Internal structure validity and internal consistency reliability of the Minnesota Living with Heart Failure Questionnaire: a systematic review protocol.

INTRODUCTION: The Minnesota Living with Heart Failure Questionnaire (MLHFQ) is one of the most used tools to measure health-related quality of life in heart failure. Despite extensive use in research, evidence on the MLHFQ's internal structure validity remains heterogeneous and inconclusive. There are no known reviews that systematically summarise the evidence related to the MLHFQ's factor structure (internal structure validity). This gap highlights a need to critically appraise, summarise and compare the available evidence on the internal structure and internal consistency reliability (ICR) of the MLHFQ. METHODS AND ANALYSIS: The review will adhere to the reporting guidelines of the Cochrane Handbook for Systematic Reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. We will systematically search eleven electronic databases/search engines (Medline, EMBASE, Cumulative Index for Nursing and Allied Health Literature, PsycINFO, Global Health, Health and Psychosocial Instruments, Scopus, Journals, Web of Science, Google Scholar, and Dissertation and Theses Global) for quantitative studies assessing the MLHFQ's factor structure and ICR. Two reviewers will then independently screen studies for eligibility and assess the quality of included studies using the COnsensus-based Standards for the selection of health status Measurement Instruments checklist. Throughout the review, discrepancies will be resolved through consensus or by the involvement of the third reviewer. We will analyse and present results using descriptive statistics (frequencies, proportions and ranges) and narrative synthesis. We will include all the relevant studies published within the timeframe covered by the database. We carried out the preliminary search in November 2022 except for Dissertation and Theses Global which was searched in September 2023; however, we will update the entire search right before the review completion in January 2024. ETHICS AND DISSEMINATION: Ethical approval is not required as no primary data is being collected from individuals. We intend to share the findings of the review at international conferences and publish manuscripts in peer-reviewed journals. PROSPERO REGISTRATION NUMBER: CRD42023346919.

Development and Psychometric Evaluation of Bilingual English-Urdu Pakistani Critical Thinking Disposition Scale.

Objective: To develop and test the psychometric properties of the Pakistani Critical Thinking Dispositions Scale. Methods: In the item generation phase, constructs of the scale were identified through an in-depth literature review and items were written to measure the constructs. Following this, input of the experts was obtained for content validity index. In the item reduction phase, psychometric properties were measured. Initially, the scale was administered to 580 study participants during May 2018-2020 after approval from the institutional review board. Data was analyzed through SPSS v21, AMOS v21 and Omega extension. Results: First phase identified 54-items for seven constructs including contextual perspective, perseverance, reflection, intellectual integrity, creativity, open-mindedness, and inquisitiveness. Second phase determined KMO test value of 0.974 and Bartlett's test (P-Value < 0.001). The second-order confirmatory factor analysis showed a good fit model explaining 73.37% total variance. Parsimony and baseline comparison indices were favorable. Alpha and Omega value of 42-items was 0.869. Conclusion: Pakistani Critical Thinking Dispositions scale owning seven constructs and 42-items is valid, reliable, and feasible to use in undergraduate nursing education. However, its utilization in other healthcare disciplines can be tested.

Psychosocial interventions and mental health in patients with cardiovascular diseases living in low- and middle-income countries: A systematic review and meta-analysis.

OBJECTIVE: Mental health issues are closely associated with symptoms and outcomes of cardiovascular diseases (CVDs). The magnitude of this problem is alarmingly high in low and middle-income countries (LMICs). This systematic review and meta-analysis aimed to examine the effectiveness of psychosocial interventions on mental health outcomes among patients with CVDs living in LMICs. METHODS: This review includes Randomized controlled trials (RCTs) and quasi-experimental studies conducted on adult patients who had a CVD and/or hypertension and located in LMICs. Studies published in English between 2010 and March, 2021 and which primarily reported mental health outcomes of resilience, self-efficacy, Quality of life (QoL), depression and anxiety were included. Studies were screened, extracted and critically appraised by two independent reviewers. Meta-analysis was conducted for RCTs and narrative summaries were conducted for all other studies. PRISMA guidelines were followed for reporting review methods and findings. RESULTS: 109 studies included in this review reported educational, nursing, behavioral and psychological, spiritual, relaxation, and mindfulness interventions provided by multidisciplinary teams. 14 studies reported self-efficacy, 70 reported QoL, 62 reported one or both of anxiety and depression, and no study was found that reported resilience as an outcome in this population. Pooled analysis showed improvements in self-efficacy and QoL outcomes. The majority of studies showed improvement in outcomes, though the quality of the included studies varied. CONCLUSION: Patients with CVDs in LMICs may experience improved mental health through the use of diverse psychosocial interventions. Evaluations are needed to investigate whether the impact of interventions on mental health are sustained over time.

Psychosocial interventions and mental health in patients with cardiovascular diseases living in low and middle-income countries: A systematic review protocol.

OBJECTIVE: The objective of this review is to evaluate the effectiveness of psychosocial interventions on mental health outcomes in adult patients with Cardiovascular Diseases (CVDs) living in low- and middle-income countries (LMICs). INTRODUCTION: Mental health issues are highly prevalent among patients with CVDs leading to poor disease prognosis, self-care/ management, and Quality of Life (QOL). In the context of LMICs, where the disease burden and treatment gap are high and resources are inadequate for accessing essential care, effective psychosocial interventions can make significant contributions for improving mental health and reducing mental health problems among patients who live with cardiovascular diseases. INCLUSION CRITERIA: This review will include studies published between 2010 and 2021 that evaluated the effect of psychosocial interventions on mental health outcomes (resilience, self-efficacy, QOL, depression and anxiety) on adult patients (aged ≥18 years) with any cardiovascular diseases using experimental and quasi experimental designs. METHODS: The search will be conducted from the following databases: MEDLINE via OVID (1946-Present), EMBASE via OVID (1974 -Present), Cumulative Index for Nursing and Allied Health Literature (CINAHL) via EBSCOhost (1936-Present), PsycINFO via OVID (1806-Present), Scopus via Elsevier (1976-Present), and Cochrane Library via Wiley (1992-Present). Data will be critically appraised using standard tools and extracted by two reviewers and disagreement will be solved by the third reviewer. Meta-analysis will be performed, if possible, otherwise, data will be synthesized in narrative and tabular forms. DISCUSSION: The findings of this review will provide a key insight into contextually relevant psychosocial interventions for promoting mental health of patients with CVDs living in LMICs. The review findings will be potentially useful for health care providers and researchers to implement such interventions not only for reducing the burden of mental health issues but also for improving the overall well-being among patients with chronic illnesses. SYSTEMATIC REVIEW REGISTRATION NUMBER: Prospero-CRD42020200773.

Levels and Predictors of Self-Care Among Patients with Hypertension in Pakistan.

BACKGROUND: Globally, hypertension is the leading non-communicable disease and strongest predictor of cardiovascular diseases. To mitigate and prevent hypertension-related complications, self-care behavior adaptation has proven to be vital. In this study, we examined the six clinically prescribed levels of self-care as prescribed by the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure and its predictors among a select sample of hypertensive individuals in Karachi, Pakistan. METHODS: This study reports the cross-sectional survey of a sequential mixed method study which assessed the levels of self-care of hypertensive individuals residing in an urban cosmopolitan setting within Karachi Pakistan. Four hundred and two patients were screened using the H-SCALE questionnaire, while socio-demographic predictors of self-care and level of knowledge of hypertension were identified using a study-specific checklist. Self-care was assessed against six clinical domains including medication adherence, diet, weight management, physical activity, and abstinence from alcohol. RESULTS: Participants were recruited from the two largest tertiary care hospitals in Karachi. Good knowledge about hypertension, including its causes, management, and complications was reported by 4.47% of the participants. Highest levels of self-care adherence were found for abstinence from alcohol (100%), smoking cessation (83.33%), and medication compliance (71.89%), whereas lowest levels were found for diet (27.11%), and physical activity (24.88%). In terms of predictors for self-care, age, male gender, and self-checking of blood pressure at home, followed by the level of education were the most common predictors for each self-care behavior in the given population. CONCLUSION: Overall knowledge of self-care for hypertension is sub-optimal among hypertensive patients in Pakistan which is reflected in their behaviors. There is a need to introduce healthcare educational programs in Pakistan which can improve self-care behaviors of hypertensive individuals and potentially reduce the prevalence of associated cardiovascular diseases and its complications.

Introducing a flipped classroom in a pharmacology course.

BACKGROUND: Flipped classroom pedagogy has been shown to improve nursing students' academic performance. AIM: The study aimed to determine the effect of a flipped classroom approach on students' pharmacology assessment scores in a school of nursing in Karachi, Pakistan. METHODS: A retrospective chart review was performed. The pharmacology test scores of the BSc nursing cohort of 2020, when flipped classroom pedagogy was used, was compared with those of the BSc nursing cohort of 2019, where traditional pedagogy was employed. Students' summative evaluation for the course and their verbal feedback were analysed. RESULTS: The median continuous assessment test score of the 2019 cohort was 35 (interquartile range (IQR) 32-38), while that of the 2020 cohort was 38 (IQR 35-41). The difference in the score was statistically significant (P<0.001). CONCLUSION: The study gives an insight into a relatively novel pedagogy that was found to improve pharmacology knowledge test scores among nursing students.

Developing the Reliability and Validity of an Urdu Version-Self-Efficacy Scale for Breast Cancer Patients in Pakistan.

BACKGROUND AND PURPOSE: No suitable scale has been identified in literature that comprehensively measure self-efficacy of Pakistani breast cancer patients. The study aimed to develop a self-efficacy scale in Urdu language and determine its dimensions. METHODS: The scale was developed with input from experts and literature. It was administered, in cross-sectional phase of two pilot studies, on breast cancer patients receiving chemotherapy. Post hoc internal consistency reliability was computed and principal component analysis (PCA) was performed. RESULTS: U-SES comprised 17 questions. PCA revealed a total of five factors explaining cumulative variance of 68.7%. These factors were self-confidence, faith, coping, optimism, and decision making. Post hoc internal consistency (Cronbach's alpha) value was high (∞ = 0.87). CONCLUSION: The self-efficacy scale has acceptable validity and reliability and has potential to obtain information related to self-efficacy of cancer patients receiving chemotherapy.

Making prescriptions "talk" to stroke and heart attack survivors to improve adherence: Results of a randomized clinical trial (The Talking Rx Study).

BACKGROUND: We developed and tested the effectiveness of a tailored health information technology driven intervention: "Talking Prescriptions" (Talking Rx) to improve medication adherence in a resource challenged environment. METHODS: We conducted a parallel, randomized, controlled, assessor-blinded trial at the Aga Khan University (AKU), Karachi, Pakistan. Adults with diagnosis of cerebrovascular accident (CVA) or coronary artery disease (CAD) diagnosed least one month before enrollment, on anti-platelets and statins, with access to a mobile phone were enrolled. The intervention group received a) Daily Interactive Voice Response (IVR) call services regarding specific statin and antiplatelet b) Daily tailored medication reminders for statin and antiplatelet and c) Weekly lifestyle modification messages for a period of 3 months. We assessed Medication adherence to statin and antiplatelets by a validated version of the 8-item Morisky Medication Adherence scale 8 (MMAS-8) at 3 months by a blinded assessment officer. Analysis was conducted by intention-to-treat principle (ITT). RESULTS: Between April 2015 and December 2015, 197 participants (99 in intervention and 98 in the usual care group) enrolled in the Talking Rx Study. The dropout rate was 9.6%. Baseline group characteristics were similar. At baseline, the mean MMAS-8 was 6.68 (SD = 1.28) in the intervention group and 6.77 (SD = 1.36) in usual care group. At end of follow-up, the mean MMAS-8 increased to 7.41(0.78) in the intervention group compared with 7.38 (0.99) in usual care group with mean difference of 0.03 (S.D 0.13) (95% C.I [-0.23, 0.29]), which was not statistically significant. (P-Value = 0.40) CVA patients showed a relatively greater magnitude of adherence via the MMAS-8 at the end of follow up where the mean MMAS-8 increased to 7.29 (S.D 0.82) in the intervention group as compared to 7.07(S.D 1.24) in usual care group with mean difference of 0.22 (SD = 0.22) 95% C.I (-0.20, 0.65) with (P-value = 0.15). Around 84% of those on intervention arm used the service, calling at least 3 times and listening to their prescriptions for an average of 8 minutes. No user was excluded due to technologic reasons. CONCLUSION: The use of a phone based medication adherence program was feasible in LMIC settings with high volume clinics and low patient literacy. In this early study, with limited follow up, the program did not achieve any statistically significant differences in adherence behavior as self-reported by the MMAS-8 Scale. TRIAL REGISTRATION: Clinical Trials.gov NCT02354040.

Facilitators and barriers to NCD prevention in Pakistanis-invincibility or inevitability: a qualitative research study.

BACKGROUND: Non-communicable diseases (NCD) are the leading causes of death globally. In Pakistan, they are among the top ten causes of mortality, especially in the productive age group (30-69 years). Evidence suggests that health perceptions and beliefs strongly influence the health behavior of an individual. We performed focus group interviews to delineate the same so as to design the user interface of a non-invasive stroke risk monitoring device. METHODS: It was a qualitative study, designed to explore how health perceptions and beliefs influence behavior for NCD prevention. Four focus group discussions (FGD) were conducted with 30 stable participants who had diabetes mellitus, ischemic heart disease, blood pressure, and stroke. The data was collected using a semi-structured interview guide designed to explore participants' perceptions of their illnesses, self-management behaviors and factors affecting them. The interviews were transcribed and content analysis was done using steps of content analysis by Morse and Niehaus [10]. RESULTS: Medication adherence, self-monitoring of blood sugars and blood pressures, and medical help seeking were the commonly performed self-management behaviors by the participants. Personal experience of illness, familial inheritance of disease, education and fear of premature death when life responsibilities were unfulfilled, emerged as strong facilitators of self-management behaviors. A sense of personal invincibility, Fatalism or inevitability, lack of personal threat realization, limited knowledge, inadequate health education, health care and financial constraints appeared as key barriers to the self-management of chronic disease in participants. CONCLUSIONS: Behavioural interventional messaging will have to engender a sense of personal vulnerability and yet empower self-efficacy solutions at the individual level to deal with both invincibility and inevitability barriers to adoption of healthy behavior.

Using a tailored health information technology- driven intervention to improve health literacy and medication adherence in a Pakistani population with vascular disease (Talking Rx) - study protocol for a randomized controlled trial.

BACKGROUND: Vascular disease, manifesting as myocardial infarction and stroke, is a major cause of morbidity and mortality, especially in low- and middle-income countries. Current estimates are that only one in six patients have good adherence to medications and very few have sufficient health literacy. Our aim is to explore the effectiveness and acceptability of Prescription Interactive Voice Response (IVR) Talking Prescriptions (Talking Rx) and SMS reminders in increasing medication adherence and health literacy in Pakistani patients with vascular disease. METHODS: This is a randomized, controlled, single center trial. Adult participants, with access to a cell phone and a history of vascular disease, taking multiple risk-modifying medications (inclusive of anti-platelets and statins) will be selected from cerebrovascular and cardiovascular clinics. They will be randomized in a 1:1 ratio via a block design to the intervention or the control arm with both groups having access to a helpline number to address their queries in addition to standard of care as per institutional guidelines. Participants in the intervention group will also have access to Interactive Voice Response (IVR) technology tailored to their respective prescriptions in the native language (Urdu) and will have the ability to hear information about their medication dosage, correct use, side effects, mechanism of action and how and why they should use their medication, as many times as they like. Participants in the intervention arm will also receive scheduled SMS messages reminding them to take their medications. The primary outcome measure will be the comparison of the difference in adherence to anti-platelet and statin medication between baseline and at 3-month follow-up in each group measured by the Morisky Medication Adherence Scale. To ascertain the impact of our intervention on health literacy, we will also compare a local content-validated and modified version of Test of Health Literacy in Adults (TOFHLA) between the intervention and the control arm. We estimate that a sample size of 86 participants in each arm will be able to detect a difference of 1 point on the MMAS with a power of 90 % and significance level of 5 %. Accounting for an attrition rate of 15 %, we plan to enroll 100 participants in each arm (total study population = 200). We hypothesize that a linguistically tailored health IT intervention based on IVR and SMS will be associated with an improvement in adherence (to anti-platelet and lipid-lowering medications) and an improvement in health literacy in Pakistani patients with vascular disease. DISCUSSION: This innovative study will provide early data for the feasibility of the use of IT based prescriptions in an lower middle incorme country setting with limited numeracy and literacy skills. TRIAL REGISTRATION: Clinical Trials.gov: NCT02354040 - 2 February 2015.

Translating knowledge for action against stroke--using 5-minute videos for stroke survivors and caregivers to improve post-stroke outcomes: study protocol for a randomized controlled trial (Movies4Stroke).

BACKGROUND: Two thirds of the global mortality of stroke is borne by low and middle income countries (LMICs). Pakistan is the world's sixth most populous country with a stroke-vulnerable population and is without a single dedicated chronic care center. In order to provide evidence for a viable solution responsive to this health care gap, and leveraging the existing >70% mobile phone density, we thought it rational to test the effectiveness of a mobile phone-based video intervention of short 5-minute movies to educate and support stroke survivors and their primary caregivers. METHODS: Movies4Stroke will be a randomized control, outcome assessor blinded, parallel group, single center superiority trial. Participants with an acute stroke, medically stable, with mild to moderate disability and having a stable primary caregiver will be included. After obtaining informed consent the stroke survivor-caregiver dyad will be randomized. Intervention participants will have the movie program software installed in their phone, desktop, or Android device which will allow them to receive, view and repeat 5-minute videos on stroke-related topics at admission, discharge and first and third months after enrollment. The control arm will receive standard of care at an internationally accredited center with defined protocols. The primary outcome measure is medication adherence as ascertained by a locally validated Morisky Medication Adherence Scale and control of major risk factors such as blood pressure, blood sugar and blood cholesterol at 12 months post discharge. Secondary outcome measures are post-stroke complications and mortality, caregiver knowledge and change in functional outcomes after acute stroke at 1, 3, 6, 9 and 12 months. Movies4Stroke is designed to enroll 300 participant dyads after inflating 10% to incorporate attrition and non-compliance and has been powered at 95% to detect a 15% difference between intervention and usual care arm. Analysis will be done by the intention-to-treat principle. DISCUSSION: Movies4Stroke is a randomized trial testing an application aimed at supporting caregivers and stroke survivors in a LMIC with no rehabilitation or chronic support systems. TRIAL REGISTRATION: NCT02202330 (28 January 2015).

Safety and efficacy of drug-eluting balloons in the treatment of drug-eluting in-stent restenosis: experience of a tertiary care hospital.

BACKGROUND: The advent of drug-eluting balloons (DEBs) is a promising development for coronary revascularization procedures, especially for in-stent restenosis (ISR). This study aims to highlight our experience with DEBs in the treatment of drug-eluting ISR at a tertiary care hospital in Pakistan. METHODS: All patients presenting to our institution from August 2008 to February 2011 with significant drug-eluting in-stent restenosis (DES-ISR) who were eligible to receive treatment via DEB were included in the analysis. Patient baseline characteristics and angiographic data about the lesion characteristics were obtained. Postprocedural and follow-up endpoints, including cardiac death, myocardial infarction, and repeat revascularization, ie, major adverse cardiovascular events (MACE), were included in the analysis. RESULTS: A total of 26 patients received treatment with DEB in the study period, with a significant number having major predisposing factors for the development of ischemic heart disease (IHD; 46% diabetics; 92% hypertensives). The culprit lesion was most commonly identified in the left anterior descending (31%), with presence of American College of Cardiology/American Heart Association lesion type C in 68% of patients. The SeQuent Please paclitaxel-eluting balloon (B. Braun) was used for revascularization. Patients were followed for a median of 16 months. Only 5 patients (19%) developed MACE during this period. CONCLUSION: Our experience demonstrates the effectiveness of DEBs in the treatment of drug-eluting ISR, especially in complex lesions with patients having significant risk factors for development of IHD. However, further studies are needed to define their indications in this role.