Rural Pakistan Research Articles

Cultural Adaptation of Community Informant Tool for Detection of Maternal Depression in Rural Pakistan.

Background: Evidence indicates that mental health issues like depression, epilepsy, and substance misuse can be detected with reasonable accuracy in resource-poor settings. The Community Informant Detection Tool (CIDT) is one such approach used for detecting mental health problems, including depression. We adapted this community informant approach for detecting maternal depression in Pakistan.Methods: Adaptation of Community Informant Detection Tool for Maternal Depression (CIDT-MD) involved five steps. First, a scoping review of the literature was conducted to select an appropriate tool for adaptation. Second, in-depth interviews were conducted to explore the idioms of depression and distress, perceived causes, and the effects of maternal depression among currently depressed and recovered mothers (n = 11), mothers in law (n = 6), and Primary Care Providers (Primary Care Physicians and Lady Health Supervisors) (n = 6). Third, case vignettes and illustrations were created with input from a panel of mental health experts, incorporating the idioms of depression and distress used, causes, and effects for each symptom described. Fourth, to assess the comprehensibility of the illustrations and level of understanding, Focus Group Discussions (n = 4) were done with purposely selected community health workers (Lady Health Workers and Lay Peers, n = 28) trained in delivering maternal depression intervention. The final step was reflection and inputs by a panel of mental health experts on all steps to finalize the content of the tool.Results: Context-specific cultural adaptation in the presentation and format of CIDT-MD was conducted successfully. Lady Health Workers (LHW) and Lay Peers (LP) were found to be the most appropriate persons to use the tool and function as the informants. The adapted tool with all its vignettes and illustrations was found to be easily understandable, comprehensible, and culturally appropriate, meaningful, and contextually relevant by the community health workers and peers working in the relevant settings. They easily relate to and identify potentially depressed such women lining up with the tool. Lastly, the coding of the tool was found easy to follow as well.Conclusion: The Community Informant Detection Tool for Maternal Depression (CIDT-MD) is a culturally acceptable, easy to use, and comprehensible tool for detecting maternal depression in community settings of Pakistan. The community informants found the content and approach highly relevant to the local needs.

Teledentistry-based Program to Improve Oral Hygiene Indicators in Rural Pakistan—A Protocol

The primary aim of this research protocol is to secure funding to initiate a teledentistry pilot project in order to improve the oral hygiene conditions of the most vulnerable population of rural Sindh in Pakistan, through hands-on training of 1,000 lady health workers by dentists and community dentistry specialists of other colleges led by Jinnah Medical and Dental College. Training courses on digital health consultation would be given to participating healthcare workers. The trainees would be trained on all aspects of dental hygiene including precautions, tooth brushing techniques, and oral care. During the 2-day-long course, lady health workers will be taught various tooth brushing techniques, as well as basic instructions about oral hygiene and how to address queries of people regarding oral health. They will also get guidance about the various multimedia softwares in the phone and how to use them. The study would also include teledentistry consultation as a real-time patient learning tool for patients, healthcare workers, and trainees. Results will be made available when the trial has been completed in 2021. The program will be evaluated by assessing its usability, acceptability, knowledge, and satisfaction of users. The protocol is designed to illustrate the underlying concept that a more reliable and robust model can be built through creating interactive communities of practice for consumers of telehealth in dental education. The Telehealth Skills Coaching and Delivery Initiative would incorporate and test a technically oriented paradigm of Internet-based medical education for vertically incorporated, community-based learning environments. Teledentistry has the ability to expand access to oral health care, increase the provision of oral health care, and decrease costs. In view of the immense advances made in this field, teledentistry can continue to promote specialized health care in the remotest corners of the world. Many countries have already embraced virtual health care (telemedicine) in the face of an increase in cases of COVID-19; however, teledentistry has yet to play its role in this pandemic by enhancing the accuracy and efficiency of dental treatment. In the case of LMICs such as Pakistan, which lack advanced technologies such as teledentistry within their national healthcare network, the COVID-19 pandemic is a challenge to introduce the requisite legislative changes to promote the widespread use of teledentistry.

An Analysis of Families Experiences with Young Children with Intellectual and Developmental Disabilities (IDDs) during COVID-19 Lockdown in Pakistan

The shadow impacts of the COVID-19 pandemic are critical, especially for children with intellectual and/or developmental disabilities (IDDs). Financial constraints and home confinement have increased the challenges for caregivers to meet the educational and health needs of children with IDDs. Hence, this research examines the impact of COVID-19 lockdown on families with IDDs children in rural Pakistan. Overall, 176 parents participated in this study and provided valuable responses through interview technique. Parents responded to five (05) open-ended questions. Results indicated that parents of children with IDDs are facing various challenges including financial constraints, social lockdown, deteriorated health conditions of their children, reduced or no health services, closure of educational institutes, negative behavioral impacts, and slow mental development. Still, a subset of parents also reported the positive side of lockdown, indicating that staying at home resulted in improved relationships. The findings of the study suggest that parents of children with IDDs are confronted with significant challenges that increase their stress.

Female labour force participation and dowries in Pakistan

AbstractDowries are prevalent in South Asian countries, despite legal bans. Theoretical studies suggest that increasing women's financial contribution to households is the key to effectively abolishing this practice. To empirically examine this proposition, we conducted a unique survey in rural Pakistan and gathered contemporaneous information about the expected amount of dowry for unmarried daughters. The estimation results show a negative association between female labour force participation and the expected amount of dowry, whereas no negative association is observed with other marriage expenses. These findings suggest that the negative association derives from appreciation of working women rather than their stigmatization.

Stepping outside home culture: Stories of three women from rural Pakistan in pursuit of identity

Abstract This paper explores experiences and perspectives of women from poor rural areas of Pakistan regarding their choice to get higher education and pursue their individual identity. It is based on the narratives of three women from different villages of Sindh, the southern province of Pakistan. Participants’ narratives indicate that they faced gender discrimination since their birth at home. When they showed a wish to get higher education, they were permitted with an unwritten contract with their families that their education would never be a hurdle in performing their duties as women. Society stifled their motivation to move ahead and grow out of the accepted social norms. Yet once they realised themselves as individuals, they strive for their place and make space in society. The study suggests further research in the lives of women who refuse to be overwhelmed by social challenges and continue their pursuit for identity.

Longitudinal effects of perinatal social support on maternal depression: a marginal structural modelling approach

BackgroundDepression in the perinatal period, during pregnancy or within 1 year of childbirth, imposes a high burden on women with rippling effects through her and her child’s life course. Social...

Adverse childhood experiences and depression among women in rural Pakistan

BackgroundAdverse Childhood Experiences (ACEs) are a common pathway to adult depression. This pathway is particularly important during the perinatal period when women are at an elevated risk for depression. However, this relationship has not been explored in South Asia. This study estimates the association between ACEs and women’s (N = 889) depression at 36 months postpartum in rural Pakistan.MethodData come from the Bachpan Cohort study. To capture ACEs, an adapted version of the ACE-International Questionnaire was used. Women’s depression was measured using both major depressive episodes (MDE) and depressive symptom severity. To assess the relationship between ACEs and depression, log-Poisson models were used for MDE and linear regression models for symptom severity.ResultsThe majority (58%) of women experienced at least one ACE domain, most commonly home violence (38.3%), followed by neglect (20.1%). Women experiencing four or more ACEs had the most pronounced elevation of symptom severity (β = 3.90; 95% CL = 2.13, 5.67) and MDE (PR = 2.43; 95% CL = 1.37, 4.32). Symptom severity (β = 2.88; 95% CL = 1.46, 4.31), and MDE (PR = 2.01; 95% CL = 1.27, 3.18) were greater for those experiencing community violence or family distress (β = 2.04; 95%; CL = 0.83, 3.25) (PR = 1.77; 95% CL = 1.12, 2.79).ConclusionsFindings suggest that ACEs are substantively distinct and have unique relationships to depression. They signal a need to address women’s ACEs as part of perinatal mental health interventions and highlight women’s lifelong experiences as important factors to understanding current mental health.Trial registrationNCT02111915. Registered 11 April 2014. NCT02658994. Registered 22 January 2016. Both trials were prospectively registered.

Understanding the role of lady health workers in improving access to eye health services in rural Pakistan \u2013 findings from a qualitative study

BackgroundIn 1994, the Lady Health Workers (LHWs) Programme was established in Pakistan to increase access to essential primary care services and support health systems at the household and community levels. In Khyber Pakhtunkhwa (KPK) province in northern Pakistan, eye care is among the many unmet needs that LHWs were trained to address, including screening and referral of people with eye conditions to health facilities. However, despite an increase in referrals by LHWs, compliance with referrals in KPK has been very low. We explored the role of LHWs in patient referral and the barriers to patient compliance with referrals.MethodsQualitative methodology was adopted. Between April and June 2019, we conducted eight focus group discussions and nine in-depth interviews with 73 participants including patients, LHWs and their supervisors, district managers and other stakeholders. Data were analysed thematically using NVivo software version 12.ResultsLHWs have a broad understanding of basic health care and are responsible for a wide range of activities at the community level. LHWs felt that the training in primary eye care had equipped them with the skills to identify and refer eye patients. However, they reported that access to care was hampered when referred patients reached hospitals, where disorganised services and poor quality of care discouraged uptake of referrals. LHWs felt that this had a negative impact on their credibility and on the trust and respect they received from the community, which, coupled with low eye health awareness, influenced patients’ decisions about whether to comply with a referral. There was a lack of trust in the health care services provided by public sector hospitals. Poverty, deep-rooted gender inequities and transportation were the other reported main drivers of non-adherence to referrals.ConclusionsResults from this study have shown that the training of LHWs in eye care was well received. However, training alone is not enough and does not result in improved access for patients to specialist services if other parts of the health system are not strengthened. Pathways for referrals should be agreed and explicitly communicated to both the health care providers and the patients.

Can Irrigation Conditions Improve Farmers’ Subjective Well-being? An Investigation in Rural Pakistan

In many developing countries, including Pakistan, the enormous water losses due to outdated irrigation infrastructure threaten livelihoods and food security, while investment in the development of efficiency improvements can help the countries to cope with water scarcity and improve farmers’ wellbeing. This study evaluates how rural farmers’ decisions regarding improving irrigation watercourses and other irrigation conditions affect their wellbeing. We employ hypothesis testing and an ordered logit model on field survey data of 300 farming households from rural Pakistan. The mean test results suggest that farmers on lined watercourses are happier than those on unlined and partially lined watercourses. The regression results suggest that farmers on a fully lined watercourse have higher wellbeing than those on a partially lined watercourse. The time taken by canal water and groundwater to reach farmers’ land reduces their wellbeing. Irrigation quotas, the return of stolen water and the distance of groundwater sources from land have positive effects on farmers’ wellbeing. The study establishes a strong correlation between irrigation conditions, improved irrigation network and farmers’ wellbeing.

The flight of the self: Exploring more‐than‐human companionship in rural Pakistan

AbstractThe construct of multispecies anthropology has helped explain some of the ways through which humans develop sensory and embodied connectedness with the more‐than‐human. Yet there is a need to fully comprehend how such connectedness leads to the discovery of the inner self. Through an ethnographic study carried out with rural South Punjabi pigeon flyers in Pakistan between 2008 and 2018, this paper argues that companionship with pigeons allows people to generate a meaningful relationship with their animals, explore their inner emotions and achieve a deeper understanding of the self. This paper takes inspiration from Donna Haraway's critique of Jacques Derrida's cat encounter, and philosophical thoughts of a 12th‐century Muslim mystic poet, Farid ud‐Din Attar, to examine how becoming‐with pigeons enables the flyers to structure their lifeworlds, develop entrenched companionship and shape their social choices to achieve wellbeing despite everyday social troubles and emotional anxieties.

The effect of family planning exposure on fertility choices and reproductive health care in rural Pakistan

This paper investigates whether family planning exposure mainly through the Lady Health Worker Program has had any effect on women’s fertility choices and use of reproductive health care service in rural Pakistan, using the 2013 Pakistan Demographic and Health Survey (PDHS). Exploiting variations in the program intensity across regions, we conduct instrumental variables (IV) estimation on the impact of family planning exposure on women’s fertility preferences and reproductive behaviors. Our analysis shows that even in the presence of strong son preferences in Pakistan, increasing family planning exposure reduces women’s incentive to have additional children. Moreover, family planning exposure is associated with more antenatal care visits, more deliveries performed by skilled professionals, and a greater chance of delivery at the health center. Finally, we examine the heterogeneity in the effect on fertility preference by age group and education level, and find that the effect is mainly significant for the educated and young women.

Accuracy of Community Informant Led Detection of Maternal Depression in Rural Pakistan.

Maternal depression is a global mental health and a public health priority. Despite the priority its active detection is still a challenge. We tested the accuracy of an adapted version of Community Informant Detection Tool for Maternal Depression (CIDT-MD) in rural settings of Pakistan. Using a single stage design, trained community informants (lady health workers and lay peers) identified women (pregnant and/or with children) with symptoms of probable depression using CIDT-MD. This was immediately followed by diagnostic interviews of all the women using the Structured Clinical Interview for the Diagnostic and Statistical Manual (SCID-V) for current major depressive episode by trained assessors, blinded to the outcome of CIDT-MD. Data were analyzed using Statistical Package for Social Sciences (Version 25.0, IBM Corp., Armonk, NY, USA) and FACTOR software (Version. 10.3.01, Virgili University, Tarragona, Spain). Descriptive statistics, factor analysis, validity, reliability and known group validity was conducted to evaluate the psychometric properties of the adapted CIDT-MD. In all, 425 women, with mean age of 28 years (SD = 4.7), participated. Nearly 10% were illiterate, while the rest (90%) had an education ranging from eight to 15 years of schooling. The majority (73.2%) of the participants had 1–3 children while only 17.4% had >3 children. The sensitivity and specificity of CIDT-MD in detecting depressive symptoms was 97.5% (95% CI: 94.2–99.1) and 82.4% (95% CI: 77.8–86.4) respectively. It’s positive predictive value (PPV), 77.3% (95% CI: 72.9–81.2) and the negative predictive value (NPV) was 98.17% (95% CI: 95.7–99.2). While factor analysis revealed high inter-item correlation for most items (0.62–0.77) with an adequately fair Kaiser-Meyer-Olkin (KMO) sampling adequacy (0.73), significant Bartlett’s test of sphericity (p < 0.001). Uni-dimensionality for the CIDT-MD based on one-dimensional congruence (0.97), explained common variance (0.85), excellent internal consistency (0.90), good criterion validity (Area Under Curve = 81%), tester-test reliability (0.87–0.89) and statistically significant known group analysis (p < 0.001). The adapted version of the Community Informant Detection Tool for Maternal Depression is a valid and a reliable tool for active case detection of maternal depression in rural settings of Pakistan.

Scaling\u2010up school mental health services in low resource public schools of rural Pakistan: the Theory of Change (ToC) approach

BackgroundNinety percent of children with mental health problems live in low or middle-income countries (LMICs). School-based programs offer opportunities for early identification and intervention, however implementation requires cross-sector collaboration to assure sustainable delivery of quality training, ongoing supervision, and outcomes monitoring at scale. In Pakistan, 35% of school-aged children are reported to have emotional and behavioral problems. As in many other LMICs, the government agencies who must work together to mount school-based programs have limited resources and a limited history of collaboration. The “Theory of Change” (ToC) process offers a way for new partners to efficiently develop mutual goals and long-term prospects for sustainable collaboration.ObjectiveDevelop a model for scale-up of school based mental health services in public schools of Pakistan.MethodsWe used ToC workshops to develop an empirically supported, ‘hypothesized pathway’ for the implementation of WHO’s School Mental Health Program in the public schools of rural Pakistan. Three workshops included 90 stakeholders such as policy makers from education and health departments, mental health specialists, researchers, head teachers, teachers and other community stakeholders including non-governmental organizations.ResultsThe ToC process linked implementers, organizations, providers and consumers of school mental health services to develop common goals and relate them (improved child socioemotional wellbeing, grades and participation in activities) to interventions (training, monitoring and supervision of teachers; collaboration with parents, teachers and primary health care facilities and schools). Key testable assumptions developed in the process included buy-in from health care providers, education officials and professionals, community-based organizations and families. For example, teachers needed skills for managing children’s problems, but their motivation might come from seeking improved school performance and working conditions. Poverty, stigma and lack of child mental health literacy among teachers, administration, and parents were identified as key hypothesized barriers. Children and their families were identified as key stakeholders to make such a program successful.DiscussionToC workshops assisted in team building and served as a stakeholders’ engagement tool. They helped to develop and support testable hypotheses about the structures, collaborations, and knowledge most important to scaling-up school based mental health services in Pakistan.

Socio-economic characteristics influencing farmers' willingness-to-adopt domestic biogas technology in rural Pakistan.

Worldwide, biogas programs fail to achieve broad acceptability because of failure to account for socio-economic constraints during program design and implementation. This paper attempts to revisit the relationship between socio-economic characteristics of rural households and adoption of biogas technology at the household level in Pakistan by using a predicted willingness-to-adopt approach in addition to considering energy-related variables which have been rarely accounted for in previous literature. The study is based on primary data collected from 200 households across eight villages in Khyber Pakhtunkhwa (KP) Province. A chi-square test of association is applied to determine the relationship between farmers' socio-economic characteristics and their willingness-to-adopt domestic biogas technology. Results confirm that socio-economic factors such as education, total landholdings, cost of energy consumption, duration of electric shortfalls, occurrence of smoke-related diseases, and possession of livestock had a significant relationship with farmers' willingness-to-adopt biogas technology. The study concludes that for the successful deployment of biogas technology in rural areas, it is imperative to account for the socio-economic conditions of the population.

Role of community engagement in maternal health in rural Pakistan: Findings from the CLIP randomized trial.

BackgroundCommunity-based strategies to promote maternal health can help raise awareness of pregnancy danger signs and preparations for emergencies. The objective of this study was to assess change in birth preparedness and complication readiness (BPCR) and pregnant women’s knowledge about pre-eclampsia as part of community engagement (CE) activities in rural Pakistan during the Community Level Interventions for Pre-eclampsia (CLIP) Trial.MethodsThe CLIP Trial was a cluster randomized controlled trial that aimed to reduce maternal and perinatal morbidity and mortality using CE strategies alongside mobile health-supported care by community health care providers. CE activities engaged pregnant women at their homes and male stakeholders through village meetings in Hyderabad and Matiari in Sindh, Pakistan. These sessions covered pregnancy complications, particularly pre-eclampsia/eclampsia, BPCR and details of the CLIP intervention package. BPCR was assessed using questions related to transport arrangement, permission for care, emergency funds, and choice of facility birth attendant for delivery during quarterly household surveys. Outcomes were assessed via multilevel logistic regression with adjustment for relevant confounders with effects summarized as odds ratios and 95% confidence intervals.ResultsThere were 15 137 home-based CE sessions with pregnant women and families (n = 46 614) and 695 village meetings with male stakeholders (n = 7784) over two years. The composite outcomes for BPCR and pre-eclampsia knowledge did not differ significantly between trial arms. However, CE activities were associated with improved pre-eclampsia knowledge in some areas. Specifically, pregnant women in the intervention clusters were twice as likely to know that seizures could be a complication of pregnancy (odds ratio (OR) = 2.17, 95% confidence interval (CI) = 1.11, 4.23) and 2.5 times more likely to know that high blood pressure is potentially life-threatening during pregnancy (OR = 2.52, 95% CI = 1.31, 4.83) vs control clusters.ConclusionsThe findings suggested that a CE strategy for male and female community stakeholders increased some measures of knowledge regarding complications of pre-eclampsia in low-resource settings. However, the effect of this intervention on long-term health outcomes needs further study.Trial registrationClinical Trials.gov – INCT01911494.

Preparing for parenthood: developing a life-skills and socioemotional health program for young married couples in rural Pakistan

ABSTRACT Background Socioemotional life-skills to negotiate important life-transitions such as marriage and parenthood are critical for the wellbeing of young couples and their offspring, but programs addressing this issue are lacking in Low and Middle-Income Countries (LMICs). Objective This study describes the development of a ‘life-skills’ program for young married women, their husbands and families, living in rural settings in Pakistan. Methods Our methods included: a) a targeted review of relevant literature on life-skills and mental health in young people, b) a qualitative study and, c) intervention development workshops with experts and stakeholders. The review showed that common life-skills employed as part of psychosocial interventions in LMICs were communication skills, problem-solving, assessing relations, stress management, emotional regulation, identifying/eliciting affect, and self-awareness. Results The qualitative study indicated that areas of particular need included interpersonal communication skills with significant others, coping with the pressures of parenthood, and mental well-being. Existing helpful practices included social support by family members and elders. Lack of empowerment in young married women and poor engagement of husbands were identified as a barrier to accessing a potential intervention. Our proposed intervention called ‘Preparing for Parenthood’ consisted of 10 core sessions and 10 follow-up sessions designed to be delivered by lay health workers. It synergistically combined evidence-based socioemotional life-skills (awareness, communication skills, assertiveness, decision-making skills, goal-setting, critical thinking, problem-solving, and coping with stress), with cognitive behavioural strategies (gently challenging existing thoughts and attitudes, behaviour activation and problem solving). The intervention focuses on engagement of the entire family, including husbands. Conclusions The intervention can supplement existing sexual and reproductive health programs by providing skills to prospective parents to effectively negotiate stressful life-transitions and life-events. We envisage the intervention would improve mental as well as sexual and reproductive health of young couples and plan to test this in future randomised trials.

Contextual Challenges in the Implementation of the Alliance for Maternal and Newborn Health Improvement, Prospective Cohort Study, an Experience from Rural Pakistan

Introduction: Improving maternal and newborn survival needs robust data on patterns of morbidity and mortality from well-characterized cohorts. It is equally important for researchers to document and understand the contextual challenges of data collection and how they are addressed. Methods: This was a prospective cohort study implemented from December 2012 to August 2014 in Matiari, Pakistan. A total of 11,315 pregnancies were enrolled. Participants were approached at home for sequential data collection through the standard pretested structured questionnaires. Some indicators were sourced through health facility records. Information on field challenges gathered through field diaries and minutes of meetings with field staff. Results: Inaccurate reporting of last menstrual period (LMP) dates caused difficulties in the planning and completion of antenatal data collection visits at scheduled gestational weeks. We documented ultrasound reports wherever available, relied on quickening technique, and implemented a seasonal event calendar to help mothers’ recall their LMP. Health system coordinators of public sector and private healthcare providers were individually approached for maximum data collection. But an unregulated private health system with poor record maintenance and health care providers’ reluctance for cooperation posed a greater challenge in data collection. Conclusions: Within a broader understanding of the health systems and socio-cultural environment, temporal and spatial feasibility of data collection should be considered thoroughly at the early stages of study designing, planning, resource allocation, and implementation. Pre-defined regular and need-based meetings with each tier of data collection teams and study managers help to reinvigorate field execution plans and optimize both quantity and quality of study data.

Supplemental Material for Early and Concurrent Home Stimulation: Unique and Indirect Links With Fine Motor Skills Among 4-Year-Old Children in Rural Pakistan

Supplemental Material for Early and Concurrent Home Stimulation: Unique and Indirect Links With Fine Motor Skills Among 4-Year-Old Children in Rural Pakistan

The economic impacts of COVID-19 on household mental health: Panel evidence from Pakistan

We combine data collected just prior to the unfolding of COVID-19 with follow-up data from July 2020 to document the adverse economic effects of the pandemic and resulting impact on parental and child mental well-being in rural and semi-urban Pakistan. 22% of the households in our sample are affected by job loss, with monthly income down 34% on average. Our difference-in-difference results show that job loss is associated with a 0.73 standard deviation (SD) reduction in adult mental health score (K10), a 0.55 SD reduction in a ‘Hope’ index of children’s aspirations, agency and future pathways, and a 0.33 SD increase in children’s depression symptoms. In addition, we observe higher levels of parental stress and anger reported by children, as well as an increase in reported prevalence of domestic violence. Overall, we document that the pandemic has disproportionately and negatively affected the economic and mental well-being of the most vulnerable households in our sample.

Covering the last mile for vaccination: Feasibility and acceptability of traditional birth attendant-based referral system in hard-to-reach areas in rural Pakistan.

BackgroundPakistan has a decent network of community-based workers including lady health workers (LHWs) and vaccinators. However, a major section of the population is not covered by LHWs/vaccinators, labeled here as hard-to-reach (HTR) areas, where immunization coverage is also considerably low. This study explored the feasibility of engagement of traditional birth attendants (TBAs) to improve EPI vaccination coverage in HTR areas in rural Sindh, Pakistan.MethodsThis implementation research was conducted in two sub-districts of Sukkur (a district in Sindh Province). In an HTR selected intervention arm, TBAs were trained for vaccination and monetary incentives were provided to counsel and refer mothers for vaccination. While LHWs covered areas in the adjacent sub-district were provided with refresher training for vaccination only without any monetary incentive, and were considered as control arm. Considering the inherent differences in intervention and comparison group (HTR intervention area being worse regarding infrastructure and access), between groups and within group change in knowledge of TBA/LHWs and vaccination coverage was assessed before and after the intervention. Furthermore, focus group discussions were conducted with vaccinators, TBAs and LHWs and in-depth interviews with supervisors of vaccinators.ResultsTBAs and LHWs’ vaccine related knowledge increased significantly after training (pretest vs post test score: 10.5 to 15.4). The BCG coverage improved 74.1% (percentage change) in TBA arm. While completion of vaccination (ie, Penta-3 coverage) increased by 147% from baseline following the intervention. The TBAs, LHWs, vaccinators and their supervisors all welcomed the initiative and considered it as a feasible option.ConclusionsInvolvement of TBAs’ to form a referral system has potential to improve vaccine coverage and completion in HTR areas in Pakistan. The system is acceptable to the population and implementation is feasible due to availability of TBAs. However, in order to sustain the initiative minimal incentive need to be provided to TBAs to improve the vaccination coverage. Compared to establishing the infrastructure in HTR the intervention seems less costly however, it requires formal cost-effective or cost-benefit analysis.