Rural Pakistan Research Articles

Cost-effectiveness analysis of implementing an integrated neonatal care kit to reduce neonatal infection in rural Pakistan

ObjectiveTo evaluate the cost-effectiveness of distribution of the integrated neonatal care kit (iNCK) by community health workers from the healthcare payer perspective in Rahimyar Khan, Pakistan.SettingRahimyar Khan, Pakistan.ParticipantsN/A.InterventionCost-utility analysis using...

A differential analysis for men and women's determinants of livelihood diversification in rural rain-fed region of Pakistan: An ordered logit model (OLOGIT) approach

Gender responsiveness is a crucial element in achieving inclusive economic and developmental growth of an economy. A gender-differentiated analysis in determining livelihood diversification strategies is, therefore, important for developing gender sensitive policies. The study examined and presented the determinants of livelihood diversification for men and women smallholders' households in rural Pakistan. A multistage data sampling technique was used in selection and collection of the data from 148 men and 147 women households. Considering the three types of ordered structured dependent variable of livelihood strategies preferences (LC1, LC2 and LC3) ordered logit model (OLOGIT) was applied. The results revealed that there were some similarities and some differentials among men and women's for determining livelihood diversification strategies. The first differential was based on signs of the coefficients such as natural disasters, access to public transport and women role in building social relations showed varied nature of response for men and women. The second differential was explored on the basis of statistical significance levels, that revealed the factors that were highly significant for men seems to be non-significant for women and vice versa scenarios existed for most of the determinants of livelihood strategies. Like, the factors family labor, membership in any organization, social linkages, access to latest machinery and accessibility of credit were highly significant for men but non-significant for women. While only education, and family labor were the common significant factors in diversification. The role of formal financial institution was lacking in the study. Women's major livelihood sources was LC1-(on-farm) while men were more towards LC2-(off-farm) and LC3-(Non-farm) strategies. These differentials highlight the importance of a policy initiative to be taken to increase access and availability of assets and services to women households, improve their capacity to participate in non-farm sectors, and accelerate transformative changes at both local and policy levels.

Antimicrobial Resistance in Pneumococcal Carriage Isolates from Children under 2 Years of Age in Rural Pakistan.

ABSTRACTAntimicrobial resistance is an emerging public health concern. Ten-valent pneumococcal vaccine (PCV10) was introduced in Pakistan’s Expanded Program on Immunization (EPI) in 2012 as a 3 + 0 schedule without catchup. From 2014 to 2018, children <2 years were randomly selected in two rural union councils of Matiari, Pakistan. Nasopharyngeal swabs were collected using standard WHO guidelines by trained staff and processed at Infectious Disease Research Laboratory at The Aga Khan University, Karachi using culture on sheep blood agar and Multiplex PCR methods described by CDC, USA. Pneumococcal isolates were identified by optochin sensitivity and bile solubility tests. Isolates were then tested for antimicrobial susceptibility by standard Kirby-Bauer disk-diffusion method on Mueller-Hinton Agar (MHA) with 5% sheep blood agar as per Clinical & Laboratory Standards Institute (CLSI) recommendations. Of 3140 children enrolled, pneumococcal isolates were detected in 2370 (75%). Vaccine coverage improved from 41% to 68.4%. Out of the 2370 isolates, 88.4%, 37.6% and 25% were resistant to cotrimoxazole, tetracycline and erythromycin, respectively. There was no resistance to penicillin, ceftriaxone, and vancomycin. For erythromycin, resistance increased from 20% in 2014/15 to 30.8% in 2017/18 and for tetracycline it increased from 34.9% to 41.8% both of which were explained by an increase in prevalence of serotype 19A. Pneumococcal isolates were susceptible to penicillin, ceftriaxone, and vancomycin. They were largely resistant to cotrimoxazole and tetracycline. There was an increase in erythromycin and tetracycline resistance attributed to increasing prevalence of serotype 19A. Pneumococcal isolates from carriage and invasive disease should be closely monitored for antimicrobial susceptibility.IMPORTANCE Antimicrobial resistance is an emerging public health concern particularly in low- and middle-income countries where there is poor regulation and easy availability of antibiotics. This is the first study from Pakistan to report antimicrobial resistance patterns of pneumococcus after vaccine introduction in the community. Pakistan was the first South-Asian country to introduce PCV10 in its Expanded Program on Immunization (EPI) in 2012 as a 3 + 0 schedule without catchup. In this study, we describe the PCV10 impact on antimicrobial resistance patterns of pneumococcal nasopharyngeal carriage in children younger than 2 years of age in a rural district in Pakistan after the introduction of the vaccine.

Mothers-in-law as Key Influencers: Study on a Radio Drama Intervention to improve Maternal and Child Health in Pakistan

Mothers-in-law play an integral role in promoting maternal and child health practices in rural Pakistan. This study discusses the design, implementation, and evaluation of a 25-episode radio drama featuring the mother-in-law as the primary influencer for maternal and child health practices. The radio drama was designed after an extensive pre-drama audience research comprising of 10 focus groups, and 14 in-depth interviews in Bagh and Mansehra. Post-drama evaluation comprised two focus groups in the target areas. The endline evaluation found that viewership of the drama improved communication between people of all age groups and social roles without offending their dignity, intelligence, and sense of tradition. Additionally, the findings showed that the audience demonstrated improvement in knowledge about danger signs for mother and child, as well as positive attitudes to seeking timely service from a trained healthcare provider. The study makes a contribution to existing health communication campaigns by introducing a culture-centric approach, through radio dramas, to influence mothers-in-law and consequently impact maternal and child health practices. Keywords: mother-in-law, radio drama, entertainment education, maternal health, child health, Pakistan

Child diet and mother-child interactions mediate intervention effects on child growth and development.

This study examined whether child diet and mother–child interactions mediated the effects of a responsive stimulation and nutrition intervention delivered from 2009 to 2012 to 1324 children aged 0–24 months living in rural Pakistan. Results showed that the intervention improved children's cognitive, language and motor development through child diet and mother–child interactions. Although the intervention did not improve child growth or socio‐emotional development, we observed positive indirect effects on child growth via child diet and on socio‐emotional development via both child diet and mother–child interactions. In addition, child diet emerged as a shared mechanism to improve both child growth and development, whereas mother–child interactions emerged as a distinct mechanism to improve child development. Nevertheless, our results suggest the two mechanisms were mutually reinforcing and that interventions leveraging both mechanisms are likely to be more effective at improving child outcomes than interventions leveraging only one of these mechanisms.

Embodied Metaphor: Playing with Gender in South Asian Sufism

AbstractThis paper brings the life and social world of a cross-dressing Sufi in rural Pakistan into relationship with the Sufi textual tradition to demonstrate that living gendered practices of sexual difference may serve as a form of what I call embodied metaphor that carries multiple layers of significance. Such embodied metaphors are not mere expressions or negotiations of identity but go beyond gender to point to other desires and realities. Drawing on a Lacanian interpretation of metaphor and metonymy, I argue that gender play allows confrontation with an aporia of sexual difference that unsettles the speaking subject. I demonstrate the rich intertextuality of the Sufi body as metaphor while also addressing how the metaphorical possibilities of the Sufi body have been affected by the recent development of a legal discourse of the third gender in Pakistan and the intensification of efforts to reform or purify Islam.

Implementation challenges from a prospective, interventional biopsy-based study of Environmental Enteropathy in rural Pakistan

The Study of Environmental Enteropathy (EE) and Malnutrition in Pakistan (SEEM) is a community intervention trial designed to understand the pathophysiology of EE and its associated clinical phenotypes in children less than two years of age. Undernutrition is the underlying cause of three million deaths worldwide annually, accounting for 45% of all deaths among children under five years of age. Linear growth stunting affects a further 165 million, especially in low- and middle-income countries. In Pakistan, an estimated one in three children are underweight and nearly half are stunted. This manuscript summarizes the challenges faced by the field team and the solutions employed for achieving our research objectives at the rural Matiari field site. Our study design involved a longitudinal collection of field data and biological samples which required constant engagement of field staff with the participating families. Challenges faced in SEEM included: 1) quality assurance parameters of anthropometry data; 2) 24-hour food recall data collection; 3) clinical management of sick enrolled children; 4) obtaining informed consent for upper gastrointestinal (UGI)endoscopy (an invasive procedure); and 5) biological sample collection (blood, urine, stool) from enrolled children. We enrolled 350 malnourished children(Weight for Height Z (WHZ) score &lt;-2) and 50 well-nourished children(WHZ score ≥ 0 and height-for-age Z (HAZ) score ≥ -1) with more than 95% success rate of collecting blood, urine and stool specimens. We collected 72% microbiome stool samples within 30 minutes of the child passing stool. We conducted a UGI biopsy in 63 children. Solutions to these challenges included good project governance, the establishment of credibility, and the development of a longitudinal bidirectional relationship embedded in trust and effective communication with the caretakers of the enrolled children. Continuous monitoring, regular training of staff, and effective teamwork were key factors that led to the successful execution of our study.

Distance from Healthcare Facilities Is Associated with Increased Morbidity of Acute Infection in Pediatric Patients in Matiari, Pakistan.

The relationship between environmental factors and child health is not well understood in rural Pakistan. This study characterized the environmental factors related to the morbidity of acute respiratory infections (ARIs), diarrhea, and growth using geographical information systems (GIS) technology. Anthropometric, address and disease prevalence data were collected through the SEEM (Study of Environmental Enteropathy and Malnutrition) study in Matiari, Pakistan. Publicly available map data were used to compile coordinates of healthcare facilities. A Pearson correlation coefficient (r) was used to calculate the correlation between distance from healthcare facilities and participant growth and morbidity. Other continuous variables influencing these outcomes were analyzed using a random forest regression model. In this study of 416 children, we found that participants living closer to secondary hospitals had a lower prevalence of ARI (r = 0.154, p < 0.010) and diarrhea (r = 0.228, p < 0.001) as well as participants living closer to Maternal Health Centers (MHCs): ARI (r = 0.185, p < 0.002) and diarrhea (r = 0.223, p < 0.001) compared to those living near primary facilities. Our random forest model showed that distance has high variable importance in the context of disease prevalence. Our results indicated that participants closer to more basic healthcare facilities reported a higher prevalence of both diarrhea and ARI than those near more urban facilities, highlighting potential public policy gaps in ameliorating rural health.

Do Private Schools Improve Learning Outcomes? Evidence from Within-Household Comparisons in East Africa and South Asia

A contentious debate in academic as well as policy circles relates to the growth in private schooling in the Global South. While proponents highlight the superior learning outcomes of pupils in private schools, others have argued that this is merely a reflection of the more advantaged family background of private school pupils, rather than an effect of private schooling itself. We contribute to this debate by providing estimates derived from household fixed-effect models, which control for any observed or unobserved differences between government and private school pupils at the household level. We argue that these can be interpreted as an upper bound estimate of the effect of private schooling on learning. We rely on large-scale, comparable household survey data from Kenya, Uganda, India, and Pakistan, focusing on children enrolled in grades 2–6 of primary school. Private school attendance ranges from 12 percent in Kenya to 33 percent in rural India, with substantial within-household variation. The findings show that controlling for family background almost eliminates the positive effect of private schooling in rural Pakistan and reduces it by around half in rural India, Kenya, and Uganda, to about a quarter of a standard deviation. Subgroup analyses show that the effect of private schooling is similar for children from poor and wealthier families. We argue that the benefits of private schooling are unlikely to outweigh its social costs.

Age-Based Anthropometric Cutoffs Provide Inconsistent Estimates of Undernutrition: Findings from a Cross-Sectional Assessment of Late-Adolescent and Young Women in Rural Pakistan.

ABSTRACTAmbiguity around age ranges for adolescence and adulthood can make the application of age-based nutrition cutoffs confusing. We examined how estimates generated using the age-based anthropometric cutoffs for adolescent girls (10 to <19 y) and women of reproductive age (15–49 y) compared between late-adolescent and young women, and determined how application of both cutoffs affected late-adolescents’ estimates. Using cross-sectional data from participants aged 15–23 y in the Pakistan-based Matiari emPowerment and Preconception Supplementation (MaPPS) Trial (n = 25,447), notably large differences in estimates were observed for stunting (30.5% and 7.9% for late-adolescent and young women, respectively; P < 0.001) and thinness (9.3% and 30.8%, respectively; P < 0.001). When both cutoffs were applied to adolescents’ data, estimate differences were maintained. With each year of age, the difference for stunting increased and thinness decreased. Given the discrepancies observed both between and within groups, clarity around application of anthropometric cutoffs for youth (aged 15–24 y) is needed.This trial was registered at clinicaltrials.gov as NCT03287882.

Adaptation Implications of Climate-Smart Agriculture in Rural Pakistan

In this paper, we analyze the drivers of the adoption of climate-smart agricultural (CSA) practices and the impact of their adoption on farm net returns and exposure to risks. We use recent farm-level data from three agroecological zones of Pakistan to estimate a multinomial endogenous switching regression for different CSA practices used to reduce the adverse impact of climate change. These strategies include changing input mix, changing cropping calendar, diversifying seed variety, and soil and water conservation measures. The empirical results show that the adoption of different CSA practices is influenced by average rainfall, previous experience of climate-related shocks, and access to climate change information. The findings further reveal that adoption of CSA practices positively and significantly improves farm net returns and reduces farmers’ exposure to downside risks and crop failure. The results also reveal significant differences in the impacts of CSA practice adoption on farm net returns in different agroecological zones. Thus, policies aimed at achieving sustainability in agricultural production should consider agroecological, specific, climate-smart solutions.

Feasibility assessment of immunization carpool model for &amp;lt;2 years children in rural Pakistan

Abstract Almost 20 million children globally do not get routine vaccines, 1.4 million of which reside in Pakistan. Immunization coverage in rural settings of Pakistan, comprising &amp;gt;60% population, is lower than their urban counterparts. Barriers such as distant-centers, lack of transportation, and restrictions on women to travel alone, exacerbate the problem. We introduced immunization carpool services in rural settings to facilitate vaccination of &amp;lt; 2 years children. Low-coverage immunization clinics were selected based on availability of vaccinators and vaccines in Shikarpur, a rural district in Pakistan. Local transport providers were identified and vehicles were rented-in. Community mobilization was done through awareness sessions and branding vehicles. Data was recorded on the number of round trips and immunization visits facilitated by each vehicle. Details of children transported and feedback on carpool services were captured from caregivers. Immunization coverage was calculated using the government's electronic immunization registry data. Between January to October 2020, 6 vehicles were deployed, which provided free transport services in 98 catchment areas of 4 immunization clinics. On average, each vehicle completed 420 (SD: 58.2) round trips and facilitated 781 (SD: 171) immunization visits. A total of 2,391 children were enrolled, 1,182 (49.7%) of them were females and 1,197 (50%) aged &amp;lt;6months. Enrolled children compared to non-enrolled at the same immunization clinic, showed 19.1% higher coverage rate for penta-3 (81% vs 68%, p &amp;lt; 0.00) and 23.6% for measles-2 (73% vs 57%, p &amp;lt; 0.00). Immunization timeliness among enrolled children increased by 4.8% for penta-3 (9% vs 4%, p &amp;lt; 0.00) and 18% for measles-2 (25% vs 7%, p &amp;lt; 0.00). Reported advantages of services include time-saving (92%), cost-saving (79%), and reduced dependence on family members (95%). Immunization carpool service is well-accepted by rural women and can improve immunization coverage and equity in rural areas. Key messages Provision of commuting options can overcome accessibility barriers and has the potential to improve immunization coverage and timeliness. Free transport services for rural women could aid in promoting gender equity and reducing urban-rural disparities.

Applications of a Chronic Care Model for Self-Management of Type 2 Diabetes: A Qualitative Analysis.

The main aim of this study was to explore the suitability, practicality, and acceptability of the self-management support and delivery system design components of the Chronic Care Model (CCM) in type 2 diabetes self-management in primary care settings in rural Pakistan. Thirty patients living with type 2 diabetes and 20 healthcare professionals (10 general practitioners and 10 nurses) were recruited from Al-Rehman Hospital at Abbottabad, Pakistan. The study data were collected using semi-structured interviews and analyzed using thematic analysis. The self-management element of the CCM played an important role in managing type 2 diabetes, and self-efficacy in relation to diet and diabetes management were the most effective strategies. Surprisingly, considering the local culture around diabetes, patient care reflecting their cultural background was identified as an important factor by patients not healthcare professionals. The delivery system design element of the CCM promoted multidisciplinary teamwork. Our findings suggest that the self-management support and delivery system design components of the CCM provided an effective framework for supporting diabetes self-management education and support in rural areas.

Climate change in rural Pakistan: evidence and experiences from a people-centered perspective

Pakistan is home to a wide range of geographical landscapes, each of which faces different climate change impacts and challenges. This article presents findings from a National Geographic Society funded project, which employed a people-centered, narratives-based approach to study climate impacts and adaptation strategies of people in 19 rural study sites in four provinces of Pakistan (N = 108). The study looked at six climate-related stressors—changes in weather patterns, floods, Glacial Lake Outburst Floods, drought, heat waves, and sea-level rise—in the coastal areas of Sindh, the desert of Thar, the plains of Punjab, and the mountains of Hunza, Gilgit, and Chitral. Speaking to people at these frontlines of climate change revealed much about climate suffering and trauma. Not only is the suffering induced by losses and damages to property and livelihood, but climate impacts also take a heavy toll on people’s psycho-social wellbeing, particularly when they are displaced from their homes. The findings further demonstrate that people try to adapt in various ways, for instance by altering their agricultural practices, but they face severe barriers to effective adaptation action. Understanding people’s perceptions of climate change and incorporating their recommendations in adaptation planning can help policy-makers develop a more participatory, inclusive, and holistic climate resilience framework for the future.

Association of Risk Factors for Early Childhood Disability in Rural Pakistan.

Association of Risk Factors for Early Childhood Disability in Rural Pakistan.

Healthcare Professionals' Perspectives of Patients' Experiences of the Self-Management of Type 2 Diabetes in the Rural Areas of Pakistan: A Qualitative Analysis.

The main objective of this research work was to explore the healthcare professionals’ perspectives of type 2 diabetes patients’ experiences of self-management of diabetes in the rural area of Pakistan. In this study, we have carried out a methodological approach to use a self-management framework to direct the interview guide for healthcare professionals to examine their perceptions and expectations of their diabetes patients’ adherence to the medications prescribed. Twenty healthcare professionals were recruited in this study consisting of ten general practitioners and ten nurses from various clinics (medical centres) of Al-Rehman Hospital at Abbottabad, Pakistan. This qualitative study explored the feelings and opinions of general practitioners on patients’ compliance and adherence by using the semi-structured interview guide using a methodological framework. All interviews of participants were audiotaped and transcribed for content analysis. Six major themes were identified: patient–doctor relationship; patient’s non-adherence to diet and exercise; conflicts with the patients; low self-efficacy and feeling of “resignation with poor care”; the influence of culture on patients’ self-management activities and lack of support for patients by health care providers, patients, and their families. We have derived relevant solutions from qualitative studies and considered that communication, tailored, and shared care is the best approach for patient adherence to treatment. GPs felt that a structured consultation and follow-up in a multidisciplinary team might help to increase adherence. The results of this qualitative health research highlighted the challenges healthcare professionals are facing in rural Pakistan in managing patients with type 2 diabetes and supporting their management activities. Healthcare professionals and patients may benefit by adopting a methodological framework approach to ensure meaningful participation and adjusting the patient–doctor relationship, and setting up achievable management and self-management goals.

Barriers in the progress of domestic biogas plants in rural Pakistan

ABSTRACT The energy crisis has pushed Pakistan way down the economic rankings. More than 70% the total population resides in rural regions. The energy crisis has crippled the lifestyle of the rural class (RC) in many aspects. For rural Pakistan, the energy scarcity, a hurdle in sustainable development, can be eliminated by biogas. Almost every rural family is associated with agriculture and owns livestock animals, therefore self-sufficient in biogas plant’s fuel. Fuel abundance and favourable climatic conditions make energy extraction from biomass facile and fruitful; still there are many reasons that RC is dumped in the energy crisis. In this paper, a survey is conducted in villages of Pakistan to discover the reasons due to which domestic biogas plants have not yet gained their due importance. Institutional, financial, awry planning and social barriers are highlighted at the grass root level in the development of biogas technology in rural Pakistan. In contrast, villages where biogas plants are present, the survey analysis revealed prosperity rendered through savings, reduction in diseases and workload. The paper concludes with an emphasis on the requirement of concrete and comprehensive policy that is capable to deal with the barriers in the route of biogas technology.

Exploring the phenomenon of suicidal behaviour (SB): An explanatory, mixed-method study in rural Pakistan.

Despite scientific literature and media reports of rising cases of suicide and attempted suicide in different parts of Pakistan, the extent of this problem remains unknown, particularly from outside the main urban centres of the country. To report data on Suicidal Behaviour (SB) from Malakand Division, a rural and marginalised part of Khyber Pakhtunkhwa (KPK) province, explore aetiological factors and propose preventive strategies. This study followed an explanatory, mixed-method study design. The first part quantitative [QUANT] comprised of police reports on suicidal behaviour, from 2001 till first 8 months of 2018. Detailed analysis of only data from 2013 was undertaken, as data prior to 2013 contained insufficient information. The second part that is, qualitative (QUAL) consisted of in-depth interviews with relevant stakeholders. A mixed method of inductive and deductive analytical approach was used. From 2013 until the first quarter of 2018, the police recorded 1,645 attempts of both males and females of which 144 (8.75%) resulted in fatalities. Suicide attempts rose by 83.4% over the 5 years and 8 months. Approximately, 43.3% of the attempts were attributed to 'depression'. Domestic abuse was reported in 49.6% of cases. Of the total victims, 1,049 (63.7%) were females, whereas 60.1% were married. Ingestion of the organophosphates poison (pesticide) was reported in 53.2% (n = 999) of suicide attempts. In more than 90% of the non-fatal suicide attempts, victims were booked under punitive laws. Poor socio-economic status, inter-personal stressors, violence against women and mental illnesses were the major causes of suicidal behaviour in Malakand [QUAL]. Investment in human development, strengthening of the healthcare system, de-stigmatisation of mental illnesses and women empowerment could possibly prevent suicidal behaviour in Malakand [QUAL]. SB in Malakand Division is steadily increasing. The increase is more evident in vulnerable populations such as women and the younger population. 'Psychosocial stressors' and 'depression' were the main causes of suicidal behaviour. A broad-based, proactive, multi-sectorial approach is needed to prevent SB in the region.

Predictors of Prenatal Depression: A Cross-Sectional Study in Rural Pakistan

Objective: To determine the prevalence and association of prenatal depression with socioeconomic, demographic and personal factors among pregnant women living in Kallar Syedan, Rawalpindi, Pakistan.Methods: Five hundred women in the second and third trimester of pregnancy, living in Kallar Syedan, a rural area of district Rawalpindi Pakistan, were included in the study. Depression was assessed using “Patient health questionnaire” (PHQ9) in Urdu, with a cut-off score of 10. Multi-dimensional scale of perceived social support (MSPSS) was used to assess perceived social support. Life Events and Difficulties Schedule (LEDS) were used to measure stressful life events in past 1 year. Tool to assess intimate partner violence (IPV) was based on WHO Multi Country Study on “Women's Health and Domestic Violence against Women.”Results: Prevalence of prenatal depression was found to be 27%. Number of pregnancies was significantly associated with prenatal depression (p < 0.01). Women living in a joint family and those who perceived themselves as moderately satisfied or not satisfied with their life in the next 4 years were found to be depressed (p < 0.01, OR 6.9, CI 1.77–26.73). Depressive symptomatology in women who experienced more than five stressful life events in last 1 year was three times higher (p < 0.001, OR 3.2, CI 1.68–5.98) than in women with 1–2 stressful events. Women who were supported by their significant others or their family members had 0.9 times (p < 0.01, OR 0.9, CI 0.85–0.96) less chance of getting depressed. Pregnant women who were psychologically abused by their partners were 1.5 times more depressed (p < 0.05 CI 1.12–2.51). Odds of having depression was also high in women who had less mean score of MSSI (p < 0.05, OR 1.1, CI 1.01–1.09). Women who had suitable accommodation had 0.5 times less chance of having depression than others (p < 0.05, OR 0.5, CI 0.27–0.92).Conclusion: Over a quarter of the women in the study population reported prenatal depression, which were predicted predominantly by psychosocial variables.

Contextual factors influencing the effectiveness of professional development for teachers in rural Pakistan

ABSTRACT This research examines the perceptions of key stakeholders in rural Pakistan to understand the contextual factors influencing the effectiveness of Continuing Professional Development (CPD) programmes for teachers. To do so, the research uses a qualitative case study approach and draws on the experiences of the key stakeholders including providers of CPD, officials of education department, school principals and teachers. Focus group interviews are used to generate data. The research outcomes highlight several significant contextual factors which influence the possibility and quality of CPD. These factors include limited recognition of CPD, reduced motivation of teachers towards CPD and approaches to gender influencing female participation in CPD activities. Since CPD providers intervene without considering these contextual factors, the existing CPD programmes on offer for teachers in rural Pakistan have been less successful in positively impacting the practices of teachers.