Healthcare Facilities In Pakistan Research Articles

Assessment of the impact of integrated disease surveillance and response system on surveillance management at healthcare facilities in Pakistan.

Disease surveillance is very crucial especially in high vulnerability settings like Pakistan. However, surveillance and outbreak response management are still evolving in the country and research studies are needed to assess the existing system. To assess the impact of integrated disease surveillance and response system (IDSRS) implemented by the provincial government to strengthen infectious disease surveillance and reporting in 6 districts of Pakistan in 2016. A baseline cross-sectional assessment of health facilities and the healthcare workforce was conducted in 2016 to identify needs and gaps in public sector health facilities and the health system of 6 selected districts of Khyber Pakhtunkhwa Province, Pakistan. This was followed by a 2018 endline survey of the same facilities using the same variables. Overall, there was improvement in district management and facility level performance (χ2 (1, 314) = 21.19, P < 0.001, V = 0.26). District level management improved significantly in areas with relatively lower Gross Domestic Product (GDP)? χ2(1, 154) = 30.41, P <0.001, V = 0.44). Facilitation domain variables improved in the lower GDP districts (χ2 (1, 74) = 5.76, P = 0.016, V = 0.28) and showed counterintuitive deterioration (χ2 (1, 74) = 4.80, P = 0.028, V = 0.25) in relatively higher GDP areas. IDSRS is effective in improving surveillance and response systems, however, its effectiveness appears to depend on locale-specific economies and can be enhanced by modifying the implementation approach. Better empowerment of the local workforce can contribute to such improvement.

Omeprazole (Risek®) Use in Inpatient and Outpatient Departments: A Post-marketing Surveillance Investigation

Proton pump inhibitors (PPIs) are widely used for the treatment of acid-related gastrointestinal disorders. However, their overuse or inappropriate prescription can lead to adverse effects, increased healthcare costs, and development of antibiotic-resistant infections. Objectives: To ascertain whether the Omeprazole (Risek®)-PPIs prescription patterns by practitioners in the inpatient and outpatient departments of various healthcare facilities in Pakistan are in compliance with the therapeutic indications and to evaluate the safety profile associated with each therapeutic indication. Methods: A cross-sectional multicenter study was conducted for 4 months at various healthcare facilities inpatient and outpatient departments. A total of 1384 patients ≥ 18 years prescribed Omeprazole (Risek®) were enrolled while pregnant or lactating women, patients with chronic diarrhea, those with a history of Omeprazole allergic reaction, and with diagnosed malignancy of the GI tract were excluded. The drug use was determined based on the prescribed frequency, dosage, and duration of therapy with respect to each indication. Results: Of the total, 29.8% were already taking oral PPI or Histamine H2-Receptor Antagonists. The common indication for Omeprazole (Risek®) was Gastroesophageal Reflux Disease (GERD), followed by peptic ulcer. Mostly the drug was infused/injected in 40 mg dosage, once daily and for five days among 76.6% and 41.8%, respectively. Around 13.3% of patients experienced mild adverse events like flatulence, fever, vomiting, abdominal pain, constipation, diarrhea, nausea, rash, etc. Most off-label uses were observed in GERD concerning the duration of therapy (55.9%), prescribed frequency (19.7%), and dosage (5.9%). The Omeprazole (Risek®) treatment was also prescribed for stress ulcer prophylaxis and upper GI bleeding against the treatment protocol for the particular therapeutic indication. The adverse events were most frequent among patients with GERD, followed by NSAID-induced ulcers. Conclusions: This study provides clinical evidence on the Omeprazole (Risek®) use in concordance with the product label, in both inpatient and outpatient departments of Pakistan for various therapeutic indications.

Demand for Public Health Care in Pakistan

A health care demand model is estimated for each province in Pakistan to explain the outpatient visits to government hospitals over the period 1989-2006. The explanatory variables include the number of government hospitals per capita, doctors’ fee per visit at a private clinic, income per capita, the average price of medicine and the number of outpatient visits per capita in the previous period. All variables are significant determinants of the demand for health care in at least one province but their signs, magnitudes and the levels of significance vary. These variations may be attributed to cultural, social and religious factors that vary across provinces. Variations in health care quality offered at public hospitals may also be a factor. These factors and improved accessibility of health care facilities should be the focus of public policy aimed at increasing the usage of public sector health care facilities in Pakistan. JEL classification: I110, I180, O150 Keywords: Health Care, Hospitals, Human Resources, Policy, Public Health

Pre-Marital Screening: Thalassemia Trait and Iron Deficiency Anemia in Rahim Yar Khan, Pakistan

Objective: β- thalassemia Minor (BTM) and Iron Deficiency Anemia (IDA) are the main causes of microcytic hypochromic anemias currently in Asian subcontinent. Healthcare facilities in Pakistan have to encounter massive number of patients with anemias every day, where we need to distinguish between (IDA) and (BTM). A number of discrimination indices have been suggested for rapid differentiation of these entities over parameters achieved from automated blood-count analyzers. Objective. To determine the prevalence of β-thalassemia and IDA amongst the unmarried youngsters of Rahim Yar Khan. Methods: A cross-sectional study performed in Sheikh Zayed Medical College/Hospital Rahim Yar Khan, Pakistan in 04 months from October 2021 to February 2022, 506 unmarried youngsters were included in the study. CBC, Serum Ferritin and Hb Electrophoresis were performed in Hematology Section, Pathology Department of SZMC Rahim Yar Khan. Results: Out of 506 subjects, the prevalence of beta thalassemia trait was found 3.3% in males followed by 2.2% in females whereas the prevalence of IDA was 1.7% in males followed by 1.3% in females. Conclusion: These results indicates that intensive education and awareness strategies are necessary to increase consumption of iron-rich dietary sources. This screening program is beneficial in prevention of high-risk marriages. Screening of spouses by pre-marital screening program is an actual way to control β-thalassemia major. Keywords: βeta-thalassemia trait (BTT), iron deficiency anemia (IDA), premarital screening.

The Psychological Impact of Coronavirus Disease 2019 on Patients Attending a Tertiary Healthcare Facility in Pakistan: A Cross-Sectional Study

The COVID-19 pandemic has had a damaging impact on global health. Post-infection, patients may experience mental health difficulties and therefore require suitable psychological treatment and support. The objective of this study was to identify the psychological impact of COVID-19 on patients who were recovering from the physical effects of the disease, and to examine socio-demographic correlates within one month of treatment at a tertiary healthcare facility in Pakistan. A cross-sectional study was employed that utilized the Depression Anxiety Stress Scale-21 and Post-Traumatic Stress Disorder (PTSD) Checklist for DSM-5. A questionnaire was administered to 250 patients, with data collected over three months. Mild to extremely severe scores of depression, anxiety and stress were reported by approximately 43%, 52% and 42% of participants, respectively, and 8% developed PTSD. The incidence of depression, anxiety, stress or PTSD was not significantly associated with gender, age or previous interaction with COVID-19 patients. Depression was significantly associated with levels of education, severity of COVID-19 disease and a patient’s current condition. Anxiety was associated with healthcare worker status. The severity of disease and a patient’s current condition were also linked to the levels of anxiety, stress and the presence of PTSD. Collectively, these results indicate that a high percentage of patients recovering from COVID-19 experience psychological distress.

Association between efficiency and quality of care of public healthcare facilities: Evidence from Pakistan.

Maternal and child health is an important component of the Sustainable Development Goals. Pakistan has one of the worst maternal and neonatal health outcomes in the world. This is despite significant health system investments across the country. The objectives of this study are twofold. First, the study estimates the technical efficiency of the public healthcare facilities in Pakistan, defined as the number of obstetric deliveries compared to the number of medical specialists, nurses, and other health and non-health staff members. Second, the study evaluates the relationship between efficiency and quality of care; the latter is measured in terms of maternal and neonatal mortality. The data were taken from the Pakistan Health Facility Assessment Survey. Efficiency score was calculated for 843 public healthcare facilities, using Stochastic Frontier Analysis. We then used two-stage residual inclusion approach with bootstrapping to evaluate the relationship between efficiency and quality. The average efficiency score was 0.48 (range: 0-1) and none of the public healthcare facilities were on the frontier, implying that efficiency gains can be made across the board. The relationship between efficiency and quality is found to be positive and statistically significant, that is, more efficient healthcare facilities also had lower rates of maternal and neonatal mortality. We conclude that more efficient public healthcare facilities also had lower mortality rates, probably due to better infrastructure and health system financing.

Study of Trends of Antimicrobial Resistance in Clinical Bacterial Isolates from Three Private Tertiary Healthcare Facility in Pakistan

Purpose of this study was to determine the prevalence of antimicrobial resistance in microbial pathogens from different clinical samples. The current study was conducted in Lahore, Faisalabad,Rawalpindi and Islamabad as these cities are ranked as highly populated cities of Pakistan. Isolation and identification of pathogens from almost 750 diverse urine, blood and pus samples by aid of selected media cultures, gram staining and various biochemical tests. Isolated pathogens were checked for antimicrobial susceptibility patterns against frequently prescribed antibiotics. In present study, Gram-negative isolates were found in maximum percentages (80 Percent) while the remaining (20 Percent) were Gram-positives. The isolate which was most recurrently recognized from Gram-positives was S. aureus and most frequently identified isolate from Gram-negative was E. coli and P. aeruginosa. The prevalence of E. coli was 20 Percent in urine, 14Percentin blood, 12Percent in stool and 4 Percent in pus. Furthermore, the resistance rate of E. coli for Streptomycin, Nalidixicacid, Ciprofloxacin, Levofloxacin, Doxycycline, Moxifloxacin, Amikacin, Gentamycin, and Amoxicillin werebetween 12 Percent to a maximum of 100Percent. Gram positive S. aureus was found considerable in urine (9Percent), bloodand pus cultures. The resistance shown by the isolates ranged from 12Percent to 100Percent against ceftriaxone,ampicillin, chloramphenicol, doxycycline, co-trimoxazole, penicillin, erythromycin, vancomycin and tetracycline. Moreover, the antibiotics like Augmentin (71Percent) and Moxifloxacin (60Percent) showed highest resistance so these are considered as poor choices for treating S. aureus infections. We concluded from this study that strict legislation and better management techniques in context to use of antimicrobial for therapeutic purposes in human and animals can minimize the chances of development of antimicrobial resistance.

EFFECTIVENESS OF BCG VACCINATION AGAINST SARS-COV-2

Background: Bacillus Calmette-Guerin (BCG) vaccine is weakened Mycobacterium bovis based preparation that provides protective effects and immunotherapy against many ailments and may be tested against SARS-COV-2. Herein, we compare the prevalence of COVID-19 in countries with and without mandatory BCG vaccination program along with a study to examine its incidence in doctors working at quarantine facility with and without history of prior BCG vaccination. Methods: For cross-sectional examination, the data was collated from worldometer.info, BCG World Atlas and COVID-19 stats at National Command and Operation Centre (NCOC), Government of Pakistan accessed on Apr 30, 2021. For a real-time analysis, total of one hundred random male and female doctors working at a COVID-19 healthcare facility in Pakistan were voluntarily selected. Chi-square test was used to perform the statistical analysis with the help of SPSS-22. Results: The prevalence of COVID-19 in countries with and without a mandatory BCG vaccination policy was found to be 5,512 and 75,592 cases per million, respectively, and mortality rates were 98 and 1,435 per million, respectively. Amongst our randomly selected doctors, only 28% of the BCG vaccinated doctors were affected by COVID-19 contrary to 94% of those who were unvaccinated. Conclusions: The incidence of COVID-19 was considerably lower in the doctors with a history of BCG vaccination supported by the evidence that the countries with a universal BCG vaccine policy had a significantly low incidence and lower mortality rate due to COVID-19.

REVIEWING CLINICAL WASTE MANAGEMENT UNDER THE LEGISLATIVE FRAMEWORK IN PAKISTAN: PRACTICES AND CHALLENGES

The waste generated at healthcare facilities has two distinct categories: hazardous and non-hazardous waste. 10- 15% of the total waste generated at hospitals is hazardous which is termed as clinical waste. This review article has reported and reviewed the practices of clinical waste management in Pakistan’s major cities. Researches demonstrated that about 1.35 Kg / bed waste has been produced by the tertiary health care facilities in Pakistan. Studies for review process are selected through an iterative process. More than 100 research articles, National legislations, international protocols and newspaper reports are consulted and reviewed to extract the data of interest. Clinical waste management in Pakistan is the responsibility of the individual health care facility producing it under Hospital Waste Management Rules, 2005. Due to lack of proper checks and weak implementation of legislations many gaps have been identified in this review article like lack of segregation, inappropriate vehicles for transportation, poor storage and no advanced pollution control treatment strategies. Most of the hospitals lack documented waste management plan. Staff was mostly untrained and under educated. International standards for safe hazardous waste disposal are not being followed resulting in spread of diseases like hepatitis and AIDS. Cases of poor recycling and reuse of used clinical instruments is also documented. However, the condition is much satisfactory in big cities. There is an understanding to focus on the proper implementation of clinical waste management rules with strict checks. Establishment of incineration facility at major hospitals with proper maintenance, safe transportation to secure landfills and utilization of proper SOPs are suggested improvements towards safe management of clinical waste.

Effect of adding a psychological intervention to routine care of common mental disorders in a specialized mental healthcare facility in Pakistan: a randomized controlled trial

BackgroundIn many low resource settings, the provision of government mental health care services is limited to specialized psychiatry units in urban hospital care facilities, where the most common treatment for common mental disorders (CMDs) is pharmacotherapy, occasionally with adjunct nonspecific psychological support. We aimed to evaluate the effectiveness of adding a low intensity, psychological intervention, Problem Management Plus (PM+) for CMDs into routine care in a specialized mental health care facility in Pakistan.MethodsA two arm, single-blind individual randomized controlled trial (RCT) was carried out with adults (N = 192), referred for psychological support by psychiatrists. The study participants were randomized (1:1) to PM + plus Treatment as Usual (TAU) (n = 96) or TAU only (n = 96). The primary outcomes were symptoms of anxiety and depression, measured by the Hospital Anxiety and Depression Scale (HADS) and functional impairment as measured by WHO Disability Assessment Schedule (WHODAS 2.0) at 20 weeks after baseline.ResultsThe analysis was done on intention-to-treat principle. The linear mixed model analysis showed that at 20 weeks after baseline, there was a significant reduction in symptoms of anxiety and depression (mean [SD], 16.23 [8.81] vs 19.79 [7.77]; AMD, − 3.10; 95% CI, − 0.26 to − 5.76); p = 0.03 and improvement in functioning (mean [SD], 22.94 [9.37] vs 27.37 [8.36]; AMD, − 4.35; 95% CI, − 1.45 to − 7.24); p = 0.004 in PM + plus TAU versus TAU arm. The follow-up rate was 67% at primary end-point.ConclusionsSpecialized care facilities in LMICs may consider adding brief, evidence-based psychological treatments for CMDs to their routine care.Trial Registration Australian New Zealand Clinical Trials Registry, ACTRN12616000381482. Registered March 23, 2016. Retrospectively registered, https://www.anzctr.org.au/Default.aspx/ ACTRN12616000381482

How childhood diseases awareness contributes to minimize the risk of disease severity in children under five age: An evolutionary study.

To scrutinise the contribution of childhood disease awareness in mothers to minimise the risk of disease severity in children aged <5 years and to evaluate the effectiveness of a proposed app in this context. The evolutionary study was conducted in Children's Hospital and the Institute of Child Health Multan from September 2018 to February 2019 and comprised two sessions with the app involving 30 mothers who were provided with smartphones with the app installed. The mothers were divided into 4 age groups. The app was evaluated using quantitative and qualitative measures. Suggestions and opinions were obtained in the first session and all suggestions were implemented by the second session. Of the 30 mothers, 8(26.6%) were in Group 1 aged 14-20 years, 12(40%) in Group 2 aged 21-27 years, 7(23.3%) in Group 3 aged 28-34 years and 3(10%) in Group 4 aged 35 years and above. The participants were able to diagnose their children's diseases accurately by following the instructions provided by the app. The subjects also agreed that they diagnosed the diseases accurately. All the participants were interested in the app and expressed the desire to have it available across the healthcare facilities in Pakistan. All subjects showed acceptance for the app and affirmed its easy usability, especially for illiterate mothers.

Infection Prevention and Control Measures at the Children Hospital Lahore: A My Child Matters Collaborative Project.

PURPOSEInfection prevention among children with cancer is a major challenge at Children Hospital Lahore (CHL), a public health care facility in Pakistan with 1,000 new pediatric cancer admissions annually. The objective has been to reduce infections through collaboration between CHL and the St Jude Children’s Hospital Global Infectious Disease program via a grant by the Sanofi Espoir foundation through the My Child Matters program. The aim of the current study was to describe the effect of the collaborative improvement strategy on existing infection prevention and control (IPC) standards at CHL.MATERIALS AND METHODSOur work was a prospective before-and-after study to improve IPC standards. We compared the WHO Hand Hygiene Self-Assessment Framework and four modules of the St Jude modified Infection Control Assessment Tool (ICAT) scores over a 3-year period. Our strategy included creating a multidisciplinary team of pediatric oncologists, infectious disease physicians, nurses, a microbiologist, and a data manager; engaging in monthly online IPC mentoring sessions with St Jude Children’s Hospital Global Infectious Disease program and My Child Matters mentors; performing daily inpatient health care–associated infection surveillance rounds; and performing regular hand hygiene training and compliance audits.RESULTSBaseline needs assessment showed health care–associated infections identified by positive blood cultures as 8.7 infections per 1,000 patient-days. Deficient hand hygiene supplies, health education measures, and bed sharing of neutropenic patients were identified as major challenges. Our hand hygiene facility level, per WHO scores, increased from Inadequate to Intermediate/Consolidation by the end of the 3-year implementation (122 v 352 WHO Hand Hygiene Self-Assessment Framework scores). The sink:bed and hand sanitizer:bed ratios improved to 1:6 and 1:1, respectively. The ICAT general infection control module increased by 40% (45 v 78 ICAT scores) and hygiene compliance improved by 20%.CONCLUSIONImplementing a collaborative improvement strategy improved IPC standards in our center, which can be easily replicated in other pediatric oncology centers in lower- and middle-income countries.

Feasibility of delivering integrated COPD-asthma care at primary and secondary level public healthcare facilities in Pakistan: a process evaluation.

BackgroundIn Pakistan,the estimated prevalence of chronic obstructive pulmonary disease (COPD) and asthma are 2.1% and 4.3% respectively, and existing care is grossly lacking both in coverage and quality. An integrated approach is recommended for delivering COPD and asthma care at public health facilities.AimTo understand how an integrated care package was experienced by care providers and patients, and to inform modifications prior to scaling up.Design & settingThe mixed-methods study was conducted as part of cluster randomised trials on integrated COPD and asthma care at 30 public health facilities.MethodThe care practices were assessed by analysing the clinical records of n = 451 asthma and n = 313 COPD patients. Semi-structured interviews with service providers and patients were used to understand their care experiences. A framework approach was applied to analyse and interpret qualitative data.ResultsUtilisation of public health facilities for chronic lung conditions was low, mainly because of the non-availability of inhalers. When diagnosed, around two-thirds (69%) of male and more than half (55%) of female patients had severe airway obstruction. The practice of prescribing inhalers differed between intervention and control arms. Patient non-adherence to follow-up visits remained a major treatment challenge (though attrition was lower and slower in the intervention arm). Around half of the male responders who smoked at baseline reported having quit smoking.ConclusionThe integrated care of chronic lung conditions at public health facilities is feasible and leads to improved diagnosis and treatment in a low-income country setting. The authors recommend scaling of the intervention with continued implementation research, especially on improving patient adherence to treatment.

Process evaluation of integrated diabetes management at primary healthcare facilities in Pakistan: a mixed-methods study.

BackgroundIntegrated care for diabetes and associated conditions at primary level health facilities can make care available to a much larger population, especially in rural areas.AimThis process evaluation was to understand how the authors' integrated care was implemented and experienced by the care providers and patients, and to inform modifications prior to province-wide scale-up.Design & settingThe mixed-method study was conducted as part of a cluster randomised trial on integrated diabetes care at 14 public health facilities.MethodThe care practices were assessed by analysing the routine clinical records of 495 registered patients with diabetes. Then semi-structured interviews with service providers and patients were used to understand their respective care experiences. A framework approach was applied to analyse and interpret the qualitative data.ResultsThe intervention and the study were implemented as intended under routine conditions in rural health centres. Key service processes effectively delivered included: skill-based training; screening and diagnostic tests; treatment card records; and the additional case management as per desk guide, including monitoring progress in glucose and weight at follow-up consultations, and mobile phone calls to help adherence. However, social and cultural factors affected clients' ability to change lifestyles, especially for women. The intervention effect was limited by the short study follow-up of only 9 months.ConclusionIntegrated diabetes care was feasible, both for providers and patients, and potentially scalable at primary care facilities under routine conditions in Pakistan. Additional operational interventions are required for sustained drug supplies, supervision, in-service training, and to address the social challenges to healthy activity and eating, especially for women.

Improvement in Infection Prevention and Control Measures at The Children Hospital, Lahore. A My Child Matters Collaborative Project

Background: Overcrowding, lack of operational funds, and healthcare associated infections are major challenges at the Children Hospital Lahore, a public healthcare facility in Pakistan with 900 new pediatric cancer admissions annually. In 2014, a collaboration between My Child Matters (MCM), St. Jude Global Infectious Diseases Program (SJ-GID), and our institution was established to address these issues. Aim: To describe the effect of a collaborative improvement strategy on the infection prevention and control (IPC) standards in a pediatric oncology unit in a resource-limited setting. Methods: Our study was a prospective before-and-after study. We compare the WHO Hand Hygiene Self-Assessment Framework (HHSAF) and 4 modules of the St. Jude modified Infection Control Assessment Tool (ICAT) scores. Our strategy included: (1) creating a multidisciplinary team of pediatric hematology-oncology, infectious disease physicians, nurses, microbiologist, and a data manager, (2) engaging on monthly online IPC mentoring sessions with the SJ-GID and MCM mentors, (3) performing daily inpatient healthcare associated (HAI) surveillance rounds, and (4) providing regular hand hygiene training and compliance audits. Results: Our hand hygiene facility level per WHO scores increased from “Inadequate” during the baseline assessment to “Intermediate/Consolidation” by the end of 3-year implementation (122 vs 352 HHSAF scores). The sink: bed and hand sanitizer: bed ratios improved to 1:6 and 1:1 respectively. Six washrooms were added to our unit. ICAT general infection control module increased by 40% (45 vs 78 ICAT score) and hygiene compliance improved by 20% from baseline. Identification of HAI increased from baseline (4.07 vs 8.7 infections per 1000 patient days). A 25% of the isolates were multidrug-resistant microorganisms. Conclusion: Implementing a collaborative improvement strategy improved the IPC standards in our pediatric cancer center. The increase of HAI might be a result of a better surveillance and laboratory identification. Further targeted interventions should be develop to decrease HAI rates and infection-related morbidity and mortality in our population.

\u201cKeeping family matters behind closed doors\u201d: healthcare providers\u2019 perceptions and experiences of identifying and managing domestic violence during and after pregnancy

BackgroundViolence against women is an international public health concern and a violation of women’s rights. Domestic violence can first occur, and increase in frequency and severity, during and after pregnancy. Healthcare providers have the potential to identify and support women who experience domestic violence. We sought to investigate the knowledge and perceptions of domestic violence among doctors who provide routine antenatal and postnatal care at healthcare facilities in Pakistan. In addition, we explored possible management options from policy makers, and enabling factors of and barriers to the routine screening of domestic violence.MethodsSemi-structured key informant interviews were conducted with doctors (n = 25) working in public and private hospitals and with officials involved in domestic violence policy development (n = 5) in Islamabad, Pakistan. Transcribed interviews were coded and codes grouped into categories. Thematic framework analysis was undertaken to identify emerging themes.ResultsMost doctors have a good awareness of domestic violence and a desire to help women who report domestic violence during and after pregnancy. Enabling factors included doctors’ ability to build rapport and trust with women and their suggestion that further education of both healthcare providers and women would be beneficial. However, domestic violence is often perceived as a “family issue” that is not routinely discussed by healthcare providers. Lack of resources, lack of consultation time and lack of effective referral pathways or support were identified as the main barriers to the provision of quality care.ConclusionsDoctors and policy advisors are aware of the problem and open to screening for domestic violence during and after pregnancy. It is suggested that the provision of a speciality trained family liaison officer or healthcare provider would be beneficial. Clear referral pathways need to be established to provide quality care for these vulnerable women in Pakistan.

Problem Management Plus (PM+) in the management of common mental disorders in a specialized mental healthcare facility in Pakistan; study protocol for a randomized controlled trial

BackgroundThe World Health Organization (WHO) has developed Problem Management Plus (PM+), a 5-session, psychological intervention program delivered by trained non-specialist that addresses common mental disorders. The objectives of this study are to evaluate effectiveness and cost-effectiveness of PM+ in a specialized mental health care facility in Pakistan.MethodsA single blind individual randomized controlled trial (RCT) will be carried out in the outpatient department of a specialized mental healthcare facility in Rawalpindi, Pakistan. After informed consent, patients with high psychological distress (General Health Questionnaire-12 (score >2) and functional impairment (WHO Disability Assessment Schedule 2.0 score >16) will be randomised to PM+ plus treatment as usual (n = 96) or TAU only (n = 96). The primary outcome is the psychological distress, measured by levels of anxiety and depression on the Hospital Anxiety and Depression Scale and improvement in functioning as measured by WHODAS at 20 weeks after baseline. Secondary outcomes include improvement in symptoms of depression, post-traumatic stress disorder, levels of social support and cost effectiveness evaluation. Qualitative interviews will be conducted to evaluate the process of implementing PM+ including barriers and facilitators in implementation and possibility of integration of PM+ program in specialized mental health care facilities in Pakistan.DiscussionThe results of this study will be helpful in evaluating the effectiveness of the approach of training non specialists, based in the specialized mental health care facilities in delivering evidence based psychological interventions in the low resource settings.Trial registration Australian New Zealand Clinical Trials Registry, ACTRN12616000381482. Registered Retrospectively on March 23, 2016

Barriers in seeking health information from primary healthcare facilities in Pakistan

Primary care physicians (PCPs) need a wide range of health information resources to manage their patients. The present study aimed to investigate the barriers that obstruct the health information seeking behavior of primary care physicians in Pakistan from their practice setting. A survey was carried out in 77 basic health units (BHUs), seven rural health centers (RHCs), and two tehsil headquarters (THQs) of Multan District, Pakistan. A three-part questionnaire containing participants’ demographic information, barriers in seeking health information, and required sources and services, was distributed to primary care physicians through post, email, and personal visits to participating healthcare facilities. The data was analyzed statistically using SPSS. Chi square and Kruskal Wallis tests were applied to determine if there were any significant differences in demographic information of different healthcare facilities participants, the barriers they faced in seeking health information, and the required sources and services available to them. The major barriers included: no onsite library, no health sciences librarian, scarcity of health information resources, inaccessibility of health information system, and lack of information and technological infrastructure. Consultation with seniors, improved connectivity and document delivery services were among the sources and services most required by primary care physicians. The study concluded that primary care physicians encounter multiple barriers that obstruct their health-related information seeking behavior, which compromises patient care. Medical librarians should design outreach library and information services in health sciences and health information literacy programs to overcome the barriers primary care physicians face while seeking health information from their practice settings.

Reducing Cost of Rabies Post Exposure Prophylaxis: Experience of a Tertiary Care Hospital in Pakistan.

BackgroundRabies is a uniformly fatal disease, but preventable by timely and correct use of post exposure prophylaxis (PEP). Unfortunately, many health care facilities in Pakistan do not carry modern life-saving vaccines and rabies immunoglobulin (RIG), assuming them to be prohibitively expensive and unsafe. Consequently, Emergency Department (ED) health care professionals remain untrained in its application and refer patients out to other hospitals. The conventional Essen regimen requires five vials of cell culture vaccine (CCV) per patient, whereas Thai Red Cross intradermal (TRC-id) regimen requires only one vial per patient, and gives equal seroconversion as compared with Essen regimen.Methodology/Principal FindingsThis study documents the cost savings in using the Thai Red Cross intradermal regimen with cell culture vaccine instead of the customary 5-dose Essen intramuscular regimen for eligible bite victims. All patients presenting to the Indus Hospital ED between July 2013 to June 2014 with animal bites received WHO recommended PEP. WHO Category 2 bites received intradermal vaccine alone, while Category 3 victims received vaccine plus wound infiltration with Equine RIG. Patients were counseled, and subsequent doses of the vaccine administered on days 3, 7 and 28. Throughput of cases, consumption utilization of vaccine and ERIG and the cost per patient were recorded.Conclusions/SignificanceGovernment hospitals in Pakistan are generally underfinanced and cannot afford treatment of the enormous burden of dog bite victims. Hence, patients are either not treated at all, or asked to purchase their own vaccine, which most cannot afford, resulting in neglect and high incidence of rabies deaths. TRC-id regimen reduced the cost of vaccine to 1/5th of Essen regimen and is strongly recommended for institutions with large throughput. Training ED staff would save lives through a safe, effective and affordable technique.

Service quality in contracted facilities.

The purpose of this paper is to explore the readiness of contracted and non-contracted first-level healthcare facilities in Pakistan to deliver quality maternal and neonatal health (MNH) care. A balanced scorecard (BSC) was used as the assessment framework. Using a cross-sectional study design, two rural health centers (RHCs) contracted out to Aga Khan Health Service, Pakistan were compared with four government managed RHCs. A BSC was designed to assess RHC readiness to deliver good quality MNH care. In total 20 indicators were developed, representing five BSC domains: health facility functionality, service provision, staff capacity, staff and patient satisfaction. Validated data collection tools were used to collect information. Pearson χ2, Fisher's Exact and the Mann-Whitney tests were applied as appropriate to detect significant service quality differences among the two facilities. Contracted facilities were generally found to be better than non-contracted facilities in all five BSC domains. Patients' inclination for facility-based delivery at contracted facilities was, however, significantly higher than non-contracted facilities (80 percent contracted vs 43 percent non-contracted, p=0.006). The study shows that contracting out initiatives have the potential to improve MNH care. This is the first study to compare MNH service delivery quality across contracted and non-contracted facilities using BSC as the assessment framework.