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Background: Burnout, characterized by emotional exhaustion (EX), depersonalization (DP), and a reduced sense of personal efficacy (PF) among medical and nursing students can lead to suicidal ideation, lack of empathy, and dropouts. Previous studies have used over-simplified definitions of burnout that fail to capture its complexity. We describe the prevalence of burnout profiles and its risk factors among medical and nursing students., Methods: A cross sectional study was conducted at a tertiary care University Hospital in Pakistan. The Maslach Burnout Inventory (MBI) survey was disseminated via SurveyMonkey over a period of 4 months (November 2019 to February 2020) to 482 Medical and 441 nursing students. The MBI tool measures the dimensions of EX, DP, and PF to describe seven burnout profiles. Multivariable regression was used to identify predictors of burnout., Results: The response rate was 92% in nursing and 87.3% in medical students. The prevalence of burnout in medical and nursing students was 16.9% and 6.7% respectively (p<0.001), with 55.7% (n = 427) suffering from at least one burnout profile. Only 32.5% (n = 250) students felt engaged, (42.3% medical, 22.7% nursing students, p<0.001). The most common profile was ineffective (32.5%, n = 250), characterized by a reduced sense of personal efficacy (35.6% medical, 29.4% nursing students; p = 0.065). Medical students were at higher risk of burnout compared to nursing students (OR = 2.49 [1.42, 4.38]; p<0.001) with highest risk observed in year 4 (OR = 2.47 [1.02, 5.99]; p = 0.046). Other risk factors for burnout included occasional drug use (OR = 1.83 [1.21, 8.49]; p = 0.017) and living in a hostel (OR = 1.64 [1.01,2.67]; p = 0.233)., Conclusion and Relevance: Two-thirds of our participants experienced at least one dimension of burnout with the highest prevalence of a reduced sense of PF. Drivers of burnout unique to a lower-middle-income country need to be understood for effective interventions. Faculty training on principles of student evaluation and feedback may be beneficial., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Mufarrih et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

A pre-post-training workshop was conducted among 22 postgraduate trainees of the Psychiatry and Emergency Department of a public sector hospital in Karachi. The workshop aimed to build the capacity of postgraduate trainees in trauma management by providing training on screening, clinical interviewing skills, and Psychological first aid to those exposed to domestic violence (DV). The effectiveness of each training module was evaluated by conducting a brief assessment before and after each module and scores were compared using the Wilcoxon signed-rank test. The post-test showed significant improvement in participants' knowledge on screening of domestic violence and trauma symptoms (p = 0.026) and psychological first aid (p <0.001). Postgraduate training programmes need to integrate trauma screening and management education, to prepare healthcare professionals to deal with sensitive clinical presentations at their work settings. Key Words: Postgraduate trainees, Trauma, Domestic violence, Medical education, Workshop.

Background: Although the concept of telehealth is of great interest globally, its potential has not yet been realized in Pakistan. It is therefore essential to explore the perspectives of stakeholders on the technology, particularly for mental health, to be able to increase and improve its use., Aim: To assess the perceptions and experiences of patients receiving tele-mental health services, including telepsychiatry and tele-psychotherapy, in Pakistan., Methods: For this qualitative exploratory study, we conducted in-depth interviews with 49 individuals at a tertiary care hospital in Karachi, Pakistan. Using the Cresswell framework for content analysis, we identified 3 major themes that focused on the positive and negative aspects of tele-mental health services and made suggestions for enhancing them., Results: Twenty-six of the participants received telepsychiatry, while the remaining 23 received tele-psychotherapy services. Technical literacy, cost of consultation, privacy, and therapeutic alliance were the major challenges identified by the patients, while convenience and the absence of stigma were highlighted as key facilitators for tele-mental health. Tele-consultations reduced travel and waiting time, thus improving access to healthcare. Participants suggested that the processes for booking appointments and making payments should be streamlined and the cost of tele-consultation reduced., Conclusion: This study provides insightful findings on tele-mental health services from the perspectives of patients living in an Asian culture. The major benefits highlighted were destigmatization of mental health and elimination of commuting costs and travel time. There were concerns about privacy, therapeutic alliance and availability and affordability of the technology., (Copyright: © Authors 2024; Licensee: World Health Organization. EMHJ is an open access journal. All papers published in EMHJ are available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).)

Objective: A pilot study using a pre-post interventional design, was carried out to evaluate the effectiveness of a resilience-based training workshop on the self-efficacy and resilience of schoolteachers in a peri-urban area of Karachi, Pakistan. Four in person workshops were held at the school's location during January to June 2022., Results: A total of 14 teachers participated in the workshop. The effectiveness of interventions was evaluated by assessing self-efficacy and resilience in pre- and post-teaching modules. The Wilcoxon Signed Rank Test determined a significant difference between the pre- to post-module scores of Self Efficacy (p = 0.016) and resilience (p = 0.006). The pre-median scores with IQR of Self-Efficacy were 28 (10), and Resilience scores 76 (12); and post-scores for Self-Efficacy and Resilience scores increased to 35 (5.5) and 88 (14) respectively. This indicated significant improvement in general self-efficacy and resilience skills after four weeks of training. This pilot study showed that building knowledge regarding mental health struggles in students and oneself, learning ways to cope with stress and manage student behavior, and forming a peer support system are crucial in building self-efficacy and resilience in teachers., (© 2024. The Author(s).)

The Swat and Kabul rivers of northern Pakistan are within an important regional watershed that supports river-based livelihoods and is impacted by untreated effluent discharges and municipal solid waste. Evidence indicates that fish populations are decreasing in these rivers. One potential cause of poor aquatic health is pollution; therefore, we investigated the presence of contaminants of emerging concern (CECs) in the river systems. Water samples were collected in the Kabul River (n = 9) and Swat River (n = 10) during seasons of high (summer 2018) and low (winter 2019) river flow. Agrochemicals, pharmaceuticals, plasticizers, chemicals in personal care products, and hormones were quantified via liquid chromatography high-resolution mass spectrometry. In the Swat River, caffeine (18-8452 ng/L), N,N-diethyl-meta-toluamide (DEET; 16-56 ng/L), and plasticizers (13-7379 ng/L) were detected at all sites during both seasons, while butachlor (16-98 ng/L) was detected only during high flow. In the Kabul River, caffeine (12-2081 ng/L) and several plasticizers (91-722 ng/L) were detected at all sites during both seasons, while DEET (up to 97 ng/L) was detected only during high flow. During low flow, pharmaceuticals (analgesics and nonsteroidal anti-inflammatory drugs) were quantified in both rivers (up to 823 ng/L), with detection frequencies from 70% to 100% and 0% to 78% in the Swat and Kabul Rivers, respectively. Intermittent-use and natural seasonal processes (increased runoff and dilution from rainfall and snowmelt) yielded higher agrochemical concentrations and lower concentrations of continuous-use compounds (e.g., caffeine) during high flow. The present study provides the first insight into CEC concentrations in the Swat River, additional insight into the Kabul River stressors, and, overall, contaminant risks to aquatic life. Environ Toxicol Chem 2023;42:2599-2613. © 2023 The Authors. Environmental Toxicology and Chemistry published by Wiley Periodicals LLC on behalf of SETAC., (© 2023 The Authors. Environmental Toxicology and Chemistry published by Wiley Periodicals LLC on behalf of SETAC.)

A prominent issue associated with HIV is the stigma around it owing to a lack of awareness. This study aimed to find the association between HIV and AIDS-related knowledge and discriminatory attitudes amongst Pakistani women of reproductive age using the 2017-18 Pakistani Demographic Health Survey (PDHS) data. We analyzed a sample of 3381 Pakistani women of reproductive age using ordinal logistic regression for complex survey data. Two composite variables were created using the HIV module to denote the respondents' HIV-related knowledge and their attitude toward people living with HIV (PLHIV) and calculated using a scoring method. Additional variables included the respondents' age, education level, socioeconomic status, residential setting, and HIV testing history. More than half (58.8%) of the respondents presented with a negative attitude toward PLHIV and 64.3% of the respondents had poor knowledge regarding the illness. In the multivariable analysis, knowledge about HIV and level of education reported significant associations with discriminatory attitudes. We concluded that the odds of individuals living in a rural setting and hailing from a low socioeconomic background presenting with a negative attitude towards PLHIV were 2.52 times (95% CI 1.07-5.89) higher as compared to those living in an urban setting from a high socioeconomic background., (© 2023. Springer Nature Limited.)

A pilot quasi-experimental study was conducted in which participants in the intervention group (n = 31) received positive learning environment through Positive Disciplining (PLEPD) module, while those in the control group (n = 29) received routine training. Teachers' knowledge and attitude regarding corporal punishment (CP) and Beck Depression Inventory-II (BDI-II) were measured before (T0), immediately after (T1) and 3 months after the intervention (T2). Descriptive analysis and analysis of variance (ANOVA) were used to describe participants' characteristics and mean scores for knowledge and attitude among teachers. A total of 60 teachers completed the 16 hours training module. The overall response rate was >90%. Most participants recommended increasing the overall duration of the programme by reducing 4 to 2 hours per day, thus, increasing the period from 4 to 8 days of training. There were no differences between control and intervention groups at baseline regarding participant characteristics (p= > .05). The difference in depression (F = .0863, p = .357) and knowledge and attitude (F = 1.589, p = .213) scores among groups were not statistically significant. However, the mean score for knowledge and attitude followed a positive trend, increasing depression mean scores at T1 and T2. A positive disciplining programme is a feasible school intervention for public schools and may effectively reduce depression to ensure overall well-being., (© 2023 The Authors. International Journal of Psychology published by John Wiley & Sons Ltd on behalf of International Union of Psychological Science.)

Objective: Optimizing health care workers' (HCWs) willingness to respond (WTR) is critical in low-and-middle-income countries (LMICs) for proper health system functioning during extreme weather events. Pakistan frequently experiences weather-related disasters, but limited evidence is available to examine HCW willingness. Our study examined the association between WTR and behavioral factors among emergency department HCWs., Methods: A cross-sectional survey was conducted from August to September 2022 among HCWs from 2 hospitals in Karachi, Pakistan. Non-probability purposive sampling was used to recruit participants. A survey tool was informed by Witte's Extended Parallel Process Model (EPPM). Multivariate logistic regression analyses were performed to examine the association between WTR and attitudes/beliefs as well as EPPM profiles., Results: Twenty-nine percent of HCWs indicated a low WTR. HCWs using public transportation had a higher WTR. Perceived knowledge and skills, self-efficacy, and perceived impact of one's response showed positive associations with WTR if required. Perception that one's colleagues would report to work positively predicted WTR if asked. Consistent with the EPPM, HCWs with high efficacy and perceived threat were willing to respond to weather disasters., Conclusions: Our findings highlight the need of strengthening WTR by promoting self-efficacy and enhancing accurate risk perception as a response motivator, among emergency department HCWs in Pakistan.

Objective: Despite quality of life (QoL) being recognized as an important outcome in neuro-oncology, there is a lack of research from Pakistan where sociocultural differences may influence QoL. This study aimed to measure the QoL in patients with primary brain tumors (PBTs) and assess its association with mental health outcomes and social support., Results: Our study included a total of 250 patients, with a median age of 42 years (range 33-54 years). The commonest brain tumors were glioma (46.8%) and meningioma (21.2). The mean global QoL of the sample was 75.73 ± 14.9. The majority of patients had high social support (97.6%) and were not depressed (90%) or anxious (91.6%). On multivariable linear regression, global QoL was inversely associated with no or low income (beta coefficients: -8.75 to -11.84), having hypertension (-5.53), currently using a urine catheter (-13.55), having low social support (-28.16) suffering from mild (-15.31) or symptomatic (-23.84) depression, or mild anxiety (-13.22)., (© 2023. The Author(s).)

Since last few decades, preserving the natural environment has been considered an important issue. Almost every organization is paying attention to environmentalism worldwide. The successful green management in a firm depends on the employee's pro-environmental behavior. The purpose of this study is to examine the impact of green human resource management practices on employee's pro-environmental behavior. While considering the mediating role of green commitment. Both Green Human Resource Management Practices and pro-environmental behavior have been considered by various studies but determining green behavior through Green Human Resource Management practices was neglected before. Therefore, this study adopts a quantitative approach to fill the gap. Data has been collected from 279 employees through convenience sampling from the pharmaceutical industry of Pakistan. Structural equation modeling was used to analyze the developed constructs. The findings show that there is a direct and indirect effect of Green Human Resource Management practices on employee's pro-environmental behavior through green commitment. The study is unique in its implications. It provides practical and theoretical implications. This study not only bridges the gap highlighted in the literature by introducing Green Human Resource practices as antecedents toward green behavior but also contributes to the literature of organizational behavior, environmental studies, and human resource management and strengthen the AMO framework by using it to explain employee's green behavior through Green Human Resource Management practices., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Infertility is a major reproductive health problem in Pakistan. It has the potential to cause serious negative impact on a couple's marital life and psychological health., Aim: This study aimed to assess the factors associated with maladjustment among infertile couples., Method: An analytical cross-sectional design was employed. Validated scales were used to assess marital adjustment, depression, resilience and quality of life among infertile couples. Purposive sampling was employed to enrol 334 infertile couples from a private infertility medical centre, of Karachi, Pakistan., Results: Among couples, marital adjustment scores were comparable, but resilience and quality of life were significantly low among wives whereas depression was significantly high among wives compared with husbands. Wives' marital adjustment was positively correlated with husband's resilience and quality of life and negatively related with his depression. After employing adjusted actor-partner interdependence modelling, wives' own depression and resilience had significant effect on their marital adjustment and their partner's resilience, depression and quality of life did not have any impact on their outcome. On the contrary, wives' resilience had a significant effect in increasing the marital adjustment of their husband., Conclusion: This study highlights the need to promote psychological support (resilience building skills) or couples' therapy to all those couples undergoing infertility treatment., (© 2022 John Wiley & Sons Australia, Ltd.)

Introduction: Suicide is a major global public health problem. Low-income and middle-income countries contribute 78% of all suicidal deaths. Pakistan, a South Asian country, lacks official statistics on suicides at national level. Statistics on suicide are neither collected nationally nor published in the annual national morbidity and mortality surveys. Medicolegal reports on suicides and self-harm are extremely rich and important source of information but greatly underused in Pakistan. We aim to examine the patterns of suicides and self-harm retrospectively in patients who were registered with medicolegal centres (MLCs) in Karachi, during the period January 2017 to December 2021., Methods and Analysis: Using retrospective descriptive design, the data will be collected from the medical records maintained at the main office of the Karachi police surgeon. Data from all nine MLCs of Karachi are collated and stored at the main office of Police surgeon. Information on suicide and self-harm cases will be extracted from records of all MLCs. The data will be collected using structured proforma and it will be analysed using descriptive and inferential analysis., Ethics and Dissemination: The study was approved for exemption from Aga Khan University, Ethical Review Committee. The findings of the study will be disseminated by conducting seminars for healthcare professionals and stakeholders including psychiatrists, psychologists, counsellors, medicolegal officers, police surgeons, mental health nurses, general and public health physicians and policy makers. Findings will be published in local and international peer-reviewed scientific journals., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

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., (© 2022. The Author(s).)

Objective: This study aims to determine the burden and factors associated with perceived stress in the Pakistani population amidst the COVID-19 pandemic., Setting: A web-based cross-sectional survey was conducted from April to August 2020., Population: This survey was broadcasted on the web using a Google form link and 1654 Pakistani residents had completed this survey. Individuals belonging to any province, city, village, or district of Pakistan irrespective of any age, having internet access and a link of Google form, with English/Urdu competency, consent to participate, and currently residing in Pakistan were eligible to participate., Outcome Measure: Perceived stress was measured using a validated tool of perceived stress scale-10. Multiple ordinal regression was used, and an adjusted OR along with a 95% CI are reported., Results: The mean score of perceived stress was 19.32 (SD ±6.67). Most of the participants screened positive for moderate (69%) and high levels (14%) of stress, respectively. The odds of high-perceived stress among severely anxious participants were 44.67 (95% CI: 21.33 to 93.53) times than participants with no/minimal generalised anxiety during the complete lockdown. However, the odds of high levels of perceived stress among moderately anxious respondents were 15.79 (95% CI: 10.19 to 24.28) times compared with participants with no/minimal anxiety during the smart lockdown., Conclusion: This study evidence that the pandemic was highly distressing for the Pakistani population causing the maximum level of perceived stress in more than half of the population. Adequate and timely interventions are needed before high-stress levels culminate into psychological disorders., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: The study aims to explore the perceptions and experiences of menopausal women living in Karachi, Pakistan., Study Design: Using qualitative exploratory design, in-depth interviews were conducted with eleven women, aged 35-55 years. The data was collected through face-to-face interviews using semi structured interview guide. Creswell frame work for content analysis was used to analyze the data., Main Outcome Measures: Perceptions and experiences of menopause women living in Karachi, Pakistan., Results: Women described positive and negative experiences of menopause, though predominantly negative intensified by mental distress, lack of support from intimate partner, and misperceptions about menopause. A majority of the women emphasized the need for educating their husbands regarding menopausal changes. In clinical practices, health care professionals should screen the women for menopause challenges when they visit health care facilities and offer education regarding self-care and management to achieve better quality of life and positive coping., Conclusions: We conducted a preliminary study on women's perceptions and experiences of menopause in the context of Pakistan. Our study offers significant findings from an Asian cultural perspective, in which norms are predominantly patriarchal and male dominated. The study provides useful guidelines for health care providers to better address health care needs of menopausal women.

Early childhood trauma can have adverse effects on brain development. This results in higher rates of mental health and medical problems in adults. Unfortunately, psychiatry trainees are not adequately trained in dealing with trauma survivors. Hence, we implemented an online trauma curriculum and assessed its efficacy. Socratic methods of teaching, flipped classroom approach, brainstorming, role play, and case-based discussions were utilized. Participants were able to exhibit good knowledge and clinical skills as assessed through summative assessment and communication skills assessment. This curriculum showed online training can help with clinical skill development along with improving knowledge when dealing with trauma survivors., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Trauma is a major global health problem. Currently a trauma curriculum, from a psychological perspective, has not been uniformly incorporated in medical education. Nonetheless, professionals from various medical disciplines have an integral role in providing trauma care to survivors. The current COVID-19 pandemic only underscores the relevance and urgent need of this training, as studies show an uptick in mental health disorders due to this trauma. This article will present a discussion on the need for trauma curriculum for health care professionals, using information gained through trauma informed care workshops for healthcare personnel at Aga Khan University Hospital Pakistan., (Copyright © 2021 Elsevier B.V. All rights reserved.)

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., (© 2021. The Author(s).)

Objective: To explore healthcare provider's perspectives and experiences of the barriers and facilitators to treat and manage COVID-19 cases., Design and Setting: We conducted an exploratory qualitative study using a purposive sampling approach, at a private tertiary care teaching hospital in Karachi, Pakistan. Study data were analysed manually using the conventional content analysis technique., Participants: Key-informant interviews (KIIs) were conducted with senior management and hospital leadership and in-depth interviews (IDIs) were conducted with front-line healthcare providers., Results: A total of 31 interviews (KIIs=19; IDIs=12) were conducted, between April and May 2020. Three overarching themes emerged. The first was 'challenges faced by front-line healthcare providers working in COVID-19 wards. Healthcare workers experienced increased anxiety due to the fear of acquiring infection and transmitting it to their family members. They felt overwhelmed due to the exhaustive donning and doffing process, intense work and stigmatisation. The second theme was 'enablers supporting healthcare providers to deal with the COVID-19 pandemic'. Front liners pointed out several enabling factors that supported hospital staff including a safe hospital environment, adequate training, a strong system of information sharing and supportive management. The third theme was 'recommendations to support the healthcare workforce during the COVID-19 crisis'. Healthcare workers recommended measures to mitigate current challenges including providing risk allowance to front-line healthcare providers, preparing a backup health workforce, and establishing a platform to address the mental health needs of the healthcare providers., Conclusion: This study provides an initial evidence base of healthcare providers' experiences of managing patients with COVID-19 in the early stage of the pandemic and highlights measures needed to address the encountered challenges. It offers lessons for hospitals in low-income and middle-income countries to ensure a safe working environment for front-line workers in their fight against COVID-19., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

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, and patients' 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 with not 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]), mild depression (-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., (© 2021 John Wiley & Sons Ltd.)

Background : Children with disabilities are more likely to experience violence or injury at school and at home, but there is little evidence from Central Asia. Objective : To describe the prevalence of disability and associations with peer violence perpetration and victimization, depression, corporal punishment, school performance and school attendance, among middle school children in Pakistan and Afghanistan. Method : This is a secondary analysis of data gathered in the course of evaluations of interventions to prevent peer violence conducted in Pakistan and Afghanistan as part of the 'What Works to Prevent Violence against Women and Girls Global Programme'. In Pakistan, the research was conducted in 40 schools, and disability was assessed at midline in 1516 interviews with Grade 7s. In Afghanistan, the data were from the baseline study conducted in 11 schools with 770 children. Generalized Linear Mixed Modeling was used to assess associations with disability. Results : In Afghanistan, the prevalence of disability was much higher for girls (22.1%) than boys (12.9%), while in Pakistan 6.0% of boys and girls reported a disability. Peer violence victimization was strongly associated with disability in Afghanistan and marginally associated in Pakistan. In Pakistan, perpetration of peer violence was associated with disability. In both countries, disability was significantly associated with higher depression scores. Food insecurity was strongly associated with disability in Afghanistan. Conclusion : Disability is highly prevalent in Afghanistan and Pakistan schools and this is associated with a greater risk of experiencing and perpetrating peer violence. It is important to ensure that all children can benefit from school-based prevention interventions.

Background: Peer violence is common globally, but a little researched topic in low-and middle-income countries. This study presents the evaluation of a two-year randomized controlled trial of a structured play-based life-skills intervention implemented in schools in Hyderabad, Pakistan., Objective: To determine the impact of the intervention on school-based peer violence (victimization and perpetration) and depression among school children., Methods: 40 single-sex public schools were randomized into two study arms (20 per arm 10 of each sex). A total of 1752 grade 6 students (929 from intervention and 823 from control schools) were enrolled in the trial. The two-year intervention was a biweekly structured game led by a coach followed by critical reflection and discussion for 30 minutes. Primary outcomes (exposure to peer violence exhibited through victimization and perpetration and depression) were evaluated using generalized linear-mixed models., Results: Of the enrolled children (N = 1752) 91% provided data for analysis. There were significant decreases in self-reported peer violence victimization, perpetration and depression. For peer violence victimization, the reductions in the intervention and control arms were: 33.3% versus 27.8% for boys and 58.5% versus 21.3% for girls. For peer violence perpetration, the reductions were: 25.3% versus 11.1% for boys and 55.6% versus 27.6% for girls in the intervention and control arms, respectively. There were significant drops in mean depression scores (boys 7.2% versus 4.8% intervention and control and girls 9.5% versus 5.6% intervention and control)., Conclusion: A well-designed and implemented play-based life-skills intervention delivered in public schools in Pakistan is able to effect a significant reduction in peer violence.

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< 0.001); however, QoL for the social domain was not significantly different in both the groups. On multivariable linear regression resilience and depression among males had a significant association with QoL, after adjusting for the covariates educational status, monthly income, and number of friends. Similar association was observed among females after adjusting for the covariate monthly income only., 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.

The COVID-19 pandemic has overwhelmed hospitals all over the world. To reduce the risk of transmission of COVID-19 and meet the increasing mental health demands due to this trauma, psychiatry outpatient services have gone online in various countries. We describe steps taken at a tertiary care hospital in Karachi, Pakistan, to start these services during this pandemic. We also discuss the obstacles faced. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Objective: To measure the psychological distress among the informal caregivers of disabled young adults with traumatic brain injuries (TBI) and to identify its associated factors., Methods: An analytical cross sectional study was conducted with 76 informal caregivers of young adults (19 - 50 years) with TBI, using admission records of one of the tertiary care hospitals in Karachi, Pakistan from 2015 to 2016. Data were collected using a structured questionnaire comprising a general demographic questionnaire and the General Health Questionnaire- 28. The effect of the predictors on the psychological distress was determined by applying multiple linear regression analysis., Results: The mean score of the psychological distress was found to be 23.5±14.28. The findings indicated that anxiety and insomnia, and social dysfunction were the most affected domains of psychological distress; whereas, depression was the least affected. Factors including the management of finances, number of children, patient's gender, and patient's level of disability and lack of socialization were positively associated with the level of distress. As reported by participants, religious beliefs served as a coping mechanism for most of them., Conclusions: The study showed a high level of distress among informal caregivers of young adults with TBI. For recognizing the psychological effects of TBI in patients and their informal caregivers, it is important to initiate and ensure the provision of psychological support to the patients and their families.

Abuse is associated with short and long term psychiatric consequences. There is a need to develop more culturally competent treatment, especially in the South Asian context. We present an account of our clinical experience with hospital-based therapeutic strategies that we found to be successful in a largely conservative, developing country., Competing Interests: Declaration of competing interest None., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Cancer 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 Analysis: A 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 <0.05 will be considered significant., Ethics and Dissemination: Ethical 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 Number: Clinicaltrials.gov registry (NCT03466762)., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

There is a scarcity of research on suicidal phenomena in the Muslim world. Therefore, this study aimed at investigating the self-reported prevalence of suicidal thoughts, attempts and motives in 12 Muslim countries. A total of 8417 (54.4% women) university students were surveyed by means of a self-report questionnaire. Overall, 22% of the participants reported suicidal ideation and 8.6% reported attempting suicide. The odds of suicidal thoughts were elevated in Azerbaijan, Indonesia and Saudi Arabia, while reduced ORs were recorded in Egypt, Jordan, Lebanon and Malaysia. While odds of suicide attempts were high in Azerbaijan, Palestine and Saudi Arabia reduced odds ratios (OR) were detected in Indonesia, Iran, Jordan, Lebanon, Malaysia and Tunisia. Taking drugs and using a sharp instrument were the two most frequently used methods to attempt suicide. Only 32.7% of attempts required medical attention. Escape motives were endorsed more than social motives by participants who attempted suicide. Suicidal behaviors were more frequent in women than in men. Compered to men, fewer attempts by women required medical attention. Moreover, our results show that making suicide illegal does not reduce the frequency of suicidal behavior. Results from this comparative study show that suicidal thoughts and attempts are frequent events in young adults in countries where religious scripture explicitly prohibit suicide and the frequencies of nonfatal suicidal behavior show large variation in nations adhering to the same religion.

Background: In Pakistan, there is high prevalence of mental health disorders, but mental health services to address these are not well developed. To provide effective mental health services, the World Health Organization emphasizes the integration of mental health into primary health care (PHC)., Objectives: This study aimed to assess the views of key stakeholders about integration of mental health into PHC in Karachi, Pakistan., Methods: A qualitative, exploratory study was conducted between June and September 2013 among 15 decision-making (from the Department of Health) and implementation-level stakeholders (mental health and public health professionals and primary care staff) from both the public and private sectors. Face-to-face, in-depth interviews were conducted using a semi-structured interview guide. Data were collected until theoretical saturation was achieved and conventional content analysis was carried out., Results: Although there was general support among all the stakeholders for integration of mental health services within PHC, there were also a number of reservations. First was the perceived lack of support within the system in terms of resource allocation and acceptance from the community. Second was the lack of human resources in the field of mental health. In addition, resistance at the PHC level is likely as staff are already burdened with other preventive care services., Conclusions: The study suggests that strong political commitment, adequate human and financial resources, and strong advocacy are needed for the integration of mental health into PHC in Pakistan., (Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https://creativecommons.org/licenses/by-nc-sa/3.0/igo).)

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.

Objective: Significant neurodevelopmental sequelae are known to occur after acute bacterial meningitis (ABM). This study determined the burden of such sequelae in Pakistani children aged <5 years to guide policies for Haemophilus influenzae type b (Hib) and pneumococcal vaccination., Study Design: Cases of ABM were recruited from hospital-based surveillance and assigned to 1 of 3 etiologic groups (Hib, Streptococcus pneumoniae, or unknown etiology). Two age-matched controls were recruited for each case. Six months after enrollment, each case underwent neurologic history and examination, neurodevelopmental evaluation, and neurophysiological hearing test. Controls were assessed in parallel., Results: Of 188 cases, 64 (34%) died. Mortality among subgroups were 7 (27%), 14 (28%), and 43 (39%) for Hib, Streptococcus pneumoniae, and unknown etiology, respectively. Eighty cases and 160 controls completed the assessments. Sequelae among cases included developmental delay (37%), motor deficit (31%), hearing impairment (18.5%), epilepsy (14%), and vision impairment (14%). Sequelae were higher after pneumococcal meningitis (19, 73%) compared with Hib meningitis (8, 53%). Compared with controls, cases were at significantly higher risk for all sequelae (P < .0001)., Conclusions: ABM causes a substantial long-term burden of poor neurodevelopmental outcomes. Hib and pneumococcal vaccines are very effective interventions to prevent meningitis and its disabling sequelae., (Copyright © 2013. Published by Mosby, Inc.)

Pakistan ranks 125th out of 169 countries on the Gender Development Index and has high prevalence rates of Violence against Women (VAW). Contributing factors toward gender based violence at the micro, meso and macro levels include the acceptability of violence amongst both men and women, internalization of deservability, economic disempowerment, lack of formal education, joint family systems, entrenched patriarchal norms and values, and a lack of awareness of legal and other support systems. These factors have a long-lasting impact on the health of women and children. The gender disparities in the experience of women seeking health care in Pakistan are well-recognized and documented. In the past, common government policy responses to these disparities have included developing the role of community health workers (CHWs) and lady health visitors (LHVs). Despite being commendable initiatives, these too have been unsuccessful in addressing these multi-faceted disparities. Within this complex scenario, new interventions to address VAW and its impact on health in Pakistan include Group Counselling, Economic Skills Building, Health-Based Microfinance, and Family-Based models that increase male involvement, especially at the primary health care level. The purpose of this article is to outline key contributing factors to VAW, explore tested and new interventions, and highlight the opportunities that exist in implementing them.

In a developing country such as Pakistan, where illiteracy, poverty, gender differences, and health issues are prevalent, violence against women is a commonly observed phenomenon. The rising incidences of abuse among women indicate a need to introduce evidence-based community-derived interventions for meeting Millennium Developmental Goals by 2015. This article discusses the application of counseling, economic skills building, and microcredit programs as practical and effective interventions to improve the health outcomes of abused women and, therefore, improving maternal and child health in the Pakistani society., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: Pakistan is a patriarchal society where men are the primary authority figures and women are subordinate. This has serious implications on women's and men's life prospects., Objective: The aim was to explore current gender roles in urban Pakistan, how these are reproduced and maintained and influence men's and women's life circumstances., Design: Five focus group discussions were conducted, including 28 women representing employed, unemployed, educated and uneducated women from different socio-economic strata. Manifest and latent content analyses were applied., Findings: TWO MAJOR THEMES EMERGED DURING ANALYSIS: 'Reiteration of gender roles' and 'Agents of change'. The first theme included perceptions of traditional gender roles and how these preserve women's subordination. The power gradient, with men holding a superior position in relation to women, distinctive features in the culture and the role of the extended family were considered to interact to suppress women. The second theme included agents of change, where the role of education was prominent as well as the role of mass media. It was further emphasised that the younger generation was more positive to modernisation of gender roles than the elder generation., Conclusions: This study reveals serious gender inequalities and human rights violations against women in the Pakistani society. The unequal gender roles were perceived as static and enforced by structures imbedded in society. Women routinely faced serious restrictions and limitations of autonomy. However, attainment of higher levels of education especially not only for women but also for men was viewed as an agent towards change. Furthermore, mass media was perceived as having a positive role to play in supporting women's empowerment.

Objective: to determine the prevalence of suicidal thoughts and attempts and to identify demographic variables and mental health correlates such as anxiety/depression and domestic violence among pregnant women in an urban community in Pakistan., Design: cross-sectional data from a prospective cohort study are presented., Setting: women enrolled in an antenatal care clinic and followed to delivery in an urban area of Pakistan., Population: cohort of pregnant women in Pakistan., Methods: a total of 1,369 pregnant women were enrolled and interviewed regarding various maternal characteristics and pregnancy outcomes, and were asked specific questions about suicidal thoughts and attempts and administered the Aga Khan University Anxiety Depression Scale at 20-26 weeks of gestation., Main Outcome Measures: suicidal thoughts and attempts, verbal, sexual or physical abuse., Results: overall, 148 of the 1,369 (11%) women studied had considered suicide. Of these, 148 women, 67 (45%) had attempted suicide. In all, 18% of the women were classified as having depression/anxiety, almost half (48%) reported experiencing verbal abuse and 20% reported physical/sexual abuse. Women who had anxiety/depression or had experienced verbal or physical/sexual abuse were significantly more likely to have had suicidal thoughts and attempts., Conclusions: women at the greatest risk for having suicidal thoughts or a suicide attempt were those who were depressed/anxious and had experienced some form of domestic abuse. With the high prevalence of these conditions, attention should be given to the establishment of effective mental health treatment programs for pregnant women.

Violence against women is a global epidemic phenomenon that can result in major mental health problems. Not only are women affected but also the health and well-being of their children are in jeopardy. To prevent violence and promote women's safety, several strategies have been tested in various cultural contexts. This article describes the process of developing and validating an economic skill building intervention for women of an urban slum area of Karachi, Pakistan. The purpose of the intervention is to increase women's economic independence, promote women's safety, and improve the behavioral functioning of their children.

Background: Few studies have examined the relationship between antenatal depression, anxiety and domestic violence in pregnant women in developing countries, despite the World Health Organization's estimates that depressive disorders will be the second leading cause of the global disease burden by 2020. There is a paucity of research on mood disorders, their predictors and sequelae among pregnant women in Pakistan., Aims: To determine the prevalence of anxiety and depression and evaluate associated factors, including domestic violence, among pregnant women in an urban community in Pakistan., Methods: All pregnant women living in identified areas of Hyderabad, Pakistan were screened by government health workers for an observational study on maternal characteristics and pregnancy outcomes. Of these, 1,368 (76%) of eligible women were administered the validated Aga Khan University Anxiety Depression Scale at 20-26 weeks of gestation., Results: Eighteen per cent of the women were anxious and/or depressed. Psychological distress was associated with husband unemployment (p = 0.032), lower household wealth (p = 0.027), having 10 or more years of formal education ( p = 0.002), a first (p = 0.002) and an unwanted pregnancy ( p < 0.001). The strongest factors associated with depression/anxiety were physical/sexual and verbal abuse; 42% of women who were physically and/or sexually abused and 23% of those with verbal abuse had depression/anxiety compared to 8% of those who were not abused., Conclusions: Anxiety and depression commonly occur during pregnancy in Pakistani women; rates are highest in women experiencing sexual/physical as well as verbal abuse, but they are also increased among women with unemployed spouses and those with lower household wealth. These results suggest that developing a screening and treatment programme for domestic violence and depression/anxiety during pregnancy may improve the mental health status of pregnant Pakistani women.