (13.8%) as compared to males (6%). The mean QoL scores for the general health domain, emotional domain, mind and body domain, and relational domain, and the total QoL were significantly higher in males as compared to females (p value Conclusion Fertility related QoL of men and women has a significant association with no formal education, number of friends, income, depression and resilience. Therefore, health care professionals in the field of infertility must be adequately trained to respond to the needs of individuals going through these psychological problems.

Purpose This study was undertaken to determine the effects of individualized education with support intervention on breast cancer patients’ anxiety and depression while undergoing radiation therapy (RT). Moreover, the intervention was assessed for its feasibility in the context of Pakistan. Methods A quasi-experimental design was used to conduct this study in RT department of a public hospital in Karachi. A total of 61 breast cancer patients receiving radiation as adjuvant therapy participated in the study. The experimental group (n = 31) received individualized education with support in the form of face-to-face sessions and information booklet prior to the commencement of RT. In addition, the nurse remained available for the consultation during the RT sessions and on telephone throughout the RT period. However, the control group received only information booklet. Patients' anxiety and depression were measured in both of the groups before the commencement of RT, and at the completion of RT by using the Aga Khan University Anxiety and Depression Scale (AKUADS). Results A significant reduction was found in the overall mean anxiety and depression scores of the experimental group (p = 0.000) from pre-test to post-test. The overall mean anxiety and depression scores of the control group showed no significant difference (p = 0.187). The effect size of the intervention was large (Cohen's d = 2.5). Conclusion The intervention was effective in reducing anxiety and depression among breast cancer patients receiving RT. Replication of the study on a larger scale in multiple settings on other cancer patients is recommended.

Background Recent Life Changes Questionnaire (RLCQ) developed by Richard Rahe has enabled quantification of stress by analyzing life events. The overall aim of the study was to create a reliable version of the Rahe’s RLCQ for measuring stress in individuals living in developing countries and assess its validity. This paper discusses criterion validation of the adapted RLCQ in urban communities in Pakistan. Methods This is a criterion validation study. Four urban communities of Karachi, Pakistan were selected for the study in which households were randomly chosen. Two data collectors were assigned to administer the adapted RLCQ to eligible participants after obtaining written informed consent. Following this interaction, two psychologists interviewed the same participants with a diagnostic gold standard of Mini International Neuropsychiatric Interview (MINI) which is utilized in usual practice within Pakistan to confirm the presence of stress related mental disorders such as Depression, Anxiety, Dysthymia, Suicide, Phobia, OCD, Panic Disorder, PTSD, Drug abuse and dependence, Alcohol abuse and dependence, Eating Disorders and Antisocial Personality Disorder to validate the accuracy of the adapted RLCQ. We generated the ROC curves for the adapted RLCQ with suggested cut-offs, and analyzed the sensitivity and specificity of the adapted RLCQ. Results The area under the receiver operating characteristic curve (ROC) of common mental disorders such as depression and anxiety was 0.64, where sensitivity was 66%, specificity was 56% and the corresponding cut off from the adapted RLCQ was 750. Individuals scoring ≥750 were classified as high stress and vice versa. In contrast, the area under the ROC curve for serious mental disorder and adverse outcomes such as suicide, bipolar and dysthymia was 0.75, where sensitivity was 72% and specificity was 60% at the cut off of 800 on the adapted RLCQ. Individuals scoring ≥800 were classified as high stress and vice versa. The rate of agreement between the two psychologists was 94.32% (Kappa = 0.84). Conclusion The adapted and validated RLCQ characterizes common mental disorders such as depression and anxiety with moderate accuracy and severe mental disorders such as suicide, bipolar and dysthymia with high accuracy. Trial registration Clinicaltrials.gov NCT02356263. Registered January 28, 2015. (Observational Study Only).

To determine the socio-economic status of a peri-urban community.The cross-sectional study was conducted at Deh Chuhar village, Gaddap Town, Karachi from December 2015 to February 2016. The Water/Sanitation, Assets, Maternal Education and Income Index was used. All variables were given a score on the scale of 0-8. The resulting index was illustrated in the form of quintiles.: A total of 254 households were surveyed. Total population was 2117 with mean number of household members being 8±4. Mean index score was 0.39±0.14 and the median score was 0.375. Percentile distribution of the score indicated that 152(60%) households scored below 0.40 whereas, 51 (20%) were in the highest quintile with a score above 0.50.Water/Sanitation, Assets, Maternal Education and Income index suggested poor socio-economic status of the community studied.

BackgroundCancer is a devastating disease and has detrimental effects on the quality of life (QoL) of cancer survivors and interferes with their treatment compliance. The aim of the study is to assess resilience and QoL among cancer survivors and to evaluate the important factors affecting their resilience and QoL, with respect to the Pakistani cultural context.Method and analysisA cross-sectional study will be conducted at a tertiary care hospital in Karachi, Pakistan. A minimum sample size of 250 head and neck cancers and 250 brain tumour survivors with 10% inflation for non-response rate will be required. The SD of QoL and resilience will range from 16.5 to 40.8 for head and neck cancer, and 12.7 to 34.1 for brain tumour, at 5% level of significance, with 2.5 precision. QoL will be assessed by European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30, EORTC QLQ-H&N35 and EORTC QLQ-BN20 and resilience will be evaluated by Wagnild and Young’s 14-item scale. Mean±SD will be reported for resilience and QoL scores. Unadjusted and adjusted β-coefficients, with 95% CI, will be reported by using multiple linear regression analysis. Correlation analysis will also be performed using Pearson or Spearman rank correlation coefficients. A p value of Ethics and disseminationEthical approval has been obtained from the Aga Khan University Pakistan’s Ethical Review Committee. Written informed consent will be taken from the participants by trained research assistants. A trained psychologist will provide on-spot counselling to the participants and those identified with severe depression will be referred to a psychiatrist. The study materials will be kept under lock and key and the electronic data base will be password protected and will only be accessed by the research team. The study findings will be disseminated through publications conferences and workshops and research briefs.Trial registration numberClinicaltrials.gov registry (NCT03466762).

Background Contextually relevant stressful life events are integral to the quantification of stress. None such measures have been adapted for the Pakistani population. Methods The RLCQ developed by Richard Rahe measures stress of an individual through recording the experience of life changing events. We used qualitative methodology in order to identify contextually relevant stressors in an open ended format, using serial in-depth interviews until thematic saturation of reported stressful life events was achieved. In our next phase of adaptation, our objective was to scale each item on the questionnaire, so as to weigh each of these identified events, in terms of severity of stress. This scaling exercise was performed on 200 random participants residing in the four communities of Karachi namely Kharadar, Dhorajee, Gulshan and Garden. For analysis of the scaled tool, exploratory factor analysis was used to inform structuring. Finally, to complete the process of adaption, content and face validity exercises were performed. Content validity by subject expert review and face validity was performed by translation and back translation of the adapted RLCQ. This yielded our final adapted tool. Results Stressful life events emerging from the qualitative phase of the study reflect daily life stressors arising from the unstable socio-political environment. Some such events were public harassment, robbery/theft, missed life opportunities due to nepotism, extortion and threats, being a victim of state sponsored brutality, lack of electricity, water, sanitation, fuel, destruction due to natural disasters and direct or media based exposure to suicide bombing in the city. Personal or societal based relevant stressors included male child preference, having an unmarried middle aged daughter, lack of empowerment and respect reported by females. The finally adapted RLCQ incorporated “Environmental Stress” as a new category. Conclusion The processes of qualitative methodology, in depth interview, community based scaling and face and content validity yielded an adapted RLCQ that represents contextually relevant life stress for adults residing in urban Pakistan. Trial registration Clinicaltrials.gov NCT02356263. Registered January 28, 2015. (Observational Study Only). Electronic supplementary material The online version of this article (doi:10.1186/s12888-017-1315-1) contains supplementary material, which is available to authorized users.

Background: There were no instrument exists in South Asia to assess resilience. Thus, this study assessed the validity and reliability of the Urdu version of Wagnild and Young's long and short Resilience Scales. Methods: Study was carried out in two urban squatter settlements of Karachi, Pakistan. Resilience Scales were validated against the depression, anxiety, and life satisfaction scales among 20- to 40-year-old married women. Sample size for validity and reliability were 636 and 319. Results: Moderate negative correlation with the depression and anxiety and moderate positive significant correlation with life satisfaction were found with both scales. The test-retest correlation were .54 and .49, respectively. Internal consistency were found acceptable. Concurrent validity were .729 and .813. Conclusions: Study found a valid and reliable resilience scale in Urdu language.Keywords: resilience scale; validation; Urdu language; Pakistani populationThe resilience concept is widely discussed in history by diverse disciplines, such as psychology, philosophy, and theology. It is defined as "the ability to rebound or spring back, the power of something to resume its original shape or position after compression or bending" (Dowrick, Kokanovic, Hegarty, Griffiths, & Gunn, 2008). Some have also viewed resilience as a defense mechanism, which allows people to grow in the face of adversity (Davydov, Stewart, Ritchie, & Chaudieu, 2010). Thus, improving resilience can be a significant factor in mental health treatment because it represents one's internal power, strengths, positivity, flexibility, competency, and ability to cope effectively when faced with adversity (Abiola & Udofia, 2011).Resilience is a powerful antidote to depression. Strong resilient individuals are able to handle change and adversity well. They become less depressed. Resilience has been measured in thousands of people and the results have proven that it measures individual strengths that are potentially preventive for depression (Wagnild, 2009). Hence, measuring resilience helps because when the resilience scores increase, symptoms of depression and stress decrease. Thus, it can be said that resilience protects against depression and reduces the associated psychological effects. In addition, anxiety is negatively associated with resilience. If individual's resilience score is less, they will be more likely to dwell on problems, feel overwhelmed, and ultimately adapt unhealthy coping techniques to handle stress, which will further increase their anxiety.Most studies have suggested that resilient persons tend to manifest adaptive behavior, especially in the areas of social functioning. One study found that resilience displayed high measures of consistency and correlation with life satisfaction scales in different situations (Salazar-Pousada, Arroyo, Hidalgo, Perez-Lopez, & Chedraui, 2010). Moreover, when people experiences positive emotions to meet life's challenges and opportunities, their satisfaction with life rises because learning to cope with the down times is essential to life satisfaction (Cohn, Fredrickson, Brown, Mikels, & Conway, 2009).Assessing resilience in high-risk populations, who are vulnerable to psychological and developmental problems, is very essential. Poverty is considered as one of the confirmed contributors that causes vulnerability among individuals, families, and communities. Those individuals who experience economic and employment hardships might feel discouragement and fear, and the individual might believe that life is pointless (Wagnild & Collins, 2009). Literature in this area is very scarce (Oft, 2009).Resilience is an important trait for promoting positive psychological well-being and studying this can contribute to our understanding of constructive adaptation and stress resistance. In South Asia, there is no known validated tool for measuring resilience, this limits our ability to carry out empirical research in this area and to identify people who have the capacity for resilience. …

Background Child peer violence is a global problem and seriously impacts health and education. There are few research studies available in Pakistan, or South Asia. We describe the prevalence of peer violence, associations, and pathways between socio-economic status, school performance, gender attitudes and violence at home. Methods 1752 children were recruited into a cluster randomized controlled trial conducted on 40 fairly homogeneous public schools (20 for girls and 20 for boys), in Hyderabad, Pakistan. This was ranging from 20–65 children per school. All children were interviewed with questionnaires at baseline. Results Few children had no experience of peer violence in the previous 4 weeks (21.7% of girls vs.7% of boys). Some were victims (28.6%, of girls vs. 17.9% of boys), some only perpetrated (3.3% of girls vs. 2.5%) but mostly they perpetrated and were victims (46.4%.of girls vs 72.6%. of boys). The girls’ multivariable models showed that missing the last school day due to work, witnessing her father fight a man in the last month and having more patriarchal gender attitudes were associated with both experiencing violence and perpetration, while, hunger was associated with perpetration only. For boys, missing two or more days of school in the last month, poorer school performance and more patriarchal attitudes were associated with both victimization and perpetration. Witnessing father fight, was associated with peer violence perpetration for boys. These findings are additionally confirmed with structural models. Discussion Peer violence in Pakistan is rooted in poverty and socialization of children, especially at home. A critical question is whether a school-based intervention can empower children to reduce their violence engagement in the context of poverty and social norms supportive of violence. In the political context of Pakistan, reducing all violence is essential and understanding the potential of schools as a platform for intervention is key.

Peer violence was remarkably high at baseline. Among urban public school students, 94% of 6th-grade boys and 85% of girls reported being victimized by peers in the last 4 weeks. And 85% of boys and 66% of girls reported perpetrating such violence. Boys scored worse on a number of mental health measures. A cluster RCT is underway to evaluate a well-established school-based intervention using sports and games to reduce peer violence., Background: Violence against and among children is a global public health problem that annually affects 50% of youth worldwide with major impacts on child development, education, and health including increased probability of major causes of morbidity and mortality in adulthood. It is also associated with the experience of and perpetration of later violence against women. The aim of this article is to describe the intervention, study design, methods, and baseline findings of a cluster randomized controlled trial underway in Pakistan to evaluate a school-based play intervention aiming to reduce peer violence and enhance mental health. Methods: A cluster randomized controlled design is being conducted with boys and girls in grade 6 in 40 schools in Hyderabad, Pakistan, over a period of 2 years. The Multidimensional Peer-Victimization and Peer Perpetration Scales and the Children's Depression Inventory 2 (CDI 2) are being used to measure the primary outcomes while investigator-derived scales are being used to assess domestic violence within the family. Specifics of the intervention, field logistics, ethical, and fidelity management issues employed to test the program's impact on school age youth in a volatile and politically unstable country form this report. Baseline Results: A total of 1,752 school-age youth were enrolled and interviewed at baseline. Over the preceding 4 weeks, 94% of the boys and 85% of the girls reported 1 or more occurrences of victimization, and 85% of the boys and 66% of the girls reported 1 or more acts of perpetration. Boys reported more depression compared with girls, as well as higher negative mood and self-esteem scores and more interpersonal and emotional problems. Interpretation: Globally, prevalence of youth violence perpetration and victimization is high and associated with poor physical and emotional health. Applying a randomized controlled design to evaluate a peer violence prevention program built on a firm infrastructure and that is ready for scale-up and sustainability will make an important contribution to identifying evidence-informed interventions that can reduce youth victimization and perpetration.