Search

Background: Patient and public involvement and engagement (PPIE) in clinical trials is increasingly recognized as vital for ensuring research relevance and accessibility. Despite its proven benefits, PPIE remains limited, particularly in low- and middle-income countries, and more examples of effective strategies for involvement are needed. This commentary outlines the establishment of a PPIE group for clinical trials in a lower-middle-income country setting with limited research infrastructure. Main Body: We established Pakistan's first ever PPIE group for clinical trials within a new clinical trials unit at Ziauddin University in Karachi. The objectives of our project were focused on group formation, redesign of informed consent documents for trials, and dissemination of trial results to the public. Recruitment strategies involved referrals from clinicians and existing collaborators as well as engagement at public events, distribution of advertising leaflets and social media posts. Ten potential members were selected based on motivation, commitment and ability to contribute critically, with six members continuing their involvement long-term. An existing tool designed to establish the access needs of public partners was adapted to our project to help us document and account for members' expectations and support requirements. The process of using the tool enabled deep engagement, clarified roles, and fostered trust between coordinators and group members. Patient and public members gained confidence about the legitimacy of the project and felt more comfortable participating in the first group meeting. Lessons learned emphasize the importance of wide-ranging engagement efforts and transparent discussions about expectations to build effective collaborative relationships. Conclusion: Our experience demonstrates the feasibility of establishing a PPIE group for clinical trials in Pakistan and highlights strong public interest for research involvement. The use of a formal tool to document needs, prior experiences and expectations encouraged relationship-building and helped coordinators make relevant accommodations for members. This account contributes to the growing body of literature on effective PPIE practices, emphasizing the value of tailored support and transparent communication in facilitating meaningful public involvement in clinical trials. Plain English summary: Working together with patients and members of the public has the potential of making clinical trials better, more person-centered and relevant. Unfortunately, partnerships between trial researchers and the public are still uncommon. It is not known what the best ways are to involve the public in clinical trials, especially when it comes to non-Western populations. We set up the first-ever patient and public involvement and engagement group to support clinical trials in Pakistan. In this commentary, we share our initial experiences of successfully establishing the group and the two main lessons we learned. Ten group members were identified by widely advertising our project to doctors, community organizations, patients and their carers at our hospital. Before the first group meeting, two coordinators met with each potential member to discuss and document their interests, expectations and needs. Both researchers and group members felt that these discussions were a good use of their time and helped make the project a success. The first main lesson learned from our experience was that enough time, funding, staff and resources are needed to identify members and build meaningful collaborative partnerships. The second main lesson learned was that honest discussions are needed at the very beginning of a collaboration about expectations. Our experience shows that involving patients and members of the public in clinical trials in Pakistan is possible and we hope it inspires and helps other researchers in their patient and public engagement efforts. [ABSTRACT FROM AUTHOR]

Background and context: Providing care to the elderly is an emerging area of interest due to the increase in elderly population not only in the developed world but also in low and middle income countries. In Pakistan a country with an overall population of over 200 million, the elderly population amounts to 11.3 million. Caregiving of the elderly tends to occur within the kinship motivated by sociocultural norms as well as absence of government support facilities. While quantitative literature exists in Pakistan describing the "caregiver's burden," an in-depth analysis into the experiences of familial caregivers is missing. Methods: The research used qualitative methods with the aim to explore the lived experiences of 7 daughters and 3 daughters-in-law, living in Karachi, Pakistan providing care to the elderly requiring assistance in at least two tasks of daily living. Results: Five themes were developed inductively through the phenomenological method. All participants were Muslim and belonged to the upper economic strata of the society. Findings reveal that obligations to care are dominant in kinship circles particularly among women. Participants highlighted the importance of elderly in the Pakistani society, especially due to the religious lens that considers them as blessings. Daughter caregivers spoke about caregiving of their parents as a form of role reversal, emphasizing also upon the life-long emotional bond that served as a strong motivator. On the other hand, for daughter-in-law caregivers, motivations to care also stemmed from social expectations and kinship obligations. All participants reported multiple difficulties during the caregiving experience, despite existence of paid formal help, with respect to balancing multiple role demands and the nature of caregiving that requires constant effort. Results also illustrate that despite the desire to care for the elderly within a collectivist and patrilocal society, participants experienced multiple physical and emotional effects. However, a few also reported an increase in self-mastery and self-worth. Conclusion: This study reveals that despite increasing urbanization and more women working outside the home, providing care to the elderly appears to be centered within the kinship circle. The research makes important contributions to the ageing literature in Pakistan with relevance to other South Asian contexts. [ABSTRACT FROM AUTHOR]

South Asia contributes the most to stroke mortality worldwide. This study aimed to determine the long-term trends in stroke mortality across four South Asian countries and its associations with age, period, and birth cohort. In 2019, nearly one million stroke deaths occurred across South Asia, and the associated age-standardized mortality rate (ASMR) was 80.2 per 100,000. Between 1990 and 2019, India had the largest decrease in the ASMR (−35.8%) across the four South Asian countries. While Pakistan had the smallest decrease in the ASMR (−7.6%), an increase was detected among males aged 15 to 34 years and females aged 15 to 19 years. Despite a 22.8% decrease in the ASMR, Bangladesh had the highest ASMR across the four South Asian countries. Nepal reported a witness increase in the stroke ASMR after 2006. Improved period and cohort effects on stroke mortality were generally indicated across the analyzed countries, except for recent-period effects in males from Nepal and cohort effects from those born after the 1970s in Pakistan. Stroke mortality has decreased in the four South Asian countries over the past 30 years, but potentially unfavorable period and cohort effects have emerged in males in Nepal and both sexes in Pakistan. Governmental and societal efforts are needed to maintain decreasing trends in stroke mortality. [ABSTRACT FROM AUTHOR]

During the COVID‐19 pandemic, healthcare professionals around the world were driven by universal values of solidarity and duty to provide care. However, local societal norms and existing healthcare systems influenced interactions among physicians, and with patients and their families. An exploratory qualitative study design using in‐depth interviews was undertaken with physicians working at two public sector hospitals in Karachi, Pakistan. Using the constant comparison method of data analysis, several key themes were identified highlighting norms of kinship and interdependencies characteristic of collectivistic societies that influenced professional interactions. The role of seniors in the hierarchical society of Pakistan played a major role in provision of care. Physicians reported numerous challenges in dealing with patients and their families amidst public denial fueled due to ill‐formed government policies. This included interruption of funeral rites which undermined public trust. The study provides insights into the local moral world of two healthcare institutions in Pakistan. [ABSTRACT FROM AUTHOR]

Why do India and Pakistan always quarrel over terrorism? The prevailing arguments more often implicate intriguing South Asian geopolitics surrounding the unresolved Kashmir dispute or pathological partition of British India in 1947 to explain this puzzle. Surprisingly, why and how the two countries verbalise terrorism has hardly been investigated in a comparative framework as a potential underpinning of this historical syndrome. This void has deprived South Asia's existing literature and public and policy debates of an understanding of the underlying determinants of the terrorism discourse. Namely, how has the discourse originated, what are its distinct metaphysics, and how it has shaped and normalised discursive practices at significant moments in the history of these two countries, and with what consequences? This article responds to these broader questions. It argues that among other vital underpinnings, the Indo-Pakistan terrorism discourse, with its origins in colonialism, functions to institute and enable rival practices of exclusionary politics, doublespeak and propaganda. More importantly, it nurtures self-fulfilling concepts of statehood deriving from a constructed "real" reality characterising an imagined geopolitical pathology that, in turn, perpetuates Indo-Pakistan imperialism. In addressing this argument, the paper makes multiple original contributions, including identifying research avenues and indicating various intersecting causes of friction that afford reconciliation possibilities to the stakeholders. [ABSTRACT FROM AUTHOR]

Background: The burden of childhood trauma (violence, injury/illness, loss) in low-resource settings is high, although the effect of trauma on children's mental and cognitive health is under-researched. Child gender may moderate the association between trauma and outcomes; boys are more likely to experience trauma, but girls are more likely to show distress following trauma. Methods: We draw on data from the Bachpan cohort (n = 888), a sample of mother-child dyads in rural Pakistan, to investigate these associations among 6-year-old children in a South Asian, low-resource setting. Mothers reported on children's lifetime exposure to 15 possible traumas and their current mental health. In addition, children were assessed for their verbal skills, working memory, and inhibitory control. We estimated trauma prevalence and used generalized estimating equations to test the association between number of traumatic events and child mental health and cognitive skills in the overall sample and by gender. Results: 90.5% of children experienced at least one trauma. The most common traumas were death of a loved one (47%) and hearing about war/terrorism on the TV/radio (48%). On average, boys experienced more traumas (M = 3.00) than girls (M = 2.67). Specifically, boys were more likely than girls to experience an injury or hospitalization (30% vs. 21%, p <.05) and to hear about war/terrorism on the TV/radio (52% vs. 43%, p <.05). Trauma was associated with increased mental health difficulties and increased anxiety scores. There was little evidence that trauma exposure was associated with child cognitive skills. The strength of association between trauma and outcomes was similar for boys and girls. Conclusions: Findings show that childhood trauma exposure is common in this setting and associated with worse mental health problems among young boys and girls. Results suggest that trauma-informed interventions are important for supporting child mental health in South Asia. [ABSTRACT FROM AUTHOR]

Background and aims: Smokeless tobacco (ST) use in South Asia is high, yet interventions to support its cessation are lacking. We tested the feasibility of delivering interventions for ST cessation in South Asia. Design: We used a 2 × 2 factorial design, pilot randomized controlled trial with a duration of 26 weeks, including baseline and follow‐up (6, 12 and 26 weeks) assessments. Setting: Two primary health‐care facilities each in Dhaka (Bangladesh) and Karachi (Pakistan) and a walk‐in cancer screening clinic in Noida (India) took part. Participants: Adult daily ST users willing to make a quit attempt within 30 days. Of 392 screened, 264 participants [mean age: 35 years, standard deviation = 12.5, 140 (53%) male] were recruited between December 2020 and December 2021; 132 from Bangladesh, 44 from India and 88 from Pakistan. Interventions: Participants were randomized to one of three treatment options [8‐week support through nicotine replacement therapy (NRT, n = 66), a behavioural intervention for smokeless tobacco cessation in adults (BISCA, n = 66) or their combination (n = 66)] or the control condition of very brief advice (VBA) to quit (n = 66). Measurements Recruitment and retention, data completeness and feasibility of intervention delivery were evaluated. Biochemically verified abstinence from tobacco, using salivary cotinine, was measured at 26 weeks. Findings Retention rates were 94.7% at 6 weeks, dropping to 89.4% at 26 weeks. Attendance in BISCA pre‐quit (100%) and quit sessions (86.3%) was high, but lower in post‐quit sessions (65.9%), with variability among countries. Adherence to NRT also varied (45.5% Bangladesh, 90% India). Data completion for key variables exceeded 93% among time‐points, except at 26 weeks for questions on nicotine dependence (90%), urges (89%) and saliva samples (62.7%). Among follow‐up time‐points, self‐reported abstinence was generally higher among participants receiving BISCA and/or NRT. At 26 weeks, biochemically verified abstinence was observed among 16 (12.1%) participants receiving BISCA and 13 (9.8%) participants receiving NRT. Conclusions: This multi‐country pilot randomized controlled trial of tobacco cessation among adult smokeless tobacco users in South Asia demonstrated the ability to recruit and retain participants and report abstinence, suggesting that a future definitive smokeless tobacco cessation trial is viable. [ABSTRACT FROM AUTHOR]

South Asian region contributes 59 % to the global mortality due to burns. However, we find a paucity of literature on the outcomes of burns from low- and middle-income countries (LMICs). South Asian Burn Registry (SABR) is a facility-based burns registry that collected data on in-patient burn care. This study assesses factors associated with mortality, length of hospital stay at the burns center, and functional status of burn patients. Prospective data was collected from two specialized public sector burn centers between September 2014 – January 2015 from Bangladesh and Pakistan. Multivariable logistic, linear, and ordinal logistic regression was conducted to assess factors associated with inpatient-mortality, length of hospital stay, and functional status at discharge, respectively. Data on 883 patients was analyzed. Increased association with mortality was observed with administration of blood product (OR:3, 95 % CI:1.18–7.58) and nutritional support (OR:4.32, 95 % CI:1.55–12.02). Conversely, antibiotic regimens greater than 8 days was associated with decreased mortality (OR:0.1, 95 % CI:0.03–0.41). Associated increase in length of hospital stay was observed in patients with trauma associated with their burn injury, history of seizures (CE:47.93, 95 % CI 12.05–83.80), blood product (CE:22.09, 95 % CI:0.83–43.35) and oxygen administration (CE:23.7, 95 % CI:7.34–40.06). Patients who developed sepsis (OR:6.89, 95 % CI:1.92–24.73) and received blood products during hospitalization (OR:2.55, 95 % CI:1.38- 4.73) were more likely to have poor functional status at discharge. This study identified multiple factors associated with worse clinical outcomes for burn patients in South Asia. Understanding these parameters can guide targeted efforts to improve the process and quality of burn care in LMICs. • Multiple factors determine clinical outcomes for burn injury patients. • In addition to mortality, morbidity and level of functioning are critical outcomes associated with burden of burn injuries. • Patients with comorbid conditions and multiple injuries have long in-patient stay and poorer functional status. [ABSTRACT FROM AUTHOR]

The pomfret fish, particularly the black pomfret (Parastromateus niger), serves as a significant economic resource in South Asia, particularly in the coastal regions of Balochistan, Pakistan. This study investigates various biological parameters of Parastromateus niger collected from the Gaddani coastal area of Pakistan, focusing on length-weight relationships, gut fullness, and population demographics. A total of 117 fish specimens were collected, with females dominating the samples. Length and weight data were analyzed separately for males and females, with statistical calculations revealing strong correlations (r2 values ranging from 0.918 to 0.985) between length and weight for both sexes. Gut fullness was categorized into five levels, with the highest percentage observed during July, suggesting potential breeding activity during this period. The zooplanktons were identified as primary dietary components of Parastromateus niger. The study also highlights the importance of regulatory measures to sustainably manage fish populations, especially during breeding seasons, and calls for further research into the intensive culturing and feeding regimes of black pomfret to enhance its production. Overall, these findings contribute to a better understanding of the biological characteristics and potential for aquaculture development of Parastromateus niger in the region. [ABSTRACT FROM AUTHOR]

The aim of this multi-country, cluster-randomized trial is to test the impact of pharmacy-based health promotion to reduce the blood pressure of individuals with hypertension over a 12-month period in Bangladesh and Pakistan. The trial will be implemented with two arms. In Bangladesh, the estimated sample size is around 3600 hypertensive patients. In Pakistan, we will select samples equivalent to 10% of the participants from Bangladesh, comprising 360 hypertensive patients from four pharmacies. Community pharmacies will be randomized into one of two parallel groups (allocation ratio 1:1). Pharmacy professionals in the treatment arm will provide their patients with educational training and counseling, as well as phone calls/mobile text messages and care coordination in the health sector, as part of the intervention. The study will be conducted in three phases: a baseline survey with intervention, a midline survey with intervention and follow-up, and an endline survey with impact evaluation. The primary outcome of the study will be BP. The secondary outcomes will be BP controlled to target, treatment adherence, quality of life, mortality or hospital admission rates resulting from hypertension and its related complications, incremental cost per health-related quality of life gained, knowledge on healthy lifestyle and dietary behavior, and change in the prevalence of current smoking status. [ABSTRACT FROM AUTHOR]

AbstractThis study takes a unique approach by empirically examining the political economy of US aid to Pakistan in the South Asian regional strategic context, including the geopolitics of China, India, Iran, and Russia. Using the dynamic Autoregressive Distributed Lag (ARDL) method from 1971 to 2016, we find that US economic assistance responds positively to regional wars in Afghanistan and the Indo-Russian strategic relationship in the long run. The improvement in the relationship between India and Pakistan increases US economic aid in the short run but reduces it in the long run. The Pak-Iran economic relationship reduces US economic assistance in the short run while in the long run, it is positive but insignificant. Washington’s policy for South Asia is now more China-centric in reshaping regional geopolitics. The US-foreign-aid-policy instrument generally plays a dynamic role in achieving manifold strategic objectives in the South Asian region. These findings contribute to a deeper understanding of the complex dynamics of foreign aid and geopolitical relationships. [ABSTRACT FROM AUTHOR]

This study examines the question as to whether Pakistan's fertility transition is stalling. The paper reviews the trajectories of fertility and its various determinants and compares Pakistan's trends with those of India and Bangladesh. Countries in the South Asia region share features such as cultural similarities (e.g. the low status of women and son preference) and high poverty levels. However, while Bangladesh and India are near replacement fertility today with modern contraceptive prevalence rates well above 50 per cent, Pakistan still has one of the highest fertility and lowest contraceptive prevalence levels in Asia. Our main conclusion is that Pakistan's fertility transition is close to stalling in mid-transition. The key causes of this stall are a high and unchanging desired family size, stalling demand for contraception and relatively low satisfaction of this demand. These are important obstacles to future decline in fertility. [ABSTRACT FROM AUTHOR]

Skeletal dysplasias (SKDs) are a heterogeneous group of more than 750 genetic disorders characterized by abnormal development, growth, and maintenance of bones or cartilage in the human skeleton. SKDs are often caused by variants in early patterning genes and in many cases part of multiple malformation syndromes and occur in combination with non‐skeletal phenotypes. The aim of this study was to investigate the underlying genetic cause of congenital SKDs in highly consanguineous Pakistani families, as well as in sporadic and familial SKD cases from India using multigene panel sequencing analysis. Therefore, we performed panel sequencing of 386 bone‐related genes in 7 highly consanguineous families from Pakistan and 27 cases from India affected with SKDs. In the highly consanguineous families, we were able to identify the underlying genetic cause in five out of seven families, resulting in a diagnostic yield of 71%. Whereas, in the sporadic and familial SKD cases, we identified 12 causative variants, corresponding to a diagnostic yield of 44%. The genetic heterogeneity in our cohorts was very high and we were able to detect various types of variants, including missense, nonsense, and frameshift variants, across multiple genes known to cause different types of SKDs. In conclusion, panel sequencing proved to be a highly effective way to decipher the genetic basis of SKDs in highly consanguineous families as well as sporadic and or familial cases from South Asia. Furthermore, our findings expand the allelic spectrum of skeletal dysplasias. [ABSTRACT FROM AUTHOR]

Objective To assess the availability of information on indicators of the World Health Organization and United Nations Children's Fund primary health-care measurement framework in Bangladesh, India, Nepal, Pakistan and Sri Lanka and to outline the opportunities for and challenges to using the framework in these countries. Methods We reviewed global and national data repositories for quantitative indicators of the framework and conducted a desk review of country documents for qualitative indicators in February--April 2023. We assessed data sources and cross-sectional survey tools to suggest possible sources of information on framework indicators that were not currently reported in the countries. We also identified specific indicators outside the framework on which information is collected in the countries and which could be used to measure primary healthcare performance. Findings Data on 54% (32/59) of the quantitative indicators were partially or completely available for the countries, ranging from 41% (24/59) in Pakistan to 64% (38/59) in Nepal. Information on 41% (66/163) of the qualitative subindicators could be acquired through desk reviews of country-specific documents. Information on input indicators was more readily available than on process and output indicators. The feasibility of acquiring information on the unreported indicators was moderate to high through adaptation of data collection instruments. Conclusion The primary health-care measurement framework provides a platform to readily assess and track the performance of primary health care. Countries should improve the completeness, quality and use of existing data for strengthening of primary health care. [ABSTRACT FROM AUTHOR]

Parent-child relationship quality can have long-term impacts on child mental health into adulthood. The impact of parental behaviors on the future mental health of children has been understudied in South Asia, where parenting approaches differ from the dominant western approaches often represented in the literature. Mothers in rural Pakistan (N = 828) reported on their own mothers' parenting behaviors using the Parental Bonding Instrument (PBI) and were assessed for depression using the Structured Clinical Interview for DSM Disorders (SCID). The PBI includes scales for warmth (care scale) and over-control (protection scale), as well as subscales for behavioral control and psychological control. We used structural equation modeling to test the associations between depression and all PBI scales/subscales. Increased parental care was associated with lower probability of depression (B = −0.19, SE = 0.09). Parental protection was associated with higher probability of depression (B = 0.25, SE = 0.11). Among the protection subscales, behavioral control was associated with increased risk of depression (B = 0.24, 95 % SE = 0.11) and psychological control was associated with decreased risk of depression (B = −0.28, SE = 0.12). This cross-sectional study used retrospective self-reports of parenting experiences. Participants only reported on their mothers, not fathers or other caregivers. In a rural Pakistani sample, maternal warmth was protective against adulthood depression. The association between maternal control and depression varied based on the type of control (behavioral or psychological), emphasizing the importance of nuanced measures of parental control in this context. • Parenting behavior, including warmth and control, can affect offspring mental health into adulthood. • We studied parental warmth and control and adult depression among women in rural Pakistan. • Parental warmth was associated with lower risk of depression in women. • Parental behavioral control was associated with higher risk of depression in women. • Parental psychological control was associated with lower risk of depression in women. [ABSTRACT FROM AUTHOR]

Multi-drug resistant (MDR) E. coli constitute a major public health burden globally, reaching the highest prevalence in the global south yet frequently flowing with travellers to other regions. However, our comprehension of the entire genetic diversity of E. coli colonising local populations remains limited. We quantified this diversity, its associated antimicrobial resistance (AMR), and assessed the impact of antibiotic use by recruiting 494 outpatients and 423 community dwellers in the Punjab province, Pakistan. Rectal swab and stool samples were cultured on CLED agar and DNA extracted from plate sweeps was sequenced en masse to capture both the genetic and AMR diversity of E. coli. We assembled 5,247 E. coli genomes from 1,411 samples, displaying marked genetic diversity in gut colonisation. Compared with high income countries, the Punjabi population generally showed a markedly different distribution of genetic lineages and AMR determinants, while use of antibiotics elevated the prevalence of well-known globally circulating MDR clinical strains. These findings implicate that longitudinal multi-regional genomics-based surveillance of both colonisation and infections is a prerequisite for developing mechanistic understanding of the interplay between ecology and evolution in the maintenance and dissemination of (MDR) E. coli. E coli is an important cause of infection globally but there is limited understanding of the genetic diversity of strains circulating in South Asia. Here, the authors characterise strains in Punjab province, Pakistan by assembling >5,000 genomes sampled from outpatients and community dwellers. [ABSTRACT FROM AUTHOR]

Background: Diabetes control is poor globally and leads to burdensome microvascular and macrovascular complications. We aimed to assess post hoc between-group differences in sustained risk factor control and macrovascular and microvascular endpoints at 6.5 years in the Center for cArdiovascular Risk Reduction in South Asia (CARRS) randomized trial. Methods and findings: This parallel group individual randomized clinical trial was performed at 10 outpatient diabetes clinics in India and Pakistan from January 2011 through September 2019. A total of 1,146 patients with poorly controlled type 2 diabetes (HbA1c ≥8% and systolic BP ≥140 mm Hg and/or LDL-cholesterol ≥130 mg/dl) were randomized to a multicomponent quality improvement (QI) strategy (trained nonphysician care coordinator to facilitate care for patients and clinical decision support system for physicians) or usual care. At 2.5 years, compared to usual care, those receiving the QI strategy were significantly more likely to achieve multiple risk factor control. Six clinics continued, while 4 clinics discontinued implementing the QI strategy for an additional 4-year follow-up (overall median 6.5 years follow-up). In this post hoc analysis, using intention-to-treat, we examined between-group differences in multiple risk factor control (HbA1c <7% plus systolic BP <130 mm Hg and/or LDL-cholesterol <100 mg/dl) and first macrovascular endpoints (nonfatal myocardial infarction, nonfatal stroke, death, revascularization [angioplasty or coronary artery bypass graft]), which were coprimary outcomes. We also examined secondary outcomes, namely, single risk factor control, first microvascular endpoints (retinopathy, nephropathy, neuropathy), and composite first macrovascular plus microvascular events (which also included amputation and all-cause mortality) by treatment group and whether QI strategy implementation was continued over 6.5 years. At 6.5 years, assessment data were available for 854 participants (74.5%; n = 417 [intervention]; n = 437 [usual care]). In terms of sociodemographic and clinical characteristics, participants in the intervention and usual care groups were similar and participants at sites that continued were no different to participants at sites that discontinued intervention implementation. Patients in the intervention arm were more likely to exhibit sustained multiple risk factor control than usual care (relative risk: 1.79; 95% confidence interval [CI], 1.45, 2.20), p < 0.001. Cumulatively, there were 233 (40.5%) first microvascular and macrovascular events in intervention and 274 (48.0%) in usual care patients (absolute risk reduction: 7.5% [95% CI: −13.2, −1.7], p = 0.01; hazard ratio [HR] = 0.72 [95% CI: 0.61, 0.86]), p < 0.001. Patients in the intervention arm experienced lower incidence of first microvascular endpoints (HR = 0.68 [95% CI: 0.56, 0.83), p < 0.001, but there was no evidence of between-group differences in first macrovascular events. Beneficial effects on microvascular and composite vascular outcomes were observed in sites that continued, but not sites that discontinued the intervention. Conclusions: In urban South Asian clinics, a multicomponent QI strategy led to sustained multiple risk factor control and between-group differences in microvascular, but not macrovascular, endpoints. Between-group reductions in vascular outcomes at 6.5 years were observed only at sites that continued the QI intervention, suggesting that practice change needs to be maintained for better population health of people with diabetes. Trial registration: ClinicalTrials.govNCT01212328. Nikhil Tandon and colleagues explore the impact of a quality improvement strategy for patients with type 2 diabetes 6.5 years after its implementation for the CARRS randomised trial. Author summary: Why was this study done?: Data on whether improvements in diabetes care goal achievement can be sustained (>5 years) with quality improvement (QI) strategies are lacking from low- and middle-income countries (LMICs). Prior studies of QI strategies to improve care goal achievement among people with diabetes from high-income countries reported modest benefits in blood glucose, blood pressure, and lipids, but the effects of these improvements on reducing vascular complications and deaths related to diabetes are unknown. What did the researchers do and find?: In the Center for cArdiovascular Risk Reduction in South Asia (CARRS) randomised trial of 1,146 patients with type 2 diabetes attending 10 diverse diabetes clinics in India and Pakistan, the QI strategy was associated with benefits on diabetes care goals (HbA1c <7% plus systolic BP <130 mm Hg and/or LDL-cholesterol <100 mg/dl) at 2.5 years after randomization. Four clinics discontinued implementation, while 6 clinics continued to implement the QI strategy for an additional 4 years. This report assesses whether benefits were sustained and reduced vascular complications and deaths associated with diabetes at 6.5 years. Patients receiving the QI strategy, compared to those receiving usual care, experienced sustained benefits on diabetes care goals and less microvascular endpoints (eye, kidney, and nerve diseases) at 6.5 years after randomization. Total macrovascular and microvascular events were also lower in those receiving the QI strategy, and this was only observed at sites that continued implementation of the QI strategy for 6.5 years. What do these findings mean?: These findings add to our knowledge of the long-term effects of multicomponent QI strategies in sustaining multiple risk factor control and reducing combined vascular events compared to usual care in resource-limited settings. In view of these findings, clinical decision support and trained nonphysician health workers may be important QI strategies to consider integrating into India's healthcare system to improve diabetes care quality and reduce morbidity and mortality. One limitation of the study is that the tertiary care facilities included in the CARRS trial may not be generalizable across LMICs. [ABSTRACT FROM AUTHOR]

The advent of AI and the development of cyberspace have considerably reshaped the strategic landscape of various regions, particularly South Asia, where geo-political tensions and security concerns intersect with continuous technological advancements. This study focuses on the concept of digital strategic autonomy with a particular emphasis on the South Asian region by outlining the implications of AI and cyberspace on the security environment of the region and the pursuit of national interests. Firstly, this study explores the evolving nature of digital autonomy and how South Asian nations, especially India and Pakistan, are addressing the security concerns posed by cyberspace vulnerabilities. Employing the lens of Politics of Datafication Digital Autonomy, this study provides a nuanced understanding of the notions of contemporary sovereignty. Secondly, this research also explains the interconnection between military advancements and AI-driven technologies and the implications for the strategic stability of South Asia. Moreover, the impact of Digital Strategic Autonomy on E-commerce in India and Pakistan and the geopolitical dimensions of cyberspace related to India and Pakistan are also addressed. Finally, this study argues that digital strategic autonomy is a multi-dimensional concept involving technology, military, governance, and geopolitical dimensions by highlighting the significance of utilising technologies, AI, and Cyberspace to ensure cyber sovereignty while enhancing the security of states in digital domains. [ABSTRACT FROM AUTHOR]

The new era of counterforce in the contemporary world could unfold itself as a new era of preemption in South Asia. It is characterised by increasing vulnerabilities in nuclear arsenals and delivery systems, however, prompting a vigorous development of countermeasures to mitigate these strategic vulnerabilities. India is increasing its counterforce capabilities considerably. Apart from improving its capabilities of target acquisition, accuracy of its delivery systems and reducing their time to hit the target, India is likely to make necessary shifts in its nuclear doctrine. These factors will provide India with the incentives for preemption against Pakistan in the future. The possibility of a counterforce strike can create instability in the region. To mitigate the threat posed by India's advancing counterforce capabilities, Pakistan should enhance its ISR capabilities, develop ASAT capabilities, improve missile accuracy and speed, and bolster survivability. [ABSTRACT FROM AUTHOR]

• Distractions caused by fellow drivers (DFDs) have received little attention. • Associations between DFDs and other latent factors were evaluated using SEM. • DFDs are positively associated with stress among recipient drivers. • Stress is positively associated with anxiety-based performance deficits. • DFDs and stress are positively associated with crash propensity. Introduction: Aggressive behavior of drivers is a source of crashes and high injury severity. Aggressive drivers are part of the driving environment, however, excessive aggressive driving by fellow drivers may take the attention of the recipient drivers away from the road resulting in distracted driving. Such external distractions caused by the aggressive and discourteous behavior of other road users have received limited attention. These distractions caused by fellow drivers (DFDs) may agitate recipient drivers and ultimately increase crash propensity. Aggressive driving behaviors are quite common in South Asia and, thus, it is necessary to determine their contribution to distractions and crash propensity. Method: Our study aimed to evaluate the effects of DFDs using primary data collected through a survey conducted in Lahore, Pakistan. A total of 801 complete responses were obtained. Various hypotheses were defined to explore the associations between the latent factors such as DFDs, anxiety/stress (AS), anxiety-based performance deficits (APD), hostile behavior (HB), acceptability of vehicle-related distractions (AVRD), and crash propensity (CP). Structural Equation Modeling (SEM) was employed as a multivariate statistical technique to test these hypotheses. Results: The results supported the hypothesis that DFDs lead to AS among recipient drivers. DFDs and AS were further found to have positive associations with APDs. Whereas, there was a significant negative association between DFD, AS, and AVRD. As hypothesized, DFD and AS had positive associations with CP, indicating that distractions caused by aggressive behaviors leads to stress and consequently enhances crash propensity. Practical applications: The results of this study provide a statistically sound foundation for further exploration of the distractions caused by the aggressive behaviors of fellow drivers. Further, the results of this study can be utilized by the relevant authorities to alter aggressive driving behaviors and reduce DFDs. [ABSTRACT FROM AUTHOR]

STUDY QUESTION What is the burden of premenstrual syndrome (PMS) at the global, regional, and national levels across 21 regions and 204 countries and territories? SUMMARY ANSWER Over the past few decades, the global prevalent cases of PMS have grown significantly from 652.5 million in 1990 to 956.0 million in 2019, representing a 46.5% increase. WHAT IS KNOWN ALREADY PMS, which affects almost half of reproductive women worldwide, has substantial social, occupational, academic, and psychological effects on women's lives. However, no comprehensive and detailed epidemiological estimates of PMS by age and socio-demographic index (SDI) at global, regional, and national levels have been reported. STUDY DESIGN, SIZE, DURATION An age- and SDI-stratified systematic analysis of the prevalence and years lived with disability (YLD) of PMS by age and SDI across 21 regions and 204 countries and territories has been performed. PARTICIPANTS/MATERIALS, SETTING, METHODS The prevalence and YLD of PMS from 1990 to 2019 were retrieved directly from the Global Burden of Diseases (GBD) 2019 study. The number, rates per 100 000 persons, and average annual percentage changes (AAPCs) of prevalence and YLD were estimated at the global, regional, and national levels. MAIN RESULTS AND THE ROLE OF CHANCE Globally, the prevalent cases of PMS increased by 46.5% from 652.5 million in 1990 to 956.0 million in 2019; in contrast, however, the age-standardized prevalence rate was approximately stable at 24 431.15/100 000 persons in 1990 and 24 406.51/100 000 persons in 2019 (AAPC, 0[95% CI: −0.01 to 0.01]). Globally, the YLD was 8.0 million in 2019 and 5.4 million in 1990, with a sizable increase over the past 30 years. The age-standardized YLD rate was stable (AAPC 0.01, P  =   0.182), at 203.45/100 000 persons in 1990 and 203.76/100 000 persons in 2019. The age-standardized burden estimates were the highest in the low-middle SDI regions and the lowest in the high SDI regions. Peaks in burden rate estimates were all observed in the 40–44 years age group. Regional age-standardized burden estimates were the highest in South Asia and the lowest in Western Sub-Saharan Africa. The national age-standardized burden estimates were the highest in Pakistan and the lowest in Niger. LIMITATIONS, REASONS FOR CAUTION The accuracy of the results depended on the quality and quantity of the GBD 2019 data. Fortunately, the GBD study endeavoured to retrieve data globally and applied multiple models to optimize the completeness, accuracy, and reliability of the data. In addition, the GBD study took the country as its basic unit and neglected the influence of race. Further study is warranted to compare differences in PMS burden associated with race. Finally, no data are available on the aetiology and risk information related to PMS, which might help us to better understand the trends and age distribution of PMS and help local governments formulate more detailed policies and comprehensive interventions. WIDER IMPLICATIONS OF THE FINDINGS Although the age-standardized prevalence/YLD rate has been stable over the past 30 years, the absolute number of prevalent cases and YLD grew significantly worldwide from 1990 to 2019. Public health-related policies should be implemented to reduce the prevalence and alleviate the symptoms of PMS. Lifestyle changes and cognitive-behavioral therapy are critical in helping to reduce the burden of PMS. STUDY FUNDING/COMPETING INTEREST(S) This study was supported by the National Key Research and Development Program of China (grant number 2022YFC2704100) and the National Natural Science Foundation of China (No. 82001498, No. 82371648). The authors declare no conflict of interest. TRIAL REGISTRATION NUMBER N/A. [ABSTRACT FROM AUTHOR]

Ever since the Republic of India became an independent nation in 1947, the Indian state has strived to keep its territorial integrity, in spite of the numerous territorial claims made by neighboring states. Firstly, the Kashmir region is home to both Muslim and Hindu populations; therefore, when the Indian and Pakistani states were created, the region was split between the two new states. However, both states hold the belief that the entirety of the Kashmir region should be part of their territory,. This situation sparked numerous local conflicts and four local wars (1947, 1965, 1971, and 1999). Secondly, another disputed area is located on the border with the People's Republic of China, as the Chinese state does not recognize the McMahon Line, which was agreed upon by British India and Tibet. This led to the conflict in 1962 and to a tension-filled relationship between China and India. This paper approaches both the historical evolution of the conflicts and the way in which these two conflict areas are portrayed in literature. While Veera Hiranandani, in The Night Dia77 (2018), and Khushwant Singh, in Train to Pakistan (1956), focus on the conflicts between Muslims and Hindus after the partition of India and Pakistan, Salman Rushdie, in Midnight's Children (1981), analyzes the traumas of the conflict in Kashmir. Furthermore, Jon Cleary, in Pulse of Danger (1966), presents the context of the Sino-Indian war. The most disturbing novel about the Indian conflicts is Humphrey Hawksley's novel, Dragon Fire (2000), because the author presents an apocalyptic war between the Republic of India, on one side, and the Islamic Republic of Pakistan allied with the People's Republic of China, on die other side. [ABSTRACT FROM AUTHOR]

In recent years amid 2013-2024, Sino-Pak relations witnessed a qualitative transformation as bilateral ties expanded in strategic perspective. Pakistan has been forced to pursue a strategic collaboration with China in order to preserve the balance of power in South Asia as a result of the dynamic post 9/11 global political changes and expanding strategic partnership between the US and India. Under the auspices of the Indo-US strategic partnership, India is making most of its resources and collaborating with US in a number of areas, including energy, defense and security, so as to fulfill its ambitions of becoming a dominating force in the region and building blue water navy. India regional aspirations are too great for Pakistan to overcome on its own. In order to oppose India's imperial aspirations in South Asian area, the Sino-Pak formed a strategic alliance. This study will pose some queries about most recent iterations of this partnership. In this research, strategic partnership amid two countries is described using a Rational Actor Model. The research goes on to say that Sino-Pak will not be deterred from pursuing the project despite India's assertion that corridor route goes through disputed Northern Pakistani territory. [ABSTRACT FROM AUTHOR]

This study explores how information and communication technologies (ICTs) influence transforming attitudes toward intimate partner violence (IPV) and women's empowerment in Pakistan and Nepal. By analyzing data from married women using recent Demographic and Health Surveys, the research reveals that owning multiple ICTs is associated with decreased experiences of physical IPV and reduced acceptance of wife-beating. Notably, increased ownership of ICTs corresponds to heightened participation in household decisions. Furthermore, regular internet use further diminishes the likelihood of experiencing physical IPV and justifying wife-beating. These findings underscore ICTs' potential to empower women, reshape gender norms, and enhance decision-making autonomy. The study advocates for gender-inclusive policy interventions that leverage the transformative influence of ICTs in fostering positive sociocultural changes. [ABSTRACT FROM AUTHOR]

For the last four decades, Pakistan's northwestern Pashtun tribal areas have been in a constant state of imperialist wars. In reaction to this organized violence, a local civil rights movement, the PTM, emerged in 2014 which powerfully challenged the military's discursive regime that legitimates these US-led wars. However, the military challenged the movement's call for justice by launching a concerted discursive drive to construct an enemy image of the PTM. This study aims to discover how the military constructs the identity, as well as the cultural and political meanings of the movement. The authors found that the military strategically organizes its discourse to first build a symbolic order in which an enemy other, less than human, is created, and then its oppression is normalized and made invisible. They hope that the article contributes to the current critical scholarship on the increasing militarization of contemporary public spaces and democratic cultures, particularly in the context of South Asia. [ABSTRACT FROM AUTHOR]

Background: Despite growing evidence of the impacts of exclusively breastfeeding infants during the first 6 months of life on preventing childhood infections and ensuring optimal health, only a small number of studies have quantified this association in South Asia. Methods: We analyzed data from the Demographic and Health Surveys in Afghanistan (2015; n = 3462), Bangladesh (2017–2018; n = 1084), India (2019–2021; n = 26,101), Nepal (2022; n = 581), and Pakistan (2017–2018; n = 1,306), including babies aged 0–6 months. Multivariate logistic regression models were used to determine the association between exclusive breastfeeding in the last 24 h and diarrhoea, acute respiratory infections, and fever in the two weeks before the survey. We also examined the association between other infant and young feeding indicators and these outcomes. Results: Infants who were exclusive breastfed had decreased odds of diarrhoea in Afghanistan (AOR: 0.49, 95% CI 0.35, 0.70), India (AOR: 0.80, 95% CI 0.70, 0.91), and Nepal (AOR: 0.42, 95% CI 0.20, 0.89). Compared with infants who were not exclusive breastfed, infants who were exclusively breastfed were less likely to have fever in Afghanistan (AOR: 0.36, 95% CI 0.26, 0.50) and India (AOR: 0.75, 95% CI 0.67, 0.84). Exclusive breastfeeding was associated with lower odds of acute respiratory infections in Afghanistan (AOR: 0.57, 95% CI 0.39, 0.83). Early initiation of breastfeeding was protective against diarrhoea in India. Bottle feeding was a risk factor for diarrhoea in India and for fever in Afghanistan and India. Bottle feeding was also a risk factor for acute respiratory infection in Afghanistan and India. Conclusions: Not exclusive breastfeeding is a risk factor for diarrhoea, acute respiratory infections, and fever in some South Asian countries. These findings could have substantial implications for global and national efforts to increase exclusive breastfeeding rates. More support, advocacy, and action are required to boost breastfeeding rates as a crucial public health measure. [ABSTRACT FROM AUTHOR]

Background: Pakistan reports a significant burden of neonatal mortality, with infections as one of the major causes. We aim to assess the long-term impact of early infancy infections on neurodevelopmental outcomes during later childhood. Methods: We conducted a prospective follow-up study of the cohort enrolled at the Karachi site of the Aetiology of Neonatal Infection in South Asia (ANISA) during 2019–2020. Children with a possible serious bacterial infection (based on the WHO IMCI algorithm) at early infancy were assessed for neurodevelopment at 6–9 years of age and compared with healthy controls. The Ten Questions (TQS) questionnaire, Strengths and Difficulties Questionnaire (SDQ), and Parent's Evaluation of Developmental Stage Assessment Level (PEDS: DM-AL) neurodevelopmental assessment tools, were administered and scored by the research staff who were blinded to the child's exposure status. Generalized Structural Equation Modelling (GSEM) was employed to verify relationships and associations among developmental milestones, anthropometry, and sociodemographic variables. Results: A total of 398 children (241 cases and 157 controls) completed neurodevelopmental and growth assessments. Cases had a significantly higher rate of abnormal TQS scores (54.5% vs. 35.0%, p-value 0.001), greater delays in motor milestones (21.2% vs. 12.1%, p-value 0.02), lower fine motor skills (78.4 ± 1.4 vs. 83.2 ± 1.5, p-value 0.02). The receptive language skills were well-developed in both groups. According to the logistic regression model, exposure to infection during the first 59 days of life was associated with delayed TQS milestones (β = -0.6, 95% CI -1.2,-0.04), TQS hearing domain (β = -0.3, 95% CI: -1.2 to 0.7), PEDS: DM-AL fine motor domain (β = -1.3, 95% CI: -4.4 to 1.7), PEDS: DM-AL receptive language development (β = -1.1, 95% CI: -3.7 to 1.4) and child anthropometric measurements such as weight and height (β = -0.2, 95% CI: -0.4 to 0.01 and β = -0.2, 95% CI: -0.4 to -0.01, respectively). Early pSBI exposure was positively associated with PEDS: DM-AL self-help domain (β = 0.6, 95% CI: -1.2 to 2.4) and SDQ-P overall score (β = 0.02, 95% CI: -0.3 to 0.3). Conclusion: Children exposed to PSBI during early infancy have higher rates of abnormal development, motor delays, and lower fine motor skills during later childhood in Pakistan. Socioeconomic challenges and limited healthcare access contribute to these challenges, highlighting the need for long-term follow-ups with integrated neurodevelopment assessments. [ABSTRACT FROM AUTHOR]

Improvement in burn injury data collections and the quality of databanks has allowed meaningful study of the epidemiologic trends in burn care. The study assessed factors associated with disposition of burn injury patients from emergency department accounting for pre-hospital care and emergency care. This prospective observational pilot study of the South Asia Burn Registry project was conducted at selected public sector burn centers in Bangladesh and Pakistan (September 2014 – January 2015). All age groups with an initial presentation to the burn centers were enrolled. Descriptive and regression analysis is presented. A total of 2749 patients were enrolled. The mean age was 21.7 ± 18.0 years, 55.3% were males, and about a quarter were children < 5 years. About 46.9% of the females were housewives. Scald burns were common among children (67.6%) while flame burns were common among adults (44.3%). About 75% of patients were brought in via non-ambulance mode of transport. More than 55% of patients were referrals from other facilities or clinics. The most common first aid given pre-hospital was the use of water or oil. About 25% were admitted for further care. The adjusted odds of being admitted compared to being sent home were highest for children < 5 yrs, those with higher total body surface area burnt, having arrived via ambulance, scald and electrical burn, having an associated injury and inhalational injury. The study provides insight into emergency burn care and associated factors that influenced outcomes for patients with burn injuries. • Clinical outcomes for burns depend on prehospital and emergency care received • Common first aid at home included use of water or oil • Common treatment received at facilities prior to coming to burn centers included use of cream, wound dressing [ABSTRACT FROM AUTHOR]

In Pakistan, type 2 diabetes is widespread, and although dietary recommendations from healthcare professionals are critical to its treatment, cultural norms can have a great influence on the dietary habits of people living with diabetes (PLwD). Understanding the social aspects of the lives of PLwD is crucial when examining the effectiveness of nutritional recommendations and adjustments. This study investigated (1) how PLwD and their family members adjust their nutrition to the recommendations of healthcare professionals to manage type 2 diabetes mellitus (T2DM) and (2) what do PLwD and their family members perceive as enablers and barriers to the necessary nutritional adjustments for managing T2DM. Prime consideration was given to experiences of living in Pakistan as the cultural context. Semi-structured interviews were conducted with 30 PLwD and 17 family members; the data were analysed thematically. Three themes emerged: (i) 'Influence of family system, gender, and age on meals prepared at home': family hierarchy and opinions based on gender and age can enable or hinder nutritional adjustment in meals prepared at home; (ii) 'Temptations of "unhealthy" foods, festivals, cultural interactions, and social etiquette': family/social interactions at home, gatherings, or festivities can affect PLwD's ability to resist temptations to eat foods prohibited by healthcare professionals; and (iii) 'Folk knowledge, folk remedy, and the balance between culture and Western medicine': PLwD and their family members in Pakistan hold strong beliefs concerning foods' medicinal properties. Power dynamics within families need to be considered when making nutritional recommendations. Medical guidelines should acknowledge personal agency and cultural beliefs. [ABSTRACT FROM AUTHOR]

The Barelvi movement in South Asia—particularly in Pakistan—has long been regarded as the indigenous Islam of the region. It is equated with Sufism, and highlighted as the peaceful and moderate Islam of the majority of Muslims. In doing so, it is contrasted with competing Sunni traditions such as the Deobandis, as an explicit binary is created between the two. However, the narrative has seen a shift since 2011, with the rise of Mumtaz Qadri, who murdered a politician due to allegations of blasphemy. In this article, I trace these developments in the perceptions of, and discourses about, Barelvis in South Asia, especially over the last twenty years. In doing so I explore four key ways of being Barelvi, including love for the Prophet Muhammad, an affiliation with the founder of the movement, Sufi practices and shrines, and opposition to Deobandi Islam. [ABSTRACT FROM AUTHOR]

The Pakistan Museum of Natural History (PMNH) holds a large number and historically valuable specimens of insects that were collected from various parts of the country before and after the independence of the Indo-Pak subcontinent (1917-2024). In this study, we examined 605 specimens of dung beetles of subfamily Scarabaeinae Latreille, 1802, and identified 26 species belonging to 12 genera and seven tribes. The tribes consist of Coprini Kolbe, 1805 (nine species), Onthophagini Lacordaire, 1856 (six species), Onitini Laporte, 1840 (six species), Gymnopleurini Lacordaire, 1856 (two species), Oniticellini d´Orbigny, 1916 (one species), Scarabaeini Latreille, 1802 (one species), and Sisyphini Mulsant, 1842 (one species). This study adds one species to the scarabid fauna of Pakistan, Onthophagus (Palaeonthophagus) conspersus Reitter, 1893. [ABSTRACT FROM AUTHOR]

The dynamics of the 21st century and the regional situation in South Asia require a revisit to the theoretical framework defining Pakistan–China relations. The friendly relations between Pakistan and China can be explored under the concepts of bandwagoning as well as complex interdependence. A theoretical analysis reveals that neither of the two states is bandwagoning the other. They are, however, tied to each other under the conceptual framework of complex interdependence. [ABSTRACT FROM AUTHOR]

This research investigates strategic stability in South Asia's deterrence landscape post- 1998 nuclear tests by India and Pakistan. Examining nuclear capabilities, it highlights the region's evolving dynamics. Focusing on strategic stability's significance, the study probes India's escalation tendencies and Pakistan's deterrence reliance, fueling discourse on preemptive strategies and first-use doctrines. Using qualitative methodology, it seeks to understand 'strategic stability' and pinpoint factors fostering regional instability. Aligned with neorealism, the research argues that nuclear weapons' dire consequences stabilize the international system. Thus, it offers insights into strategic decision-making, and suggests strategies to bolster stability and avert conflict escalation in South Asia's deterrence framework. As a result, it provides insights into the likelihood of escalation and the challenges posed by differing threat perceptions and capabilities. This study recommends vital insights into South Asia's nuclear dynamics, advocating for measures to enhance stability and mitigate conflict risks. [ABSTRACT FROM AUTHOR]

The climate crisis disproportionately impacts women and girls all over the world. To understand what the priorities in terms of policy are, an examination is conducted on the impacts taking place in South Asia (focusing on the countries of Bangladesh, India, and Pakistan), an area of the globe that is highly vulnerable to climate change and is characterized by having strong patriarchal values. Gender stereotypes and roles in the region heighten women and girls’ vulnerability to climate impacts, both in general and in situations of crisis resulting from extreme weather events. Deepening the understanding of the climate crisis’ impact on gender in South Asia, a region at the frontline of these eects, can assist in reaching a baseline understanding of the challenge from a global perspective. Methodologically, we reviewed an extensive body of literature, both specialty books and scientific articles, recent institutional reports as well as news or journalistic reports from reliable international press. In this research, the argument is made that today, climate action and urban development cannot be considered separately from women’s rights. Extensive scientific data and research support the integration of a gender perspective in urban adaptation standard practices, and priorities in terms of policy to safeguard women and girls are identified accordingly. The allocation of half of climate funds, including those of loss and damage, directly to women or women-led organizations is identified as being particularly relevant. Bold and ambitious policymaking is urgently needed to build capacity to face the multiple crises unfolding. [ABSTRACT FROM AUTHOR]

Addressing South Asia's poverty, this research presents an exhaustive case study of Pakistan, exploring poverty dynamics at national and provincial levels, emphasizing the urban–rural divide. The study uses the most recent income and expenditure surveys from 2013 and 2015 and applies the Cost of Basic Needs methodology based on strong theoretical and empirical grounds. The research adjusts for price variation within and among provinces. It uses traditional Foster-Greer-Thorbecke measures and innovative measures like the Watts and Sen indices. Findings reveal a poverty decline in Pakistan between 2013 and 2015, with significant provincial variations in this decline. Despite a minor decline in the headcount ratio of the larger provinces, their poverty shares increased in 2013–15, showing a regional convergence trend with growing disparities in poverty headcount and depth. Using indices like Watts and Sen gives a more complete, nuanced poverty understanding, highlighting the need for their adoption alongside traditional measures. The research ends with policy implications, emphasizing the importance of targeted poverty reduction strategies to address regional disparities effectively. This research offers insights into South Asia's poverty dynamics and contributes significantly to SDG 1—ending poverty. The Pakistan case study is a valuable reference for other countries, guiding accurate poverty measurement, effective policy-making, and efficient SDGs performance tracking. [ABSTRACT FROM AUTHOR]

Global warming, a worldwide issue, threatens the planet. The main reason for its increase is the surge in human activities such as the establishment of industrial facilities, as well as the establishment of livestock farms, which cause an increase in the emission of greenhouse gases that have the ability to trap the energy reflected from the earth's surface in the atmospheric layer. The main objective of this study was to predict enteric methane emissions in South Asian countries (Pakistan, Afghanistan, India, Bangladesh, Bhutan, Nepal, and Sri Lanka). Historical data for methane emissions from 1971 to 2019 available on Food and Agriculture Organization (FAO) database were collected, and nine autoregressive integrated moving averages and one Holt–Winters models were applied using R-Studio. Results showed that methane emissions from enteric fermentation by livestock in Pakistan and India will pose a significant risk on climate and global warming. Moreover, in the future, the enteric methane emission in Bangladesh, Afghanistan and Nepal is increasing annually. In contrast, the least amount of methane emissions from enteric fermentation in the future will be from Sri Lanka and Bhutan. This study concluded that enteric methane emission is increasing in South Asian countries annually and the majority of these emissions will be from Pakistan and India; thus, latest interventions should be applied to reduce methane emission from dairy industry. Moreover, region-specific policies should be devised and implemented to cope up this serious issue. [ABSTRACT FROM AUTHOR]

A key component in the classification of all injury types is to differentiate whether the injury was deliberately inflicted and by whom, commonly known as "intent" in the surveillance literature. These data guide patient care and inform surveillance strategies. South Asia is believed to have the greatest number of intentional burn injuries, but national surveillance data is not disaggregated by injury intent. Scientific literature can be used for injury surveillance where national data collection does not exist. In order to synthesise research findings, it is essential to assess the potential impact of misclassification bias. We therefore conducted a systematic scoping review to understand terminology and methods used to differentiate injury intent of hospital burn patients in South Asia. We followed the methods in our registered protocol (https://doi.org/10.17605/OSF.IO/DCYNQ). Studies met defined population, concept, context, and study design criteria. The databases Embase, MEDLINE, CINAHL, PsycInfo, and PakMediNet were searched. Two reviewers independently screened results. Data were extracted in a standardised manner and verified. The rigour of the method used to differentiate injury intent was appraised. 1435 articles were screened. Of these, 89 met our inclusion criteria. Most articles were from India and Pakistan, and used an observational study design. There were 14 stem terms used in the articles. The most common was "cause". There were 40 classifier terms. The most common were "accident", "suicide", and "homicide". Few articles defined these terms. The method used to differentiate injury intent was only described explicitly in 17% of articles and the rigour of the methods used were low. Where methods of differentiation were described, they appear to be based on patient or family report rather than multidisciplinary assessment. The heterogeneity in terms, lack of definitions, and limited investigation of injury intent means this variable is likely to be prone to misclassification bias. We strongly recommend that the global burn community unites to develop a common data element, including definitions and methods of assessment, for the concept of burn injury intent to enable more reliable data collection practices and interstudy comparisons. • 89 articles about hospital burn patients in South Asia met our inclusion criteria. • We extracted data on terminology, definition, and method of assessment of intent. • The most common classifier terms were accident, suicide, and homicide. • Definitions and methods of assessment were poorly described in many articles. • A common data element for intent may reduce misclassification in surveillance data. [ABSTRACT FROM AUTHOR]

The objective of this paper is to explore the interconnectedness of volatility among the stock markets of U.S., China, India, and Pakistan in conjunction with oil and gold markets. Employing the novel Time-Varying Parameter Vector Autoregression (TVP-VAR) model for assessing connectedness, the study scrutinizes key patterns of dependency and interrelation between these markets. Furthermore, this study investigates the dynamic connectedness during the global health crisis due to COVID-19 and the geopolitical crisis due to Russia–Ukraine war periods to identify the changes in their relationship following the two crises episodes. The findings underscore the significance of volatility transmissions emanating from the U.S., a developed market, in shaping these dynamic linkages. It is observed that oil and gold returns play a limited role as sources of shocks for market returns in China, India, and Pakistan, suggesting a relatively lower contribution of oil and gold to equity market volatility. The results also emphasize the safe-haven characteristics of gold during periods of crisis such as the COVID-19 pandemic and the Russia–Ukraine war. Moreover, the study indicates that the volatility transmissions during the COVID-19 pandemic are more pronounced compared to the Russia–Ukraine war crisis. These findings hold notable implications for both investors and policymakers, emphasizing the need for a nuanced understanding of market dynamics and the development of risk-averse strategies, particularly in times of crisis. [ABSTRACT FROM AUTHOR]

The present study found that ~80 million people in India, ~60 million people in Pakistan, ~70 million people in Bangladesh, and ~3 million people in Nepal are exposed to arsenic groundwater contamination above 10 µg/L, while Sri Lanka remains moderately affected. In the case of fluoride contamination, >120 million in India, .2 million in Pakistan, and ~0.5 million in Sri Lanka are exposed to the risk of fluoride above 1.5 mg/L, while Bangladesh and Nepal are mildly affected. The hazard quotient (HQ) for arsenic varied from 0 to 822 in India, 0 to 33 in Pakistan, 0 to 1,051 in Bangladesh, 0 to 582 in Nepal, and 0 to 89 in Sri Lanka. The cancer risk of arsenic varied from 0 to 1.64× 1-1 in India, 0 to 1.07 × 10-1 in Pakistan, 0 to 2.10 × 10-1 in Bangladesh, 0 to 1.16 × 10-1 in Nepal, and 0 to 1.78 × 10-2 in Sri Lanka. In the case of fluoride, the HQ ranged from 0 to 21 in India, 0 to 33 in Pakistan, 0 to 18 in Bangladesh, 0 to 10 in Nepal, and 0 to 10 in Sri Lanka. Arsenic and fluoride have adverse effects on animals, resulting in chemical poisoning and skeletal fluorosis. Adsorption and membrane filtration have demonstrated outstanding treatment outcomes. [ABSTRACT FROM AUTHOR]

The problem of home was, in a sense, the founding problem of Pakistan: first, in the call for a new 'homeland' for South Asia's Muslims, but also because its creation provoked displacement and a condition of homelessness. The population transfers and refugee camps that accompanied the 1947 partition of India were succeeded by housing crises prompted by industrialisation and urbanization. Debates over the responsibility of government authorities to address housing inequalities animated politics in Pakistan's early decades, intersecting with global discourses around postcolonial development. This article approaches this history through one low-income housing scheme in Lahore. Designed in the 1970s by Yasmeen Lari, Anguri Bagh was constructed to provide improved accommodation to residents of an informal settlement. But it also sought to facilitate a sense of community and belonging by enlisting residents in the design process and channelling forms and rhythms familiar from local history. Anguri Bagh's successes and failures provide critical insights into the relationship between design and equality in this historical moment, shaped by a faltering faith in modernism and the recuperative gestures of postcolonial culture. The article approaches the architect as an overlooked figure in intellectual history and architecture as a vital space for thinking about inequality. [ABSTRACT FROM AUTHOR]

The city of Lahore, Pakistan inherited a colonial land bureaucracy in which land is owned according 'rights in land' rather than 'rights to land'. Unlike the absolute ownership provided by state-backed titles, rights in land is merely a presumption of ownership until proven otherwise, creating a permanent gap between ownership and property. These gaps are investigated by patwaris, or lower-level bureaucrats who confirm rights in land before property is sold. Against the backdrop of Pakistan's booming real estate market, however, land has become Lahore's most profitable financial asset, and the gap between ownership and property is increasingly exploited to wrangle control over land from others. In this context, 'fraud' has become a constant point of concern for both patwaris and residents, each of whom use fraud at various times to negotiate Lahore's colonial-era bureaucracy with the present-day demands of living in the city. In this article, I argue that fraud mediates property relations in Lahore. In the city, all property is potentially fraudulent, and all fraud can potentially become property. Rather than a fixed relationship between ownership and property, Lahore's land bureaucracy is characterized by continuously unfolding property relations as new loops of fraud are opened and old ones close. [ABSTRACT FROM AUTHOR]

Scholars of disaster politics debate how far natural hazards cause or catalyse political change. This paper builds on recent scholarship on tipping points and social contracts to argue that two case studies of historical earthquakes in 1930s British‐colonised India invite a focus on the dynamics of cooperation and conflict between state and non‐state actors. Officials of the colonial state and its nationalist rivals cooperated after one earthquake even though they otherwise bitterly opposed each other. Cooperation broke down after the second event, just one year later. Yet, in both cases, officials and nationalist leaders shared a broad vision for Indian society, which pushed both sides actively to seek to recover the social and economic status quo ante, preventing potential tipping points from crystallising. These case studies reveal how and why highly fraught social contracts can survive major disasters. The colonial state's transient and reactive approach to disaster governance continued to impact on post‐independence India. [ABSTRACT FROM AUTHOR]

Substantial change in climate over the years in South Asia is directly affecting the diet and health of the population. It is important to analyze the aftermath of this change and its impact on the thyroid status. In recent years, a complex interplay of the changing climate with the environmental, geographical and dietary factors has contributed to the continued prevalence of hypothyroidism in Pakistani women. To study the influence of various factors which might be aggravating hypothyroidism in the female population of Pakistan, a thorough search of literature was conducted of various databases including Google Scholar and PubMed. Google as a search engine was also explored. This included both interventional and observational studies, published in English, from the year 1950 onwards uptil June 2023. It also included WHO website and local news clips about the awareness campaigns on iodine deficiency over the past years. All studies conducted on females to diagnose hypothyroidism, with both positive and negative outcomes were included in this study. The factors contributing to hypothyroidism among the female population in Pakistan encompass the effects of climate change, both direct and indirect, topographical factor, indiscriminate use of hazardous pesticides, presence of chemical contaminants in food and water, and a lack of awareness among the public and healthcare professionals about the condition’s symptoms and management. [ABSTRACT FROM AUTHOR]

In developing countries, in-person surveys are frequently conducted in the presence of respondents' family, friends, or neighbors. What effect, if any, does their presence have on survey responses? We use data from an original survey in Karachi, Pakistan, to examine how such presence affects responses to questions related to ethnic identity and ethnic politics. We find that respondents are systematically more likely to express greater support for ethnic politics and greater feelings of perceived ethnic discrimination in the presence of known others. We present suggestive evidence that this finding is explained by social desirability bias due to a norm of in-group solidarity. Our findings have important implications for the study of ethnic politics and for survey researchers working in contexts where respondent privacy is rarely guaranteed. [ABSTRACT FROM AUTHOR]

This study delves into the intricate history and pivotal junctures of the Pakistan-India water dispute, examining its environmental dimensions through the lenses of environmental security and the Theory of Environmentalism in International Relations (TEIR). Amid the shared vulnerability of Pakistan and India to climate change threats impacting their shared river waters, collaborative efforts become imperative. Projections indicate climate-related losses could cost South Asia $518 billion by 2050, a substantial portion of the region's GDP. This underscores the urgency for swift cooperation to foster sustainable water management in response to climate change. A descriptive and analytical research methodology has been used in which diplomatic discussions evaluates successes, failures, and ongoing peace-building efforts. The interplay of environmental security is emphasized in fostering sustainable transboundary water management for a resilient South Asia. Conclusively, proactive measures, innovative diplomacy, and sustainable water management are advocated for building a more resilient and interconnected South Asia. [ABSTRACT FROM AUTHOR]

The Karachi Stock Exchange (KSE) is the largest stock exchange in Pakistan and one of the largest in South Asia. The KSE operates as an automated trading platform and offers a range of products, including shares of companies listed on the exchange, bonds, and other securities. The stock market in Karachi is an important indicator of the health of the Pakistani economy and is often used as a barometer of investor sentiment. The performance of the KSE can be influenced by a number of factors, including economic growth, inflation, interest rates, and political stability. Overall, the KSE has been performing well in recent years, with the benchmark KSE 100 Index reaching record highs and attracting increasing amounts of foreign investment. [ABSTRACT FROM AUTHOR]

This review systematically traces the context and evolution of climate-smart irrigation (CSI) in four South Asian countries—Bangladesh, India, Nepal, and Pakistan. CSI technologies and practices strive to address two main objectives: (1) sustainably enhance agricultural/water productivity and rural farm incomes to build community and farm-level resilience to climate change and (2) enable adaptation/mitigation to climate change across different scales through irrigation technologies and water resources management. These innovations also pose various social and environmental challenges. This review extracts findings from existing literature related to potential societal and environmental benefits and risks associated with CSI and outlines opportunities for responsible innovation to elaborate robust and democratic roles of CSI technology and engender equitable technological change. We identify three drivers (climate variability and GHG mitigation, cost savings and support structure, and water conservation and management) and five barriers (financial support, high initial cost, inadequate practice-based research, lack of knowledge and/or access, and structures of power). [ABSTRACT FROM AUTHOR]

This paper examines how the shared cultural and spiritual heritage of Guru Nanak is intertwined with the political tensions and violence that have defined the complex relationship between India and Pakistan. We argue that that Nanak is the only thinker/spiritual leader who is equally respected both in India and Pakistan. This strong and rare commonality between India and Pakistan could be the agreed basis, despite all other differences, for conversation and dialogue between the two countries. We suggest that such dialogue can remove mistrust and foster peaceful and mutually beneficial relations. [ABSTRACT FROM AUTHOR]

INTRODUCTION People with severe mental illness (SMI) tend to die early due to cardiovascular and respiratory diseases, which may be linked to tobacco use. There is limited information on tobacco use in people with SMI in low- and middle-income countries where most tobacco users reside. We present novel data on tobacco use in people with SMI and their access to tobacco cessation advice in South Asia. METHODS We conducted a multi-country survey of adults with SMI attending mental health facilities in Bangladesh, India, and Pakistan. Using data collected with a standardized WHO STEPS survey tool, we estimated the prevalence and distribution of tobacco use and assessed receipt of tobacco cessation advice. RESULTS We recruited 3874 participants with SMI; 46.8% and 15.0% of men and women consumed tobacco, respectively. Smoking prevalence in men varied by country (Bangladesh 42.8%, India 20.1% and Pakistan 31.7%); <4% of women reported smoking in each country. Smokeless tobacco use in men also varied by country (Bangladesh 16.2%, India 18.2% and Pakistan 40.8%); for women, it was higher in Bangladesh (19.1%), but similar in India (9.9%) and Pakistan (9.1%). Just over a third of tobacco users (38.4%) had received advice to quit tobacco. Among smokers, 29.1% (n=244) made at least one quit attempt in the past year. There was strong evidence for the association between tobacco use and the severity of depression (OR=1.29; 95% CI: 1.12-1.48) and anxiety (OR=1.29; 95% CI: 1.12-1.49). CONCLUSIONS As observed in high-income countries, we found higher tobacco use in people with SMI, particularly in men compared with rates reported for the general population in South Asia. Tobacco cessation support within mental health services offers an opportunity to close the gap in life expectancy between SMI and the general population. [ABSTRACT FROM AUTHOR]

The great difficulty in reconstructing the origin and development of Buddhism in the Hazara region is due to the absence of Buddhist literature and limited archaeological explorations. Many scholars believe that Ashoka was responsible for the spread of Buddhist activities both in and outside the Indian subcontinent. There is no doubt that Buddhism was not spread to the north-western part of the sub-continent including the Hazara, during the lifetime of Buddha. The Hazara also did not escape the notice of the Mauryan emperor Asoka (3rd century BCE) who not only installed his proclamations, the Mansehra Rock Edicts but also built 200ft high stupa at Machikot Abbottabad that is still intact. The present research aimed to provide a comprehensive overview of the Buddhist monastic society that emerged in the Hazara, the northernmost region of Pakistan from the 3[rd] century BC to the 5[th] century CE based on archaeological and textual evidence. Archaeological evidence such as inscriptions, stupas, and monastic remains from this period provided insights into the early establishment of Buddhist monastic society. [ABSTRACT FROM AUTHOR]