1. 1 Rozina Karmaliani, Professor Aga Khan University School of Nursing and Midwifery, & Community Health Sciences (Pakistan) 26 th February 2014 MOBILIZING WOMEN IN FIGHT AGAINST NCDs

2.  Socio-economic background of women in Pakistan  Contributing factors towards NCDs (mental health)  Impact of social and economic distress on NCDs (mental health) and well being of women in Pakistan  Recommended Interventions for Mobilizing women against NCDs 2 FOCUS OF PRESENTATION

3. 3 Ranks 99th out of 109 on the Gender Empowerment Measure (GEM) (UNDP, 2010) 6 th most populous country in the world Population: approximately 187 million – (UNDP, 2008) Ranks 125th out of the 169 countries on the Gender Development Index (GDI) – (UNDP, 2010) PAKISTAN’S SOCIAL AND ECONOMIC CONTEXT

4. 4 Ranking 145 out of 187 countries in the Human Development Index 45 million people are severely food-insecure and almost 40 percent of children are underweight. Gender Development Index (GDI) ranking of 124 out of 155 countries Pakistan Social and Living Standards Measurement survey (PSLM 2008-2009) The GDP value of Pakistan represents 0.34 percent of the world economy. PAKISTAN’S SOCIAL AND ECONOMIC CONTEXT

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6. Why We Believe NCDs are a Women’s Issue? Integral part of Maternal and Child Health – Low birth weight leads to heart diseases later in life Cooking over open fires – COPD NCDs Kill and Disable Women NCDs Cost Families and Communities Cause Stigma and Discrimination NCDs impact next generation 6

7. 7 CONTRIBUTING FACTORS

8. Ten leading global causes of death in Women 1.Cardiovascular diseases 33.2 2.Infectious and parasitic diseases 13.9 3.Cancer 13.0 4.Respiratory diseases 7.3 5.Respiratory infections 6.6 6.Unintentional injuries 5.1 7.Perinatal conditions 5.0 8.Digestive diseases 3.1 9.Diabetes mellitus 2.6 10.10 Neuropsychiatric conditions 2.3 8

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10. 10 SOCIAL AND ECONOMIC DISTRESS FOR WOMEN IN PAKISTAN

11. Key Barriers for Girls and Women with NCDs Economic Barriers Geographical Barriers Socio-Cultural Barriers Health System Barriers 11

12. Mental Wellbeing CulturalLegal Psychological Economical Social Political PSYCHOLOGICAL: Internalization of gender norms / Accept violence as part of normal marital union / Sense of entitlement among men ECONOMICAL: Economic disempowerment major barrier to self-efficacy / Few women of middle and lower class backgrounds can survive independently SOCIAL: Lack of formal education for men and women / Joint family systems CULTURAL: VAW is a private, domestic matter / There are ‘just’ causes of violence / Concept of ‘Honor’ / Notions of Masculinity and Femininity LEGAL: Most women are ignorant of the fact that violence is a crime POLITICAL: Lack of effective government systems (health, legal, education) to prevent or address domestic violence

13. Poverty Poor housing Poor education Poor transport Poor nutrition Poor health status Law & order Lack of justice Violence crime Terrorism Access drugs, alcohol Alienation Displacement Unemployment Work stress Depression in Pakistan: Associated Factors

14. REPORTED CASES OF VAW – 2008 - 2011

15.  In all, 67 (45%) of the 148 women expressing suicidal thoughts reported attempting suicide.  Of the women having any formal or informal education, 6% reported a suicide attempt versus 2% with no education. (p < 0.05).  Of the women with depression/anxiety, 16% reported a suicide attempt compared to only 2% for those without depression (p < 0.05).  Of the women who reported verbal abuse, 9% reported a suicide attempt compared to 1% with no verbal abuse (p < 0.05).  Finally, of the women who reported physical/sexual abuse, 14% reported a suicide attempt compared to only 3% among those who did not (p < 0.05). Acta Obstetricia et Gynecologica Scandinavica, 89 (12), 1545-1551 Prevalence of suicidal thoughts and attempts among pregnant Pakistani Women Asad, N., Karmaliani, R., Sulaiman, N., Bann, M.C., Mcclure, E. M., Pasha, O., Wright, L.L. & Goldenberg, L.R. (2010)

16. What are three gender-focused opportunities to address NCD? PRO-POOR AND GENDER-SENSITIVE HEALTH POLICIES USE OF PRIMARY HEALTH CARE FOR NCD PREVENTION AND CONTROL INVESTMENT IN GIRLS, WOMEN, AND THEIR HEALTH 16

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18. 18 Maternal Mental Health Outcome Variables Anxiety↓Depression ↓ Domestic Violence ↓ Child Health Outcome Variables  Child Behavior Functioning  Child Weight Self Efficacy Counseling Economic Skills Building Research Framework

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20. Behavior Change Model with 5 E’s Education Engineering Environment Enforcement Empowerment 20

21. Group I. Literacy & Counseling Class

22. Group II. Literacy and Economic Skill Building Class

23. COUNSELING BASED THERAPY 23 Barefoot Counseling Women Empowered Self- Management Emotion Management Improved Parenting Results Primary Health Care provides a window of opportunity in reducing VAW Group counseling + Economic Skills Building Community Health Workers and Lady Health Workers/Visitors

24. Routine tasks and socializing…. 24

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26. LEGAL REFORM Gender Reform Actions Plans (2005) Protection Against Harassment of Women at Workplace (2010) Domestic Violence Bill (2012) Human Trafficking Ordinance (2002) NEED AWARENESS AND IMPLEMENTATION Mental Health Act (2001)

27. Women Empowerment……..increase self esteem 27

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31. Income Generation, social and economic independence Positive Parenting, Family Harmony, and positive Marital relationship Self efficacy, anger management, improved communication, job willingness, problem solving, hope and strength EFFECTS OF INTERVENTIONS FOR ABUSED WOMEN Empowered women and less abuse

32. Women: A Powerful Solution to the NCD Crises Invest in Educating Women about NCD Prevention through Healthy Living and they will Teach their Families Arogya World 2010 32

34. Challenge: To make every PERSON count we must design and test community out-reach programs that are INTERGENERATIONAL

35. Ensuring Women’s Voices are Heard Global Communication and awareness Campaign Develop and Distribute Educational Materials for Women Deliver Optimum Healthcare for Women Leverage technology and Partnerships for Scalable, Cost Effective Programs Measure Effectiveness and Impact of community based programs WHO: A Healthy Diet, Exercise and Avoiding Tobacco 35 WAY FORWARD

36. Peace & Health