Research Article - Journal of Public Health Policy and Planning (2019) Volume 3, Issue 3
Hypertension prevalence and predictors among taxi drivers at Abura in Cape Coast metropolis of Ghana
Yasmeen Anwer, Abdullah Hafeez, Fahad Abbasi, Siham Sikander*, Assad Hafeez
Health Services Academy, Islamabad, Pakistan
- *Corresponding Author:
- Dr. Siham Sikander
Health Services Academy Islamabad, Pakistan Tel: 92512656172 Email: [email protected]
Accepted date: 16 October 2019
Citation:Anwer Y, Hafeez A, Abbasi F, et al. Taking stock: Resources for preventing and responding to violence against children in Islamabad, Pakistan. J Public Health Policy Plann 2019;3(3):33-38.
Background: Hypertension is a major health problem in developing countries including Ghana. Lifestyle and occupational factors can be associated with hypertension development among individuals and groups of people. Objective: To assessed the prevalence and determinants of hypertension among taxi drivers at Abura in the Central Region of Ghana. Methods: A quantitative cross-sectional design was adopted and a total of 200 respondents were randomly sampled at the Abura taxi station. A semi-structured questionnaire was used to obtain socio-demographic data on the taxi drivers. Anthropometric measurements were converted into Body Mass Index while blood pressure measurements were categorized as normotension, pre-hypertension and hypertension using the World Health Organization cut offs. Proportions was presented for the prevalence and Odds Ratios presented for the predictors of hypertension categories. Results: The mean age was 36.65 ± 9.76 years. Majority (61.5%) had nine years of formal education. The prevalence of hypertension and prehypertension was 23.0% and 52.5% respectively. About 11.5% had a family history of hypertension. Age (χ2=27.129;P<0.001) and years of driving a taxi (χ2=24.348;P<0.001), hours slept in a day (χ2=19.504; P=0.012) were associated with the development of hypertension. None of the characteristics studied predicted hypertension status. Conclusion: The prevalence of pre-hypertension and hypertension was high among these drivers and personal and occupational factors were associated with hypertension development. Screening for early detection and advocacy will reduce the risk among the group.
Violence against children, Child abuse, Child maltreatment, Prevention, Pakistan.
One billion of the world’s children between 2 to 17 years have experienced some form of violence in the last 12 months [1,2]. Physical, psychological, and sexual Violence Against Children (VAC)1 occurs as maltreatment and bullying; trafficking, Interpersonal and Intimate Partner Violence, and even homicide. VAC can be perpetrated by caregivers, strangers and other children in myriad settings e.g. school, home, street etc. Globally, homicide is one of the top 5 causes of death in adolescents, with boys being the perpetrators and victims 80% of the times . Girls are disproportionately the victims of sexual and emotional violence, with every 1 in 3 girls in the world between the ages of 15 to 19 having experienced abuse by a husband or intimate partner. Children living in unsafe environments such as the streets and disaster afflicted regions are more likely to be abused than others . Social status of children, cultural norms, little or no education of parents and caregivers, witnessing domestic violence, and poverty are important determinants of VAC [1-3]. Sexual violence has long been an established causal factor for psychological, interpersonal, and social issues later in life, and now association of non-sexual violence against children with high risk behaviors e.g. drug use and unsafe sex, mental disorders, suicide attempts, and Sexually Transmitted infections, especially during adolescence has also been found [4,5]. The effects of VAC are not just behavioral in nature as exposure to adversity in early childhood causes significant structural changes in the brain, leading to eventual neuropsychiatric and cognitive dysfunction [6,7]. Developmental delays can be seen as early as at 18 months of age in children having been exposed to adversity . Not only is it every child’s birthright to be free of all forms of violence, VAC also needs to be prevented to avoid the pervasive harm it causes through social and economic setbacks [1,6]. As the understanding of VAC as a major cause of physical, mental and social health issues throughout the life course increases, so does the urgent need for an effective Public Health response .
The Evidence for Better Lives Study (EBLS) by the University of Cambridge is a birth cohort, which aims to study the effects of a child’s exposure to violence and other adversities, and its impact on child development and emergence of mental health problems. In each of the eight EBLS sites across the world, EBLS will be accompanied by efforts to introduce multisectoral prevention packages that can help children achieve their full potential . A Needs and Resource Assessment (NaRA) was performed in the EBLS sites, including Islamabad Capital Territory Pakistan. This assessment followed the INSPIRE framework of WHO for preventing and responding to VAC. INSPIRE outlines seven evidence-based strategies which have shown to be effective. These are: 1- Implementation and Enforcement of laws; 2-Norms and values; 3-Safe environments; 4-Parent and caregiver support; 5-Income and economic strengthening; 6-Response and support services; and 7-Education and life skills .
Our paper is based on the NaRA we performed in 2018, and further review of available information on the resources for preventing and responding to VAC in Pakistan. Literature was searched for studies, articles, and papers which included discussion on child abuse in the context of prevention and response. Grey literature was incorporated for information on available resources. We searched for scientific literature on PubMed and Google Scholar, used GOALI for research papers on Laws and Policy, Google Scholar for Social Sciences, and Google.com for grey literature.
Our assessment aimed to have an overview of the needs and resource situation, and is based on secondary data for the most part. A full-scale mapping exercise is recommended. Moreover, our review is limited by the paucity of robust data due to unavailability of Information systems, underreporting, weak legislation, and variability of rules, regulations, and resources after the devolution2 of concerned ministries to provinces.
Pakistan is the 6th most populous country in the world with a population of 207 million and an annual growth rate of 2.4% . Human Development Index of Pakistan is 0.562; 150th in the world. When adjusted for inequality it falls to 0.387. GNI Per capita is $5311; Average Life expectancy at birth is 66.6 year; on the average children receive 5.5 years of schooling. Gender Inequality index, at 134th in the world, is 0.541 .
Between 37.6% and 40.2% of Pakistan’s children under the age of 5 years are stunted [10,12]. 36.9% of households are food insecure in Pakistan . Neonatal mortality is one of the highest in the world at 42/1000; 62 out of every 1000 children die in the first year of life; 74-75 out of 1000 before reaching 5 years . An estimated 22.8 million children between 5-16 are out of school; over 11 million children are engaged in labor . Net Attendance Ratio (NAR) is 59% at primary level and 38% at the middle/secondary level . In 2018, 3832 cases of child sexual abuse were reported from across Pakistan; of these about 55% were girls. 115 of these cases occurred in Islamabad Capital Territory . Islamabad Capital Territory (ICT) is the Federal Capital of Pakistan with a population of 2,001,579 with almost equal distribution between urban and rural population at 1,009,832 vs. 991,747 . There’s a sharp classdivide between the urban and rural (and semi-rural) populations with the urban populace enjoying a higher quality of life.
Results and Discussion
Implementation and enforcement of laws
The INSPIRE Handbook suggests that laws banning violent punishment of children, criminalizing sexual abuse and exploitation of children, preventing alcohol misuse and laws that limit youth access to firearms and other weapons, are among those which can prevent VAC . For the purposes of our review we have focused on the first three. Pakistan is signatory to many international commitments3, the UNCRC being the most important as it is the basis of national policy for the rights of children. The National Commission on the Rights of Children (NCRC) is the central body for policy making for child protection . A legislation, ICT Child Protection Act, was approved in February 2018, which directed the formation of a Child Protection Advisory Board in ICT. This act identifies “children in need of care”4, and instructs Child Protection Centers to be built for these children. The law details the steps to be taken by its appointed agents, and defines the role of Law Enforcement Agencies and courts .
A bill for Prohibition of Corporal punishment in ICT has been proposed and approved by the lower house of the senate; It’s enactment pending . However, the proposed legislation is only against violent discipline in schools and seminaries and does not cover the home and other non-institutional settings . In April 2019, The Zainab Alert, Response, and Recovery Act 2019 was proposed as a flag-and-response system for missing children . We have found no further information on it. A recently proposed amendment in the marriage law which prohibits girls to be married before the age of 18 awaits approval  Sale and consumption of alcohol is restricted in Pakistan by law.
Norms and values
Norms and values are given in Table 1.
|Current Norms and Practices in Pakistan||Description|
|Corporal Punishment||In 2017 76% of children in Pakistan were reported to have experienced psychological aggression; 66% physical punishment; 31% experienced severe physical punishment . A survey in Pakistan found that 44% of students between 12-17 years had experienced physical violence in the last 6 months; 30% had been locked in a toilet by a teacher . No action was taken in 2/3rd of the reported cases. Teachers believed that corporal punishment is necessary for good academic performance . Another study in 2013 found 84% parents and 75% teachers agreeing teachers were justified in beating students who were rude and disobedient. 85% of parents believed that children who stole “deserved” physical punishment .|
|Child Labour||There are an estimated 11-12 million children who work as labourers in Pakistan, 50% are younger than 10 years of age. In ICT, 10739 children from the slum areas work as labourers, 39% of them between the age of 11-15 years. Children are seen cleaning windshields on traffic signals, selling toys, working in hotels and auto workshops, and doing other menial jobs . Every fourth house in ICT employees a child for domestic labour .|
|Bonded Labour||Bonded labour, especially in brick kilns, has been an established problem for Pakistan. Children as part of their families are indebted to the kiln (or another establishment e.g. farm’s) owners and work their whole lives repaying a never-ending debt, suffering a life of poverty, slavery, and destitution .|
|Early Marriages||It is expected that girls should be married as early as possible. “Good girls” are expected to accept their parents’ decisions and it’s the job of a respectable girl to contribute to the husband’s household in moral, intellectual, and physical ways, including doing domestic work and satisfying the husband’s urges, Religion, family honour (fear of promiscuity), and tradition play strongly into the issue of early marriages .|
|Violence in the Name of Honour||Watta-satta (bride-exchange between two families, is common in Pakistan) . Maiming and killing for “honour” is considered justified by many. Violent crimes in the name of honour are typically perpetrated by close family members. Informal and parallel justice systems exist which punish “honour crimes” severely, and even use sexual punishment aimed at women and girls for a male relative’s crimes .|
|Juvenile Justice System||There is no jail in Islamabad. The juvenile offenders are housed in Rawalpindi’s Adiala Jail, where 5000-10000 inmates live against a capacity of 3000 prisoners. The number of juvenile offenders in ICT is hence reflected in Punjab’s statistics .|
|Taboos around Sexual & Reproductive Health||Sex-education remains controversial in Pakistan with tradition causing reluctance in bringing up the topic. A study of 460 school children, 4-14 years old, found that 197 of them had been fondled and 16 had been victims of child pornography. The issue of child sexual abuse remains buried in secrecy .
A study conducted with girls aged 16-18 in an urban centre found no participant who understood the concept of Reproductive Health, few saw benefits in learning about sex, safe-sex, and reproductive health until after marriage. Only a few seemed open to the discussion on these matters as they are considered inappropriate for unmarried girls in Pakistan [31,32].
|Preference for Male Offspring||Boys are expected to support their parents in old-age so male children are seen as economic and social assets. Cultural preference for males in a resource-scarce setting leads to increased intensity of discrimination. Girl children are not deemed worthy of investments as they will become brides to other households (“other people’s property”) and will not bring returns to the parents .|
Table 1. Current norms and practices in Pakistan.
The INSPIRE Handbook identifies three tiers of interventions which may help to prevent VAC: small group programs, community mobilization, and bystander interventions .
The Ministry of Human Right’s Action Plan 2016 includes public awareness campaigns to sensitize the public about human rights including child rights. The campaign includes strategy for mass media, workshops, seminars, and conferences for behavioral change, and the mandatory study of subjects of Human Rights interests throughout the academic span of a student . Child Protection Committees being formed in the slum areas of Islamabad by the National Child Protection Centre (NCPC) is an attempt to mobilize communities for affecting change in norms .
NCPC in ICT plans on mapping ICT for identifying “hotspots” where child protection is urgently required, provision of temporary shelter, counseling, referral and rehabilitation mechanisms in line with the Child Protection Act 2018 of ICT . WHO outlines identifying “hotspots” as one of the approaches to provide safe environment to children. Other suggested approaches are having safe built environments and interrupting the spread of violence through training credible members of communities .
Parent and caregiver support
The objective is to help parents protect their children, discourage harsh parenting practices, and create positive relationships between parents and children. Parenting groups, home-visiting programs, and comprehensive social and educational programs which include prevention of VAC in their agenda, are some of the evidence-based interventions in this regard , Ministry of Human Right’s Action Plan 2016 addresses the last approach .
Income and economic strengthening
The INSPIRE Handbook lists cash transfers, group savings and loans, and microfinance (combined with gender-norms/equity training) ad promising approaches to provide economic strengthening to families .
Pakistan Bait-ul-Maal (PBM), an autonomous financial institution, assists the vulnerable segments of the society5 including children .
Child Conditional Cash Transfer (CCCT) is a nation-wide, state-run program, linked with unconditional cash transfers of Benazir Income Support Program (BISP). Parents selected from BISP database are provided with cash transfers to send their children to school. The Gallup survey 2010 found this program to have increased primary school enrollment by 11.65% .:
The recently announced government-lead “Ehsas” program undertakes to assist the most deprived sections of the society. Its interventions include a proposition to change the constitution so that food, clothing, shelter, medical care, and education of the poor to be the responsibility of the state; an extensive social safety net program, a labor and farmer’s program, a woman’s empowerment plan, housing schemes for joint ownership for the poor, education funds, and improvement in technical certifications . Implementation is awaited.
Response and support services
The INSPIRE handbook mentions Clinical inquiry and intervention, counselling, foster care, and treatment programs as examples of evidence-based approaches for resources and support mechanisms . The National Child Protection Centre (NCPC) provides services of shelter, reunion, counselling, legal aid, and referral to children who have suffered violence in ICT. A round-the-clock helpline at 080011515 is set up to respond to calls concerning children who need immediate protection . Development of a Child Protection Information System by the NCPC in ICT is underway. Pakistan Sweet Homes (PSH), a network of shelter houses for orphans, provides the children with food, clothes, and education in addition to a place to live. There are 10 PSH shelters in ICT .
According to news reports, a “Women and Child Protection Center” has been established in the Women Police Station in ICT, which has its own mobile vehicle and a response time of 5-7 minutes ; Sahil, an NGO in ICT, provides free legal counselling and representation to victims of child sexual abuse (CSA), a teachers’ training program for improving prevention and reporting of CSA, counselling, and awareness campaigns  SPARC6, another NGO, offers shelter to street children, training workshops on child rights, works with juvenile offenders, and runs campaigns against early/child marriage . An Office of National Commissioner for Children in ICT functions with UNICEF for receiving complaints from children and their caregivers about maladministration of government agencies. This office looks into systemic issues, takes action, and shares information with stakeholders .
Education and life skills
Ministry of Federal Education and Professional Training Islamabad, in 2017, published a revised National Curriculum for Early Childhood Care and Education (NECCE) “aimed to develop indicators in early childhood care and education to cultivate an environment where children learn pro-social behaviors helping them to learn through collaborative processes, cooperation, sharing and caring for others”. The focus of the curriculum designed for 04-05 year-olds is on developing life skills .
National Center for Rehabilitation of Child Labor (NCsRCL) is a program for educating and assisting children 5-14 years who are involved in labor  NCPC provides non-formal educational, vocational training and medical aid to run-away, homeless, and lost children, as well as to children who beg. A school is built inside the NCPC premises to offer education to needy children [26,33].
Our review foremost established a dearth of data on the resources for prevention of VAC in ICT. A coherent set of laws for prevention and response in ICT is missing. The existing laws do not address VAC comprehensively, with unclear definitions of maltreatment, abuse, etc. Laws are not enforced due to multiple systemic issues. There’s no official data to guide policy, resource allocation, and programs. More significantly, no funds are ear-marked for children in the budget.
No information system for VAC could be found. Resources for child protection and prevention of VAC are few, weak, and inaccessible to people. Reporting, when it does occur, is usually through LEAs who have poor processes to address needs. No standardized mechanism for clinical inquiry and intervention, trauma-informed care, and reporting in healthcare settings was found. Available programs fall short in coverage, accessibility, and sustainability. No resources are available for parent and caregiver support. Life-skills development and education in the backdrop of poverty and inequity is all but absent. Community-based programs for prevention of VAC weren’t found. Large-scale research into the issue is missing.
As evidenced by the nature of strategies in the INSPIRE framework, VAC is multi-sectoral problem, and no solution can be effective unless it is based on an integrative model of collaboration between concerned sectors. Stakeholder and community participation is key to success. We suggest that VAC does not exist in isolation and major shifts in paradigm and policy are required to change the condition of children in Pakistan. Pakistan has 48.75% of its population under the age of 18 years; a veritable pool of potential; hence it stands to reason that this demographic bulge be given the highest consideration. We recommend that a model central body for the affairs of children is formed in ICT, comprising of representatives of all relevant sectors (e.g. education, legislation, health, law enforcement etc.) with its own budgetary allocation.
More specifically for VAC, the health sector should take the lead and view it as a priority for prevention and response interventions; as healthcare workers are often the first, and sometimes the only ones, whom cases of VAC are reported. There is a need to define VAC and have clear and comprehensive policy on the issue. Sustainable programs addressing safety for children under all settings, with improved coverage, need to be developed and implemented. Existing programs for prevention, response, and support for VAC should be integrated into other social welfare programs. There is a need for a functional, sustainable, and reliable system of monitoring and evaluation for all public and private programs addressing VAC directly or indirectly. Lastly, there is a dire need for research to develop evidence-based multi-sectoral policies and interventions for prevention of VAC.
Conflict of Interest
Sexual abuse: includes molestation & rape
Trafficking for sexual exploitation & child labour Genital mutilation/cutting
Homicide & injuries as a result of interpersonal violence (fights, and assaults) Review Article http://www.alliedacademies.org/public-health-policy-planning/
3 the Universal Declaration of Human Rights 1948 (ratified 10 December 1948), the United Nations Convention on the Rights
of the Child (UNCRC) 1989 (ratified 12 November 1990), the Convention on the Elimination of all Forms of Discrimination
Against Women, 1979 (ratified 12 March 1996), the International Labour Organization's Convention 182 on the Worst Forms
of Child Labour 1999 (ratified 11 October 2001), the Optional Protocols on the Sale of Children, Child Prostitution and Child
Pornography, 2000 & on the Involvement of Children in Armed Conflict, 2000 (ratified 5 July 2011 & 17 November 2016
respectively), the SAARC Convention on Preventing and Combating Trafficking in Women and Children for Prostitution,
2002 (ratified 5 January 2002), the SAARC Convention on Promotion of Child Welfare, 2002 (ratified 5 January 2002), the
ILO Convention 138 on Minimum Age (ratified 6 July 2006), the International Covenant on Civil and Political Rights & the
International Covenant on Economic, Social and Cultural Rights, 1966 (ratified 17 April 2008) and the Convention against
Torture and other Cruel, Inhuman or Degrading Treatment or Punishment, 1984 (ratified 17 April 2008).
4 any child in danger of child abuse (physical, mental, sexual or other), child exploitation (e.g. trafficking, sexual exploitation,
for terrorist activities etc.) is unattended, found working as domestic or other labor, found begging, victim of an offence,
imprisoned with the mother, or living in “immoral” environment.
- Hillis S, Mercy J, Amobi A, et al. Global Prevalence of Past-year Violence Against Children: A Systematic Review and Minimum Estimates. Pediatrics. 2016;137: e20154079.
- Ali NSMF, Ali FNM, Khuwaja AKMF, et al. Magnitude and factors associated with child abuse in a mega city of developing country pakistan. Iran J Pediatr. 2014; 24(2):140-6.
- London S, Quinn K, Scheidell JD, et al. Adverse Experiences in Childhood and Sexually Transmitted Infection Risk From Adolescence Into Adulthood. Sexually Trans Dis. 2017; 44:524-32.
- Norman RE, Byambaa M, De R, et al. The Long-Term Health Consequences of Child Physical Abuse, Emotional Abuse, and Neglect: A Systematic Review and Meta-Analysis. PLoS Medicine. 2012;9.
- Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 2019; 56(6):774-86.
- Lim L, Hart H, Mehta M, et al. Grey matter volume and thickness abnormalities in young people with a history of childhood abuse. Psychol Med. 2018; 48:1034-46.
- Bhopal S, Roy R, Verma D, et al. Impact of adversity on early childhood growth & development in rural India: Findings from the early life stress sub-study of the SPRING cluster randomised controlled trial (SPRING-ELS). PloS one. 2019; 14: e0209122-e.
- http://nips.org.pk/abstract_files/PDHS 2017-18 - key findings.pdf.
- Jabeen T. Pakistan's Child Protection Legislative and Policy Frameworks: A Critical Review. Pakistan J Criminol. 2013; 5(2):159.
- Islamabad Capital Territory Child Protection Act 2018, Stat. F.9(4)/20I 8-Legis (May 24 2018).
- Prohibition of Corporal Punishment Bill 2016, Senate (2017 Feb 20).
- Zainab Alert, Response, and Recovery Act, National Assembly; 2019.
- Child Marriage Response (Amendment) Act 2019, National Assembly; 2019.
- https://www.unicef.org/pakistan/media/2021/file/Annual Report 2018 Revised Final.pdf.
- Ain NE. Prevention of Child Abuse through Awareness and Curriculum Design. Psychology Res. 2017; 7:112-8.
- Bashir Q, Usman A, Amjad A, et al. ?The Taboo that Silences?: Awareness about Sexual and Reproductive Health Issues among Adolescent Females during Pubertal Transition. ISRA Med J. 9(6);381-5.
- Fikree FF, Pasha O. Role of gender in health disparity: the South Asian context. BMJ. 2004; 328:823-6.
- Pulla VR, Tarar MG, Ali MA. Child Protection System and Challenges in Pakistan. Space Culture, India. 2018; 5:54.
- http://moent.gov.pk/userfiles1/file/ECCE (22-09-17).pdf