Pakistan Health Solutions

Pakistan
Vol.01, issue 01, Jan-April 2016
EALTH
SOLUTIONS
Pakistan
EALTH
SOLUTIONS
EDITORIAL BOARD
ADVISORY BOARD
Dr. Syed Hasan Abid
Editor-in-Chief
Dr. Farah Ahmad
Associate Editor-in-Chief
Dr. Syed Hasan Danish
Technical Editor
Mr. Mushtaq Ahmad (USA)
Dr. Asif Mirza
Statistical Reviewer
Mr. Tayyab Raza Fraz
(Public Health Consultant)
Managing Secretary
Ms. Rabia Mahmood
Dr. Izhar M. Husain
Designing & Composing
Ms. Farah Waheed
(Director Center of Executive Education, IBA)
Printers
Sohail Printers
(Professor Ear Nose Throat)

Dr. Kamran Hameed
(Rheumatologist)
Dr. Minhaj A. Qidwai

(Director PGD Program in Healthcare, IBA)
Dr. Aewaz Rizvi
(PhD Scholar, Pharmacist)
Mr. Muzaffar Jaffrey
(Chief Operating Officer, Helix Pharmaceuticals (pvt). Limited
Dr. Gohar Alam
Editorial Board
Members
(Dermatologist)
Dr. Kausar Saldera
(JPMC)
Publisher
The impetus for launching a new medical Journal is the

recognition that a need of some appropriate and suitable
journal was felt for carrying health issues and health management related issues simultaneously. The published
health journals certainly comprise of valuable health and
clinical research findings but it is also imperative to take into
account health systems and people who make up health
systems- as service providers, decision-makers, patients
and members of affected communities.
Pakistan Journal of Health Solutions seeks to publish
Health related and Health management related articles
from researchers who are eager to share their knowledge
not only for betterment of the patients but also for strengthening the systems that cater to the provision of delivery of
services to the masses. We envision expanding the
evidence base by addressing issues as wide-ranging as
disease prevention and management, epidemiology,
health behavior, health service delivery, ethics, human
rights, and the role of laws, policies and guidelines in shaping health initiatives. For the first time Pharmacovigilence
Dr. Aiesha Ishaque

Dr. Mohsin Wahid
Dr. Tabinda Ashfaq
Dr. Shoaib Asghar
Dr. Raza Sayani
Dr. Wafa Hasan (England)
Dr. Syed Danish Hasan (USA)
Dr. Uzma Mehdi (USA)
Dr. Shahid Yaqub (USA)
Dr. Sabahat Mateen (New Zealand)
Dr. Harris Lari (Canada)
Dr. Muhammad Anwar Khan (KSA)
Dr. Syed Hasan Danish, People
Health Solutions Pvt. Ltd
as a separate entity will be highlighted in this Journal. We

will encourage researchers working in all areas to highlight
the policy implications of their findings as well as the practical implications for health service providers.
The journal aims to provide a forum for publishing high
quality research and original ideas, for an audience of
policy and public health researchers and practitioners. It
will publish original papers, reviews and short reports as
well as case studies on all aspects of the science, philosophy, and practice of clinical and public health.
Serving as a forum for the presentation of research
findings, scholarly exchange of ideas in the area of health
and related fields this Journal will be invaluable to those
working in health care provision and health management.
The journal is also designed to inform and engage senior
policymakers, private and public corporations, non-governmental organizations, and international bodies.
Pakistan
EALTH
SOLUTIONS
Editorial
Trained Doctor Managers: need of the hour
Farah Ahmad
01
Original Articles
Realities behind Closed Curtains: A Cross
Sectional Survey Among Women Hospitalized after
Induced Abortion
Zainab Dawood, Naeem Majeed,

Farah Ahmad, Hasan Dawood, Syed
Hasan Danish
05
Health Interaction and Consultation Outcome:

Patients experience at Tertiary Care Hospitals
of Karachi
Shumaila Nazish, Ch Shehzad, Syed

Hasan Danish, Minhaj Ahmad Qidwai,
Farah Ahmad
10
Facebook: A platform for masquerade
Darayas Gazder Percy, Syed Hasan

Danish, Farah Ahmad, Sara Javied,
Sheharyar Ahmed Jumani, S. Talha
Shah, Hafiz M. Asim Anis
15
Ibtisam Qazi, Asad Zulfiqar, Farah

Ahmad, Syed Hasan Danish
20
Aeysha Umar Siddiqui, Shazia Azhar,

Farah Ahmad, Minhaj Ahmad Qidwai,
Syed Hasan Danish
25
Mubarak Ali, Farah Ahmad,

Syed Hasan Danish,
Minhaj Ahmad Qidwai
30
Effect of insurance status on consumer

behavior towards purchasing prescribed
medicines: a cross sectional survey among
the general population of Karachi
Leadership competencies of managers
working in healthcare sector of Karachi
Comparison of Expanded program of immunization
coverage among children less than two years in
rural and urban population of Hasilpur, Pakistan.
Review Article
Human Population, Climate Change and Human Health
Farah Ahmad, Imran Samee Waraich,

Noor Hussain Gichki, Shoaib Malik,
Umair Ali, Muhammad Usama Zafar
Instruction to Authors
35
Editorial
Trained Doctor Managers: need of the hour

Farah Ahmad
Department of Community Health Sciences, Ziauddin University

In undergraduate years, students only focus is the
human body with its anatomy, physiology and pathology. The only language the students are aware of is
related to the different systems of the human body. In
those days it seems this is all what is required for
becoming a successful doctor and the meaning of
healthcare is nothing more than the care given to a
patient who is not healthy. In the new era, business is
the key term synonymous with any profession and
managing businesses successfully has now become
all the more necessary. Healthcare is no exception,
small scale hospitals have expanded to become complex healthcare organizations providing state of the art
services to patients and their families. This is now a full
blown industry with several stake holders, of which
doctors are front and center. This significant shift is not
obvious in the medical curriculum which still focuses on
the human body. As an outcome of undergraduate
teaching this insufficiency becomes apparent in
doctors who find themselves deficient in terms of managing healthcare organizations in terms of human
resource, quality, financial decision making and skills
required for providing leadership1.
Management is the foundation for the smooth operation of a healthcare organization2The world is focusing
on bringing doctors into managerial cadre and the
recent NHS reorganization proposes the same that
more managerial power to be entrusted upon
doctors3.Doctors, on the other hand, are not that enthusiastic to become part of management as consider this
a more of an administrative burden, which is not entirely true as administration is basically a subset of management.4
Formal training of doctors in management is the need
of the hour. Well quoted by M A Hunt in his letter to
editor BMJ The assumption that managing is something that doctors are "doing all day long, and by and
large do it very well" is a fallacy. 5This is also supported by Charles Handy. According to him, "managers
need to be well and appropriately educated before they
start managing."6 and he also says "common sense
and character will always be important, but they should
not be handicapped by an absence of training.6 Way
back during1977 in England, a Kings fund working
party had recommended that "the high and demanding
responsibilities of the National Health Services (NHS)
require explicit systems of training."7
Doctors as compared to non doctors in managerial
positions result in improved performance of the healthcare organization as well as enhanced patient
care.8Though a case study from Nigeria refutes this
claim as according to them some doctors in top management perform less honorably than their counterparts because of lack of formal training9. To provide
better educational opportunities for doctors certain
universities are adding leadership and management

courses in their medical curriculum. Ample research is
now being conducted on healthcare systems management however evidence for this notion is still awaited
as no empirical researches have been conducted that
can compare physician led organizations with the
others.
Recent decade has seen application of new managerial theories in healthcare organizations in the West.
These initiated debates based specifically to the role of
doctors as managers and the outcomes of the changing roles in healthcare organizations. Whether these
changes are beneficial for the organizations and
patient care is still very much contentious.10 A study
conducted in USA, compared the leadership potential
of doctors and managers in which the outcome was the
quality of services provided. This study clearly
confirmed that doctors are taking managerial jobs but
their true potential for leadership is far from clear11.
The European nations have evolved the complex
relationship of doctors and management and several
different models are being practiced in different countries. In Germany, medical profession has combined
with management and professionalism making it more
adaptable for the doctors to improvise and use managerial tools for their own advantage. 12 An Italian case
study pointed out that doctors create their own managerial procedures rather adopting or modifying existing managerial procedures or circumventing them.13
The local scenario is no less different, though there are
management schools who are training medical
students but since they themselves are not running
mainstream hospitals, the maximum they can do is to
train the students theoretically. One way to overcome
this is to make internships within healthcare industry
mandatory for the students. The onus is now on the
healthcare organizations to hire trained staff in order to
comply with the changes which are taking place globally.
To bridge the gap between doctors and managers, a
locally developed module on healthcare managing
tools needs to be incorporated in the undergraduate
medical curriculum which can be very valuable in
humanizing the managerial capabilities of doctors by
augmenting the leadership skills and in better understanding the strategic aims of the healthcare industry.
Last but not least practices based on empirical
research findings should be incorporated not only in
the curriculum but also conveyed through symposia
and conferences to the budding doctor managers and
physician leaders of healthcare organizations. Emphasis is on quality research in managing healthcare
organizations and health systems which encompass
both biomedical and management sciences.
01
J Pak Health Soln
References
1. Thomason S. Becoming a Physician Executive:
Where to Look Before Making the Leap. Fam
PractManag. 1999; 6(7):37-40.
2. Dixon M. Doctors as managers. World hospitals.
1992 Dec; 29(2):3-5.
3. Pollard M. Essex Rivers Healthcare Trust. The
Health Service Journal 2001: 111(5783):22-5
4. General Medical Council. GMC: Standards for
Managing Hospitals. [Online]Available from:
http://www.gmc-uk.org/standards/man
age.htm [Accessed 26 November 2016]
5. Hunt MA, Walton PK. Doctors becoming manag
ers. BMJ: British Medical Journal. 1989 Mar 11;
298(6674):670.
6. Handy C. Mlaking better managers. London:
National Economic Development Organization,
1987.
7. Kathryn ONeill (ed.) Patient-centered leadership
rediscovering our purpose. U.K. The Kings
Fund. Report number: 1126980, 2013.
8. Darzi A. A Time for revolutions The role of
physicians in health care reform, New England
Journal of Medicine 2009, 361:e8.
9.
10.
11.
12.
13.
Kajang DR. Organization and Management of

Health Services in Nigeria:1960-2004 (A Case
Study of the Federal Ministry of Health,
Abuja, Nigeria) PhD Dissertation. St Clements
University; British
West Indies.
2004.
Aasland O: The physician role in transition: is
hypocrates sick?.SocSci Med. 2001, 52:
171-73.
Goodall AH: Physician-leaders and hospital
performance: is there anassociation?.SocSci
Med. 2011, 43: 535-39.
Kuhlmann E: Modernising health care. Rein
venting professions, the state and the public.
2006, Bristol: Policy Press
Tousijn W: Integration of health and social
care: inter professional relations in multidisci
plinary teams in Italy. CurrSociol. 2012, 60:
522-37.
References
J Pak Health Soln
Original Article
Realities behind Closed Curtains: A Cross Sectional Survey
Among Women Hospitalized after Induced Abortion
Zainab Dawood1, Naeem Majeed2, Farah Ahmad3, Hasan Dawood4, Syed Hasan Danish5
Abstract
Objective:
To identify the reasons for induced abortions and the age group of women who seek such measures.
Method:
A cross sectional study was conducted on 63 females admitted for post abortion complications in three
major public hospitals of Lahore. The study was conducted from June 2015 to October 2015. Non-Probability Purposive sampling was done. Self administered questionnaire was used to collect data. Data was
analyzed using SPSS version 21 and associations were worked out using chi-square test. Descriptive
analysis was performed for numerical data. P value less than 0.05 was taken as significant. Permission
was sought from ethical review board of respective hospitals.
Results:
Majority of the women who had come for an abortion were using some family planning methods but only
24% of them were using modern contraceptive measures while the others were using traditional methods
(47%). Use of contraceptive was significantly associated with both the husbands income and the womans education; higher income group and higher educated women had higher rate of use of contraceptives (p=0.001 and p=0.006 respectively). Reason for abortion were given as unavailability of contraceptive measures (20.6%), failure of contraceptive (38%), lack of awareness about proper use of contraceptives (19%), husbands dislike to use contraceptive (20.6%) and other reasons (1.5%) including poverty
and too many kids. Methods used by service providers showed that all TBAS and 41% of midwifes used
chemicals or herbal products, while none of the LHVs or nurses did that (p=0.000).
Conclusion:
Failure, unavailability, husbands dislike of contraceptive and lack of contraceptive awareness were major
reasons quoted for inducing abortion. Most females getting abortions belonged to 30-40 years age group.
Keywords:
Abortion, pregnancy, contraceptives

How to cite this article: Dawood Z, Majeed N, Ahmad F, Dawood H, Danish SH. Realities behind Closed
Curtains: A Cross Sectional Survey Among Women Hospitalized after Induced Abortion. Pak J Health
Solns 2016; 1 [3-7]: The page numbers should not be in brackets. It should write as such Dawood Z,
Majeed N, Ahmad F, Dawood H, Danish

SH. Realities behind Closed
Dr. Farah Ahmad Community Health Sciences Department Ziauddin University,
Curtains: A Cross Sectional Survey
Email: farga24@gmail.com
Among Women Hospitalized after Induced
Abortion. Pak J Health
Solns 2016; 1 [1]:3-7. Kindly change the
page numbers in all the references
1
Corresponding Author:
Public Health Consultant, Lahore
Health Officer UNICEF, Lahore
Department of Community Health Sciences, Ziauddin University, Karachi
Area Manager, The Health Foundation, Lahore
4
5
J Pak Health Soln
Introduction
Unintended pregnancies (UPs) are a global challenge
with substantial negative consequences for women,
their families, and society.1 The termination of pregnancy or abortion in a woman when it takes place voluntarily is a matter of great concern for all.2 World Health
Organization (WHO) defined illegal or unsafe abortion
as a procedure for terminating unwanted pregnancy
either by persons lacking the necessary skills or in an
environment lacking the minimum medical standards
or both.3 Maternal morbidity and mortality due to complications of unsafe abortions constitute a major public
health concern in many countries.4 WHO estimates
that about 25% of all pregnancies worldwide end in an
induced abortion.5 It is projected that approximately 50
million unwanted pregnancies are terminated each
year and about 150,000 each day. Of these abortions,
20 million are being performed under dangerous conditions.6 The risk of death is 25 - 250 times greater for a
woman who undergoes an unsafe abortion in an under
developed country as compared to a woman in a
developed country. Deaths as a result of unsafe abortions in developing countries are estimated at 80,000
annually i-e 400 deaths per 100000 abortions.6
South Asia is home to 28% of the world's people and
accounts for about a third (30%) of the world's maternal
deaths. Thirteen percent of all maternal deaths in
South Asia are attributed to complications of unsafe

abortion and are almost entirely preventable.7It is
estimated that 890,000 induced abortions are
performed annually in Pakistan, with an annual abortion rate of 29 per 1000 women aged 15-49 years. Of
every 100 pregnancies, 14 ended in induced abortion.8
Nearly one in four births in Pakistan (24%) is
unplanned, according to the 20062007 National
Demographic and Health Survey.9 A study showed that
the most commonly reported reason women cite for
having an abortion is to postpone or stop childbearing.
The second most common reasonsocioeconomic
concernsincludes disruption of education or employment; lack of support from the father; desire to provide
schooling for existing children; and poverty, unemployment or inability to afford additional children.10 The
profile of a Pakistani woman opting or admitted for
complications of abortion is married, multiparous (average four children) and in their thirties as reported from
community and hospital based studies.11,12The most
common procedures for these abortions are pills and
manual vacuum aspiration(MVA) -- usually these take
place at non-governmental organizations (NGO)
clinics8 . Keeping in view the significance of issue this
study was conducted to identify factors which instigate
women to resort to induced abortion.
Methods
using a structured questionnaire which was translated
into Urdu and pre-tested. Verbal and written consent
was taken from the participants. Study participants
were assured of confidentiality.
The data was analyzed using the Statistical Package
for Social Sciences (SPSS) version 20. Data auditing
was done to detect anomalies in the entered data.
Frequencies and percentages were taken out for categorical variables and association between different
variables was assessed through chi-square. P value
less than 0.05 is taken as significant. Permission was
taken from the ethical review board of the hospital.
A cross sectional study was conducted on 63 females

admitted for post abortion complications in three major
public hospitals of Lahore. The study was conducted
from June 2015 to October 2015. Participants were
selected using the non-probability purposive sampling.
The actual sample size was 44 women which were
calculated using the standard formula for calculating
sample size on the basis of prevalence;
n=
z2, p (1-p)
e2
The prevalence was taken at 2.9% because of an

estimated annual abortion rate of 29 per 1,000 women
aged 15-49.8 The bond of error was taken at 50% with
95% confidence interval. The sample size was inflated
to 63 to exclude non-response. Data was collected
Results
A total of n= 63 females participated in the survey. Our
participants included majority females from 31-35
years age group comprising n=39(61.9%) females,
while those between 36-40 years included

n=18(28.6%) females and up to 30 years age group
included n=6(9.5%) females. Distribution of sample
Table 1: Educational Status of participants and the number of children

Educational
Status
n
women
(out of total
sample)
%
having 3 or less
children
%
having more than
3 children
None
18
66%
34%
Primary
23
64%
36%
Matric
71%
29%
Intermediate
10
83%
17%
Graduate
75%
25%
J Pak Health Soln
It was observed that females with low education had

greater tendency of having more children. Although
majority of the women who had come for an abortion said
they were using some family planning methods, only
15%
n=15(24%) of them were using modern contraceptive

measures while the others were using traditional methods
n=30(47.6%) with remaining participants using no
method of contraception.
9%
No method
Lactational Amenorrhea
Withdrawal
25%
Safe period
28%
Condoms
17%
Oral pills
6%
Figure1: Contraceptive usage among participants

Use of contraceptive was significantly associated with
both the husbands income and the womans education; with higher income group and higher educated
women were having higher rate of use of contraceptives (p=0.001 and p=0.006 respectively).
When asked about the reason for abortion, the
respondents gave different reasons like unavailability
of contraceptive measures n=13(20.6%), failure of
contraceptive n=24 (38%), lack of awareness about
proper use of contraceptives n=12(19%), husbands
dislike to use contraceptive n=13(20.6%) and other

reasons (too many kids)n=1 (1.5%).
Women were also asked about the service provider
contacted for abortion and the methods used by those
service providers (Table 2). It was observed that all the
Traditional Birth Attendants (TBA) and 41% of midwifes
used chemicals or herbal products, while none of the
Lady Health Workers (LHW) or nurses did that
(p=0.000, highly significant).
Table 2: Methods used by service provider for inducing abortions

Method Used
Service Provider
D&C
Uterotonic
Drugs
Chemicals
Plants/herbal
products
Others
0%
0%
44%
31%
25%
39%
61%
0%
0%
0%
Midwife
0%
59%
0%
41%
0%
Nurse
50%
50%
0%
0%
0%
Traditional Birth
Attendant (TBA)
Lady Health Visitor (LHV)
Interestingly n=62(98.4%) women who had more than five children confessed of having previous history of abortions. Also n=58(92%) of the women with more than five children did not know the proper use of contraceptive
method.
Discussion
This study shows that the compliance with contraceptive usage is associated directly with husbands
income. It is also positively associated with the educational background of the women. Most females coming
with complications post abortion fell between 30-35
years age group According to a study the mean age at
the time of the first induced abortion was 28.50 years.
In a study from JPMC, Karachi about 6.71% of women
aged 36 years or above, and about 45.68% with parity
of five and above resorted to induced abortions.13
This study observed that the most common reason
given by more than 50% of females for seeking
induced abortions were unavailability of contraceptive
measures and failure of contraceptive. Similar to our
study, studies in the past have showed that the two

most common reasons for seeking abortion were
unwanted pregnancy and contraceptive failure. Another study showed that the predominant reasons for
abortion were "too many children", contraceptive
failure, premarital affairs,medical reasons, and extramarital affairs.14 In our study most participants were
illiterate or attained education till primary level. Similarly findings from the key informants of a study revealed
that almost 60% were illiterate and 40% had illiterate
spouses. 83.3% were housewives, 10% of spouses
were unemployed, and almost 40% of spouses were
clerks. 12
5
J Pak Health Soln
traditional birth attendant (TBAs); 29% through a physician; and 17.6% used self-induction. Most abortifacients were oral preparations. Physicians used dilation
and curettage. TBAs used a variety of methods, including insertion of objects into the vagina.2
In Pakistan abortion is considered to be legal only
when it is carried out to save the life of the woman or to
provide necessary treatment to her. Such an abortion
is also categorized as being therapeutic, as opposed
to a criminal abortion which is not performed in good
faith (good faith meaning to save the life of the woman
or to provide necessary treatment to her).The 1994
ICPD Program of Action emphasizes that expanding
and improving family planning services can help
reduce unintended pregnancy and induced abortion2.
Women who wish to terminate their pregnancy should
have ready access to reliable information, compassionate counseling and, in parallel, services for the
prevention of unintended pregnancy and management
of complications as outlined in the Program of Action of
the International Conference on Population and Development and at the follow-up conference.20 We faced a
limited sample size for our study which barricades the
generalization of findings. However limited research
has been conducted on this issue. In future further
researches can be conducted specially at health facilities providing such measures.
This study showed that all the TBAS and 41% of

midwives used chemicals or herbal products, while
none of the LHVs or nurses did that. According to a
study only 22% of the abortion clinics met the World
Health Organization (WHO) standards required for
safe termination of pregnancy. At all these clinics, the
procedure used to terminate the pregnancy was dilatation and curettage (D&C). Only one clinic was using
manual vacuum aspiration (MVA).15 A study has also
shown that the patients seeking abortion are often
treated in an unprofessional manner, when there is a
conflict between the values of the patient and those of
health care providers.16 Many studies have documented the similar phenomenon.17,18 A study by World
Health Organization showed that some women rely on
unskilled providers for pregnancy termination, even
though medical services are available6. One study in
Bangladesh showed that only 58 of 143 women seeking abortion first turned to health facilities, while others
consulted two or three healthcare providers; in the end,
of four females referred to the district hospital with
serious complications one died due to consultation with
untrained practitioners including traditional birth attendants, homeopaths, herbalists, religious healers, village
doctors and relatives.19 Another study conducted in the
squatter settlements of Karachi showed that the
frequency of abortion among the 283 pregnancies was
11.7%. Forty nine percent had their abortion through
Conclusion
Most females hospitalized for post induced abortion complications belonged to 30-40 years of age group. Failure
of contraceptive, dislike of contraceptive by husband, lack of awareness and unavailability were stated as the
major reasons for not using contraceptives.
Disclaimer: None
Conflict of Interest: None
Source of Funding: None
References
1
3
4
5
Klima CS. Unintended pregnancy: consequences

and solutions for a worldwide problem.
Journal of Nurse-Midwifery. 1998
Nov12;43(6):483-91.
Rehana K. Review of Abortion Material in Pakistan.
Available from: http://www.shirkatgah.org/_up
loads/_files/f_14-abortion_material_in_pak.pdf
[accessed on 10 June 2013]
Ahman E, Shah I. Unsafe abortion: global and
regional estimates of the incidence of unsafe
abortion and associat ed mortality in 2003.
Haddad LB, Nour NM. Unsafe abortion: unneces
sary mater nal mortality. Reviews in obstetrics
and gynecology. 2009;2(2):122.
Berer M. Making abortions safe: a matter of good
public health policy and practice. Bulletin of the
World Health Organization. 2000
Jan;78(5):580-92.
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World Health Organization. Unsafe abortion: global

andregional estimates of incidence of and mortality
due to unsafe abortion with a listing of available
country data.1988
Ganatra B, Johnston HB, Arnold F, Kishor S, Roy
TK, Chita lia S, David RJ, Frasca T, Whittaker A,
Mekrut WP, Rossier C.Reducing abortion-related
mortality in South Asia: a review of constraints and
a road map for change.Journal of the American
Medical Womens Associa tion. 2002;57(3):159-64.
Sathar ZA, Singh S, Fikree FF. Estimating the
incidence of abortion in Pakistan. Studies in Family
Planning. 2007 Mar 1:11-22.
Pakistan Demographic and health survey
2006-2007. National institute of population studies
(NIPS) and Macro International, Islamabad,
Pakistan: NIPS, 2008
J Pak Health Soln
10 Bankole A, Singh S, Haas T. Reasons why women

have induced abortions: evidence from 27 count
ries. International Family Planning Perspectives.
1998 Sep 1:117-52.
11 Rehnian N. Unsafe abortion: Magnitude and
perceptions J. Fain. Plaint. Assoc. Pak., 1998:27:
22-3
12 Fikree FF, Rizvi N, Jamil S, Husain T. The emerg
ing problem of induced abortions in squatter settle
ments of Karachi Pakistan. Demography India.
1996 Jan;25(1):119-30.
13 Zaidi S, Mastoor S, Jaffry HF, Parveen R. Maternal
deaths in induced abortions. Journal of the College
of Physicians and Surgeons of Pakistan.
1993;3(1):20-3.
14 Rehan N, Inayatullah A, Chaudhary I. Characteris
tics of Pakistani women seeking
abortion and a profile of abortion clinics. Journal of
wo 's health & gender-based medicine. 2001 Oct
1;10(8):805-10.
15 Korejo R, Noorani KJ, Bhutta S. Sociocultural
determi nants of induced abortion. Journal of the
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18
19
20
College of Physicians and Surgeons--Pakistan:

JCPSP. 2003
May;13(5):260-2.
Lazarus ES. Politicizing abortion: personal morality
and professional responsibility of residents training
in the United States. Social Science & Medicine.
1997 May 31;44(9):1417-25.
Caldwell B, Barkat-e-Khuda, Ahmed S, Nessa F,
Haque I. Pregnancy termination in a rural subdis
trict of Bangladesh: a microstudy. International
Family Planning Perspectives. 1999 Mar 1:34-43.
Sihvo S, Hemminki E, Kosunen E, Koponen P.
Quality of care in abortion services in Finland. Acta
obstetriciaet gynecologica Scandinavica. 1998 Jan
1;77(2):210-7.
Ahmed S, Islam A, Khanum PA. Induced abortion:
what's happening in rural Bangladesh. Reproduc
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Population and development. Programme of Action
adopted at the International Conference on
population and Development
J Pak Health Soln
Original Article
Health Interaction and Consultation Outcome: Patients

Experience at Tertiary Care Hospitals of Karachi
Shumaila Nazish1, Ch Shehzad2, Syed Hasan Danish3, Minhaj Ahmad Qidwai4, Farah Ahmad5
Abstract
Objective:
To assess out patients experience with respect to communication skills of physicians, auxiliary services and
final outcome at tertiary care hospitals of Karachi.
Methods:
The cross sectional survey was carried in a charity and private tertiary care hospitals for a period of three
months using convenience sampling technique. Patients above 18 years of age were included while those
who failed to consent were excluded from the study. After taking informed consent data was collected from
443 patients using Patient Experience Questionnaire (PEQ) measuring patient experience in the domains of
communication;short-term outcomes; barriers and relations with auxiliary staff. The cutoff scores for each
domain were: Communication scale (2.5), Outcome scale (2.5), Barrier scale (2.5), Auxillary staff scale (2.5).
Analysis was performed using SPSS (Statistical Packages of Social Sciences) version 20.0. P-value <0.05
was considered as significant. Approval was taken from the Ethical review committee of both hospitals.
Results:
A total of n=443 patients participated in the study including 51% females and 49% males. Maximum satisfaction of the patients was observed in two domains namely outcome of the visit (4.1+/-0.4) and communication
experience with the physicians (4.2 +/- 0.7). The score for communication barrier was 3.70.6 where majority reported that barriers were highly prevalent. The least mean score came out to be with the auxillary staff
1.81.1 where 86% (n=380) patients displayed dissatisfaction towards auxiliary staff.
Conclusion:
Outcome of visit and communication experience yielded satisfactory experience whereas experience with
auxiliary staff had lowest satisfaction along with communication barriers between physician and patient.
Keywords:
Communication; Patient experience; Barriers
How to cite this article:
Nazish S, Shehzad C, Danish SH, Qidwai MA, Ahmad F. Health Interaction and Consultation Outcome:
Patients experience at Tertiary Care Hospitals of Karachi. Pak J Health Solns 2016; 1 [8-12]:
kindly follow the

previous comment
Syed Hasan Danish 4Community Health Sciences Department Ziauddin University,

Email: dowite_hasan@hotmail.com
1, 2,
3, 5,
4
Postgraduate Diploma in Health Management, Institute of Business Administration

Director, PGD in Health Management, Institute of Business Administration
J Pak Health Soln
Introduction
Over the past few decades, there has been a shift of
attention from the biomedical side to humanistic side of
medicine and nowadays a greater emphasis is given to
effective patient physician communication. 1, 2 Effective
Communication means the health care providers must
ensure that the information regarding the disease and
drug are well communicated and understood by the
patient as per their abilities and needs.3 Patients
assess the quality of their care largely through their
experiences of consultation with their physicians.
When patients feel that the physicians listen carefully,
understand their needs and provide information in a
clear fashion, they are most likely to be satisfied with
their care. Studies published in Western Journal of
Medicine have consistently shown that the best medical outcomes occur when patients are fully informed
and involved in decisions about their care. It is rare that
medical trainees receive instructions on communication or feedback on their performance as communicators. Furthermore, almost no opportunities exist for
practicing physicians to learn new communication

skills. Even if such opportunities exist, physicians do
not get systematic feedback on their interactions with
their patients.4 When patients get the empathy that
stems from effective communication, they're more
satisfied and more likely to comply with treatment.5
By some estimates, fully one-third of the US population
uses alternative practitioners instead of or in addition to
allopathic physicians because of their focus on communication, quality of life and understanding patients
as people. Goals for high quality, patient-centered care
cannot be achieved if consumers cannot access
services or make informed health care decisions.
Health care organizations need to reduce the complexity of the health care system and ensure consumers
can understand and use information and services to
take care of their health.6Hence we conducted the
study to assess out patients experience with respect to
communication skills of physicians, auxiliary services
and final outcome at tertiary care hospitals of Karachi.
Methods
This cross sectional study was conducted for a period
of 6 months in outpatient department of different disciplines in two tertiary care hospitals. Taking an estimated proportion of 50%, at 95% confidence level with a
bound of error of 5% the calculated sample was
approximated to n=450 after adding wastage. The
study included patients above 18 years of age immediately after attending outpatient department. Patients
who did not consent or were diagnosed dementia
cases were excluded from the study. Convenience
sampling technique was utilized for collection of data.
After taking informed consent and explaining the study
objectives data was collected using Patient Experience
Questionnaire (PEQ). PEQ measures patient experience along the domains of communication; short-term
outcomes; barriers and relations with auxiliary staff.
The questionnaire was translated into Urdu language.
The PEQ was given to patients at the end of their
outpatient consultation. Patients were asked to fill it in
the waiting area or reception without any interruption.
The 14 questions on the PEQ were scored on a 1-5

tick-box response scale. The cutoff scores for each
domain were: Communication scale (2.5), Outcome
scale (2.5), Barrier scale (2.5), and Auxillary staff scale
(2.5). Scores above these cutoffs indicated that there
are no problems with patient experience while scores
below the cutoff indicated problems with that element
of patient experience. 7The data collected was analyzed using computer package SPSS (Statistical Packages of Social Sciences) version 20.0. Descriptive analysis was computed for quantitative variables (such as
age). Categorical variables such as gender, marital
status and educational level were measured in
frequencies and percentages. Stratification was done
with regard to age group and gender. ANOVA was
applied for finding difference in the mean scores categorized on the basis of educational levels. P-value
<0.05 was considered as significant. Approval was
taken from the Ethical review committee of both hospitals.
Results
The final sample was n=443 patients, of them half 51%
(n=226) were females. Majority 71% (n=316) participants were married. Educational status revealed that
33% (n=148) participants were graduates and above.
Maximum satisfaction of the patients was observed in
two domains namely outcome of the visit (4.1+/-0.4)
and communication experience with the physicians
(4.2 +/- 0.7). The descriptive analysis for four domains
in Patient experience questionnaire revealed that maximum means score was with the communication experience with the physician 4.20.7. This was then categorized and 96.8% (n=429) participants showed satisfaction with the communication skills of the physician.
Mean score of outcome of their visit to the hospital
came out to be 4.10.4 where 99% n= (439) partici-
pants showed satisfaction with the visit to the hospital.

The score for communication barrier was 3.70.6
where majority reported that barriers were highly prevalent as confirmed by 89.8% (n=398) of the participants. The least mean score came out to be with the
auxiliary staff 1.81.1 where 86% (n=380) patients
displayed dissatisfaction towards auxiliary staff. When
gender was associated with the four domains it was
found that males 78.6% (n=11) were more dissatisfied
with communication as compared to females 21.4%
(n=3). Majority females, 53.4% (n=203) were dissatisfied with the auxiliary staff experience versus 46.6%
(n=177) males. (P value 0.009).
J Pak Health Soln
From the domain of outcome of their visit, dissatisfaction was observed when inquired if they will be able to
handle their health problems after the visit, as 43.6%
(n=193) were of the opinion that they will not be able to
handle their problems differently while merely 16.9%
(n=75) had a positive outlook for future handling of
health problems. When participants were asked if they
were taken care of by the physician 56.9% (n=252)
agreed completely while only 4.1 %( n=18) disagreed
to it. Reservations was displayed when the patients
were inquired regarding the connectivity with the

doctor as 65.3% (n=289) agreed to poor interaction
with the doctor. Patients were maximally disturbed
96%(n=425) regarding decision making power as
according to them they had no say in this regard. When
hospital environment was taken into account patients
showed dissatisfaction towards privacy where majority
84.9% (n=376) agreed that other unconcerned people
could listen to their conversation with the staff.
Table 1: Mean scores of the four domains of patient satisfaction and their categorization
N
Mean
Standard Deviation
Outcome of Visit to
the Hospital
443
4.1
0.4
Satisfied
Dissatisfied
439
4
99.1
.9
Communication
Experience with the
Physician
443
4.2
0.7
Communication
Barriers
Satisfactory
Dissatisfactory
429
14
96.8
3.2
443
3.7
0.6
Auxiliary Staff
Experience
Absent
Present
45
398
10.2
89.8
443
1.8
1.1
Satisfactory
Dissatisfactory
63
380
14.2
85.8
Discussion
negatively correlated to satisfaction.14 Our participants
showed maximum dissatisfaction with auxillary staff.
Four studies conducted in tertiary care hospital
revealed that respect, courtesy, careful listening and
easy access of care was considered the strongest
driver of patient satisfaction. Aspects of nursing care
were rated much higher compared to physician care,
admission process, physical environment and cleanliness. 15 These findings were further augmented by
Otani et al. 9 Another study found in 430 hospitals in
USA that patient nurse ratio and nurse work environment had positive effects on patients satisfaction as
well as recommendation. 15 A cross sectional survey in
Istanbul showed that acceptance of health care services by patients is affected by the duration of waiting
period. The fundamental factor influencing preference
or recommendation of a health care institute is the
communication skill of the health care professional. 16
A study in Nigeria suggested that patients satisfaction
relies on the efficiency of services rendered to them. 17
Our study had fewer weaknesses, non probability
sampling technique being most potential. Strengths
being firstly the study setting, one of the hospitals was
governed by a charitable trust, validated questionnaire
was used, an adequate sample size of participants
and last being the novelty of the topic. Over past years
surveys on patient satisfaction have served as meaningful and vital sources of information for identifying
the lacuna and creating an effective plan for upgrading
quality in healthcare organization. 16 Studies observing
physician communication style and patient response
gave birth to the saying that How you say something
matters more than what you say . 12
Our study emphasizes the significance of communication as expressed by Levinson and Pizzo If the medical profession wishes to maintain or perhaps to regain
trust and respect from public, it must meet patients
needs with a renewed commitment to excellence in
the communication skills of physicians. It is time to
make this commitment.8 Our results displayed high
scores on communication experience with the physician. Our results also showed great satisfaction with
the outcome of visit. Similar results have been seen in
earlier studies where Otani et all surveyed 32 tertiary
care hospitals in USA and showed that all components
including physician care, nursing care and environment were positively related to outcome of visit and
overall satisfaction. 9 Communication experience yielded high mean results by the participants. This was
contrary to a study conducted in USA where merely
33% physicians were rated satisfactory for their
behavior. 10 Another study showed that communication
is much better in physicians of same gender in both
children as well as adults. 11 Other studies have shown
that communication style should be sensitive to
patients emotional state and improves bonding
outcome while attenuating dissatisfaction.12 Communication has serious implications as according to Institute of Healthcare Communication (IHC) half of all
malpractice is a consequence of poor communication
between patients and doctors. 13However our results
did display communication barriers between patients
and doctors where patients felt decisions were made
without their involvement. In a study by Buller interpersonal communication satisfaction scale was utilized
and it was found that dominance by the doctor was
10
J Pak Health Soln
Table 2: Mean difference in the scores of the four domain with respect to educational status
95% Confidence
Interval for Mean
Mean
Std.
Deviation
Lower
Bound
UpperBound
80
12
77
126
148
3.97
3.92
4.10
4.11
4.10
.57
1.25
.50
.45
.41
3.84
3.12
3.99
4.03
4.03
4.10
4.71
4.22
4.19
4.17
Illiterate
Primary
Communication Secondary
Experiences
Intermediate
Graduate and
above
80
12
77
126
148
3.87
4.42
4.18
4.29
4.23
.85
.47
.64
.58
.65
3.68
4.12
4.04
4.19
4.13
4.05
4.71
4.33
4.39
4.34
Illiterate
Primary
Barriers
Intermediate
Graduate and
above
80
12
77
126
148
3.67
2.50
3.63
3.71
3.74
.86
.45
.86
.63
.59
3.47
2.21
3.43
3.60
3.65
3.86
2.79
3.83
3.82
3.84
Illiterate
Primary
Intermediate
Barriers
Graduate and
above
80
12
77
126
148
1.96
4.00
1.91
1.57
1.67
1.25
.88
1.26
.85
.81
1.68
3.44
1.62
1.42
1.54
2.23
4.56
2.19
1.72
1.80
Illiterate
Primary
outcome Secondary
Intermediate
Graduate and above
Anova (F)
P Value
1.47
0.21
5.9
0.001
8.87
0.001
17.5
0.001
Conclusion
Communication barriers and auxiliary staff experience demonstrated poor scores while outcome of the visit was
satisfactory. We need to provide the highest quality of care to our patients and we need to learn these skills and
practice them ensuring effective communication.
Disclaimer: None
References
1. Parrot R. Emphasizing communication in health
communication. J Commun. 2004;54:751-87
2. Stewart MA. Effective physician-patient commu
nication and health outcomes: a review. CMAJ:
Canadian Medical Association Journal. 1995;
152(9):1423.
3. Fong Ha J, Longnecker N.Doctor Patient Com
munication:A Review. The Ochsner Journal
2010;10 (1):38-43
4. Levinson W. Patient-centred communication: a
sophisticated procedure. BMJ quality & safety.
2011; (10):823-5.
11
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6.
Doctors lack empathy[online] 2008 [cited 2012

Oct14]URLwww.articles.chicagotrib
une.com/2008-10-12/
features/0810080281_1_empathy-doctor-pa
tient-non-verbal
Branch C, Keller D, Hernandez L.M, Baur C,
Parker R, Dreyer B.et al. Ten Attributes of health
literate health care [online] 2012 [cited 2012 Oct
14]URL:
www.iom.edu/global/perspectives/2012/healthli
tattributes.aspx
J Pak Health Soln
7.
Steine, S, Finset A, Laerum E. A new, brief ques

tionnaire (PEQ) developed in primary care for
measuring patients experience of health interac
tion, emotion and consultation outcome. Family
Practice 2001;18(4):410-17
8. Levinson W, Pizzo PA. Patient-physician communi

cation: it's about time. JAMA. 2011;
305(17):180203
9. Otani K, Herrmann PA, Kurz RS. Improving patient
satisfaction in hospital care settings. Health Serv
Manage Res 2011. Nov; 24(4):163-19
10. Sarah LC, Lei J, Wendy L, David OM. Does
Doctor-Patient Communication Affect Patient
Satisfaction with Hospital Care: Results of an Anal
ysis with a Novel Instrumental Variable? Health
Science Research 2008: 43
11. Bernzweig J, Takayama JI, Phibbs C, Lewis C,
Pantell RH. Gender differences in physician-pa
tient communication: evidence from pediatric visits.
Archives of pediatrics & adolescent medicine.1997;
151(6):586-91.
12. Swaminath, G. Doctor-patient communication:
Patient perception. Indian Journal of Psychiatry
2007;49(3):15053.http://
doi.org/10.4103/0019-5545.37309
12
13. Haskard KB, Williams SL, DiMatteo MR, Rosenthal

R,White MK, Goldstein MG. Physician and patient
communication training in primary care: effects on
participation and satisfaction. Health Psychology.
2008;27 (5):513.
14. Williams S, Weinman J, Dale J. Doctorpatient
communication and patient satisfaction. Fam
Pract.1998; 15(5):480-92.
15.
16.
17.
Kutney-Lee A, McHugh MD, Sloane DM, Cimi

otti JP, Flynn L, Neff DF, Aiken
LH. Nursing: a key to patient
satisfaction.Health Affairs. 2009;28(4):w669-77
Vural F, Ciftci S, Cakiroglu Y, Vural B. Patient
satisfaction with outpatient health care servic
es: evaluation of the components of this service
using regression analysis. North Clin Istanbul
2014;1(2):71-7
Ofili AN, Ofovwe CE. Patients' assessment of
efficiency of services at a teaching hospital in a
developing country. . Annals of African Medi
cine 2005; 4 (4):150 53.
J Pak Health Soln
Original Article
Facebook: A platform for masquerade
Darayas Gazder Percy1, Syed Hasan Danish2, Farah Ahmad3, Sara Javied4,
Sheharyar Ahmed Jumani5, S. Talha Shah6, Hafiz M. Asim Anis7
Abstract
Objective:
To determine the role of facebook usage among university students.
Method:
A cross-sectional study was conducted in a private medical school of Karachi, Pakistan. A total of 416
students were selected through convenience sampling technique from first year to fourth year MBBS. Self
administered questionnaires were used for data collection. Data was entered on SPSS version 21. Descriptive analysis was performed. Permission was taken from ethical review board.
Results:
The mean (SD) age of the students was 20.65 +(1.34) years. For picture uploading most frequent category
consisted of n=44(30.13%) males compared to n=26(9.6%) females. It was observed that n=151(36.3%) of
the students had between 200-300 friends, n=134(32.2%) had more than 400 friends. Three hundred and
forty four students (82.7%) stated that a person with more likes, comments on photos frequent status update
changes were perceived as being more popular. Majority n=319(76.7%) stated they project their true self
while believed n=283(68.1%) people projected a false image on facebook. Most participants n=99(67.8%)
males and n=213(78.8%) females perceived like option as a form of acknowledgement
Conclusion:
It was seen that majority of students use facebook to update personal information, for social networking and
believe that most people have false projections. A person with more likes, comments on photos as well as
status update changes were perceived as being more popular in making an impression via their profile. Activities on Facebook were found to be similar among both gender.
Keywords:
Facebook; Social networking; University students
Percy DG, Danish SH, Ahmad F, Javied S, Jumani SA et al. Facebook: A platform for masquerade. Pak J Health Solns 2016;1 [13-7]:kindly
Dr. Darayas Gazder Percy House Officer Department of Medicine Ziauddin Hospital, Email:darayusthegreat@gmail.com
1, 4-7
2, 3
House Interns, Ziauddin Hospital, Karachi

13
J Pak Health Soln
see the
previous
commen
ts
Introduction
According to the Internet World Statistics, 40.7% of
global population used the Internet.1 Social networks
are changing the way human beings are interacting.2
Facebook has been established as a network site
where people share personal information, snaps and
join social groups.3A study ranked facebook as the
most used social website by worldwide networking
service monthly active users.4 According to latest
statistics, over six million Pakistanis use facebook,
placing the country at 26th position in the list of countries with facebook users. Research shows that 5.19
million Pakistani facebook users are over the age of 18
years.5 Studies have demonstrated that undergraduate
students spend substantial time on facebook.6 Another
study showed that 70% of facebook users are under 25
years of age with majority males. In Pakistan, studies
state 44000 users join this network every week.7 A
survey in Arab peninsula stated that 60% of students
were using facebook in university.8Another study has
shown that mostly students use facebook for uploading
images and creating statuses.9 Additionally it serves as

a tool for maintaining and strengthening social ties
which is helpful in both academic and social settings.6
Previous studies on online social networks have
worked on Myspace, Orkut, Twitter, Flickr, Cyworld,
Yahoo! 360, and LiveJournal along with others.10 Facebook has attracted researchers in the past.11 Among
various social networking websites even today facebook is regarded as a famous site in social sharing
sites because of its magnanimous usage and its ability
to channel social connections.12 Only few researches in
Pakistan have focused on the usage of facebook
specially the social networks of university students.11
According to research key question still persists that
what people do with facebook.13 Because different
people have separate online pursuits even with equal
access. 14 hence we conducted this research on
university students to determine their activities on facebook.
Methods
The study was undertaken at Ziauddin University. It
was a one year cross sectional survey and a total of
450 students were selected based on 50% proportion
and selected through non-probability convenience
sampling. Inclusion criteria were MBBS students from
first year to fourth year who were studying at a private
University inclusive of repeaters and transfer students.
Exclusion criteria were those who failed to consent or
were absent at the time of data collection. The nature
of survey, applicability of results and confidentiality
were explained to the participants. Completion of questionnaire was voluntary. Self administered questionnaires were distributed in face-to-face session in
lecture hall separately according to the year of study.
The students were informed to follow the instructions

and were not allowed to talk during filling of questionnaires. Filling of questionnaires took approximately 20
minutes and students were advised to return it after
filling. Some multiple choice questions and few open
ended questions were filled by the students. Less
frequently was defined as those using facebook once a
week and more frequently was defined as those using
it for atleast 2-3 times a week. Descriptive analysis was
performed on received data. Clearance was taken
from the ethical review board prior to the start of study.
The study was done with the permission of the head of
the institution.
Results
The study included n=450 participants. The mean age
of the students was 20.651.34. There were n=146
(35%) males and n=270 (65%). females. Of the total
participants n=416 (92%) had a facebook account.
Those who did not have a facebook account, 34% of
them used other social networking sites in the following
order such as Twitter, Tumblr and Instagram. It was
seen that 15.82 + 1.01 hours were spent on facebook

per week. Frequency of uploading pictures was least
frequent for n=75(51.36%) males as compared to
n=147(54.4%) females. For Uploading pictures most
frequent category comprised of n=44(30.24%) males
compared to n=26(9.6%) females.
Table 1: Role of Facebook for building interpersonal relationships

Males
Find new friends
Chat with Friends
Check out what
Friends are doing
Females
n
Least Frequent
68.4
100
76.2
206
Most Frequent
31.6
46
23.7
64
Least Frequent
26.8
39
12.3
33
Most Frequent
73.2
107
87.7
237
Least Frequent
17.2
25
11.2
30
Most Frequent
82.8
121
88.8
240
14
J Pak Health Soln
It was seen that n=151(36.3%) of the students had between 200-300 friends, n=134(32.2%) had more than 400
friends, n=111(26.5%) had between 100-200 friends and n=20(4.8%) had less than 100 friends. Three hundred
and forty four students (82.7%) stated that a person with more likes, comments on photos and frequent status
updates were perceived as being more popular. Frequency of usage of facebook parameters to build impression
has been illustrated in figure 1.
Figure 1: Frequency of Facebook parameters used to build impression

When questioned how other people project themselves on facebook merely n=6(4.1%) males and
n=10(3.7%) females opined that it is their true self
whereas a magnanimous portion of participants
n=100(68.4%) males and n=199(73.7%) females
thought that people project themselves as partially fake
while only few n=22(15%) males and n=36(13.3%)
females thought they projected themselves completely
fake remainder having no opinion. When inquired
regarding interaction with strangers n=6(4.1%) males
and n=15(5.5%) females stated they enjoyed talking to
them while n=28(19.17%) males and n=25(9.25%)
females quoted saying that they were curious to know

about them whereas n=15(10.27%) males and
n=16(5.92%) females said they were interested in
expanding their social network while all remaining
participants stated they do not accept strangers.
Majority n=99(67.8%) males and n=213(78.8%)
females perceived like option as a form of appreciation and acknowledgement while n=11(7.53%) males
and n=30(11.11%) females took it as a routine whereas
remainder had no comments to it. Perception of participants regarding how people project themselves is
shown in Figure 2 and 3.
23.3
31.9
68.1
76.7
Fake Projection
Fake Projection
True Selves
True Selves
Figure 2: Perception of
oneself on Facebook
Figure 3: Perception of
oneself on Facebook
15
J Pak Health Soln
Discussion
Social media sites are frequently utilized by young
adults 18-25 years age such findings have been there
with other studies as well.15University students in our
study had greater than 200 friends for the majority
which was more compared to previous studies where
one study found 130 friends on average16 and another
found 190 friends as an average17 whereas a study in
United Arab Emirates found 100 friends on average
among university students.8
Studies have shown that greater than 13 million users
update their status daily and greater than 3 million
follow certain pages at a certain base.8 A study in
Turkey stated that chatting, messaging, uploading
pictures are the most commonly used tools of facebook
by the participants. Whereas facebook is most preferably utilized as a communication tool.6
Similar to our study a previous study in Dow University
Pakistan stated that most students visit facebook to
update, edit or check their profile. 16 Our study showed
that female students had greater frequency in all activities including building interpersonal relationships and
using facebook tools to build impression indicating that
facebook plays a more important role in the female
students life than it does for their male counterparts.
This was similar to previous study in Arabic students.8
It has been shown that facebook have been used as a
vital tool for identity construction and development of
relationship, playing a significant role in shaping future
society. 13
The current study found that having more likes, comments in ones profile pictures, facebook posts positively influenced perceived popularity and social attractiveness. This is consistent with previous findings that
having more social cues, especially in ones profile
pictures, yields more positive impressions because of
the perceived reliability of the self-presentation.18
Our data also affirmed previous findings that observers

base their impressions not only on self-presentations
but also on other peoples feedback about a profile
owner.19 However our study highlighted that majority
students stated that they had true projections of themselves while opined that others mostly have fake
projections of themselves. As studies have indicated
that people tend to present themselves in a favorable
way on their facebook profile.20 Studies have shown
weak trust of people using facebook. Females
perceived more according to studies people as honest
and reliable whereas males had conflicting opinions8
while in our study both genders were of similar opinion
that most people project themselves as fake. A study in
USA displayed that students use links and photos for
boosting communication. 21 Another study highlighted
the more people felt lonely the higher they used facebook.22
All attempts were made to ensure that the data collected was reliable and the methods were reproducible.
However, our study was also not free from limitations.
The most important limitation was that data was
collected from one medical university. Furthermore,
convenient sampling was employed, which may have
led to selection bias, and hence is not truly representative of the population under study. This implies that
further studies should be conducted on a larger scale,
with a more diverse set of institutes in order to minimize
bias and for better generalization. Future research
should also examine whether these findings generalize
to other online social networks. We focused on university students as studies in the past have informed that
they represent the core demographic users.22 Very few
studies in the past have looked at facebook utilization
in Pakistan in such perspective.
Conclusion
It was seen that majority of students use facebook to update personal information, keep themselves aware of
activities of friends and relatives, with false projections projected by most of them. A person with more likes,
comments on photos as well as status update changes were perceived as being more popular in making an
impression via their profile. Activities on facebook were found to be similar among both gender.
Disclaimer: None
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J Pak Health Soln
Original Article
Effect Of Insurance Status On Consumer Behavior Towards
Purchasing Prescribed Medicines: A Cross Sectional Survey
Among The General Population Of Karachi
Ibtisam Qazi1, Asad Zulfiqar2, Farah Ahmad3, Syed Hasan Danish4 ,Asima Faisal5
Abstract
Objective:
To assess how insurance status affects the attitude of consumers towards purchasing prescription medicines in the context of doctors and chemists influence, awareness and availability of medicine.
Method:
A descriptive cross sectional survey was conducted in the first quarter of 2016 among the general population living in 18 towns of Karachi. Sample size was n=544 calculated using the online Raosoft sample size
calculator. Data was collected using self administered questionnaires. SPSS version 21 was used for data
analysis & Chi square test was applied for finding association between factors and consumer behavior. A
P-value of <0.05 was taken as significant.
Results:
A total of 544 consumers were surveyed out of which only 44.7% were insured. A majority of people regardless of insurance status disagreed that they would buy a medicine even if it is expensive (p= 0.0001). Out
of the insured group (53.1%) said they would consult their doctor for a low priced alternate if the prescribed
medicine was expensive (p= 0.0001) & a majority of the people from both categories disagreed that they
would only consider the recommendations of a doctor (p=0.002). When a chemists role was taken into
account a majority of people in both categories agreed that they would consult with their chemist for another low priced alternate (p=0.0001) & if a chemist recommends a low price medicine they would purchase
it (p=0.04). In addition, a majority (59.6%) agreed that they would buy medicines from pharmacies giving a
maximum discount (p=0.007).
Conclusion:
Our study concludes that being insured or uninsured had no effect on consumer behavior and overall
purchasing decision. A low priced product & chemists opinion were found to be an important consideration
when purchasing medicines regardless of insurance status.
Keywords:
Consumers, Health insurance, purchase behavior, Consultants, Chemist
Qazi I, Zulfiqar A, Ahmad F, Danish SH. Effect of insurance status on consumer behavior towards purchasing prescribed
medicines: a cross sectional survey among the general population of Karachi. Pak J Health Solns 2016; 1 [18-23]: follow the previous
comments
IbtisamQazi1 Resident FCPS 1, Department of Community Health Sciences, Ziauddin University. Email: ibtisamqazi@gmail.com

LOC Quality Manager, Glaxo Smithkline
3
4
5
Institute of Business Management
1
2
18
J Pak Health Soln
Introduction
Medications generally fall into two categories: either
over the counter or prescription medicines (physician
endorsed). 1, 2 Spending on medicines increased in
double digits & touched $425 billion in the year 2015 in
the United States. 3 In the US prescription drug coverage is an important part of employer provided health
care plans. Due to the rising costs these plans have
shifted focus towards low cost alternatives. 4 In the
United States 65% of people on Medicare had
prescription drug coverage while in Canada, 98% of
people over the age of 65 years have prescription drug
coverage. 5 In Canada public insurance plans cover
44% of total prescription costs, private plans cover
34% & out of pocket expenses cover 22% of these
costs. 6
The increased use of medication over the past few
years has put a lot of economic pressure on consumers and where available on publicly funded drug plans
which are part of health insurance coverage. 7, 8 Pharmacy costs account for 15% of total in healthcare
spending. Due to the increased cost sharing and
deductibles cost is a growing concern for consumers
and has an effect on the healthcare choices they make.
A health research institute (HRI) survey conducted in
December 2013 found out that 40% of consumers said
that their budgets were strained due to healthcare
expenses. Families who used high-deductible health
plans (ones in which out of pocket expenses were
more than the insurance coverage) used fewer branded drugs, had fewer doctor visits and hunted for pricing
information on their own. A lot of the consumers
wanted more user friendly information too and
preferred using an online portal. 9
Being cheaper than branded medicines, the financial
benefits that generic medicines offer in terms of cost
saving are essential to curb healthcare spending for
both individuals and also for government sponsored
plans. 10 Consumer trends over the past few years
indicate that a variety of measures are being used to
curb increased costs like visiting low price pharmacies
and using pharmaceutical company or state drug
assistance programs. 11, 12 Price sensitivity has been
found to be one of the chief reasons that affect intent to
purchase & repurchase of a medicine. 13 Consumers
buying generic products were found to be more price
sensitive by comparison and showed a trend towards
switching to high quality branded medicine if there was
a reduction in price. 14 Additionally, a healthcare professionals attitude, price tolerance and brand trust was
also found to be an influencing factor for purchase &
repurchase of the product. 15
Studies have found that direct to consumer (DTC)
advertisements from the internet or pharmacist influence purchasing behaviors in consumers and they
were then more likely discuss their drug choices with
their doctor. 15, 16 A large number of the physicians in the
United States said that they frequently discuss out of
the pocket costs with their patients with 62% saying
that they shifted their patients to a cheaper alternative
and 58% saying they utilized office samples for their
patients prescriptions. 17 Opposition to drug substitution is also a problem in certain settings and usually
comes from patients who are covered by fully paid
insurance plans. However, in Canada 20% of patients
on Pharmacare (fully paid government plan) accepted
substitution with a lower priced product. This acceptance rate among insured patients was also dependant
on a number of other factors like the pharmacist's
verbal assurance about quality, actual savings accrued
and being given a choice for both generic and branded
drugs. 18
In countries where advertising of prescriptions is not
legally allowed other factors affect purchasing decisions. These may include socioeconomic status, insurance status, age, gender and educational levels which
may all play an important role in purchasing power.
Pakistans pharmaceutical industry which was worth an
estimated Rs. 191 Billion (USD 1.8 Billion) September
2015 is currently experiencing an exponential growth.
19
In the last three to five years this trend has largely
been due to the large number of local companies that
have mushroomed and the introduction of high quality
low priced generics. This has made it possible for a
large proportion of the population to access medicines
that would otherwise have been inaccessible because
of high pricing due to brand value. The factors influencing purchase of over the counter and prescription medicine which have contributed to this growth have not
been studied in our population. 19 Our study aims to
assess how insurance status affects the attitude of
consumers towards purchasing prescription medicines
in the context of doctors and chemists influence,
awareness and availability of medicine.
Methods
A descriptive cross sectional study was conducted
among the general population living in 18 towns of
Karachi. The study was conducted in registered pharmacies, chemist shops and hospital pharmacies situated in different towns of Karachi during the first quarter
of 2016. Multistage sampling technique was used. In
the first stage 10 towns out 18 were randomly selected.
In the second stage quota sampling was employed
n=50 participants were recruited from the selected
locations. Sample size was calculated using the online
Raosoft sample size calculator. The calculator calculates sample size after putting the relevant data including margin of error i.e. 5% & confidence level 95%.
Response distribution was selected as 50%. As a
result the sample size came out to be 384. The actual

sample was n=544 after adding 20% wastage. Participants of both genders aged 18 and above with a minimum educational level of intermediate or equivalent
were included in the study. Exclusion criteria were
participants who refused to give consent and those
with a language barrier.
The researcher himself collected the data through a
self-administered questionnaire which was designed
from a literature review of previous studies 14, 20 on a
similar topic from their results and conclusions.
19
J Pak Health Soln
The questionnaire consisted of 25 questions comprising of the demographic profile which included factors
like age, gender, educational status, health insurance,
socio economic status and consumer attitudes based
on 4 domains namely the role of the physician and
chemist, availability of medicines and consumer knowledge. The questionnaire was administered after
explaining the objectives of the study. On an average
10 minutes were utilized for filling out the questionnaire. The researcher made the participants fill out the
questionnaire in front of him. Data entry was done on
MS Excel and data analysis was carried out on SPSS

version 21. Descriptive analysis for the entire variables
was conducted in the first step. Percentages and
frequencies were taken out for all the variables as all
were categorical. In the second stage Chi square test
was applied to find association between factors and
consumer behavior. P value of less than 0.05 was
taken as significant. Informed consent was taken
before data collection from the respondents. Confidentiality was ensured that data will be retained till publication of the research findings.
Results
In our study we inducted sample size of n=544 participants, n=243 (45%) had medical insurance while
n=301 (55%) did not have any medical insurance.
When insurance was associated as factor with consultation with a doctor it was found that 61.7% (n=150) of
insured people & 61.2% (n=184) of uninsured people
disagreed that they would consider the recommendations of their consultant (p=0.002). In addition, 53.1%
(n=129) of insured people agreed & 33.5% (n=101) of
uninsured people agreed that they consult their doctor
to prescribe a low priced product (p=0.0001). When

inquired if they will consult for quality with their doctor
majority,69.9% (n=170) of insured people and 63.1%
(n=190) of uninsured people disagreed that they
consult for quality with their doctor (p=0.001). Around
45.7% (n=111) of insured people agreed & 59.5%
(n=179) of uninsured people agreed that they take
medicines from a pharmacy recommended by their
doctor (p=0.005).
Table 1: Health Insurance and its association with drug availability and purchase
Yes
(n=243)
n
I need to think before
purchasinga prescribed
medicine
I am exceptionally alert
in obtaining prescribed
medicines
I frequently change my
purchasing decision/
buying choice for a
prescribed medicine
If I am aware that
alternative low price
medicine is available I
will buy it
I take medicine
from the pharmacy
giving maximum
discount no matter
where it is situated
I take medicines only
from recognized
pharmacies
No
(n=301)
P
value
agree
107
44%
123
40.9%
neutral
33
13.6%
57
18.9%
disagree
103
42.4%
121
40.2%
agree
22
9.1%
47
15.6%
neutral
63
25.9%
52
17.3%
disagree
158
65%
202
67.1%
agree
113
46.6%
174
57.8%
neutral
53
21.8%
86
28.6%
disagree
77
31.6%
41
13.6%
agree
105
43.2%
105
34.9%
neutral
42
17.3%
49
16.3%
disagree
96
39.5%
147
48.8%
agree
145
59.6%
160
53.1%
neutral
49
20.2%
61
20.3%
disagree
49
20.2%
80
26.6%
agree
40
31
48
16%
neutral
16.5%
disagree
172
12.8%
70
70.7%
183
20
23.2%
60.8%
0.015
0.004
0.0001
0.009
0.007
0.011
J Pak Health Soln
Table 2: Health Insurance and its association with doctor consultation

Yes
(n=243)
n
I just consider the
recommendation of a
consultant
After purchasing the
product I often recheck
my prescribed medicine
with my doctor
If the prescribed medicine
is expensive I will consult
with my doctor to
prescribe a low price
product
I often consult for
quality with my doctor
I take medicines
from the pharmacy
recommended by
my doctor
No
(n=301)
P
value
agree
52
21.4%
37
12.2%
neutral
41
16.9%
80
26.6%
disagree
150
61.7%
184
61.2%
agree
77
31.7%
83
27.5%
neutral
47
19.3%
84
27.9%
disagree
119
49%
134
44.6%
agree
129
53.1%
101
33.5%
neutral
70
28.8%
64
21.3%
disagree
44
18.1%
136
45.2%
agree
37
15.2%
40
13.3%
neutral
36
14.8%
71
23.6%
disagree
170
69.9%
190
63.1%
agree
79
32.5%
74
24.6%
neutral
53
21.8%
48
15.9%
disagree
111
45.7%
179
59.5%
When insurance was associated as factor with the

availability of medicine it was found that 44% (n=107)
of insured people and 40.9% (n=123) of uninsured
people agreed that they need to think before purchasing a prescribed medicine (p=0.015). When inquired if
they are exceptionally alert in obtaining prescribed
medicine 9.1% (n=22) of insured people and 15.6%
(n=15) of uninsured people agreed to it (p=0.004).
Forty Six percent (n=113) of insured people and 57.8%
(n=174) of uninsured people agreed that they frequently change their purchasing decision/ buying choice for
a prescribed medicine (p=0.0001). Forty three percent
0.002
0.105
0.0001
0.0001
0.005
(n=105) of insured people agreed and 34.9% (n=105)

of uninsured people agreed that if they were aware that
an alternative low price medicine was available they
would buy it (p=0.009) while 59.6%(n=145) of insured
people and 53.1% (n=160) of uninsured people
agreed that they would buy medicine from the pharmacy giving a maximum discount no matter where it was
situated (p=0.007). Majority 70.7% (n=172) of insured
people & 60.8% (n=183) of uninsured people disagreed that they take medicines only from recognized
pharmacies (p=0.011).
Fig 1: Health Insurance and its association with chemist consultation

21
J Pak Health Soln
When insurance was associated as factor with consultation with a chemist it was found that 53.9% (n=131)
of insured people & 63.1% (n=190) uninsured people
agreed that they consulted the chemist for another low
priced medicine (p=0.0001), 49% (n=119) of insured
people & 42.8% (n=129) uninsured people agreed that
if a chemist advised them about a low priced medicine
they would purchase it (p=0.040) and 53.1% (n=129)
of insured people & 45.2% (n=136) of uninsured
people disagreed that they often consult for quality with
their chemist (p=0.009).
When insurance was associated as factor with awareness it was found that 80.3% (n=195) of insured people
and 81.7% (n=246) of uninsured people disagreed that
if the prescribed product was not available they would
go to another chemist (p= 0.002), 58.9% (n=143) of
insured people & 74.4% (n=224) of uninsured people
disagreed that they If the prescribed medicine was
expensive they would still buy it (p=0.0001) and 61.4%
(n=149) of insured people & 45.9% (n=138) of uninsured people disagreed that they buy medicine from
their neighborhood pharmacy (p=0.003).
Discussion
dations were considered important before purchasing
a medicine 26 and were a vital reason for accepting an
alternate brand. In addition, consumers were found to
have supplemented the advice they got from their
doctor with that of a pharmacist. Surprisingly majority
of customers did not even consult their doctors about
their prescriptions but relied solely on their pharmacists advice. 24Among insured patients Medicare
patients took into account the opinions of their pharmacists more (75%) as compared to their physicians
(60%).25A similar study done on Medicaid patients
found that they went to a pharmacist more often for
advice as compared to their physician. By contrast
people covered by traditional insurance and those
benefitting from managed care plans tended to talk to
their doctors more (83%) as compared to pharmacists
(71%). 25
When location or familiarity with a pharmacy was taken
into account in our study a majority disagreed that they
would buy medicines from a neighborhood pharmacy
(p=0.003). In addition more people who were insured
disagreed that they bought medicines from recognized
pharmacies (70.7%) & a majority agreed that they
would buy from pharmacies giving a maximum
discount (59.6%). Studies available have found that
the consumers general attitude towards purchasing
medicines is influenced to a large extent by its price.
27
Large discount pharmacies are seen to be associated
with more purchases and similar to our study this study
also found that pharmacy staff played a major role in
influencing purchasing decision. 28
Wolfgang & Perri conducted a study that highlighted
the fact that cost was an important factor in purchasing
behaviors & most consumers were conscious about
savings in medical expense and were of the opinion
that cheaper medicines were just as good as expensive ones. 29In addition people with a lower income
were seen to spend less on purchasing medicines and
vice versa. 30 In our part of the world a large influence
on purchasing decision is word of mouth or advice
taken from family or friends. This issue has not been
explored in our study and is a limitation. Another practice seen in our culture is that of direct medicine buying
as compared to going to a doctor. This is largely seen
elsewhere for over the counter (OTC) products where
television advertisements and pharmacist influence
play a large role in influencing purchasing decision.
31
However, in Pakistan this applies to prescription
drugs also especially antibiotics which are bought
largely as OTC medications usually on the recommendations of a chemist, family or friend. We recommend
that this trend should also be explored in a separate
study as this factor is a major role player in purchasing
medicines.
Our research has been done with the aim to focus on

consumer attitude towards the purchase of prescription
medicines. We assessed consumers in four categories
namely consultation with a doctor, consultation with a
chemist, awareness & availability of medicine in association with insurance.
Our study found that a majority of the consumers
belonged to the ages ranging from 18-33 years. By
contrast a similar study done in the British population
found that 67% of the customers were 3544-year-olds
& 75% were 6574 year-olds. 21, 22
Out of the 544 people we surveyed, only 44.7% were
insured. In our study a majority of people regardless of
insurance status disagreed that they would still buy a
medicine if it was expensive (p= 0.0001). Another interesting finding was that the a majority of the insured
group said they would consult their doctor for a low
priced alternate if the prescribed medicine was expensive (53.1%) thus highlighting the fact that price was an
important consideration for them despite having insurance. A study done by Shrank in 2009 on people who
were insured found that though a majority (94%) knew
that generics were lower priced as compared to branded medicines only 37.6% said that they would buy a
generic drug which is low priced. This finding reinforces the fact that if out of the pocket expenses were
covered insured patients would were more likely buy a
more expensive drug which is in contrast to our study.
The reason for this was found to be the belief that
branded drugs are more effective. This study also
found that wealthiest patients preferred generics more.
This finding has similarities with our study and highlights the fact that even if price was not an issue the
wealthier customer was still price conscious. 23Another study found that people aged less than 60 years of
age who had been covered by insurance for prescription charges were twice as likely to purchase their
prescription medicine as compared to those who had
to pay out of the pocket expenses. 24, 21A study
conducted in USA on Medicare insured patients found
that 40% thought that they were paying the right
amount for their medicines while 30% felt that they paid
too much despite being insured. 25
The opinions of a doctor or pharmacist also play an
important role in influencing consumer behavior. In our
study majority of the people from both categories disagreed that they would only consider the recommendations of a doctor (p=0.002) & would consult for quality
with their doctor (p=0.001). By contrast when a chemists role was taken into account a majority of people in
both categories agreed that they would consult with
their chemist for another low priced alternate
(p=0.0001) & if a chemist recommends a low price
medicine they would purchase it (p=0.04). Similar studies done have found that the pharmacists recommenVol.01, issue 01, Jan-April 2016
22
J Pak Health Soln
Conclusion
Our study concludes that being insured or uninsured had no effect on consumer behavior and overall purchasing
decision. A low priced product & chemists opinion were found to be an important consideration when purchasing
medicines regardless of insurance status.
Disclaimer: None
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J Pak Health Soln
Original Article
Leadership Competencies Of Managers Working
In Healthcare Sector Of Karachi
Aeysha Umar Siddiqui1, Shazia Azhar2, Farah Ahmad3, Minhaj Ahmad Qidwai4, Syed Hasan Danish5,
Abstract
Objective:
To assess leadership competencies of managers working in healthcare sectors of Karachi.
Method:
A cross sectional survey among healthcare managers in private and government tertiary care hospitals
was conducted using purposive sampling technique. Employees belonging to upper and middle management were taken into the study while those refusing consent were excluded. A self administered questionnaire was used to collect data. Data was entered on Microsoft excel 2010 and transformed after editing
to SPSS version 20 for analysis. . Frequencies and percentages were taken for categorical variables and
mean and standard deviation was calculated for numerical variables. Association between categorical
variables was assessed through application of chi square. p value less than 0.05 was taken as significant.
Permission was taken from the ethical review board of hospitals for conducting the study.
Results:
Majority of males 66% (n=91) as compared to females 34% (n=47) were found to be more competent but
experts were seen equally in both gender. Middle management participants were more competent
64%(n=88) and expert 70%(n=14) in leadership qualities as compared to upper management where
36%(n=50) were competent and 30%(n=6) were experts. Those who were solely in administrative departments showed more competency 74% (n=102) and expert levels 75% (n=15) in leadership. When compared among Government and Private organization more competent 78.3% (n=108) and expert leaders
85% (n=17) were observed in private sector.
Conclusion:
Competent style was most common leadership style in participants. Middle management participants
were more competent and expert in leadership qualities as compared to upper management.
Keywords:
Leadership, Healthcare Managers, tertiary care hospital
Siddiqui A U, Azhar S, Ahmad F, Qidwai M A, Danish S H. Leadership qualities of managers working in

healthcare sector of Karachi. Pak J Health Solns 2016; 1 [24-8]:
Syed Hasan Danish 4Community Health Sciences Department Ziauddin University,

Email: dowite_hasan@hotmail.com
Postgraduate Diploma in Health Management, Institute of Business Administration

, Department of Community Health Sciences, Ziauddin University, Karachi
Director, PGD in Health Management, Institute of Business Administration
1, 2,
3, 5
4
24
J Pak Health Soln
Introduction
In the midst of rapid technological advancements along
with the ever increasing demands being put on our
Health Service Organizations, healthcare managers
are finding themselves directly on the frontline facing
the impact of these changes.1 No one can argue that
now more than ever is the need for healthcare managers to step up and lead with great leadership skills.2
Several researchers have accounted that in the current
climate change, healthcare managers simply cannot
afford to manage without having the ability to lead
effectively.2 Health service organizations have reputedly been known to thrive under great leadership. Yet
some have faced considerable difficulty and even
failure when leadership has been poorly performed.3
Naturally this begs to ask the question, how do you
differentiate between a manager and a leader?
Leadership has been described as a process whereby
an individual endeavors to influence a group by driving
them towards achieving a common goal.2 Thus in order
to perform; a manager must wear several different hats
to execute the task at hand. According to Shortell &
Kaluzny leadership is the central role of a manager
however; other aspects of a managerial role will
include the ability to process information, prompt decision making skills and a vision.2 Yet, none of the above
mentioned will have the intended impact unless the
manager first becomes an effective leader.2
Past studies have shown that undertaking a leadership
role in a healthcare environment can be a resistive and
a complicated task.3 A study conducted in US ten years
ago by the Institute of Medicine showed that the rigidity

of the hierarchal healthcare system led to discouraging
effective teamwork.3 Numerous specialty groups have
been viewed as separate entities from one another, all
the while believing that resisting change and reducing
variation will lead to a better performance.3 Therefore,
a good manager needs to capitalize on the diversity
that lies within a healthcare organization by using a
number of leadership models and approaches to maximize good management amidst a highly complex environment.4 Current research shows that to avoid a crisis
in healthcare leadership and to lead towards a progressive healthcare systems investment should be made in
leadership development for entire senior management
teams, rather than just focusing on an individuals leadership skills.5 Thus, a new form of leadership is now
required to be performed and practiced by healthcare
managers in order for organizations to successfully
function in the current ambiguous times known as
Transformational Leadership. 6, 7
Currently with economic and market changes taking
place, organizations are unable to survive without good
leadership skills.8 There are certain traits and qualities
that good managers must possess for an organization
to succeed. At present there is a gap in literature in
leadership qualities of healthcare managers employed
in Karachi. Hence we conducted this study to investigate the leadership qualities and skills present in
healthcare managers working in a healthcare setting in
Karachi.
Methods
A cross sectional study was conducted among two
tertiary care hospitals of Karachi including private and
government hospitals. A total of n=235 managers were
identified from the hospitals, whereas the final sample
size was n=190 after refusal for participation from certain
individuals. The study was carried out for a period of 6
months. Data was collected using Purposive sampling
technique. Our inclusion criteria were all employees who
were working as healthcare managers; directly involved
in working in a hospital care setting and belonging to
upper or middle management. Employees who did not
consent and those absent while data was being collected were excluded from the study. After receiving
informed consent data was collected using a self-administered questionnaire to assess leadership qualities
among participants. The questionnaire was developed
through extensive literature search. This study was

based on an opinion based leadership questionnaire
design and referenced from the American College of
Healthcare Executives Competencies Assessment
Tool.9 Based on the scores leadership competency
were labeled as Novice, Competent and Expert. Data
was entered on Microsoft excel 2010 and transformed
after editing to SPSS version 20 for analysis. Before
analysis data was checked for data entry errors.
Frequencies and percentages were taken out for categorical variables and mean and Standard Deviation was
calculated for numerical variables. Association between
categorical variables was assessed through application
of chi square. P value less than 0.05 was taken as significant. Permission was taken from the ethical review
board of hospitals for conducting the study.
Results
A total of n=190 participants were recruited in the study.
Participants who were working in different managerial
positions were recruited in the study. The mean age of
the sample was 45.88.2 years. Of total participants
60% were males (n=114) while 40% were females
(n=76). Thirty eight percent participants (n=72) were
from upper management while the remaining 62%
(n=118) were from the middle management. When
nature of job was inquired 29.5% (n=56) were conducting both clinical and managerial task, 68.4% (n=130)
were exclusively from the administrative side while only
2.1% (n=4) were from academic side as well as
running managerial position. When the academic qualVol.01, issue 01, Jan-April 2016
ification of the participants were assessed 26.8%

(n=51) were having a medical degree, another 28.9%
(n=55) were from paramedical side including those
with nursing diplomas and technicians while remaining
44.2% (n=84) were having exclusively non- medical
related qualification. Of total participants 76.8%
(n=146) were from private sectors while 23.2% (n=44)
were from Government health care organizations.
When leadership competencies were associated with
different attributes of the participants it was found that
majority of the males 66% (n=91) as compared to
females 34% (n=47 ) were found to be more competent
but experts were seen equally in both gender.
25
J Pak Health Soln
Interestingly middle management participants were

more competent 64%(n=88) and expert 70%(n=14) in
leadership qualities as compared to upper management where 36%(n=50) were competent and merely
30%(n=6) were experts. When nature of job was
considered those who were solely in administrative
departments showed more competency 74 %( n=102)
and expert levels 75% (n=15) in leadership. When
academic qualification were affiliated with leadership

competency those who had paramedical background
showed the highest expert leadership qualities 50%
(n=10). Likewise when compared among Government
and Private organization more competent 78.3%
(n=108) and expert leaders 85% (n=17) were observed
in private sector.
Novice
17%
73%
10%
Expert
Competent
Fig1 Participants Leadership Competency

Table 1: Association of Demographic factors with Leadership Competency of Participants
Age
Up to 40 Years
40- 50 Years
Greater than 50 Years
Gender
Male
Female
Department
Clinical +
Management
Academics +
Management
Administration
Educational Background
Medical Doctors
Paramedical Staff
Non-Medical staff
Type of Institute
Government
Private
Designation
Upper Management
Middle Management
Pvalue
17
12
3
29.3
17.1
4.8
34
50
54
58.6
71.4
87.1
7
8
5
12.1
11.5
8.1
0.006
13
19
11.4
25
91
47
79.8
61.8
10
10
8.8
13.2
0.020
17
30.4
34
60.7
8.9
0.005
2
13
50
10
2
102
50
78.5
0
15
0
11.5
6
14
12
11.8
25.5
14.3
39
31
68
76.5
56.3
81
6
10
4
11.8
18.2
4.7
0.016
11
21
25
14.4
30
108
68.2
74
03
17
6.8
11.6
0.205
16
16
22.2
13.6
50
88
69.4
74.5
6
14
8.3
11.9
0.261
Discussion
control in dynamic and demanding healthcare environment and become effective leaders within healthcare
organizations today.11
Interestingly, the study found that middle management
understood and recognized the qualities and attributes
of a transformational leader, much better than the
upper management. As a result, middle management
participants were more competent 64%(n=88) and
expert 70%(n=14) in leadership qualities as compared
to upper management who were 36%(n=50) competent and merely 30%(n=6) were experts.
As the saying goes If you want to build a ship, do not

drum up the men to gather the wood, divide the work
and give orders. Instead, teach them to yearn for the
vast and endless sea In a similar context it can be
seen that a good leader can renovate organizations by
fostering and nurturing the creation of a shared
vision and persist to generate a creative
tension between the existing reality and the ideal
vision in order to motivate people to work towards
improvement.10 Studies have identified this style of
leadership as transformational and that it is a key
leadership style that will enable managers to take
26
J Pak Health Soln
Currie and Procter conducted a study and developed

the works of Floyd and Woodridge who found that
organizational performances were heavily influenced
by the middle management rather than the upper management. Their study was based on National Health
Service (NHS) in the UK.10
Subsequently, the above finding can be identified as
typical behavior expected from the organization structuring found within most healthcare organizations,
which function as a professional bureaucracy.12
According to the works of Mintzberg, organizational
structuring is defined as the sum total of the ways in
which an organization divides and coordinates its labor
into distinct tasks.12 Consequently, professional
bureaucracy is the manner in which these healthcare
organizations function. According to the Five Structure
Mintzberg Model in an organizational structure, the
role of middle management is to form a chain joining
the strategic apex to the operating core by the use of
delegated formal authority.12 However, it is the role of
upper management which is charged with ensuring
that the organization serves its mission in an effective
way, and also that it serves the needs of those people
who control or otherwise have power over the organization.4, 12
Alas, it was highly concerning to find that the competency in upper management in comparison to the
middle management was only 36 %( n=50) and merely
30 %( n=6) were experts. This was a critical finding as
it was emphasized by Currie and Procter.10 that professional bureaucracy limits the role of middle management, as they do not have the freedom or the power to
manage strategically, on the other hand upper management (such as administration) have the freedom
and the power to shape policies and develop strategies
geared towards quality in healthcare for patients.10, 12
Keeping this in account it was therefore interesting to
find that Managerial way of leadership also known as
transactional leadership style were better at adherence to policy but were not open to innovation within
their working environment since it is only based upon
reward and punishment strategy.11, 13 A study conducted by Spinelli in 2010 evaluated empirically in the
hospital administrative environment the relationship of
leadership behaviors to subordinate manager's
perceived outcomes, through examination of B. M.
Bass's (1985) model of transformational, transactional,
and laissez-faire leadership. Findings of the study
revealed that the relationship between transformational
leadership and the outcome factors were far stronger
and more positive than were the transactional leadership styles. This was due to transformational leaders
ability to relate to their environment by understanding
how their work impacted their team members and
others around them.13
In a similar study, Dunham-Taylor&Janne14 examined a
sample of 396 nurse executives which found that the
executives who choose transformational leadership
style to manage their teams achieved better staff
satisfaction and higher work group effectiveness as
compared to those who did not. On the contrary, staff
satisfaction and group effectiveness decreased for
nurse executives who chose to lead as transactional
leaders.14 In addition it was found that nurse executives
who had higher transformational scores were associated with higher educational degrees and were practicing in more participative organizations.14 This result
corresponds with our study findings that when
academic qualifications were affiliated with leadership
competency those who had paramedical background
showed the highest expert leadership qualities. In
addition, our study found that when compared among
Government and Private organization more competent
78.3% (n=108) and expert leaders 85% (n=17) were
observed in private sector which are perceived as
being participative organizations. To emphasize this
association further, a study was conducted in Australia
using a sample size of 5979 employees indicating that
the government employees rate the quality of their
work experience significantly below the level of their
private sector counterparts.15
Finally, it was found in this study that when nature of
job was considered as expected those who were solely
in administrative departments showed more competency 74%(n=102) and expert levels 75% (n=15) in
leadership compared to those 29.5% (n=56) were
conducting both clinical and managerial task, 68.4%
(n=130). According to Lawson and Rotem, being a
health service manager has a range of characteristics
that differentiate it from many other types of management. These characteristics include knowledge of
hospitals and health services, their values and their
culture. However, the transition from clinician to manager can present itself as practically difficult task in
nature. The main area of difficulty is to find the right
balance between the requirement of managers to
place the welfare of the organization as the highest
priority and the conditioning of clinicians, to place to
patient as the highest priority.16 Hence, it was to no
surprise to a certain extent that administrative members of management were found to be more competent
in comparison to clinician managers.16
Can healthcare organizations in Karachi become great
places to work for? - A charming notion, but at the heart
of such a concept it should be seen that good leadership qualities in healthcare managers should essentially bring trust and mutual respect between senior executives and their employees and encourage value
driven leadership. Moreover, a commitment should be
shown by the Chief Executive Officer and senior management with a genuine belief that people are dispensable for their organization. Active communication
among the entire organization should be the key and
sensitivity towards a unique culture and identity should
lead from a well -articulated vision and values to be
experienced at all levels of the Organization. Henceforth, if we are able to bring all of these elements
together, leadership will move leaps and bounds in its
entirety within Healthcare Organizations not just in
Karachi but throughout Pakistan.
To conclude, it can be said that transformational style
leadership where the manager is more of an inspirational leader working along with the team holds the key
for health care service managers to successfully lead
in organizations not only in Karachi but throughout
Pakistan today that are being faced with constant
change and challenge on an everyday basis.
27
J Pak Health Soln
Conclusion
As compared to Novice and Expert categories all age
groups showed more competent style of leadership.
Middle management participants were more competent and expert in leadership qualities as compared to
upper management. Those in administrative depart-
ments showed more competency and expert levels in

leadership. Among Government and Private organization more competent and expert leaders were
observed in private sector.
Disclaimer: None
References
1. Leat P, Porter J. Where are the healthcare leaders"
the need for investment in leadership develop
ment. Europe PMC 2003; 4[1]: 14-31.
2. Roberts C. Manager or Leader? Capitalize on the
best of both!. Europe PMC 2005; 19 [3] E: 4.
3. Leape L, Berwick D, Clancy C, Conway J, Gluck P,
Guest J et.al. Transforming healthcare: a safety
imperative. BMJ 2009; 18 [16]: 424-28.
4. Pointer DD, Sanchez JP. Leadership: A Frame
work for Thinking and Acting. In: Shortell SM,
Kaluzney AD: Healthcare Management Organiza
tion Design and Behaviour. 4th ed. New York:
Delmar 2000; 107-26
5. Al-Sawai A. Leadership of Healthcare Profession
als: Where Do We Stand?. Oman Med J 2013; 28
[4]: 285-87.
6. Plsek EP, Wilson T. Complexity, leadership and
management in healthcare organisations. BMJ
2001; 323 [7315]: 746-49
7. Dowten SB. Leadership in medicine: where are the
leaders? MJA 2004; 181 [11/12]: 652-54.
8. Stewart DW. Leaders Managers and Employee
Care. 2012; 31 [1]: 94-101.
9. ACHE Healthcare Executive Competencies
Assessment Tool 2015. Healthcare Leadership
Alliance and the American College of Healthcare
Executives 2014; 1-28.
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10. Currie G, Procter S J. The Antecedents of Middle

Managers Strategic Contribution: The Case of a
Professional Bureaucracy. Journal of Management
Studies 2005; 42[7]: 1325-56.
11. Aarons G A. Transformational and Transactional
Leadership: Association with Attitudes toward
Evidence-Based Practice. PMC 2006; 57 [8]:
1162-69.
12. The Professional Bureaucracy In: Henry Mintz
berg: Structure In Fives Designing Effective
Organizations. 2nd ed. United Kingdom: Pren
tice-Hall 1992; 189-213.
13. Spinelli RJ. The Applicability of Bass's Model of
Transformational, Transactional, and Lais
sez-Faire Leadership in the Hospital Administra
tive Environment. Taylor & Francis 2006; 84 [2]:
11-9.
14. Dunham T, Janna P. Nurse Executive Transforma
tional Leadership Found in Participative Organiza
tions. JONA 2000; 30 [5]: 241-50.
15. Cacioppe. R, Mock P. A Comparison of the Quality
of Work Experience in Government and Private
Organizations. Sage 1984; 37 [11]: 923-940.
16. Lawson. J, Rotem. A. From Clinician to Manager
an Introduction to Hospital and Health Service
Management. 2nd ed. Australia: Mcgrew Hill 2004;
1-73.
J Pak Health Soln
Original Article
Comparison Of Expanded Program Of Immunization (EPI)
Coverage Among Children Less Than Two Years In Rural and
Urban Population Of Hasilpur, Pakistan
Mubarak Ali1, Farah Ahmad2, Syed Hasan Danish3, Dr. Minhaj Ahmed Qidwai4
Abstract
Objective:
To assess frequency of Immunization, knowledge and perceptions of residents in urban and rural areas
of Tehsil Hasilpur
Method:
A cross sectional study was conducted in 2014. The study setting was district Hasilpur and target population was both urban and rural population. A total of n=450 participants were recruited through cluster sampling technique. For sample selection parents having children of less than 2 years of age and only
residents of Hasilpur Tehsil were included while refusal of consent by participants, language barrier and
house locked at the time of data collection were excluded. Data was analyzed on SPSS version 20.
Results:
It was observed that n=221(98.2%) children less than 2 years from urban areas and n=211(93.7%) from
rural areas were vaccinated. Knowledge of parents regarding individual vaccines in EPI was far greater
in urban participants as compared to rural ones. When perception was seen it was observed that
n=212(94.2%) of urban participants as compared to n=161(71.5%) deemed vaccination in EPI as mandatory. In urban areas n=159(70.6%) whereas n=104(46.2%) in rural areas accepted that children will suffer
from diseases if EPI vaccination schedule is not followed. Regarding regular vaccinators visit at home in
urban areas n=187(83.1%) compared to n=146(64.8%) in rural areas acknowledged it.
Conclusion:
Urban dwellers are more knowledgeable regarding EPI program. Perception regarding the importance of
EPI Program was similar in rural and urban areas. Majority of urban and rural residents were vaccinated
according to EPI schedule.
Keywords:
Vaccination, EPI, Urban, Rural, Under 2 years
Ali M, Ahmad F, Danish SM, Qidwai MA. Comparison of Expanded program of immunization (EPI) coverage among children less than two years in rural and urban population of Hasilpur, Pakistan. Pak J Health
Solns 2016; 1 [29-3]: follow the comment above
Dr. Mubarik Ali, Medical Officer District Hasilpur, Health Department, Punjab,
Email:drmubarik169@yahoo.com
Medical Officer, Health Department, Punjab

Institute of Business Administration
2, 3
4
29
J Pak Health Soln
Introduction
Pakistan is ranked among the top countries where
mortality among infants and under five children is still
considered very high with death among children emanating to as high as 1 in 11 for those less than 5 years
age .1 Most of these deaths are attributable to vaccine
preventable diseases. If the Expanded Program on
Immunization (EPI) is not sustained, everyday around
1000 children will lose their lives .2 EPI was launched in
Pakistan in 1978 to protect children by immunizing
them against tuberculosis, poliomyelitis, diphtheria,
pertussis, tetanus(DPT) and measles.3 The EPI coverage in Pakistan is about 80% for first injection of BCG,
65% for DPT and polio and about 67% for measles.4
The Tetanus Toxoid (TT) coverage of pregnant women
is 56% which is very low.4 In Punjab three million
children & 19.5 million mothers of child bearing age
(CBAs) are being protected against these diseases. 2
Overall trends in coverage of fully vaccinated children
ages 12-23 month has been increasing where coverage was 35% in 1990-91and 47% in 2006-7 compared
to 54% in 2012-2013 however rural areas had lower
(48%) coverage than in the urban (66%).3
Studies are relatively scarce when immunization
coverage is taken into account with only few in Bangladesh, Belgium, Ethiopia, Cambodia and Thailand.
Literature review revealed that mothers living in the
rural areas have attenuated knowledge concerning EPI
along with misconceptions and this low coverage is

significantly associated with their education and low
accessibility. Urban areas displayed separate causes
for low coverage including busy parental schedule, and
lack of availability of medical/paramedical staff along
with scarcity of knowledge. 5-9A study among different
districts in Punjab in 2012 yielded unsatisfactory
outcomes with coverage merely 57.5%. 10
According to Millennium Development Goals mortality
should reduce to 2/3rd in 2015 as compared to year
2000. 2 Although improvement in programs have been
carried out in the last few years including auto disposable syringes, safety boxes for sharp disposals and
maintenance of cold chain 11 and Government of Pakistan is doing endeavors, immunization indicators have
yet to reach expected benchmarks.2 Routine vaccination coverage is still suboptimal because polio eradication, measles and neonatal tetanus elimination have
not been reached. This is evidenced by frequent
outbreaks of measles, diphtheria and Pertussis among
different parts of country.2 Since we are still far away
from achieving Millennium Development goal 4 related
to infant mortality, this study will explore the awareness
of parents regarding EPI Program and frequency of
complete immunization for children under 2 years of
age.
Methods
The cross sectional study was conducted in the population of rural and urban areas of Tehsil Hasilpur. The
target population was parents of children under 2 years
of age with duration of six months for data collection.
The sample size was calculated by the following formula
and by using Openepi software respectively.
randomly from the list of villages. Each cluster had 15

participants. For sample selection parents having
children of less than 2 years of age and only residents
of Hasilpur Tehsil were included while refusal of
consent by participants, language barrier and house
locked at the time of data collection were excluded.
The criterion for complete vaccination was taken as
vaccination till the second dose of measles. For data
collection proforma was developed for quantitative
analysis which covered the demographic profile of the
child and awareness of parents regarding EPI vaccination. For collecting data a local team of two persons,
one male and one female, trained in data collection
took personal interviews of the participants. For analysis, the original data was entered on MS Excel and
after editing transferred to SPSS version 20. The
research was cleared through the ethical review board.
Informed consent were taken from the participants and
the nature of the study was explained to them. From
Ministry of health Punjab (deputy district officer Health,
Hasilpur) permission was taken for conducting the
study.
N=z2xpx(1-p)
d2
Where z=1.96 was taken at 95% confidence level,

prevalence of immunization was taken at 57%4 and the
bound of error was 5%. The calculated sample size
was n=376, which was increased to n=450 after applying 20% attrition.
The Cluster random sampling technique was used (30
cluster sampling technique) 13.First the sample size
was divided into two equal halves, n=225 from both
urban and rural areas. Our total clusters were 15 from
the urban and 15 from the rural areas. Since Hasilpur
Urban is divided into 18 wards, 15 clusters were selected from 15 randomly selected wards. While Hasilpur
Rural has 111 chak (villages) 15 villages were selected
Results
There were total n=450 parents, n=225(50 %) from
urban and n=225(50 %) from rural population of Tehsil
Hasilpur having children less than two years included
in the study. Children under study were n= 218 (48.4%)
boys and n=232 (51.6%) girls. Small number of parents
were either separated or divorced n=28 (6.2%). When
educational status of parents were assessed, mothers
almost half n=218 (48.4%) were illiterate as compared

to fathers where one third n=146 (32.4%) were illiterate. Almost half of the participants had one child n=222
(49. 3%). It was observed that from urban localities
n=221(98.2%) and n=211(93.7%) from rural residential
areas were routinely vaccinated.
30
J Pak Health Soln
It was further observed that n=225(100%) of urban

population and n=216(96%) of rural population had
heard of Expanded Program of Immunization. When
knowledge regarding different EPI included vaccines
was assessed, maximum participants n=449 (99.8%)
knew about poliomyelitis whereas pneumonia was

least known by the participants n=318 (71%). Association of mothers educational status with Knowledge of
vaccines in EPI is presented in figure 1.
Fig 1: Association of mothers educational status with knowledge regarding vaccine preventable diseases (%) (P value ***)
26
74
26
74
36
64
33
67
31
69
27
73
26
74
38
62
51
42
Table 1: Perception regarding vaccination in EPI

Mandatory
n
Optional
Do not know
Urban
212
94.2
3.1
2.6
Rural
161
71.5
34
15.1
30
13.3
Fig 2: Knowledge regarding consequences if child is not immunized
31
J Pak Health Soln
When inquired regarding visit of vaccinators at home it

was seen that in urban areas n=187(83.1%) compared
to n=146(64.8%) in rural areas acknowledged that
vaccinator visits their homes regularly. It was seen that
in urban areas n=155(68.8%) while in rural areas
n=107(47.5%) stated that vaccinator informs them of
their next scheduled date for vaccine. Among urban

areas residents stated that n=155(68.8%) while in rural
areas n=109(48.4%) vaccinators inform regarding the
side effects of vaccines. Consequences of unvaccinated children with regards to their health are demonstrated in figure 2.
Discussion
From our research it was found that urban population
were better acclimatized as compared to rural population with the possible health consequences for unvaccinated children. Before our study work has been done
on missing or low vaccination in other regions of Pakistan where the main causes highlighted were laziness
of parents, mother being busy, minor illness of children,
religious beliefs and adverse effects of vaccines. 12
Another issue represented in our study that in urban
population parents took keen interest in asking questions about the schedule of visiting, revisits of vaccinators and side effects of vaccines. Although this type of
study has not been done before but similar type of
study was done in the Karachi and Peshawar on the
absence of vaccinators, inconvenient EPI centers,
poor quality care fear of side effects and lack of faith in
the immunization program.12
The first strength of the study was that the main investigator had involvement during the whole study as data
were collected under the direct supervision of principle
investigator. Secondly data collection tool was utilized
in local language. Data is scarce on studies where
urban and rural areas have been taken into account.
Based on the results of our study there should be more
vaccinators in the rural areas and allocations of more
resources in the rural areas with recruitment and selection of more Lady Health Workers in the rural areas.
Health administration should have more billboards,
health programmes should be conducted in compatible
socio cultural context for effective reception while
sensitizing the community directly involving community
health workers for regular reminders.
This study showed that in the urban areas the coverage of EPI was 98.2% (n=221) of urban population and
93.7% (n=211) of rural population. However previous
studies showed that EPI coverage in Pakistan is about
80% for first injection of BCG and 65% for DPT and
polio and about 67% for measles. 4 Another study
conducted in four regions of Pakistan showed that EPI
coverage is 48%. 11 In Punjab overall coverage of fully
vaccinated children aged 12-23 months was 35% in
1990-91 and 47% in 2006-7 compared to 54% in
2012-2013 however similar to our studies rural areas
had lower (48%) vaccination coverage than in the
urban areas(66%).3
When knowledge was assessed regarding EPI, 90%
showed ample knowledge. However knowledge of
Urban parents was more than rural parents.
Regarding EPI knowledge more than 90 % population
of the rural areas displayed knowledge. Knowledge of
parents better was much better in urban population as
compared to rural population. Only for Polio, excellent
results were obtained as 100 % of population from both
urban and rural areas had knowledge about it. A similar
study was done in Karachi in which knowledge of
parents was studied in the urban and rural area.
Results showed that the population in the peri urban
areas were better that urban areas while it was also
eminent that educated mother care for their children
better as compared to illiterate mother. Similar studies
were done in Peshawar on this topic and internationally
some studies have been performed in Bangladesh,
Belgium, Ethiopia, Cambodia and Thailand. These
studies were done mainly on coverage of immunization
in children under 5 years children but nothing was done
on comparison in the rural and urban population.6, 12
Conclusion
Knowledge of EPI vaccines was more in urban areas as compared to rural areas. However both urban and rural
areas had more than 90% compliance with vaccination according to EPI schedule.
Disclaimer: None
References
1. Navaratne KV. The Expanded Program on Immu
nization in Pakistan. HNP Discussion Paper.
Washington. World Bank; 2012 Apr.
2. Punjab government health department. Children
dying because of preventable diseases.[Online]
Available from: http: www.health.punjab.gov
.pk.[Accessed: 5 October 2014].
3. Mahmood A, Sultan M. National Institute of Popu
lation Studies (NIPS)(Pakistan), and Macro Inter
national Inc. Pakistan Demographic and Health
Survey. 2006; 7:123-45.
2004.United Nations International Children Edu

cation Fund. Report Number: 63, 2004.
5. Vellinga A, Depoorter AM, Damme P. Vaccination
coverage estimates by EPI cluster sampling
survey of children (1824 months) in Flanders,
Belgium. Acta Paediatrica. 2002 May
1;91(5):599-603.
6. Rahman MM, Islam MA, Mahalanabis D. Mothers'
knowledge about vaccine preventable diseases
and immunization coverage of a population with
high rate of illiteracy. Journal of tropical pediatrics.
1995 Dec 1;41(6):376-8.
4. Carol Bellamy. State of the World Children

32
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7. Gedlu E, Tesemma T. Immunization coverage and

identification of problems associated with vaccina
tion delivery in Gondar, north west Ethiopia. East
African medical journal. 1997 Apr;74(4):239-41.
8. Bhunbhu T. Expanded programme on immuniza
tion in Thailand. Review of Infectious Diseases.
1989 May 1;11(Supplement 3):S514-7.
9. Main B, Lower T, James R, Rouse I. Changes in
Expanded Program for Immunization coverage for
mother and child in Krakor, Cambodia 19961998.
Tropical Medicine & International Health. 2001 Jul
33
1;6(7):526-8.
10. Lillah HS. Religious Extremism in Pakistan. Naval
postgraduate school Monterey CA; 2014
11. World Health Organization. Cancer control: knowl
edge into action: WHO guide for effective
programmes. World Health Organization; 2007
12. Siddiqi N, Khan A, Nisar N, Siddiqi AE. Assess
ment of EPI (expanded program of immunization)
vaccine coverage in a peri-urban area. JPMA.
2007 Aug;57(8):391-5.
J Pak Health Soln
Review Article
Human Population, Climate Change and Human Health
Farah Ahmad1, Imran Samee Waraich2, Noor Hussain Gichki3, Shoaib Malik4,
Umair Ali5, Muhammad Usama Zafar6
Abstract
It is important to appreciate how changes in climate have affected human health from time immortal.
Global warming is largely because of increase in human activity. The worlds population has doubled
since 1965 and with the current growth rate every year 80 million people are added to the population
world bank. Geographical shift in disease patterns specifically associated with vector borne diseases is
evident from researches conducted throughout the world.
Keywords:
Leadership, Healthcare Managers, tertiary care hospital
Ahmad F, Waraich IS, Gichki NH, Malik S, Ali U. Human Population, Climate Change and Human Health.
Pak J Health Solns 2016; 1 [34-7]:
Umair Ali5 Training Staff Officer. Armed Forces Institute of Cardiology, Rawalpindi.
Email:alisq2002@hotmail.com

Commanding Officer, 74 Medical Battalion, Kharian
3
Provincial Campaign Support Officer, PEI WHO Baluchistan
4
Admin Officer, CMH Malir, Karachi
5
Training Staff Officer, Armed Forces Institute of Cardiology, Rawalpindi
6
Visiting Faculty, College of Physicians and Surgeons, Pakistan
1
2
33
J Pak Health Soln
Introduction
The major dimensions of any complex human problem,
including climate change, are the human population,
economics, culture, and environment. The amplification in the green house gases over the last century is
proportional to the increase in human activity. Connoisseurs of the field agree that this build-up of greenhouse
gases has added 1.3 degrees Fahrenheit in the Earths
average surface temperature over the century. Continuation of this build-up will cause further warming and
induce additional changes in the climate system that
would be huge with what we have observed in 20th
Century.1 The worlds population has doubled since
1965 and with the current growth rate every year 80
million people are added to the population world bank.
Demographers at the United Nations project this
growth will continue and future estimations are in the

range of 7.8 billion to 10.8 billion by 2050.2 The largest
single threat to the ecology and biodiversity of the
planet in the decades to come will be global climate
disruption due to the buildup of human-generated
greenhouse gases in the atmosphere.3
The altering weather conditions can have detrimental
effect on agriculture, fisheries, ecosystems, health,
energy demand and air quality, and increases the risks
of wildfires around the world. The changing climate
also not only affects the living environment but holistically involves human settlements, food production and
diseases.2
Methods
A thorough study of numerous recent and not so recent
researches published worldwide was done. These
researches had all been published in the indexed
journals and were searched in Pubmed and Google
Scholar. Also several articles were searched which highlighted the climatic changes and human health in several different fields of medicine and in different regions of
the world. Some researches that analyzed the number
of different types of articles on the topic that have been
published in specific journals in recent years were also
studied. Therefore about sixty articles were screened
and from that about thirty five studies have been included in this review. The keywords that yielded the best and
most relevant articles were environmental changes and
human health. The filters were also applied. All the
articles that were published within the last 20 years were
preferred. Abstracts and full texts both were included in
the search. No filter was applied for article types as we
had to analyze all the work that had been done previously which highlighted the importance of any specific article
type over the others.
Discussion
can break this chain and changes in weather may have
an effect on communicable diseases through upsetting
this chain of infection. Several studies have highlighted
that the continuing global warming tends to favor
geographic spread of a number of communicable
diseases and in future this trend will be observed in the
clustering of disease outbreaks at their original distribution in terms of time, place and person or in fresh areas
where the said disease occurrence is rare.5, 12-14
Disease vectors namely arthropods are influenced by
climate changes which will eventually alter the vector
borne disease current pattern of distribution. Arthropods being cold blooded are greatly influenced by
ambient temperature. Profound effect will be observed
on the vector population which eventually influences
the occurrence of vector borne diseases like malaria,
dengue, encephalitis and plague.15, 16
Health and well being of human populations is greatly

influenced by weather changes and with special reference to communicable diseases which are significantly
affected.4-10 The triangular model which best explains
the infectious disease occurrence necessarily needs
three components: agent, host and environment.10 The
role of climate is evident in the life cycle and breeding
of pathogens and their intermediate hosts. Apposite
climate and weather conditions are vital for all the
vectors, host and disease pathogens in terms of endurance, reproduction, distribution and transmission. In
order for infection and disease to occur in an individual,
a process involving six related components: pathogen
(infectious agent), reservoir, portal of exit, means of
transmission, portal of entry, and the new host must
occur. This process has been referred to as the Chain
of Infection. 10,11 Any disruption in the chain of events
Historical Evidence of Influence of Climate Change on Human Health

The evolution of infectious disease epidemiology from
early eighteenth century implicated the role of climate
in disease occurrence. Late in the nineteenth century
Roman aristocrats retreated to hill resorts each
summer to avoid malaria. South Asians learnt early
that, in high summer, strongly curried foods were less
likely to cause diarrhea.
Malaria from time immortal has been of highest
concern as far as the vector borne diseases are
involved and Public Health has always given it due
share of importance with the results that control measures are maintained. This disease has shown its maximum affinity to climate change as compared to other
mosquito affiliated diseases. In prevalent areas, climatVol.01, issue 01, Jan-April 2016
ic deviations have lead to variations in the cases of

malaria. South Asia being endemic to Malaria is home
to a number of researches that have sought a linkage
between weather fluctuations and malaria episodes.
Last century is witness to this phenomenon where
cyclic episodes of malaria in places irrigated by river
water especially in Punjab were accounted for. Early
researches have clearly highlighted the association
between monsoon rains, high humidity and increase in
number of mosquito breeding sites and ultimately their
survival. The same trend is seen in current malaria
outbreaks and propensity of their occurrence after an
El Nino episode.1
34
J Pak Health Soln
Current Evidence of Influence of Climate Change on Human Health

El Nino and Health
El Nio Southern Oscillation (ENSO) is a weather
episodes has dire consequences on human health.
phenomenon that starts in the Pacific Ocean but has
This phenomenon is well explained by the malaria
an extensive range of consequences for weather
epidemics in South Asian and American countries and
around the world, and has special predilection to
the increase risk of cholera outbreaks as a result of
droughts and floods. It cycles with a frequency of 27
ENSO. Time series correlation studies conducted to
years and is considered as the strongest driver for
find association between ENSO and disease frequenweather changes throughout the world. Public Health
cy best explains this observable fact. However the
is significantly influenced by the climatic changes espeanalysis shows highest correlation with malaria and
cially the irregular El Nio and La Nia events. Worldcholera as compared to other vector borne diseases
wide the occurrence of natural disasters during El Nino
which are caused by rodents and mosquitoes.17
Climate Change and Vector borne diseases
Climate changes affect the distribution of vector across
the globe. As temperature continues to raise vectors
living in plains and low lying areas may find their way in
high latitude regions making new habitats and transporting viruses which were not endemic in that region
giving rise to the geographical expansion of diseases
unknown in those areas. This trend has been observed
for malaria, African trypanosomiasis, Lyme disease,
tick-borne encephalitis, yellow fever, plague, and
dengue.18 Majority of these diseases have surpassed
their natural distribution and have ventured into areas
of higher latitude following the expansion of the breeding sites of their natural vectors mosquitoes, ticks and
sand flies.
Oncomelania hupensis, the middle host of Schistosoma japonicum having their natural habitats in China
with the weather changes to extreme winters has
increased its boundaries of habitat to northern China.
Warmer temperatures and their association with the
spread of malaria and dengue among populations
Cholera Outbreaks
were best observed in 1997/98 Latin American

outbreaks of these two diseases. Augmenting daily
night time temperatures which is characteristically
exaggerated during El Nino events has a positive effect
on the growth of mosquitoes and ultimately the viruses
that they carry. These changes also help mosquitoes to
reach newer altitudes and effect populations who have
very little immunity against these parasitic diseases.19
The outbreaks of Leptospirosis in central America is a
consequence of heavy rains (Hurricane Mitch) which
drives the rodents from their burrows bringing them
closer to the human population. Another consequence
of heavy rains is cholera where mixing of drinking water
with impurities flushed with rain water causes epidemics of cholera.20
In Peru time series studies conducted for diarrheal
diseases in children shows substantial rise in cases
associated with warmer temperatures and 97-98 El
Nino.21
Similar findings were seen in the analysis of almost two

decades cholera time series conducted in Bangladesh
which showed temporal variability in cholera cases with
year to year variability a hallmark of ENSO.22
Dry climates are also capable of causing outbreaks of
cholera and other water borne diseases. Lack of clean
water can lead to an increase in case fatality due to
poor availability of drinkable water. Dry river beds can
lead to accumulation of microorganisms and a vicious
cycle involving poor hygiene will lead to development
of outbreaks and epidemics.23
patients which are more in number after a draught

rather than heavy downpour. Japanese Encephalitis
has also shown a drift in its distribution attributed to
climate change. 30
Extreme heat exposures
Direct effect of global warming in the form of heat
waves augment the number of deaths as was
observed in France in 2003.31 Heat waves increases
both morbidity and mortality specifically in Urban areas
as a consequence of heat island effect32 these findings
are consistent with the increase deaths in Australian
cities especially in old aged population above 65 years
of age.33,34
Another consequence of high temperature is heat
shock. Several studies conducted in Japan have
shown a positive association between high temperatures and increase in heat shock cases. A strong linear
association is observed when the temperature rises
above 32 degree centigrade.35
Tick borne encephalitis

Tick borne encephalitis has also shown shifts in its
distribution which is related to climate change. Altitudinal shifts have been reported in Sweden, Canada and
Czech Republic.24-27
Outbreaks of Murray Valley encephalitis which is
caused by mosquito borne virus has been reported
after heavy rainfall and flooding in southern Australia28
Heavy downpour which increases the breeding of mosquitoes also causes a rise in cases of Ross River fever
29 but the opposite is observed for chikungunya
35
J Pak Health Soln
Control Measures
1. The single most deterrent to the climatic change
will be from reduced reproduction in comparison to
the savings that can be accomplished through life
style modifications. The effects of the intervention
will be evident decades later. Developing coun
tries need to develop strategies to control popula
tion and bring it to replacement level at the least.
Family planning needs to be more in access to the
common man with easy access to the latest
contraceptive methods.
2. The destruction of the surface of the earth through
land use in the form of deforestation and husband
ing has greatly affected the environment in which
the host and vectors and parasites live. The exam
ples cited above are few yet convincing enough to
demonstrate the relationship between climate
variability and change in disease pattern. Increase
monitoring and surveillance is all the more
required to detect changes that may take place
due to cyclical variations in weather patterns.
3. Global warming is ongoing processes that cannot
be reverted measures are require more for adap
tation rather than mitigation.
4. In future, humans will remain at risk of diseases as
a sequel to climate change. The burden of which

will be brunt by poor and marginalized states as
they are the ones still fighting against the infec
tious disease burden. The time trend variations
will benefit some pathogens and will help in effect
ing more humanity on the other hand these chang
es may be detrimental to a number of pathogens
making their survival difficult and controlling the
spread of the disease. To keep ourselves abreast
of the situation and reducing the susceptibility of
the host adaptation measures are all the more
required for saving mankind. Two areas hold the
key for controlling the situation firstly improving the
socioeconomic standards of the society and
secondly for applying scientific measures that may
control the disease by itself. In this regard reliance
on observatory studies will not be enough they
need to be supplemented by analytical studies
that are able to explain the cause effect relation
ship.
Disclaimer: None
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J Pak Health Soln
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38
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Pakistan

Vol.01, issue 01, Jan-April 2016

Dr. Farah Ahmad

Dr. Syed Hasan Danish

Mr. Mushtaq Ahmad (USA)

Dr. Asif Mirza

Mr. Tayyab Raza Fraz

(Public Health Consultant)

Ms. Rabia Mahmood

Dr. Izhar M. Husain

Designing & Composing

Ms. Farah Waheed

(Director Center of Executive Education, IBA)

(Professor Ear Nose Throat)

Dr. Minhaj A. Qidwai

The impetus for launching a new medical Journal is the

Dr. Aiesha Ishaque

as a separate entity will be highlighted in this Journal. We

Zainab Dawood, Naeem Majeed,

Health Interaction and Consultation Outcome:

Shumaila Nazish, Ch Shehzad, Syed

Facebook: A platform for masquerade

Darayas Gazder Percy, Syed Hasan

Ibtisam Qazi, Asad Zulfiqar, Farah

Aeysha Umar Siddiqui, Shazia Azhar,

Mubarak Ali, Farah Ahmad,

Effect of insurance status on consumer

Farah Ahmad, Imran Samee Waraich,

Trained Doctor Managers: need of the hour

Department of Community Health Sciences, Ziauddin University

universities are adding leadership and management

J Pak Health Soln

Kajang DR. Organization and Management of

Vol.01, issue 01, Jan-April 2016

J Pak Health Soln

Abortion, pregnancy, contraceptives

Majeed N, Ahmad F, Dawood H, Danish

Public Health Consultant, Lahore

Health Officer UNICEF, Lahore

Department of Community Health Sciences, Ziauddin University, Karachi

Area Manager, The Health Foundation, Lahore

Department of Community Health Sciences, Ziauddin University, Karachi

Vol.01, issue 01, Jan-April 2016

J Pak Health Soln

South Asia are attributed to complications of unsafe

A cross sectional study was conducted on 63 females

The prevalence was taken at 2.9% because of an

while those between 36-40 years included

Table 1: Educational Status of participants and the number of children

Vol.01, issue 01, Jan-April 2016

J Pak Health Soln

It was observed that females with low education had

n=15(24%) of them were using modern contraceptive

Figure1: Contraceptive usage among participants

dislike to use contraceptive n=13(20.6%) and other

Table 2: Methods used by service provider for inducing abortions

study, studies in the past have showed that the two

J Pak Health Soln

This study showed that all the TBAS and 41% of

Klima CS. Unintended pregnancy: consequences

Vol.01, issue 01, Jan-April 2016

World Health Organization. Unsafe abortion: global

J Pak Health Soln

10 Bankole A, Singh S, Haas T. Reasons why women