medical education in pakistan

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• Introduction and background
• Undergraduate Medical Education
• Postgraduate Medical Education
• Competency-Based Medical Education (CBME)
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A Journey of Innovation: 40 years of Pioneering Medical Education at the Aga Khan University Medical College in Karachi, Pakistan

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Maham Vaqar, Muhammad Tariq, Muhammad Rizwan Khan, Sadaf Khan, Qamar Riaz, Sana Mahmood, Natasha Ali, Adil H Haider, A Journey of Innovation: 40 years of Pioneering Medical Education at the Aga Khan University Medical College in Karachi, Pakistan, Postgraduate Medical Journal , Volume 100, Issue 1183, May 2024, Pages 350–357, https://doi.org/10.1093/postmj/qgad139

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This article presents an overview of Aga Khan University’s (AKU) pioneering medical education initiatives over the past 40 years, exploring its impact on healthcare in the region and its commitment to advancing medical education and research in the developing world. Established in 1983 as the first private university in Pakistan, AKU has evolved into a global institution with a focus on improving healthcare standards and addressing healthcare needs in the developing world. The article also discusses the undergraduate and postgraduate medical education programs at AKU Medical College, Pakistan, highlighting their unique features and pioneering approaches to medical education. The institution’s journey highlights its ability to adapt to the evolving healthcare landscape while maintaining a focus on quality and excellence, offering a model for other institutions striving to meet healthcare needs in low- and middle-income countries.

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Public Health Education, Practice, and Research in Pakistan

• Living reference work entry
• First Online: 21 March 2024
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• Ghulam Abbas 2 ,
• Shahid Shah 2 ,
• Aqsa Sajjad 2 ,
• Faiz Ullah Khan 3 ,
• Muhammad Irfan 2 ,
• Abid Mahmood 2 ,
• Matti Ullah 4 ,
• Maryam Abdul Aziz 2 ,
• Saira Azhar 5 ,
• Fazal Rabbi 6 &
• Hamad Haider Khan 7  

Pakistan is a South Asian developing country with a high burden of communicable and non-communicable diseases. In Pakistan, public health (PH) degrees include a Bachelor of science in Public Health (BSPH), a Master of science in Public Health (MSPH), and PhD in Public Health. BSPH is a four-year program that aims to improve the health of the population. The BS degree can be completed within a maximum of 6 years. Those who pursue an MSPH degree are likely to find attractive job opportunities and salary potential after graduation. In Pakistan, 44 public and private institutions offer PH degree programs. The Higher Education Commission (HEC) is the government body that recognizes PH degree programs. After completing the education, the graduates are able to identify, prevent, and manage PH problems in Pakistan. Pakistan’s demographic and epidemiological landscape pose PH challenges. Little is known about whether the education, research, or practice in these programs is sufficient to meet the needs of the national health care system. So, in this chapter PH education, research, and practice in Pakistan will be discussed.

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Faculty of Pharmaceutical Sciences, Government College University, Faisalabad, Pakistan

Ghulam Abbas, Shahid Shah, Aqsa Sajjad, Muhammad Irfan, Abid Mahmood & Maryam Abdul Aziz

Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi’an Jiaotong University, Xi’an, China

Faiz Ullah Khan

Faculty of Pharmacy, Hamdard University Islamabad Campus, Islamabad, Pakistan

Matti Ullah

College of Pharmacy, University of Sargodha, Sargodha, Pakistan

Saira Azhar

General Intensive Care Unit Saidu Group of Teaching Hospital, Swat, Khyber Pakhtunkhwa, Pakistan

Fazal Rabbi

Department of Endocrinology, first affiliated hospital, Xian Jiaotong University, Xi’an, China

Hamad Haider Khan

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Abbas, G. et al. (2024). Public Health Education, Practice, and Research in Pakistan. In: Al-Worafi, Y.M. (eds) Handbook of Medical and Health Sciences in Developing Countries. Springer, Cham. https://doi.org/10.1007/978-3-030-74786-2_538-1

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DOI : https://doi.org/10.1007/978-3-030-74786-2_538-1

Received : 16 February 2023

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Country Paper

Medical education in pakistan: challenges & way forward.

• J. Strivens
• J. Strivens , University of Liverpool, United Kingdom
• Page/Article: 10-15
• DOI: 10.4038/seajme.v15i2.285
• Peer Reviewed

Associated Press Of Pakistan

Pakistan's National News Agency

DPM Dar emphasizes uniform high quality medical education in country

ISLAMABAD, May 24 (APP): Deputy Prime Minister Mohammad Ishaq Dar on Friday underlined the need to improve the regulatory framework for medical education in Pakistan, besides establishing a coordination mechanism between medical institutions, and the public and private sectors to ensure uniform high-quality education.

He was chairing the first meeting of the Committee on Medical Education that was constituted by the prime minister earlier this week on May 20.

The deputy prime minister emphasized the important responsibility of the committee to address the gaps in medical education in the country.

Highlighting the importance of nurturing a conducive environment for medical students to excel and contribute meaningfully to the healthcare sector, Ishaq Dar stressed that the world-class quality of medical education should be ensured in all the provinces.

The committee conducted a comprehensive review of the country’s medical education system, fee structure, and identified key areas for improvement and development of a strategic plan to align medical education with international standards.

It specifically focused on devising a plan to solve the issues faced by Pakistani medical students studying abroad. It also discussed strategies to support and empower medical students in their academic and professional endeavours.

The meeting was attended by the Minister for Law and Justice, the Coordinator to the Prime Minister on Health, Secretary Health, the Deputy Chairman Planning Commission and Chairman Higher Education Commission, MNA Dr Nafeesa Shah, heads of prominent public and private medical institutions, and eminent experts from the medical community.

The committee members include key stakeholders from the medical community, the education sector, and government officials. It aims to reform the medical education across the country. This initiative underscores the government’s commitment to improve healthcare standards and ensure the highest quality of medical training for future generations of healthcare professionals.

After a detailed discussion in the meeting, a sub-executive committee was constituted with Dr. Malik Mukhtar Ahmad, National Coordinator for Health as Convener and Tariq Bajwa as Co-Convener.

The sub-committee will deliberate on the existing terms of reference (ToRs) along with additional tasks including synergies among regulatory bodies, streamlining procedures for foreign students in Pakistan and the uniformity in curricula.

The committee will prepare its report with the objective to ensure that medical graduates in Pakistan are equipped with the knowledge and skills required to meet contemporary healthcare challenges and to provide the highest level of care to all Pakistani nationals.

This initiative is part of the government’s continuing efforts to elevate the standards of healthcare services in Pakistan and to prepare medical professionals to effectively serve in both domestic and global healthcare.

By Najam ul Hassan

Najam ul Hassan is a Sr. Reporter who reports on Prime Minister, President, Foreign Office, and special assignments.

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Medical education needs to change in Pakistan

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• 1 Department of Anatomy, FMH College of Medicine & Dentistry, Lahore.
• PMID: 22356007

The economic crisis in the last few years has reduced the role of government in social development and transferred it to the private sector. These changes have affected medical education too. Lack of resources has created a situation where outdated equipment and educational methods produce medical graduates with outdated knowledge, skills and attitudes. Students' are understandably frustrated when they discover that their long journey through medical school has yielded knowledge that does not match the requirements of their profession. Failure to structure criterion for proper selection of students and societal needs has resulted in indiscriminate admittance of thousands of students, causing many dropouts in the first two years and, eventually, ill-prepared medical doctors. Clearly, medical teachers are feeling the pressure to adapt to changes in the health care system while maintaining excellence in education. The question in their minds is; how can we change our medical education programme to meet the society's need? This paper suggests certain changes which could be considered as the first step at the beginning of a long journey.

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Satisfaction of patients in government medical teaching institutes of Peshawar Khyber Pakhtunkhwa, Pakistan: a cross-sectional analytical study.

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COVID-19 pandemic: Direct effects on the medical education in Pakistan

• • To date, the medical education literature has focused on strategies for high-income countries to optimize online education.
• • Low- and middle-income countries' students face additional challenges in providing virtual education.
• • The main challenges LMIC students face are frequent internet and electricity outages and limited technology skills.
• • The COVID-19 pandemic placed novel emotional and financial pressures on medical students.
• • Here, we presented strategies for best practices in remote medical education, such as open-access medical education content.

The coronavirus disease 2019 (COVID-19) pandemic has impacted multiple facets of medical education, ranging from the admissions process to influencing students’ specialty selection. Initially intended as temporary solutions, many institutions introduced online learning platforms that have persisted due to the unpredictable and evolving course of the pandemic. At the time of writing, online medical education is becoming a new norm that is projected to continue for years to come [ 1 ]. To date, the medical education literature has primarily focused on strategies for high-income countries (HICs) to optimize online medical education. By contrast, low- and middle-income countries (LMICs) face additional challenges in providing virtual education. These challenges include resource limitations, such as frequent internet and electricity outages, limited technology skills, and institutional challenges. In this paper, we focus on lessons learned from medical education in Pakistan. We discuss specific challenges and their potential solutions, precisely resource, receiver, and institutional challenges. Also, we discuss additional strategies, including the role of global resources in medical education.

One of the primary concerns of students is inconsistent internet access. Even in developed countries, poor internet connection has been described as a barrier to remote medical education [ 2 ]. In Pakistan, limited internet access is a significant obstacle to the successful implementation of live education. In one survey of 532 medical students in Pakistan, 14% reported not having experience with internet use, and 15% reported only rarely using the internet [ 3 ]. Strategies to address this should include institutional venues with reliable internet access and governmental and private sector efforts to improve connectivity.

Multiple areas in Pakistan are affected by frequent electricity outages. While wealthier families have backup electricity sources, many families in Pakistan lack the facility of alternative source. Particularly for live educational sessions, electricity outages can result in interruption of educational content. For students without reliable electricity access, institutions should offer computer access within socially distanced computer labs to ensure all students access uninterrupted curricular content.

The rapid transition to a new educational format has also posed challenges for students with limited experience with technology. One survey from before the COVID-19 pandemic found that only 34% of students considered themselves capable of searching for clinical information on academic databases such as PubMed [ 3 ]. The same study also identified statistically significant differences concerning gender and ability to use online databases. Institutions must be cognizant of differences in students' technological skills. Specific solutions include introducing technology skills into the curriculum for both remote learnings and online clinical referencing.

By nature, online platforms make hands-on training challenging to replicate. The literature raises concerns that online learning may significantly affect students' preparation for their clinical years [ 1 ]. Training for specific skills, such as physical exam maneuvers and anatomic education, are particularly affected by virtual training. For these skills, virtual reality (VR)-based simulations can be a helpful replacement. Haroon et al. described the successful use of manikins and VR-based devices for skills training in dental education in Pakistan [ 4 ].

Similarly, VR-based anatomy education may be a promising alternative for anatomy content [ 5 ]. Institutions should also consider blended curricular arrangements, virtual education, and socially distanced, in-person training for hands-on skills. Going forward, institutions should consider educational strategies such as VR to ensure competency in hands-on training.

There have also been concerns regarding the integrity of the virtual assessment process [ 6 ]. These include reports of students using handheld electronic devices to share answers during the assessment [ 7 ]. Institutions must be cognizant of these additional challenges in remote contexts. Strategies to address this include arranging for critical assessments to be held in person with socially distanced settings.

The COVID-19 pandemic placed novel emotional and financial pressures on medical students, many of whom unfortunately do not typically have access to mental health resources [ 8 ]. Before COVID-19, mental illness has been prevalent among Pakistani medical students, with 35% reporting suicidal ideation over the past year [ 9 ]. Remote learning during COVID-19 is associated with increased feelings of isolation and anxiety, significantly when students cannot interact with other students [ 10 , 11 ]. Globally, work-related stress associated with COVID-19 has been linked to suicide by healthcare providers [ 12 ]. All authors, who are at various stages of medical education in their careers, strongly believe that institutions should make mental health resources and counselors available to students’ top priority.

Here, we discuss specific additional considerations for strategies to improve remote medical education.

In this section, we want to emphasize. Multiple institutions have developed and shared open-access medical education content, especially since the start of COVID-19. In response to students' concerns about outdated curriculum, incorporating such open-access content can be a valuable supplement to students' learning experience. For example, Rothberg et al. described an instance of faculty incorporating publicly available content from multiple sources into a curriculum for medical student education about otolaryngology [ 13 ]. While some resources are paid (UWorld, Amboss etc), many organizations offer free educational resources. Two leading organizations in this space include Clinical Problem Solvers ( clinicalproblemsolving.com ) and the Global Medical Education Collaborative ( gmecollab.org ). While the quality of these resources is excellent, many students are unaware of these initiatives. We encourage both students and educators to consider supplementing content with relevant resources from organizations such as these.

As a result of COVID-19, telemedicine has grown exponentially worldwide. This poses an opportunity for students to obtain clinical skills remotely. In the past, Pakistani medical educators have advocated for telemedicine as it can reduce disease exposure [ 14 ]. Tele-simulation, or faculty-supervised standardized patient telehealth encounters, have been proposed in the literature as one way to build skills in the preclinical years remotely [ 15 , 16 ]. Of note, in a survey of medical students at UC San Diego School of Medicine in the United States (US), telemedicine was one of the highest-rated educational resources [ 17 ]. In Pakistan, we believe that telemedicine can be a valuable educational resource for building clinical communication skills when possible.

In online learning settings, education is often provided in a lecture format, resulting in limited student engagement and many students being distracted by other content. One nationwide survey of students in the United Kingdom (UK) concluded that one strategy for effective online medical education is using team-based/problem-based learning, in which students discuss problems with their peers [ 2 ]. Faisal et al. studied problem-based learning at a medical school in Pakistan and found that students who learned through problem-based learning had improved content comprehension compared to lecture-based learning [ 18 ]. We believe that educators should consider incorporating problem or team-based learning activities into their online education.

Across the globe, undergraduate medical education has been dramatically impacted by the COVID-19 pandemic. In countries such as Pakistan, there are additional challenges faced by students and educators. This paper presents a focused discussion of the primary challenges affecting remote education, ranging from electricity to gaps in technology skill competencies. For each of these challenges, we presented specific solutions that institutions can consider. We also presented additional strategies for best practices in remote medical education. As the COVID-pandemic evolves, additional research is needed on the most effective educational strategies, especially for LMICs.

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Authors’ contributions

Z.Y, M.J.T, and H.S conceived the idea, H·S, M.J.T, Z.Y, A.N, and I·U retrieved the data, did write up of the manuscript, and finally, Z.Y, M.S.A, Z.D, and I·U reviewed and provided inputs. All authors approved the final version of the manuscript.

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Muhammad Junaid Tahir: [email protected], https://orcid.org/0000-0002-0335-6681 .

Declaration of competing interest

The authors have no conflict of interest.

Acknowledgments

Quality of medical education in Pakistan to be measured

The committee will review the standards of private medical colleges in the country

Islamabad: Prime Minister Shehbaz Sharif Thursday decided to investigate the provision and quality of medical education in the country.

Prime Minister Shehbaz Sharif formed a high-powered committee under the patronage of Deputy Prime Minister and Foreign Minister Ishaq Dar. The notification of the 25-member committee has also been issued on the instructions of Prime Minister.

The committee will review the standards of private medical colleges in the country while the reasons for students going abroad for medical education will also be ascertained.

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ISLAMABAD: A 25-member high-powered committee was formally notified on Thursday to assess the standards of medical education and private colleges, admission processes, and reasons for students going abroad for medical education.

The notification was issued under the direction of Prime Minister Shahbaz Sharif and Deputy Prime Minister Ishaq Dar will lead the committee. The committee is tasked with compiling a report within 10 days based on five terms of reference (TORs).

The committee will investigate the quality of medical education, admission procedures, standards of private medical colleges, and reasons behind students seeking medical education abroad. Furthermore, the committee will review the current regulatory framework and propose recommendations to improve coordination between the public and private sectors in the medical field.

In the 25-member high-powered committee, federal ministers, members of the National Assembly and heads of medical universities and institutions are included.

Key members of the committee are Federal Minister Ahsan Iqbal, Law Minister Senator Azam Nazir Tarar, Health Coordinator Malik Mukhtar Bhatti, National Assembly Member Nafisa Shah, Deputy Chairman of the Planning Commission Jahanzeb Khan, Federal Health Secretary, Special Secretary for Foreign Affairs, Chairman of the Higher Education Commission (HEC), and Chairman of the Pakistan Medical and Dental Council (PMDC).

The committee will also put forward recommendations for enhancing the quality of medical education in the country.

It is worthy to mention that Wednesday, the PM took notice of the Bishkek incident with Pakistani medical students and announced forming the committee to sort out the issue.

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• Volume 14, Issue 5
• Care for the caregiver: an exploration of caregiver burden of children with chronic medical conditions at a tertiary care hospital in Karachi, Pakistan – a mixed-methods study
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• http://orcid.org/0000-0001-6157-6327 Sana Saeed 1 ,
• http://orcid.org/0009-0004-6481-0894 Marib Ghulam Rasool Malik 1 ,
• Maryam Hameed Khan 2 ,
• Shahzil Abdur Rehman Malik 3 ,
• Bisma Aziz 4
• 1 Department of Pediatrics and Child Health , The Aga Khan University , Karachi , Sindh , Pakistan
• 2 Institute for Global Health and Development , The Aga Khan University , Karachi , Sindh , Pakistan
• 3 Medical College , The Aga Khan University , Karachi , Sindh , Pakistan
• 4 Department of Medicine , The Aga Khan University , Karachi , Sindh , Pakistan
• Correspondence to Dr Sana Saeed; sana.saeed{at}aku.edu

Objectives Caregiver burden often goes unrecognised and can substantially affect caregivers’ physical, psychological and financial well-being, thereby impacting quality of care. This study investigates burden among caregivers of children with chronic medical conditions in a tertiary care hospital in Pakistan. The study aims to assess the extent of burden, explore influencing factors and recommendations for interventions.

Design Mixed-methods study, comprising of an in-person paper-based survey, employing the Zarit Burden Interview scale to assess burden scores. Qualitative component included thematic analysis of semi-structured in-depth interviews with caregivers.

Participants 383 caregivers of children admitted to the inpatient paediatric services at our tertiary care centre were surveyed. In-depth interviews were conducted with 19 caregivers.

Results The survey revealed a mean burden score of 35.35±15.14, with nearly half of the participants (46%, n=177) experiencing mild burden, while 37% (n=140) reporting moderate-to-severe burden. The most common diagnosis was cancer (24%, n=92), while the highest burden (42.97±15.47) was noted for congenital cardiac disease. Greater burden was significantly associated with lower caregiver education, young age of the child at diagnosis and increased number of hospital visits (p<0.05). Caregivers highlighted financial strain, psychosocial effects and impact on lifestyle and relationships as key challenges. They emphasised the need for improved medical coordination, financial support and enhanced hospital services.

Conclusions The study elucidates the multifaceted nature of caregiver burden in the context of paediatric chronic illnesses in Pakistan. Interventions should emphasise financial aid, educational support and development of system-level changes to improve access to resources and medical care coordination. These insights call for policy and practice integration to support caregivers effectively.

• chronic disease
• paediatric palliative care
• quality of life
• stress, psychological

Data availability statement

Data are available upon reasonable request. The datasets used and analysed during the current study are available from the corresponding author on reasonable request.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjopen-2023-083088

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STRENGTHS AND LIMITATIONS OF THIS STUDY

The mixed-methods design, integrating both quantitative surveys and qualitative interviews, provides an enriched depth of understanding in exploring caregiver experiences.

The use of a validated instrument to quantify burden levels increases the reliability of findings.

A single centre focus potentially limits the generalisability of findings to diverse healthcare settings and regional contexts.

The reliance on self-reported data introduces the possibility of recall bias and subjective responses.

Introduction

The role of caregivers encompasses many domains, as caregivers provide physical, medical, financial and emotional support to patients entrusted to their care. 1 However, this responsibility often comes at a cost, as caregivers may experience significant burden and adverse health outcomes. 1 Caregiver burden is a term used to describe the physical, psychological, emotional, social and financial impact of caring for someone who is ill or has functional impairments. 2 Although the definition could encompass all caregivers, it is often used to describe unpaid caregivers, who are usually family members of patients. These unpaid caregivers are often neglected or ignored and have been referred to as ‘the informal patient’. 3 4

Chronic diseases, also referred to as ‘non-communicable diseases’ by the WHO, are defined by WHO as conditions ‘that are of long duration and generally slow progression, and are the result of a combination of genetic, physiological, environmental and behavioral factors’. 5 The Centres for Disease Control and Prevention (CDC) defines them as conditions that last at least 1 year and require ongoing medical attention, limit activities of daily living or both. 6 In the context of low–middle-income countries, a distinctive array of challenges, including gender norms, economic hardship, stigmatisation and non-inclusive governmental measures, exacerbates the caregiving experience. 7 Addressing caregiver burden effectively requires informed strategies and policies grounded in empirical evidence to ensure that adequate support and services are provided. 8

The prevalence of children with chronic medical conditions is high in Pakistan. Although prevalence for the most common individual disorders is available online, there is no grouped data on the prevalence of children with chronic medical conditions in the region. For instance, the incidence of childhood cancer in Pakistan is 100 per million, with approximately 8000 children diagnosed cancer every year. 9 10 Similarly, the prevalence of paediatric epilepsy in Pakistan is 1% compared with the global prevalence of 0.6%. 11 Furthermore, there are insufficient support resources tailored to the psychosocial needs of caregivers, which compound the challenges, potentially impacting the quality of care and overall family dynamics. 12 13

Studies from other regions indicate varying levels of caregiver burden across different chronic conditions, emphasising the need for a comprehensive understanding of how specific illnesses influence caregiver experiences. 14 15 There are a few studies reporting the caregiver burden in individual, specific chronic conditions, however there is little data related to pattern of chronic illness and its impact on the caregiver burden. 16 17 This study aims to evaluate caregiver burden of children with chronic medical conditions in a tertiary care hospital, Karachi, Pakistan. It also aims to explore the various factors influencing caregiver burden and recommendations for potential interventions.

We conducted an explanatory sequential (Quantitative-Qualitative) mixed methods study over a duration of 6 months (November 2021 to June 2022) in the inpatient paediatric department of a tertiary care centre in Karachi, Pakistan.

Quantitative approach

The quantitative component adopted a cross-sectional design. We used non-purposive consecutive sampling, and all caregivers of patients aged 1–18 years with chronic medical illnesses, that fit the CDC definition of chronic diseases and consented for the study, were included. 6 Written informed consent was obtained from the participants prior to the survey.

The survey included both caregiver and child variables. For caregivers, demographic details included the following categorical variables collected as ranges: age, average household income, number of family members and earning members. Discrete caregiver variables included gender, educational status, occupation, marital status and family type. Children demographic data included the following categorical variables collected as ranges: age, frequency of hospitalisations and monthly medical costs. Discrete variables included their gender and diagnosis. The burden score was evaluated using the Zarit Burden Interview (ZBI) scale. 18 The scale has a validated Urdu version, which was modified for paediatric context. Permission to use the Urdu version and replace the phrase ‘your relative’ with ‘your child’ to make it relevant to the paediatric population was obtained through the official distribution portal. 19 The ZBI consists of 22 items scored in 5-point Likert scale from 0 (never) to 4 (nearly always), except for the final item on global burden, rated from 0 (not at all) to 4 (extremely). The total score ranges from 0 to 88 with higher scores, indicating higher burden. Additionally, the burden scores can be categorised into severities based on the cut-offs suggested by the authors of the ZBI: no burden (0–20 points), mild burden (21–40 points), moderate burden (41–60 points) and severe burden (61–88 points). 18 These cut-offs have been consistently used in the literature, including several validation studies. 20–22 Sample size was estimated based on the result of a previous study in which the mean±SD of the ZBI caregiver burden was 39.04±15.14. 23 Using the formula for estimating the mean of a quantitative variable, a margin of error of 5 points, 80% power, alpha of 0.05 and effect size ( d ) of 1.514 (0.1 of the given SD), a required sample size of 384 participants was calculated.

Qualitative approach

Semi-structured in-depth interviews (IDIs) were conducted to produce knowledge grounded in human experience, which might be overlooked in purely quantitative analyses. An interview guide was developed following a comprehensive review of literature pertaining to caregiver burden and chronic illnesses. Key topics included the overall caregiving experience, challenges, changes in routines and relationships as well as the impact on physical, emotional and mental well-being since the child’s diagnosis. Additionally, participants were asked about their perceived sources of support, coping mechanisms and unmet needs related to their caregiving responsibilities (the guide can be found as online supplemental file 1 ). The guide was translated to Urdu and used by the interviewers during all IDIs to ensure consistency across the interviews.

Supplemental material

Participants for the IDIs were selected through purposive sampling from those who had completed the quantitative survey and exhibited a willingness to share detailed experiences beyond the scope of the survey. Invitations to participate in the IDIs were extended to caregivers who demonstrated a propensity for providing rich qualitative data during the survey process. Participants were explained about the procedure and the audio-recording of interviews, and written informed consent was obtained.

To ensure privacy and confidentiality, IDIs were conducted in a designated patient discussion room within the paediatric ward. For the duration of the interview, it was ensured that the child was accompanied by either a second caregiver if available (such as the participant’s spouse) or a nurse present constantly at the patient’s bedside. The language of the interviews with the participants was a combination of Urdu and English, as per the participants’ preferences. These audio-recorded interviews were transcribed verbatim by a trained member of the research team. Transcripts were translated to English by a trained member of the research team and then back-translated to Urdu by a second trained member to ensure linguistic accuracy and preserve the integrity of participants’ narratives. The approved English transcripts then underwent thematic analysis.

Initially, we aimed to interview 10% (n=40) of the participants from the quantitative survey. However, after conducting a preliminary analysis of the first 10 interviews, it became evident that theoretical saturation had been reached as subsequent interviews yielded no new themes beyond those already identified. Consequently, the decision was made to conclude the interview process after sessions with 19 participants.

Data analysis

Quantitative data were analysed using STATA V.15. Categorical variables are presented as frequencies and percentages. The numerical burden scores from the ZBI scale are presented as mean±SD and median (IQR). Univariate analyses were conducted using the Mann-Whitney U and Kruskal-Wallis tests to explore associations between caregiver and child variables with burden scores. Subsequently, a multivariable regression analysis was performed, including variables with a univariate p value less than 0.25. P<0.05 was considered statistically significant.

Qualitative data were analysed to the point of theoretical saturation, the point at which no new concepts are generated from the data. 24 Thematic analysis was conducted to identify patterns, working systematically through the entire data set, giving equal attention to each item and exploring note-worthy aspects that may form the basis of themes across the data set. The themes were assigned unique codes and relevant information from each interview was added to the specific code. 25 The analysis was conducted independently by two researchers. NVivo software was used to facilitate the organisation and management of the qualitative data. 26

Patient and public involvement

Patients or the public were not involved in the design, or conduct, or reporting or dissemination plans of our research.

Quantitative results

A total of 383 caregivers completed the survey. Nearly half of the respondents were aged between 26 and 35 years old (48%, n=186), with the majority being the admitted child’s parent (93%, n=357), female (69%, n=263) and married (98%, n=374). Sixty-four per cent (n=247) of caregivers were unemployed, while 50% (n=192) had an average household income between 10 000 and 50 000 PKR. Family structures were predominantly non-nuclear or extended (52%, n=198), with at least two earning members in 52% of families (n=201).

The ages of the admitted children ranged from 12 months to 17 years old. Among these, 58% (n=224) were men, and 36% (n=136) were aged between 6 and 13 years old, with the majority (31%, n=118) being diagnosed with the chronic condition during infancy (aged less than 12 months), and around half (51%, n=197) of them having had the diagnosis for the past 1–3 years. The most common diagnosis among children in our study was cancer (24%, n=92), followed by seizure disorders (14%, n=55) and endocrine disorders (12%, n=45).

The Urdu-translated version of the ZBI employed in our study demonstrated good internal consistency, with a Cronbach’s alpha of 0.865 (n=383). The responses to the questionnaire yielded an overall mean burden score of 35.35±15.14, with 17% (n=66) of respondents experiencing no burden, 46% (n=177) experiencing mild burden, 31% (n=118) experiencing moderate burden and 6% (n=22) experiencing severe burden.

Considering specific disease types, the highest mean burden score was observed for children diagnosed with congenital cardiac disease (42.97±15.47), followed by Cerebral Palsy (CP) (40.43±17.68) ( table 1 ).

• View inline

Mean caregiver burden scores across disease types (n=383)

Results of non-parametric testing revealed significant associations between caregiver burden and several demographic factors ( table 2 ). Caregiver age, educational status and marital status were significantly associated with burden (p<0.05). Furthermore, parents reported significantly higher burden scores than non-parent caregivers (p<0.001). Burden scores were also significantly different based on average household incomes (p<0.001) and number of earning family members (p=0.044).

Non-parametric testing of children demographics revealed that burden scores were significantly different based on the child’s current age (p<0.001), age at diagnosis (p=0.014), duration of illness (p=0.028) and number of hospital visits since diagnosis or onset of symptoms (p<0.001) ( table 3 ).

Caregiver demographics and their association with caregiver burden (n=383).

Children demographics and their association with caregiver burden (n=383)

After performing multivariable analysis, the caregiver variables of ‘relationship with patient’ and ‘educational status’, along with the child variables ‘age at diagnosis’ and ‘number of hospital visits’ remained significant predictors of caregiver burden (p<0.05) ( table 4 ).

Multivariable regression analysis of caregiver burden predictors

Qualitative results

The IDIs with 19 caregivers explored their overall experiences, factors influencing caregiver burden and recommendations for potential support and improvement in care ( figure 1 ). A detailed breakdown of the various themes and subthemes as well as the verbatim quotes from the participants can be found in the online supplemental materials of the manuscript ( online supplemental file 2 ).

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Themes and subthemes emerging from the IDIs. IDIs, in-depth interviews.

All caregivers, regardless of their socioeconomic status, identified financial challenges as their primary concern, impacting various aspects of their lives, including treatment access, lifestyle adjustments, mental well-being and social interactions. Majority of the caregivers also reported significant psychosocial challenges, including the trauma of accepting the reality of their child’s condition and a lack of emotional support from the community. Adjusting to the child’s increasing dependency also posed challenges. This ranged from complete physical support to heightened care due to special dietary needs, treatment and symptom monitoring. Caregivers also identified distance as a challenge to accessing care. While some faced a problem commuting within the city due to logistical issues, others travelled across the country to access care.

Impact on lifestyle

Most caregivers expressed mental distress and noted a lack of time for self-care, attributing these challenges to the overwhelming responsibilities associated with their child’s care. Others attributed this lack of self-care to financial pressures. Despite these challenges, many caregivers maintained hope and a positive outlook, making special efforts to ensure their child’s comfort and normalcy for the family. However, caregivers of children with more severe and chronic conditions expressed distress and hopelessness. Their methods of coping varied, depending on duration, severity and chronicity of the child’s condition, frequency of hospital visits and financial stressors.

Impact on relationships

Relationship dynamics were notably affected, with caregivers reporting disruptions in their relationships with other children, often due to reduced attention and resources. Many noted a change in their emotional disposition, affecting their children’s behaviour in response to decreased parental attention. Financial challenges also led to educational setbacks for other children.

Majority of the caregivers spoke positively about their relationship with their spouse, with most acknowledging their partners as significant sources of support. However, some caregivers experienced strain in their relationships, particularly when partners failed to understand the caregiver’s changed behaviour due to stress. Responses about relationships with friends and family varied. While some received support from relatives in the care of their children, others related an almost complete absence of relatives in their life following their child’s diagnosis. A recurrent reason was their inability to be present at social events due to increased caretaking demands. Financial difficulties sometimes strained relationships, particularly when borrowing money was involved.

Caregiver health

Following their child’s diagnosis, caregivers reported a significant impact on their health, experiencing worsening of pre-existing medical conditions due to stress. Mood changes, including anxiety, depression and anger, were commonly mentioned.

Several caregivers described various coping strategies for mental stress, ranging from prayer to family outings. However, many expressed a complete absence of time for personal mental and emotional self-care.

Most caregivers were reluctant to seek professional psychiatric help. Many reasoned that the financial burden following their child’s diagnosis left little room for any extra expense, while others mentioned a lack of time. They denied feeling any hesitation in accessing psychiatric help due to sociocultural stigmas. Prioritising their child’s needs, most caregivers overlooked the impacts on their own physical and mental health.

Attitude towards child

An overwhelming majority of the responses discussed positive changes in their family and social circle’s attitudes towards their child postdiagnosis, noting an increase in love and care. However, in a few families, a child’s need for special attention and support was also accompanied by what caretakers felt was an increase in judgement and change in perception of their child among their distant relatives and family members. Despite many positive experiences, a few caregivers faced distressing negative reactions within their social circles.

Support and resources

Overall, the greatest support in every domain identified by caregivers was their spouse and partners. Additionally, many found solace in their religious faith, which provided emotional strength during challenging times. Many caregivers living in joint families discussed this as a major source of support. Hospitals were also mentioned as a major source of support for some families, offering financial assistance for treatment and long-term management, either through partial discounts or fully covering costs. A unique finding was one caregiver mentioning social media as the biggest support in their journey in the form of treatment funding. However, not all caregivers experienced such support. Some faced the challenge alone, without any external assistance, struggling to manage hospital visits and afford medications.

Hospital services

Most caregivers praised the medical team and care management during hospital visits, highlighting the emotional availability and support provided by doctors and their teams. However, there were suggestions for improving inter-team coordination and increasing access to screening tests, such as antenatal testing for Down syndrome as well as the need for health education and awareness among patients and their families. Waiting times were another concern, with calls for more efficient and streamlined procedures, especially for families who frequently visit the hospital.

The intricate dynamics of caregiving, especially for children with chronic medical conditions, present a multifaceted challenge that extends beyond the immediate medical needs of the child. Our study offers comprehensive insights into the caregiver burden of children with chronic illnesses, using both quantitative and qualitative approaches. We found that the role of the caregiver was majorly taken up by women, particularly young and middle-aged mothers, most of whom were unemployed homemakers, a demographic in line with prior literature. 14 27 Our study yielded a mean burden score of 35.35±15.14, with nearly half (46%) of the caregivers considering the burden to be mild, while 37% noting experiencing moderate-to-severe burden. A study conducted in Iran also reported a similar overall mean ZBI score of 39.04±15.14, while results from the USA found moderate caregiver burden (mean: 52.55±16.8). 23 28 This difference between white and non-white caregivers has been previously attributed to different degrees of knowledge of medical illnesses, varying sociocultural expectations, family-centred values and healthcare system dynamics. 29 30

The common diagnoses in our study, such as cancer, seizure disorders and endocrine disorders, align with global trends. 31 We found the highest burden among caregivers of children with congenital cardiac diseases, followed by CP and musculoskeletal disorders. Piran et al reported the highest caregiver burden in CP, attributing it to the wide array of challenges posed by the condition, encompassing motor, mental, emotional and communication impairments, which not only intensify caregiving demands but also strain finances and disrupt family routines. 14 Congenital cardiac diseases, often identified early life, are associated with a looming uncertainty of complications such as heart failure, pneumonia and brain abscesses, which can amplify anxiety and stress for caregivers, fearing potential life-threatening episodes. 32 Similar to CP, children with congenital heart conditions often face dietary and activity constraints, demanding unwavering attention from caregivers who may find reduced opportunities for leisure and social interactions, along with constant preoccupation with the child’s health and a relentless cycle of physical and emotional strain.

While our study did not explicitly examine the correlation between burden scores and the intensity of care required for different illnesses, it is a crucial aspect in understanding caregiver burden comprehensively. The intensity of care, healthcare access and insurance coverage can significantly influence the caregiving experience and caregiver burden. In Pakistan, over 58% of healthcare costs are out-of-pocket, as medical insurance coverage is in the single digits, which has been attributed to low insurance literacy among the population and to a lack of empaneled private providers. 33 34 The high rate of out-of-pocket expenditure stems from a low level of government spending on health, as successive governments in Pakistan have allocated much lower amounts of their budgets to healthcare, even when compared with other developing countries. 35 Factors such as the availability of healthcare resources, including specialised medical care, therapies and support services, can impact the caregiver’s ability to manage the child’s condition effectively.

Several associations with caregiver burden emerged in our study. Considering caregiver factors, we found that older participants had higher levels of burden. A study conducted on caregivers of adults with intellectual disabilities reported higher levels of worry and lower quality of life among older caregivers and suggested that older caregivers tend to lose their social support with time. 36 Additionally, older caregivers might face their own age-related health challenges, thereby compounding the stress and demands of caregiving. Our study found no difference in burden among employed and unemployed caregivers, a result also reported by Piran et al . 14 A potential explanation for this could be that the majority of our respondents were women, primarily homemakers, who might not be the primary earners in their households and thus, their employment status might not have a direct bearing on the household’s overall socioeconomic standing. This further aligns with our finding that caregivers from households with higher monthly incomes reported significantly lower burdens, an association consistently observed in the literature. 14 23 37

Interestingly, we found no significant difference in burden based on caregiver gender. Prior literature is also conflicted in this regard, with several studies reporting significantly higher burden among women and mothers while others have not discerned any gender-specific associations. 14 23 38 39 However, our qualitative insights suggest that irrespective of gender, caregivers grapple with similar emotional challenges, shaped by societal expectations and perceptions, acceptance of the child’s condition and the inherent demands of caregiving.

Our study found that caregivers of children diagnosed with chronic illnesses at younger ages tended to have significantly higher burden. This may be attributed to the increased care demands of younger children, who naturally require more attention and supervision. Additionally, an early diagnosis implies a prolonged journey with the illness, leading to extended caregiving durations. This notion is further corroborated by our finding that burden among caregivers increased with longer durations of the illness and with increased visits to the hospital. A study by Boztepe et al also found that younger patients diagnosed with leukaemia were associated with higher burden among caregivers. 40 Another study reported contrasting findings, reporting no significant associations between perceived burden and children’s age or duration of disease. 23 The authors suggested that caregivers may learn to better cope with the associated burdens. However, they also recognised that elevated burden levels could persist among these individuals, driven by concerns about their child’s disease course, prognosis, quality of life and uncertainties surrounding their future. It is also likely that a prolonged duration of illness may lead to an increase in the overall financial demands of care, thereby contributing to the overall caregiver burden.

The qualitative findings of our study serve to further illuminate the lived experience of caregivers. The recurring theme of financial strain appeared to transcend socioeconomic boundaries, being evident across various backgrounds. Interviews with the caregivers revealed that financial strain is complex, stemming not only from the direct costs of medical treatment but also indirect costs that often go unnoticed, such as transportation to and from medical facilities and potential loss of income due to missed workdays. Our study resonates with global trends and prior literature underscoring the financial challenges faced in the care of children with chronic conditions and emphasises the need for systemic interventions through financial aid, subsidised medical care or community support initiatives. 41 42 It is reasonable to infer that our study’s sample is a representative sample of the country, as majority of our patients were in the PKR 10 000 to PKR 50 000 income bracket, in line with the national average household income of PKR 41 545 documented by the Pakistan Bureau of Statistics. 43

Our qualitative results also provide valuable insights into potential avenues for intervention. Caregivers emphasised the need for improved coordination among medical teams and provision of more comprehensive information to caregivers about their child’s medical condition. Indeed, the role of health education in improving patient and caregiver outcomes is well established in the literature and employing future care strategies by clinicians regarding education of caregivers about disease information, prognoses and avenues for support can aid to reduce caregiver burden. 44 45 Accessibility to essential medications closer to home was another concern, addressing the added strain of travelling long distances for treatments.

Prior research supports the efficacy of non-pharmacological interventions in reducing caregiver burden. For example, it was found that diaphragmatic breathing resulted in lower levels of anxiety, stress, depression, burnout and decreased ZBI scores among caregivers of paediatric palliative patients. 46 Similarly, cognitive behavioural therapy resulted in lower anxiety levels in mothers of children diagnosed with cancer. 47 Multicomponent interventions, including psychoeducation and support group, offer a comprehensive approach to addressing caregiver burden. 48 Physicians treating patients requiring caregivers should be trained to recognise and address the emotional needs of caregivers and advocate for caregivers keeping in mind the important deleterious effects of caregiver burden. Training programmes should emphasise the effectiveness of non-pharmacological interventions to benefit both patients and caregivers.

Strengths and limitations

The major strength of our study lies in its mixed-methods design, which provides a comprehensive understanding of caregiver burden amidst chronic childhood illness within the context of a lower middle-income country. The use of a validated assessment tool ensures the robustness of burden measures in our study, while the inclusion of diverse paediatric illnesses addresses a critical gap, presenting comprehensive data on burden across various chronic conditions.

However, several limitations warrant acknowledgement. First, the cross-sectional design of the survey may not fully capture the dynamic and evolving nature of the caregiving experience. Specifically, we were unable to assess how changes in the child’s health status due to ongoing treatment impact caregiver stress and burden, nor could we track how accumulating medical expenses over time might exacerbate burden levels. To address these limitations, future research could adopt a longitudinal approach, allowing for a deeper exploration of these complex relationships. Next, our single-centre setting may limit generalisability to other regions or healthcare settings in Pakistan. Additionally, we have used the Centers of Disease Control and Prevention’s definition of chronic diseases. We recognise that this broad definition includes diseases with a wide range in disease course, severity of clinical outcomes and includes both diseases that are associated with acute-on-chronic exacerbations and diseases with a more chronic, indolent course. This wide range can cause fluctuations and differences in the required level of caregiver dependence.

While the use of a validated tool in the ZBI improves the reliability of our findings, a patient survey-based questionnaire and interviews may be subjected to recall or social desirability biases. Additionally, approaching caregivers during inpatient hospital stays, when stress levels may already be elevated, could potentially influence their responses to the ZBI questionnaire. To mitigate these potential biases, future studies should consider conducting surveys in the home environment or during routine outpatient follow-up visits, which may offer a more accurate depiction of caregiver burden.

While our survey inquired about the presence of multiple earning members within families and the total number of household members, aiming to capture potential sources of support that might alleviate caregiver burden, we acknowledge the importance of also assessing the availability of medical, paramedical or non-medical personnel at home to aid in the child’s care. Recognising the potential impact of such assistance on caregiver burden, future studies could benefit from incorporating these additional factors into their assessments. Finally, we recommend that future surveys include inquiries about the schooling status of children, as caregivers of school-going children may have opportunities for respite while their child is in school. This inclusion could provide valuable insights into potential strategies for alleviating caregiver burden associated with continuous caregiving responsibilities.

The findings of our study hold profound implications for the healthcare administrations, policymakers and clinicians in the realm of paediatric chronic illnesses and warrant the need for a holistic approach to care especially in the context of low and middle-income countries. The reported caregiver demographics emphasise the socioeconomic vulnerabilities that can exacerbate the caregiving burden, while qualitative insights into caregivers’ experiences present actionable areas for intervention. Alongside the resonance with global literature suggesting universal themes regarding caregiving and burden, our study necessitates the consideration of regional nuances, particularly in developing countries like Pakistan, for tailored interventions. The integration of these insights into policy and practice is essential to provide caregivers with the support and resources they need to navigate the demanding journey of caring for such children.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

Ethical approval was sought and obtained from the Aga Khan University’s ethical review committee prior to commencement of the study (reference number: AKU-ERC 2021-6653-19585). Written informed consents were obtained after thorough discussions regarding the study’s purpose and procedures with all the caregivers prior to participation in the survey and the interview.

Acknowledgments

We would like to thank all the caregivers that agreed to participate in this research. We are also grateful for the support provided by our data collectors and other staff members of the Pediatric department.

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Supplementary materials

Supplementary data.

This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

• Data supplement 1
• Data supplement 2

Contributors SS contributed to the conception and design of the work, as well as the acquisition of data and critical review. MGRM and SARM analysed and interpreted the quantitative data and contributed to drafting of the manuscript. MHK and BA contributed towards the acquisition, transcription, translation and analysis of the in-depth interviews for the qualitative component of the manuscript. All authors read and approved the final manuscript and agree to be personally accountable for all parts of the work. SS is responsible for the overall content as a guarantor.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Provenance and peer review Not commissioned; externally peer-reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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Advanced Diploma in Health Professions Education

Developed by AKU’s Department for Educational Development, the  Advanced Diploma in Health Professions Education (HPE) programme is designed to develop excellent teachers, educators and innovators in health professions education. Graduates from this Programme will know how to use best evidence medical education to make informed decisions for improving the standards of undergraduate, postgraduate and continuing health professions education in the fields of medicine, dentistry, nursing and allied health sciences, in Pakistan and abroad.

The programme will also provide a platform for educators in the health professions to share experiences resulting in the development of collaborations and linkages optimising education and research at national and regional levels.

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By the end of the programme, graduates should be able to: 

Demonstrate critical thinking and problem-solving skills in health professions education on national and international issues

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Develop and apply innovative teaching, learning and assessment strategies, using best evidence to make informed decisions in HPE

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Chairs and members of the year committees, curriculum committees, assessment and promotions committees (or equivalent), programme coordinators and programme directors of educational programmes.

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The Advanced Diploma in HPE programme consists of pre-requisite and advanced level courses which will require a minimum of two years to a maximum of four years of study. 

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Option 1: Following the completion of two/three Advanced Level Courses (ALCs) in HPE candidates are eligible to apply to the Advanced Diploma in Health Professions Education programme if they have achieved a minimum CGPA of 2.50. 

Option 2: Following the AKU graduate programme application process.

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Extreme heat waves in south and southeast Asia are a sign of things to come

by Neven S. Fučkar, The Conversation

Since April 2024, wide areas of south and southeast Asia, from Pakistan to the Philippines, have experienced prolonged extreme heat. Covering some of the most densely populated regions in the world, the series of heat waves has affected everything from human health and well-being to the economy and education.

Many pupils in India, Bangladesh, and Philippines have been told to stay at home for days due to a severe health risk from extreme heat, while the heat waves are becoming a major issue in India's election . Bangladesh even closed all primary schools for weeks while the temperature reached 43.8°C on April 30.

Once the temperature goes above 38°C, it exceeds the core human body temperature (about 37°C) and the chance of heat exhaustion and even heatstroke increases dramatically. This is compounded by increasing humidity in the region which puts additional heat stress on the human body, as sweat is not able to evaporate as effectively (the primary mechanism for cooling the human body).

That is why extreme heat in a tropical country can be less pleasant and more dangerous than the same temperature in a desert.

Tens of millions of people have been exposed to such health threatening conditions in south and southest Asia in April and May so far, and this extreme heat has substantially affected labor productivity .

How it got so hot

Extreme heat is driven by several processes, operating from global down to local scales. At the local level, less vegetation and soil moisture tends to mean more heat, while cities of concrete and asphalt are hotter than the surrounding countryside thanks to the urban heat island effect . Other local and regional factors include the wind, and whether conditions are ripe for clouds to form.

Then there are the more global factors: El Niño, and of course global warming . El Niño refers to the warm phase of a natural fluctuation of temperatures in the tropical Pacific (its opposite side is La Niña).

The Pacific has been in an El Niño phase since May 2023, releasing additional heat and exacerbating global warming in many regions. In parts of Asia, this leads to periods of extreme heat happening more often, lasting longer and being even more extreme in addition to global warming contribution.

This is particularly dangerous for the many cities in south and southeast Asia being hit by the current series of heat waves, which over the past 85 years have already experienced long-term increase in the number of days in April with such dangerously high temperatures.

Short term noise, long term trends:

Occurrences of extreme heat days over years typically looks rather noisy when plotted on a graph. Some years may have many days of extreme heat, others only few or none. But over a longer timescale of multiple decades, a clear trend emerges of more and more very hot days , driven by climate change .

Indeed, scientists from the World Weather Attribution team recently described the latest heat waves as "impossible" without climate change .

Action needed

April and May are typically the hottest months in south and southeast Asia. As the climate keeps warming, is the region ready for extreme heat?

The projected increases in extreme hot temperatures demands rapid adaptation measures, along with the obvious global efforts to reduce greenhouse gas emissions. That means heat action plans that are tailored to address the specific climate, public health and socioeconomic conditions in a given region. What works in Singapore (urban, wealthy, incredibly humid) might not be appropriate in drier, poorer and more rural parts of India.

We have to combine estimates of environmental hazards with exposure and vulnerabilities information on population and assets to provide actionable risk assessment and formulate efficient temperature mitigation measures for different levels of extreme heat.

Some countries in south and southeast Asia are making progress with their heat action plans in response to extreme heat they have already experienced. However, there is room for further improvement and a more targeted approach at the district level. This is critical as we expect that disruptive extreme heat events in this part of the world will become more frequent, widespread, and intense.

Provided by The Conversation

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