Primary headache disorders in the adult general population of Pakistan – a cross sectional nationwide prevalence survey

Back Ground: The large geographical gaps in our knowledge of the prevalence and burden of headache disorders include almost all of Eastern Mediterranean Region (EMR). We report a nationwide population-based study in Pakistan, an EMR country with the sixth largest population in the world, conducted as a project within the Global Campaign against Headache. Methods: We surveyed six locations from the four provinces of Pakistan: Punjab, Sindh, Khyber Pakhtunkhwa and Baluchistan. We randomly selected and visited rural and urban households in each. One adult member (18-65 years) of each household, also randomly selected, was interviewed by a trained non-medical interviewer from the same location using a previously-validated structured questionnaire translated into Urdu, the national language. We estimated 1-year prevalences of the headache disorders of public-health importance and examined their associations with demographic variables using multivariate analysis. Results: There were 4223 participants (mean age 34.4 ± 11.0 years; male 1957 [46.3%], female 2266 [53.7%]; urban 1443 [34.2%], rural 2780 [65.8%]). Participation proportion was 89.5%. Headache in the previous year was reported by 3233 (76.6% [95% CI: 75.3-77.8%]). The age- and gender-adjusted 1-year prevalence of migraine was 22.5% [21.2-23.8%] (male 18.0% [16.8-19.2%], female 26.9% [25.6-28.2%]), of tension-type headache (TTH) 44.6% [43.1-46.1%] (male 51.2% [49.7-52.7%], female 37.9% [36.4-39.4%]), of probable medication-overuse headache 0.7% [0.5-1.0%] (male 0.7% [0.5-1.0%], female 0.8% [0.5-1.1%]) and of other headache on ≥15 days/month 7.4% [6.6-8.2%] (male 4.4% [3.8-5.0%], female 10.4% [9.5-11.3%]). Migraine was more prevalent in females by a factor of 3:2 although this association barely survived (P = 0.039) after correcting for other factors. TTH was more prevalent in males by about 4:3 (P = 0.026). All headache and migraine were age-related, peaking in the age group 40-49 years; TTH peaked a decade earlier. Higher education (P = 0.004) and income (P = 0.001) were negatively associated with prevalence of migraine. Conclusion: With three quarters of its population affected, headache disorders must be on the public-health agenda of Pakistan. Worldwide, these disorders are the third leading cause of disability; information from specific enquiry into the burden attributable to headachedisorders in this country is needed to inform health policy and priority-setting, and will be reported soon

Pendampingan Kader dalam Sosialisasi Tanaman Obat Keluarga (TOGA) pada Santri di Pondok Pesantren Putri Wahid Hasyim Bangil

Latar Belakang Masih banyak ditemukan bahwa para santri belum mengetahui tentang tanaman obat keluarga (TOGA) beserta manfaatnya bagi kesehatan. Bila tingkat pemahaman para santri terhadap manfaat dari tanaman obat keluarga (TOGA) rendah dikhawatirkan para santri tidak dapat mengaplikasikannya dalam kehidupan sehari-hari untuk pengobatan secara alami atau herbal. Apabila para santri telah mengetahui tentang manfaat dan kegunaan dari tanaman obat keluarga (TOGA) harapannya ketika mereka sakit bisa melakukan pengobatan secara alami dengan menggunakan bahan-bahan tanaman obat yang terdapat di lingkungan pesantren. Metode Pendampingan kader dalam sosialisasi tanaman obat keluarga (TOGA) dilakukan secara daring melalui via zoom berupa presentasi dan tanya jawab. Jumlah perserta terdapat 20 perwakilan santriwati yang telah dipilih secara acak. Sebelum dan sesudah dilaksanakan sosialisasi peserta sosialisasi diberikan kuesioner untuk mengetahui tingkat pengetahuan terhadap tanaman obat keluarga sekaligus sebagai tolak ukur atau bahan evaluasi terhadap pemahaman peserta setelah diadanya sosialisasi tersebut. Data diolah secara statistik untuk mengetahui frekuensi tingkat pengetahuan sebelum dan sesudah dilakukannya sosialisasi. Hasil dan Pembahasan Hampir seluruh (90,0%) responden mengetahui Tanaman Obat Keluarga (TOGA) setelah mengikuti sosialisasi ini. Saat pelaksanaan kegiatan ini terlihat para peserta terlihat antusias dan menyimak materi dengan seksama, sehingga harapannya materi yang disampaikan bisa dapat diterima dengan baik. Kesimpulan Sosialisasi tanaman obat keluarga (TOGA) berdampak positif. Hasil analisa menunjukkan terdapat peningkatan pengetahuan santri yang signifikan terhadap tanaman obat keluarga (TOGA) hal tersebut dapat dibuktikan dari hasil post test yang dilakukan setelah diadakannya sosialisasi oleh kader setempat. Dengan adanya hasil peningkatan tingkat pengetahuan tersebut harapannya ilmu tentang tanaman obat keluarga (TOGA) tersebut dikemudian hari bisa memanfaatkan dan menggunakannya sebagai pengobatan herbal yang mudah dijangkau dilingkungan sekitar

Global, regional, and national age-specific progress towards the 2020 milestones of the WHO End TB Strategy: a systematic analysis for the Global Burden of Disease Study 2021

Background Global evaluations of the progress towards the WHO End TB Strategy 2020 interim milestones on mortality (35% reduction) and incidence (20% reduction) have not been age specific. We aimed to assess global, regional, and national-level burdens of and trends in tuberculosis and its risk factors across five separate age groups, from 1990 to 2021, and to report on age-specific progress between 2015 and 2020. Methods We used the Global Burden of Diseases, Injuries, and Risk Factors Study 2021 (GBD 2021) analytical framework to compute age-specific tuberculosis mortality and incidence estimates for 204 countries and territories (1990–2021 inclusive). We quantified tuberculosis mortality among individuals without HIV co-infection using 22 603 site-years of vital registration data, 1718 site-years of verbal autopsy data, 825 site-years of sample-based vital registration data, 680 site-years of mortality surveillance data, and 9 site-years of minimally invasive tissue sample (MITS) diagnoses data as inputs into the Cause of Death Ensemble modelling platform. Age-specific HIV and tuberculosis deaths were established with a population attributable fraction approach. We analysed all available population-based data sources, including prevalence surveys, annual case notifications, tuberculin surveys, and tuberculosis mortality, in DisMod-MR 2.1 to produce internally consistent age-specific estimates of tuberculosis incidence, prevalence, and mortality. We also estimated age-specific tuberculosis mortality without HIV co-infection that is attributable to the independent and combined effects of three risk factors (smoking, alcohol use, and diabetes). As a secondary analysis, we examined the potential impact of the COVID-19 pandemic on tuberculosis mortality without HIV co-infection by comparing expected tuberculosis deaths, modelled with trends in tuberculosis deaths from 2015 to 2019 in vital registration data, with observed tuberculosis deaths in 2020 and 2021 for countries with available cause-specific mortality data. Findings We estimated 9·40 million (95% uncertainty interval [UI] 8·36 to 10·5) tuberculosis incident cases and 1·35 million (1·23 to 1·52) deaths due to tuberculosis in 2021. At the global level, the all-age tuberculosis incidence rate declined by 6·26% (5·27 to 7·25) between 2015 and 2020 (the WHO End TB strategy evaluation period). 15 of 204 countries achieved a 20% decrease in all-age tuberculosis incidence between 2015 and 2020, eight of which were in western sub-Saharan Africa. When stratified by age, global tuberculosis incidence rates decreased by 16·5% (14·8 to 18·4) in children younger than 5 years, 16·2% (14·2 to 17·9) in those aged 5–14 years, 6·29% (5·05 to 7·70) in those aged 15–49 years, 5·72% (4·02 to 7·39) in those aged 50–69 years, and 8·48% (6·74 to 10·4) in those aged 70 years and older, from 2015 to 2020. Global tuberculosis deaths decreased by 11·9% (5·77 to 17·0) from 2015 to 2020. 17 countries attained a 35% reduction in deaths due to tuberculosis between 2015 and 2020, most of which were in eastern Europe (six countries) and central Europe (four countries). There was variable progress by age: a 35·3% (26·7 to 41·7) decrease in tuberculosis deaths in children younger than 5 years, a 29·5% (25·5 to 34·1) decrease in those aged 5–14 years, a 15·2% (10·0 to 20·2) decrease in those aged 15–49 years, a 7·97% (0·472 to 14·1) decrease in those aged 50–69 years, and a 3·29% (–5·56 to 9·07) decrease in those aged 70 years and older. Removing the combined effects of the three attributable risk factors would have reduced the number of all-age tuberculosis deaths from 1·39 million (1·28 to 1·54) to 1·00 million (0·703 to 1·23) in 2020, representing a 36·5% (21·5 to 54·8) reduction in tuberculosis deaths compared to those observed in 2015. 41 countries were included in our analysis of the impact of the COVID-19 pandemic on tuberculosis deaths without HIV co-infection in 2020, and 20 countries were included in the analysis for 2021. In 2020, 50 900 (95% CI 49 700 to 52 400) deaths were expected across all ages, compared to an observed 45 500 deaths, corresponding to 5340 (4070 to 6920) fewer deaths; in 2021, 39 600 (38 300 to 41 100) deaths were expected across all ages compared to an observed 39 000 deaths, corresponding to 657 (–713 to 2180) fewer deaths. Interpretation Despite accelerated progress in reducing the global burden of tuberculosis in the past decade, the world did not attain the first interim milestones of the WHO End TB Strategy in 2020. The pace of decline has been unequal with respect to age, with older adults (ie, those aged >50 years) having the slowest progress. As countries refine their national tuberculosis programmes and recalibrate for achieving the 2035 targets, they could consider learning from the strategies of countries that achieved the 2020 milestones, as well as consider targeted interventions to improve outcomes in older age groups

Fraud in a population-based study of headache: prevention, detection and correction

BACKGROUND: In medicine, research misconduct is historically associated with laboratory or pharmaceutical research, but the vulnerability of epidemiological surveys should be recognized. As these surveys underpin health policy and allocation of limited resources, misreporting can have far-reaching implications. We report how fraud in a nationwide headache survey occurred and how it was discovered and rectified before it could cause harm. METHODS: The context was a door-to-door survey to estimate the prevalence and burden of headache disorders in Pakistan. Data were collected from all four provinces of Pakistan by non-medical interviewers and collated centrally. Measures to ensure data integrity were preventative, detective and corrective. We carefully selected and trained the interviewers, set rules of conduct and gave specific warnings regarding the consequences of falsification. We employed two-fold fraud detection methods: comparative data analysis, and face-to-face re-contact with randomly selected participants. When fabrication was detected, data shown to be unreliable were replaced by repeating the survey in new samples according to the original protocol. RESULTS: Comparative analysis of datasets from the regions revealed unfeasible prevalences and gender ratios in one (Multan). Data fabrication was suspected. During a surprise-visit to Multan, of a random sample of addresses selected for verification, all but one had been falsely reported. The data (from 840 cases) were discarded, and the survey repeated with new interviewers. The new sample of 800 cases was demographically and diagnostically consistent with other regions. CONCLUSION: Fraud in community-based surveys is seldom reported, but no less likely to occur than in other fields of medical research. Measures should be put in place to prevent, detect and, where necessary, correct it. In this instance, had the data from Multan been pooled with those from other regions before analysis, a damaging fraud might have escaped notice

The burden of headache disorders in Pakistan: methodology of a population-based nationwide study, and questionnaire validation

Background Large geographical gaps in our knowledge of the prevalence and burden of headache disorders include Pakistan, a country with major problems of poverty, illiteracy and security. We report implementation in this country of standard methods developed by Lifting The Burden (LTB) for population-based burden-of-headache studies. Methods We surveyed six locations from the four provinces: Lahore and Multan (Punjab), Karachi and Sukkur (Sindh), Abbottabad (Khyber Pakhtunkhwa) and Gwadar (Baluchistan). We randomly selected rural and urban households in each, which were visited by trained non-medical interviewers from the same locations. One randomly selected adult member (18–65 years) of each household was interviewed using LTB’s structured questionnaire translated into Urdu, the national language. Validation was performed among patients and accompanying attendants in three (urban and rural) medical facilities. After responding to the questionnaire, these participants were re-interviewed and diagnosed by a neurologist (gold standard). Results The survey was completed by 4,223 respondents (1,957 [46.3%] male, 2,266 [53.7%] female, 1,443 [34.2%] urban, 2,780 [65.8%] rural, mean age 34.4 ± 11.0 years). The participation rate was 89.5%. There were 180 participants (46.1% male, 53.9% female, 41.7% urban, 58.3% rural, mean age 39.4 ± 14.2 years) in the validation sample, of whom 147 (81.7%) reported headache in the last year. The questionnaire was 100% sensitive in screening for headache and for headache on ≥15 days/month, and showed good agreement with the gold-standard diagnoses (kappa = 0.77). It was relatively insensitive for TTH. The questionnaire’s default diagnosis of probable MOH when medication overuse accompanied headache on ≥15 days/month was not supported by evidence of causation in most cases seen by the neurologist. In public-health terms, precise diagnosis in these cases matters less than reliably detecting the coexistence of these disorders. Conclusion In conclusion, the methods developed by LTB were applied successfully in Pakistan, despite problems unique to this country

Primary headache disorders in the adult general population of Pakistan - a cross sectional nationwide prevalence survey

Background The large geographical gaps in our knowledge of the prevalence and burden of headache disorders include almost all of Eastern Mediterranean Region (EMR). We report a nationwide population-based study in Pakistan, an EMR country with the sixth largest population in the world, conducted as a project within the Global Campaign against Headache. Methods We surveyed six locations from the four provinces of Pakistan: Punjab, Sindh, Khyber Pakhtunkhwa and Baluchistan. We randomly selected and visited rural and urban households in each. One adult member (18–65 years) of each household, also randomly selected, was interviewed by a trained non-medical interviewer from the same location using a previously-validated structured questionnaire translated into Urdu, the national language. We estimated 1-year prevalences of the headache disorders of public-health importance and examined their associations with demographic variables using multivariate analysis. Results There were 4223 participants (mean age 34.4 ± 11.0 years; male 1957 [46.3%], female 2266 [53.7%]; urban 1443 [34.2%], rural 2780 [65.8%]). Participation proportion was 89.5%. Headache in the previous year was reported by 3233 (76.6% [95% CI: 75.3–77.8%]). The age- and gender-adjusted 1-year prevalence of migraine was 22.5% [21.2–23.8%] (male 18.0% [16.8–19.2%], female 26.9% [25.6–28.2%]), of tension-type headache (TTH) 44.6% [43.1–46.1%] (male 51.2% [49.7–52.7%], female 37.9% [36.4–39.4%]), of probable medication-overuse headache 0.7% [0.5–1.0%] (male 0.7% [0.5–1.0%], female 0.8% [0.5–1.1%]) and of other headache on ≥15 days/month 7.4% [6.6–8.2%] (male 4.4% [3.8–5.0%], female 10.4% [9.5–11.3%]). Migraine was more prevalent in females by a factor of 3:2 although this association barely survived (P = 0.039) after correcting for other factors. TTH was more prevalent in males by about 4:3 (P = 0.026). All headache and migraine were age-related, peaking in the age group 40–49 years; TTH peaked a decade earlier. Higher education (P = 0.004) and income (P = 0.001) were negatively associated with prevalence of migraine. Conclusion With three quarters of its population affected, headache disorders must be on the public-health agenda of Pakistan. Worldwide, these disorders are the third leading cause of disability; information from specific enquiry into the burden attributable to headache disorders in this country is needed to inform health policy and priority-setting, and will be reported soon. Keyword