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Background: Family Medicine is growing rapidly across the Eastern Mediterranean Region. However, it needs support in terms of overall health system development. This will require strong leadership in family medicine to implement the change required to improve current conditions. Objective: To collect data that will support the development of a leadership program for the future family physicians in the region. Methods: A cross-sectional study was conducted from July 2016 to September 2016 in eight countries of the Eastern Mediterranean Region, (Bahrain, Egypt, Iraq, Jordan, Kuwait, Qatar, Pakistan, and Saudi Arabia). These countries were selected to obtain perceptions of Family Physicians (FPs) regarding the current leadership model and to explore the need for a new future innovative model in Family Medicine (FM) across the region. Results: The information of 68 family physicians was included in the final analysis. The majority of the FPs was females as compared to males (71% vs. 29%). Forty-four percent of the FPs had 10 to 19 years of experience. Almost all of the FPs (96%) had completed some training in family medicine after graduation. About three fifths of the FPs had completed postgraduate qualifications and out of those, 64% had passed Board or Membership Examinations. Twenty-one percent of them are currently in a leadership role and 45% who were not in any leadership role responded that the current situation of FM in their country is poor. All of the leaders believed that it is important to develop strong leadership in FM to take the specialty forward. Almost similar proportions (67% and 64%) of leaders and non-leaders thought that establishing regional associations would enhance the FM practice model. Approximately two thirds of leaders (67%) responded that the current role of decision makers in the Ministry of Health (MOH) regarding capacity building in FM is not effective. The majority of the FPs (54% and 38%) considers that the existing postgraduate curriculum does not address leadership skill development in FM. Eighty-eight percent of the FPs both from leadership and non-leadership groups agreed that academic institutions and practicing FPs can play an effective leadership role in taking FM forward. Conclusion: The Family Medicine specialty will have to develop leadership capabilities in line with today’s fast-moving changes in healthcare for it to obtain the due recognition in the healthcare delivery system.

Background: Consultations in primary health care are considered ideal for opportunistic health promotion. A need exists to study opportunistic health promotion practiced in our setting. Objectives: To study opportunistic health promotion among family practice patients visiting a teaching hospital for treatment. Methods: A Questionnaire-based cross-sectional survey was conducted at the Family Practice Center, Aga Khan University Hospital, Karachi, Pakistan, in July and August, 2005. It included demographic profile of the patients and questions based on study objective. Written informed consent was taken and confidentiality was ensured. SPSS computer software was used for data management. Results: 274 patients were interviewed. The mean age of the respondents was 37 years, a majority being married housewives, with above grade X education, and in private service, student or self-employed. Reasons for visit during which opportunistic care was explored were regular check-up, chest pain, palpitations, and heart...

Objectives: To study patient attendant’s views regarding their role in doctor-patient consultation. Methods: A Questionnaire-based survey was conducted at the Family Practice Center, Aga Khan University Hospital, Karachi, Pakistan, in June 2004. The Questionnaire included a demographic profile of patient’s attendant and questions in line with the study objective. It was administered by study investigators to 100 individuals, visiting Family Practice clinics. Ethical requirements including the administration of written informed consent and the provision of confidentiality were ensured. SPSS computer software was used for data management. Results: The mean age of the study population was 36.91 years, with a majority comprising well-educated housewives. Well over 90% of the attendants expect the physician and the patient to allow them to sit during consultation, while 95 (95%) expect the physician to ask questions from them about the patient’s medical problem. Eighty-nine (89%) attendants feel that their pre...

Background Diarrhoea and pneumonia contribute 30% of deaths in children under 5 in Pakistan. Pakistan’s Lady Health Workers Programme (LHW-P) covers about 60% of the population but has had little impact in reducing morbidity and mortality related to these major childhood killers. An external evaluation of the LHW-P suggests that lack of supportive supervision of LHWs by lady health supervisors (LHSs) is a key determinant of this problem. Project NIGRAAN aims to improve knowledge and skills of LHWs and community caregivers through supervisory strategies employed by LHSs. Ultimately, community case management (CCM) of childhood pneumonia and diarrhoea will improve. Methods/Design NIGRAAN is a cluster-randomised trial in District Badin, Pakistan. There are approximately 1100 LHWs supervised by 36 LHSs in Badin. For this study, each LHS serves as a cluster. All LHSs working permanently in Badin who regularly conduct and report field visits are eligible. Thirty-four LHSs have been allocated to either intervention or control arms in a ratio of 1:1 through computer-generated simple randomisation technique. Five LHWs from each LHSs are also randomly picked. All 34 LHSs and 170 LHWs will be actively monitored. The intervention consists of training to build LHS knowledge and skills, clinical mentorship and written feedback to LHWs. Pre- and post-intervention assessments of LHSs, LHWs and community caregivers will be conducted via focus group discussions, in-depth interviews, knowledge assessment questionnaires, skill assessment scorecards and household surveys. Primary outcome is improvement in CCM practices of childhood diarrhoea and pneumonia and will be assessed at the cluster level. Discussion NIGRAAN takes a novel approach to implementation research and explores whether training of LHSs in supervisory skills results in improving the CCM practices of childhood diarrhoea and pneumonia. No significant harm to participants is anticipated. The enablers and barriers towards improved CCM would provide recommendations to policymakers for scale up of this intervention nationally and regionally. Trial registration NIGRAAN is registered with the ‘Australian New Zealand Clinical Trials Registry’. Registration Number: ACTRN12613001261707

Aim: Consanguineous marriages are common in Pakistan despite their declining popularity in the developed world. In the present study, a questionnaire based survey was used to record the attitudes and perceptions of consanguineous marriages among the sample population. Methods: A questionnaire was developed to collect information on the acceptability of, and perceptions about, consanguineous marriages among patients presenting to family physicians, at the Family Practice Center of the Aga Khan University Hospital in Karachi, Pakistan. Demographic data was collected as part of the questionnaire. Each participating patient signed a consent form after assurance of confidentiality was provided. Results: A total of 393 patients were surveyed. The mean age of the study population was 29.4 years, 165 (42%) were men and 228 (58%) were women. The majority were married, well educated and were students, in private or government service or self employed. One hundred (25%) of the respondents were either married or were planning to marry their first cousin, and 57 (14%) their second cousin. The main reasons in favor of consanguineous marriages were quoted as: ‘arranged marriage’, ‘it is healthy to marry within the family’ and ‘it is traditional’. Some 271 (69%) of the respondents said ‘yes’ to their son or daughter marrying within the family. Constraints of religion, status, caste, family differences and the fear of incompatibility were among the reasons quoted as difficulties in finding a mate outside the family. Neurological diseases, diabetes mellitus and hypertension were quoted as diseases resulting from consanguineous marriages. Security of knowing the mate in the family, culture and religion, and having more information about the mate before marriage were quoted as reasons for the continued popularity of consanguineous marriages in Pakistan. Conclusions: The present study demonstrated a high degree of acceptability of consanguineous marriages among the study population and documented factors influencing such marriages. We recommend further studies, intervention strategies and debate on the issue. 2003 Blackwell Publishing Asia and Wonca

Background Out-of-pocket (OOP) payment on healthcare is dominant mode of financing in developing countries. In Pakistan it is 67% of total expenditure on healthcare. Analysis of determinants of OOP health expenditure is a key aspect of equity in healthcare financing. It helps to formulate an effective health policy. Evidence on OOP in Pakistan is sparse. This paper attempts to fill this research gap. Methods We estimated determinants of OOP payments on healthcare in Pakistan. We used data sets of Pakistan Household Integrated Economic Survey (HIES) and Pakistan Standard of Living Measurement (PSLM) Survey for the year 2004-05. We developed a multiple regression model for the determinants of OOP payments using methods of Ordinary Least Square (OLS). We mainly used social, economic, demographic and health variables in our analysis. Results Median household OOP healthcare in the year 2004-05 was Pakistani Rupees (PKR) 2500 (US$ 41.99) in 2004-05. Household non-food expenditure was the single highest significant predictor of household OOP health expenditure. Household features like literate head and spouse, at least one obstetric delivery in last three years, unsafe water, unhygienic toilet and household belonging to Khyber Pukhtonkhwa (KPK) province were significant positive predictors of OOP payments. Households with male head, bricks used in housing construction, household with at least one child and no elderly, and head of household in a white collar profession were negative predictors of OOP payments. Conclusion Our analysis confirms earlier findings that economic status and number of old aged members are significant positive predictors of OOP payments. This association can direct government to enhance allocations to healthcare and to include program focusing on non-communicable diseases. Our findings suggest further research to explore beneficiaries of government healthcare programs and determinants of high OOP payments by household residing in KPK province than other province. The interaction between white collar profession and their economic status in predicting OOP payments is also an area for further research.