The present study aimed to train Traditional Birth Attendants (TBAs) in a parenting program called Learning through Play (LTP) to improve their Knowledge, Attitude, and Practices regarding child development after completion of training, for them to be better able to support parents during their routine practice. Quasi experimental design was used. A total of 330 TBAs meeting study eligibility criteria were included and data was collected in a group setting. LTP training was comprised of weekly sessions delivered over 1 month. LTP includes knowledge about child development for children from 0 to 3 years. The Knowledge, Attitude, and Practices (KAP) questionnaire was used to measure change. Statistical analysis was done through Paired Sample T-test. There was a significant difference between pre-post scores t = -29.36 ( p < .05). Capacity building of TBAs in LTP program and integrating LTP into existing health care systems may contribute to reducing the child development gaps in Pakistan.

Oral pre-exposure prophylaxis (PrEP) is a highly efficacious biomedical HIV prevention tool, yet despite being recommended by the World Health Organization (WHO) since 2015, uptake and persistence remain limited in much of the world, including sub Saharan Africa (SSA). There is a dearth of evidence-based interventions to improve PrEP uptake and persistence in SSA, and the full costs of PrEP programs implemented in routine care settings remain largely unknown. This study aimed to evaluate the cost of delivery of daily oral PrEP, and associated outcomes, to different key and priority populations across different service delivery models (SDMs) in South Africa. We conducted bottom-up micro-costing of PrEP service delivery from the provider perspective within twelve urban SDMs providing routine PrEP services to various key and propriety populations in Gauteng and KwaZulu-Natal provinces in South Africa. The SDMs included in-facility and outreach models that focused on men who have sex with men (MSM), female sex workers (FSW) and adolescent girls and young women (AGYW). We identified all within- and above-facility activities supporting PrEP delivery, obtained input costs from program budgets, expenditure records and staff interviews, and determined individual resource usage between February 2019 and February 2020 through retrospective medical record review. Our primary outcome was PrEP coverage at six months (defined as having sufficient PrEP drug dispensed at the last visit to be covered at six months post PrEP-initiation). A subset (N=633) of all enrolled subjects had the potential for 12 months of follow-up and were included in a 12-month outcome analysis. We report the cost per client initiated on PrEP in 2021 United States Dollars (USD). We collected medical record data from 1,281 people who initiated PrEP at 12 SDMs between February and August 2019 and had at least six months of potential follow-up. The average number of visits was 2.3 for in-facility models and 1.5 for outreach models and 3,086 months of PrEP was dispensed. PrEP coverage at six months varied greatly across SDMs, from 41.8% at one MSM-focused fixed clinic to 0% in an MSM-focused outreach model. In general, in-facility programs had higher six-month coverage than outreach programs. Across all SDMs with PrEP clients with potential for 12 months of follow-up (n=633), PrEP coverage at 12 months was 13.6%, with variability between SDMs. The average six-month cost per client initiated on PrEP ranged from $29 to $590, with higher average costs generally observed for the in-facility programs ($152 in-facility versus $84 for outreach). The average monthly cost per PrEP client who had six-month PrEP coverage ranged from $18 to $160 dependent on SDM. This study is an important addition to the PrEP outcome and cost literature in the SSA region. Results show that costs and outcomes vary considerably across different SDMs and populations in real world PrEP programs and provide crucial information for further scale-up of the oral PrEP program in South Africa and the greater SSA region.

IntroductionTransgender populations face inequalities throughout the cancer pathway. Much of this stems from poor access to specialist knowledge of gender-affirming care and how it intersects with cancer. Breast cancer care in particular presents challenges for both patients and clinicians, given the interaction with sex hormones, potential to exacerbate dysphoria and differing management in cisgender men vs. cisgender women. Breast cancer risk remains of concern in trans people, and there is a sparsity of targeted research in this area. The best estimate of breast cancer incidence in trans men and non-binary people assigned female at birth (TMNB) is only 5 times less than in cisgender women. In trans women and non-binary people assigned male at birth (TFNB) the incidence is only 3 times less than in cisgender women. However cancer registries in most countries fail to accurately record gender identity and transgender status.MethodsIn response to this need, we established the UK Cancer and Transition Service (UCATS), a national multidisciplinary team meeting and clinic where any transgender patient with active or historical cancer can access specialist advice and support. This was coproduced with patient and public involvement and input from a specialist cancer charity.ResultsWe discuss 6 cases of breast cancer in TMNB where cancer and gender-affirming care were mutually impacted by each other. Two of these lead to the establishment of UCATS and a further 4 were managed by the service. Challenges experienced by patients and clinicians included access to satisfactory reconstructive options, access to and management of gender-affirming hormones, and choice of anti-estrogenic therapy.DiscussionWe recommend introduction of similar services internationally and inclusion of gender identity and trans status in cancer registries to improve data on cancer risk. Further research is required on the use of gender-affirming hormones in hormone-receptor positive breast cancer in adjuvant and metastatic settings.

Objective: The diagnosis and treatment of breast cancer is associated with significant distress that has huge impact on survivors’ quality of life. The objective of this study is to assess the effectiveness of an integrated intervention “Moving on After Breast Cancer (ABC) Plus culturally adapted Cognitive Behavior Therapy” (Moving on ABC Plus). Method: This is a randomized controlled trial that aims to recruit 354 breast cancer survivors from the inpatient and outpatient oncology departments in public and private hospitals in Karachi, Hyderabad, Lahore, Multan, and Rawalpindi in Pakistan. Patients scoring 10 or above on either the Patient Health Questionnaire—9 and/or the Generalized Anxiety Disorder scale (GAD-7) will be recruited. Baseline assessments will include Functional Assessment of Cancer Therapy—Breast; EuroQol-5D; Multidimensional Scale for Perceived Social Support; Intrusive Thoughts Scale; and Rosenberg Self-Esteem Scale. Participants randomized into intervention arm, Moving on ABC Plus, will receive 12 individual therapy sessions over 4 months. Follow-up will be completed at 4- and 6-month post-randomization, using all baseline instruments along with the Client Satisfaction Questionnaire (CSQ-8). We will also explore the participants’, their family members’, and the therapists’ experiences of the trial and intervention. Results: We will be assessing the effectiveness of intervention in reducing depression and anxiety in breast cancer survivors as a primary outcome of the trial. The secondary outcomes will include effectiveness of intervention in terms of reduction in intrusive thoughts and improvement in health-related quality of life, self-esteem, and perceived social support. Conclusion: The results of the study will inform the design of a future larger randomized control trial with long-term follow-up.

A diet high in parent's own milk (parental milk) is a lifesaving intervention for critically ill infants. Lactating parents whose infants are born with birth defects that require surgical repair (surgical infants) shortly after birth often struggle to initiate and maintain a milk supply that meets their infant's nutritional needs. Antenatal milk expression has been identified as a safe, feasible, and potentially effective strategy that promotes parents' direct chest/breastfeeding or milk expression (lactation) confidence and helps parents attain their lactation goals. Two cases are presented to illustrate the potential for using antenatal milk expression as a lactation support intervention for parents of surgical infants. Cases were drawn from a pilot study exploring the feasibility of implementing antenatal milk expression among pregnant parents of surgical infants. Participants were healthy women recruited after 30 weeks of gestation who received a fetal diagnosis of a complex congenital heart defect. Despite variability in clinical course and length of stay, parental milk was provided for the duration of each infant's hospitalization. Participant perceptions of antenatal milk expression varied. More research is needed to evaluate the feasibility, efficacy, and parent or provider perceptions of antenatal milk expression as a lactation support intervention for parents of surgical infants.

<h3>Aims</h3> To improve the identification and catch-up immunisation of children attending for an Initial Health Assessment (IHA) with an incomplete childhood immunisation record. <h3>Methods</h3> This is a re-audit, retrospectively looking at the immunisation records of the eligible children and young people. All children and young people who attended for an IHA in Manchester between January and April 2021 were included. Cases were identified using the central LAC Database. There were a total of 103 patients which included 25 UASC (Unaccompanied asylum seeking children). The results were compared with local standards. The children identified as having incomplete immunisation status had their child health record reviewed to see whether they had received catch-up immunisations. <h3>Results</h3> 44 children and young people had incomplete immunisations which was 12% increase compared to the results of the audit in 2020. There was an improvement in the proportion of children with incomplete immunisation status with their missing immunisations listed clearly in documentation to their General Practitioner. There was also an improvement in the proportion of children who had a specified time-frame for their catch-up immunisations in the IHA report. 25 children identified were UASC and all had unknown immunisation status. Child health records could not be found for one young person so he was not included in the review. All children required immunisation as per the Public Health England ‘Vaccination of individuals with uncertain or incomplete immunisation status’. Only 3 out of 24 received all outstanding immunisations. Despite this, the majority of patients did engage partially and receive some of the requested immunisations. 71% received at least two Td/IPV doses, 88% received at least one MMR dose and 54% received the single required Men ACWY dose. Of the two eligible patients for the HPV vaccination, one received a single dose. 19 of the non-UASC children were recorded as not being up to date with immunisation (figure 1). All children under 5 (6 patients) received their catch-up immunisations. Out of the 3 children aged between 5-12 years, one was already up to date and two did not receive any vaccinations. These two children had moved from Mauritius to the UK two years ago and had no immunisation history. There were 10 young people aged 12-18 years with 8 having not received their full catch-up immunisations. <h3>Conclusion</h3> Looked After Children are less likely to be up to date with their immunisations than the general population [1]. Older Children and Young people in care are less likely to have up to date immunisations than younger children in care. Documentation to General Practitioners detailing specific missing immunisations and the time-frame for these to be given has improved since the last audit cycle. The vast majority of the UASC requiring catch-up immunisations were willing to engage with services but unfortunately did not receive all doses. Further work can be done to make access to vaccination easier, such as offering the first dose at the time of IHA. <h3>Reference</h3> Immunization of looked-after children and young people: a review of the literature, S. Walton et al.

Recent evidence suggests that acute emergency management of mandible fractures does not improve surgical outcomes yet is associated with increased financial burden. Current NHS policy advocating for increased adoption of day-case and semi-elective surgical procedures to reduce bed strain must be balanced with providing timely, effective treatment. Our research aims to determine patient groups currently managed via semi-elective admission and whether this can be extended to other groups to provide safe and effective management of mandible fractures. A multi-national trainee-led audit of mandibular fractures across 49 units was completed by the Maxillofacial Trainee Research Collaborative (MTReC). Each unit prospectively collected data on fractures on admission and at follow-up. Data collected included patient demographics, behaviour, health, injury, timing to intervention and surgical complications. Data were collected on 947 mandibular fractures. Of the surgically managed patients, 649 (90%) were managed via acute emergency admission at the time of presentation, while 68 (10%) were managed semi-electively. Patient demographics, injury pattern and mechanism appeared to significantly affect timing of management, whereas patient behaviour, health status, timing of injury and presentation did not. Semi-elective management was associated with a significantly shorter inpatient duration (0.9 versus 1.9 days, p=0.000) with no differences in readmission, antibiotic usage or surgical complications (p=1.000, RR 1.030). Our study demonstrates the efficacy of planned admissions and semi-elective management of mandibular fractures. Simple mandibular fractures in compliant patients are suitable for semi-elective treatment. Holistic patient assessment and tailored surgical planning is crucial in determining admission modality to effectively manage mandibular trauma.

IntroductionSuicide is a global health concern. Sociocultural factors have an impact on self-harm and suicide rates. In Pakistan, both self-harm and suicide are considered as criminal offence’s and are condemned on both religious and social grounds. The proposed intervention ‘Youth Culturally Adapted Manual Assisted Problem Solving Training (YCMAP)’ is based on principles of problem-solving and cognitive–behavioural therapy. YCMAP is a brief, culturally relevant, scalable intervention that can be implemented in routine clinical practice if found to be effective.Method and analysisA multicentre rater blind randomised controlled trial to evaluate the clinical and cost-effectiveness of YCMAP including a sample of 652 participants, aged 12–18 years, presenting to general physicians/clinicians, emergency room after self harm or self referrals. We will test the effectiveness of 8–10 individual sessions of YCMAP delivered over 3 months compared with treatment as usual. Primary outcome measure is repetition of self-harm at 12 months. The seconday outcomes include reduction in suicidal ideation, hopelessness and distress and improvement in health related quality of life. Assessments will be completed at baseline, 3, 6, 9 and 12 months postrandomisation. The nested qualitative component will explore perceptions about management of self-harm and suicide prevention among adolescents and investigate participants’ experiences with YCMAP. The study will be guided by the theory of change approach to ensure that the whole trial is centred around needs of the end beneficiaries as key stakeholders in the process.Ethics and disseminationEthics approval has been obtained from the Ethics Committee of University of Manchester, the National Bioethics Committee in Pakistan. The findings of this study will be disseminated through community workshops, social media, conference presentations and peer-reviewed journals.Trial registration numberNCT04131179.

Prevalence of post-traumatic stress disorder (PTSD) is high in Pakistan both due to natural disasters and ongoing conflicts. Offspring of trauma survivors are at increased risk for mental and physical illnesses. Parental PTSD has been linked to troubled parent-child relationships, behaviour problems, trauma symptoms, and depression in children. This study aims to explore the acceptability, feasibility and indications of the effectiveness of group learning through play plus trauma-focused cognitive behaviour therapy (LTP Plus TF-CBT) for parents experiencing PTSD. This is a two-arm pilot cluster randomised controlled trial (RCT). We aim to recruit 300 parents with a diagnosis of PTSD. The screening will be done using the Impact of Event Scale-Revised. Diagnosis of PTSD will be confirmed using the Clinician-Administered PTSD Scale-5 (CAPS-5). Union Councils from Peshawar and Karachi will be randomised into either group LTP Plus TF CBT arm or treatment as usual (TAU). The intervention includes 12 sessions of LTP Plus TF-CBT delivered weekly in the first 2 months and then fortnightly in a group setting by trained psychologists. The groups will be co-facilitated by the community health workers (CHWs). Parents will be assessed at baseline and 4th month (end of the intervention), using the Patient Health Questionnaire (PHQ-9), Generalised Anxiety Disorder (GAD-7) Scale, Client Service Receipt Inventory (CSRI), and Ages and Stages Questionnaire (ASQ-3). This trial would help build an understanding of the acceptability, feasibility and indications of the effectiveness of a low-cost parenting intervention.