Development of palliative care clinical practice guidelines and referral care pathways for primary care practitioners in Pakistan

Despite a large burden of life-limitingillness, there exists a dearth of services of palliative care in Pakistan. International guidelines have questionable applicability in Pakistan due to the socioeconomic differences. We generated a protocol describing the process of developing comprehensive palliative care guidelines and palliative care referral pathways for primary care practitioners to adopt in Pakistan. A GRADE-ADOLOPMENT approach with modification has been employed to create guidelines for a Pakistani context. The "National Comprehensive Cancer Network Guidelines Insights: Palliative Care, Version 2.2021" was used as the source guideline. Recommendations from the source guideline were reviewed by two local palliative care specialists to either "Adopt," "Adapt" or "Exclude". The finalized recommendations were incorporated into the local palliative care guideline. Clinical diagnosis and referral pathways were made from the finalized guideline. Any gaps in management found in the pathways were filled by taking existing recommendations from other credible guidelines. Twenty-seven recommendations were adopted without modification. No recommendations were deemed to be adapted and 15 were excluded. The referral care pathways created were reflective of the local guideline and included elements of initial assessment, preliminary management, reassessment, and referral. 6 additional recommendations were made. The described clinical practice guidelines and primary care clinical referral pathways will aid to standardize palliative care provision in Pakistan. These can be used by other resource constrained settings to develop guidelines within their own local context.

Addressing the Crimean-Congo Hemorrhagic Fever Crisis in Pakistan's Healthcare System: An Urgent Call for Holistic Action.

The recent resurgence of the Crimean-Congo hemorrhagic fever (CCHF) in Pakistan's Balochistan province has significantly impacted both the medical community and the general population. Initially perceived as a concerning development, the situation has deteriorated, culminating in the infection and mortality of healthcare workers directly engaged in managing this virulent outbreak. This critical situation necessitates an urgent and collective response, transcending national boundaries to involve the international healthcare community.

Folk Knowledge and Perceptions about the Use of Wild Fruits and Vegetables-Cross-Cultural Knowledge in the Pipli Pahar Reserved Forest of Okara, Pakistan.

Wild fruits and vegetables (WFVs) have been vital to local communities for centuries and make an important contribution to daily life and income. However, traditional knowledge of the use of wild fruits is at risk of being lost due to inadequate documentation. This study aimed to secure this knowledge through intermittent field visits and a semi-structured questionnaire. Using various ethnobotanical data analysis tools and SPSS (IBM 25), this study identified 65 WFV species (52 genera and 29 families). These species, mostly consumed as vegetables (49%) or fruits (43%), were predominantly herbaceous (48%) in wild and semi-wild habitats (67%). 20 WFVs were known to local communities (highest RFC), Phoenix sylvestris stood out as the most utilized species (highest UV). Surprisingly, only 23% of the WFVs were sold at markets. The survey identified 21 unique WFVs that are rarely documented for human consumption in Pakistan (e.g., Ehretia obtusifolia, Euploca strigosa, Brassica juncea, Cleome brachycarpa, Gymnosporia royleana, Cucumis maderaspatanus, Croton bonplandianus, Euphorbia prostrata, Vachellia nilotica, Pongamia pinnata, Grewia asiatica, Malvastrum coromandelianum, Morus serrata, Argemone mexicana, Bambusa vulgaris, Echinochloa colonum, Solanum virginianum, Physalis angulata, Withania somnifera, Zygophyllum creticum, and Peganum harmala), as well as 14 novel uses and five novel edible parts. Despite their ecological importance, the use of WFVs has declined because local people are unaware of their cultural and economic value. Preservation of traditional knowledge through education on conservation and utilization could boost economies and livelihoods in this and similar areas worldwide.

Clinical Spectrum of Hereditary Tyrosinemia Type 1 in a Cohort of Pakistani Children.

Background: Hereditary Tyrosinemia Type 1 (HT1), a rare autosomal recessive metabolic disorder, arises from fumarylacetoacetate (FAH) enzyme deficiency, resulting in toxic metabolite buildup. It manifests in acute, subacute, and chronic forms, with early diagnosis and Nitisinone treatment being vital. Objectives: The study aims to highlight the different clinical presentations of Hereditary Tyrosinemia type 1 in a cohort of Pakistani children. Design: Retrospective observational study. Methodology: All patients diagnosed with HT1 at Shifa International Hospital, Islamabad and Pak Emirates Military Hospital, Rawalpindi between 2010 and 2023 were included. Information was collected regarding age, gender, symptoms, physical signs, and laboratory results. Results: The study identified 6 cases of HT1. The average age at presentation was 8 months, with a mean delay in diagnosis of 26.8 months. Males were 4 (66.7%) and 2 (33.3%) were females. All patients had underlying liver disease presenting as abdominal distension with hepatosplenomegaly and accompanying growth failure. Four cases presented with rickets, 2 of which had hypophosphatemic rickets. Urine for succinylacetone was raised in all patients. Alpha fetoprotein was raised but hepatocellular carcinoma was diagnosed in 1 patient only. Low protein diet, and vitamin supplements were used for management. Five of the 6 patients died within 2 years of diagnosis. Conclusion: Delayed referrals and unavailability of Nitisinone are the major challenges in diagnosing and treating HT1 in Pakistan.

Economic evaluation of clinical pharmacy service using integrated health system in tertiary care hospital.

BACKGROUND: Clinical pharmacy services are the specialized practices of pharmacists to provide pharmaceutical care. All these activities are documented as pharmacist interventions to avoid medication errors which occur during prescribing, dispensing, and administration. The purpose of this study is to conduct an economic analysis of the pharmacist interventions using integrated health system. RESEARCH DESIGN AND METHODS: A retrospective study was conducted in a tertiary care hospital. Pharmacist interventions were analyzed by an independent pharmacist. Cost-saving and cost avoidance analyses were carried out for drug-related interventions. Economic analysis was performed and tabulated both in PKR and USD. RESULTS: Out of 1330 interventions, 1250 (95%) interventions were accepted and changed the prescription upon the physician-pharmacist consultation while 71 (5%) were not accepted. Interventions related to prescribing and duplication errors were the highest of all (30 and 29% respectively). Pharmacist interventions were recorded with a 95% acceptance rate. Cost analysis showed that pharmacist interventions saved around 105,115.88 US dollars. CONCLUSION: Clinical pharmacy services provided by integrated health system are a cost saving program. The cost saved per intervention for our study is around USD 37 which is more than another similar study which quoted USD 30.35 per intervention.

Public Health and Health System's Responsiveness During the 2022 Floods in Pakistan: What Needs to Be Done?

OBJECTIVE: In 2022, Pakistan witnessed unprecedented flooding, submerging one-third of the country under-water, ruining millions of houses, taking lives, afflicted injuries, and displacing scores of people. Our study documents not only the public health problems that have arisen due to this natural calamity but also the state of health systems' response. METHODS: We conducted a qualitative study asking key questions around prevalent health problems, health-care seeking, government's response, resource mobilization, and roadmap for the future. We purposively selected 16 key frontline health workers for in-depth interviews. RESULTS: Waterborne and infectious diseases were rampant posing huge public health challenges. Disaster mitigation efforts and relief operations were delayed and not at scale to cover the entire affected population. Moreover, a weak economy, poverty, and insufficient livelihoods compounded the tribulations of floods. Issues of leadership and governance at state level resulted in disorganized efforts and response. CONCLUSIONS: Pakistan is famous for its philanthropy; however, lack of transparency and accountability, the actual benefits seldom reach the beneficiaries. Such climatic disasters necessitate a more holistic approach and a greater responsiveness of the health system. In addition to health services, the state must respond to financial, social, and infrastructural needs of the people suffering from the calamity.

A Holistic Strategy of Mother and Child Health Care to Improve the Coverage of Routine and Polio Immunization in Pakistan: Results from a Demonstration Project.

BACKGROUND: The eradication of poliovirus and improving routine immunization (RI) coverage rates present significant challenges in Pakistan. There is a need for interventions that focus on strengthening community engagement to improve routine immunization coverage. Our primary objective is to assess the impact of an integrated strategy designed to enhance community engagement and maternal and child health immunization campaigns on immunization coverage in Pakistan's high-risk union councils of polio-endemic districts. METHOD: We implemented an integrated approach for routine immunization and maternal and child health in the polio-endemic district of Pakistan. This approach involved setting up health camps and actively engaging and mobilizing the local community. An independent team conducted surveys at three key points: baseline, midline, and endline, to evaluate immunization coverage among children under the age of five. The primary outcome measures for the study were coverage of OPV, IPV, and changes in the proportion of unvaccinated and fully vaccinated children. To select clusters and eligible households in each cluster, we utilized a 30 × 15 cluster sampling technique. Multivariable associations between socio-demographic factors and changes in the proportion of fully vaccinated children at the UC level were assessed using hierarchical linear regression models. RESULTS: A total of 256,946 children under the age of five (122,950 at baseline and 133,996 at endline) were enrolled in the study. By the endline, full immunization coverage had increased to 60% or more in all three study areas compared to the baseline. Additionally, there was a significant increase in the coverage of both OPV and IPV across all three provinces at the endline. The full immunization rates were assessed on three levels of the framework: the distal, intermediate (access and environment), and proximal level (camp attendance and effectiveness). At the distal level, on multivariate analysis, family size was found to be a significant predictor of change in immunity within the families (ß = 0.68; p ≤ 0.0001). At the intermediate level, the likelihood of full immunization decreased with the decrease in knowledge about vaccination (ß = -0.38; p = 0.002), knowledge about polio vaccine (ß = -0.25; p = 0.011), and knowledge about IPV (ß = -0.06; p = 0.546). Perceived obstacles to vaccination were fear of adverse events (ß = -0.4; p ≤ 0.0001) and lack of education (ß = 0.23; p = 0.031), which were found to be significant in bivariate and multivariate analyses. At the proximal level, community mobilization (ß = 0.26; p = 0.008) and attendance at health camp (ß = 0.21; p ≤ 0.0001) were found to enhance full immunization coverage. On the other hand, the most prominent reason for not attending health camp included no need to attend the health camp as the child was not ill (ß = -0.13; p = 0.008). CONCLUSIONS: This study found that community mobilization and attendance at health camps significantly enhanced full immunization coverage. The findings highlight the importance of community engagement and targeted interventions in improving immunization coverage and addressing barriers to healthcare seeking.

Tracking the Variations in Trace Elements, Some Nutrients, Phenolics, and Anthocyanins in Grewia asiatica L. (Phalsa) at Different Fruit Development Stages.

Grewia asiatica L. (phalsa) is a very prevalent berry in Pakistan and is consumed extensively as raw or in the form of juice. Here, for the first time, we assessed phalsa from Pakistan in terms of variations in macro and micro minerals, nutrients, and bio-active phyto-constituents including total phenolic and anthocyanin contents at different fruit developmental stages. It was found that the sugars in phalsa increased from D1 (small at the initial fruit setting stage) to D6 development stage (fully ripened fruit) where sugars at D5 (near to fully ripe) and D6 stages were many times greater than at D1, D2 (unripe close to full-size completion), D3 (close to semi ripe), and D4 stage (semi ripened and full-size attainment). Total acidity of was declined in all developmental stages, where the D1 stage displayed maximum and D6 with the lowest acidity. Ascorbic acid was decreased from D1 to D2 and then increased gradually from D3 to D5 stages. At the D6 stage, again a steep decline in ascorbic acid was observed. The total phenolics (mg gallic acid equivalents/100g) at stage D6 were higher (136.02 ± 1.17), whereas D1 being the lowermost in total phenolic content (79.89 ± 1.72). For anthocyanins (mg/100g), an increasing pattern of changes was observed in all stages of phalsa fruit where the D1 stage showed lower (13.97 ± 4.84) anthocyanin contents which then increased gradually at stage D2 (67.79 ± 6.73), but increased sharply at D3 (199.66 ± 4.90), D4 (211.02 ± 18.85), D5 (328.41 ±14.96) and D6 (532.30 ± 8.51) stages. A total of four anthocyanins such as cyanidin, delphidine-3-glucoside, pelargonidin, and malvidin in phalsa were identified using HPLC procedures, and a significant > 90 % DPPH inhibition in phalsa was observed at the D5 and D6 development stages. The macro and micro minerals including Ni, Zn, Fe, Ca, Cu, Mg, Na, P, and K contents were decreased from initial (D1) stage to the final (D6) development stage, while only Fe displayed an increasing trend from the initial to final fruit development stages (D1-D6). Conclusively, these findings could be of great interest for patients who are intended to consume phalsa as adjuvant therapy against diabetes and metabolic syndromes and other diseases involving reactive oxygen species with minimum metal toxicity.

Positive mental imagery and mental health amongst university students in Pakistan.

Mental health problems amongst university students pose a major public health challenge, and this is particularly the case in Pakistan. Alongside broader societal and cultural pressures, cognitive factors likely also play a role in the development of and resilience to mental health problems and may provide a feasible target for interventions. The current study built on previous research in primarily European samples investigating the relationship between one cognitive factor, positive future-oriented mental imagery, and mental health, extending this to a sample of university students in Pakistan (N = 1838). In a cross-sectional design, higher vividness of positive future-oriented mental imagery was associated with lower levels of depressive symptoms and higher levels of positive mental health amongst participants completing questionnaire measures on paper (N = 1430) or online (N = 408). In the sample completing the measures on paper, these relationships remained statistically significant even when controlling for socio-demographic and mental health-related variables. The results provide a foundation for further investigating positive mental imagery as a potential mechanism of mental health and intervention target amongst university students in Pakistan.

Ethno-Dentistry of Medicinal Plants Used in North Waziristan, Pakistan.

OBJECTIVE: This study aimed at recording therapeutic plant species used by inhabitants to treat dental disorders in the district of North Waziristan, Pakistan. The indigenous people of the studied area are dependent on medicinal plants for their basic health care needs including dental care. METHODS: Ethnomedicinal data were collected using a semi-structured questionnaires, and in addition 130 local informants were interviewed. The collected data were evaluated using various quantitative indices, including use value (UV), relative frequency of citation (RFC), fidelity level (FL%), and Jaccard Index (JI). RESULTS: A total of 69 plants belonging to 48 plant families used in dental disorders were identified. The Lamiaceae was the leading family that shared 7 species, followed by Solanaceae (4 spp).The dominant life form used was herbs (47.83%), folowed by leaves (43.90%) in preparing remedies for different dental disorders. Decoction was the most common mode of preparation (34.21%), followed by pastes (21.05%). The highest RFC (0.36) was reported for Bergenia ciliata, followed by Salvadora oleoides (0.35). The majority of the plants (36 spp) were utilised as herbal medicine to treat toothache, followed by 13 species for periodontal (gum) infections, 11 species used for teeth cleaning, and 9 species for halitosis (bad breath). CONCLUSIONS: This study is the first-ever record of ethnomedicinal applications for the treatment of dental diseases from Pakistan. Some of the forgeoing hebal medications should be further evalauted for the development of pahrmaceutical bio-products for the treatment of dental disorders.

Domestic Cylinder Blasts: A Neglected Torpedo.

High-pressure cylinders are used to store liquefied petroleum gas (LPG). An instant and swift explosion of these cylinders can result in serious burn injuries. This current research was conducted to study the epidemiological characteristics of LPG-related burns to highlight a major public health issue. Analysis was conducted on patients with LPG-related burns over a span of 10 years admitted to our center between January 2011 and December 2020. The data recorded included demographic features, site of burn, %TBSA, associated injuries, and outcomes. The variable data were documented for every patient in a Microsoft Excel file and analyzed by IBM SPSS version 25.0. Over the span of 10 years, 678 patients were affected by LPG-related accidents. The peak incidence was seen in 2019 when there was a surge to 18.03%. The patient's age ranged from 1 to 79 years, with a median of 40.86 ± 15.27 years. Of the 678 patients, 52.50% were males and 47.50% were females. The majority (57.96%) of patients had a total BSA of >60% and 86.72% were diagnosed with inhalation injury. The majority of burns (84.66%) occurred at home. The mean hospital stay was 24.5 days. The total mortality rate was 59.58%. This study concludes that LPG cylinder blast is a preventable cause that can be minimized by making people aware of its safe use and by arranging awareness programs at every national level.

Effects of selenium on biogeochemical cycles of cadmium in rice from flooded paddy soil systems in the alluvial Indus Valley of Pakistan.

This study delves into the pollution status, assesses the effects of Se on Cd biogeochemical pathways, and explores their interactions in nutrient-rich paddy soil-rice ecosystems through 500 soil-rice samples in Pakistan. The results showed that 99.6 % and 12.8 % of soil samples exceeded the World Health Organization (WHO) allowable Se and Cd levels (7 and 0.35 mg/kg). In comparison, 23 % and 6 % of the grain samples exceeded WHO's allowable Se and Cd levels (0.3 and 0.2 mg/kg), respectively. Geographically Weighted Regression (GWR) model results further revealed spatial nonstationarity, confirming diverse associations between dependent variables (Se and Cd in rice grain) and independent variables from paddy soil and plant tissues (root and shoot), such as Soil Organic Matter (SOM), pH, Se, and Cd concentrations. High Se:Cd molar ratios (>1) and a negative correlation (r = -0.16, p < 0.01) between the Cd translocation factor (Cd in rice grain/Cd in root) and Se in roots suggest that increased root Se levels inhibit the transfer of Cd from roots to grains. The inverse correlation between Se and Cd in paddy grains was further characterized as Se deficiency, no risk, high Cd risk, Se risk, Cd risk, and Se-Cd co-exposure risk. There was no apparent risk for human co-consumption in 42.6 % of grain samples with moderate Se and low Cd. The remaining categories indicate differing degrees of risk. In the study area, 31 % and 20 % of grain samples with low Se and Cd indicate Se deficiency and risk, respectively. High Se and low Cd levels in rice samples suggest a potential hazard for severe Se exposure due to frequent rice consumption. This study not only systematically evaluates the pollution status of paddy-soil systems in Pakistan but also provides a reference to thoroughly contemplate the development of a scientific approach for evaluating human risks and the potential dangers associated with paddy soils and rice, specifically in regions characterized by low Se and low Cd concentrations, as well as those with moderate Se and high Cd concentrations. SYNOPSIS: This study is significant for understanding the effects of Se on Cd geochemical cycles and their interactions in paddy soil systems in Pakistan.

Cultural Influences on Making Nutritional Adjustments in Type 2 Diabetes in Pakistan: The Perspectives of People Living With Diabetes and Their Family Members.

In Pakistan, type 2 diabetes is widespread, and although dietary recommendations from healthcare professionals are critical to its treatment, cultural norms can have a great influence on the dietary habits of people living with diabetes (PLwD). Understanding the social aspects of the lives of PLwD is crucial when examining the effectiveness of nutritional recommendations and adjustments. This study investigated (1) how PLwD and their family members adjust their nutrition to the recommendations of healthcare professionals to manage type 2 diabetes mellitus (T2DM) and (2) what do PLwD and their family members perceive as enablers and barriers to the necessary nutritional adjustments for managing T2DM. Prime consideration was given to experiences of living in Pakistan as the cultural context. Semi-structured interviews were conducted with 30 PLwD and 17 family members; the data were analysed thematically. Three themes emerged: (i) 'Influence of family system, gender, and age on meals prepared at home': family hierarchy and opinions based on gender and age can enable or hinder nutritional adjustment in meals prepared at home; (ii) 'Temptations of "unhealthy" foods, festivals, cultural interactions, and social etiquette': family/social interactions at home, gatherings, or festivities can affect PLwD's ability to resist temptations to eat foods prohibited by healthcare professionals; and (iii) 'Folk knowledge, folk remedy, and the balance between culture and Western medicine': PLwD and their family members in Pakistan hold strong beliefs concerning foods' medicinal properties. Power dynamics within families need to be considered when making nutritional recommendations. Medical guidelines should acknowledge personal agency and cultural beliefs.

Ethnomedicinal and traditional uses of the Ferns of Khyber Pakhtunkhwa, Pakistan

Abstract Ferns are often used by indigenous people in Khyber Pakhtunkhwa, Pakistan. This study was designed to collect the ethnomedicinal and traditional knowledge of these locals about this group of vascular plants. Forty taxa belong to nineteen genera and ten families are used in the treatment of different diseases. The Pteridaceae was the most representative family with twelve taxa (30%), followed by Athyriaceae and Dryopteridaceae with six taxa each (30%), and Thelypteridaceae with five taxa (12.5%). Regarding the genera, Adiantum, Asplenium and Dryopteris ranked first with four taxa each (30%), followed by Aleuritopteris, Diplazium, Pteris and Equisetum with three taxa each (30%), followed by Athyrium, Oeosporangium, Polystichum and Pseudophegopteris with two taxa each (20%). These taxa were commonly used in the treatment of respiratory disorders i.e. asthma, bronchitis, emphysema, pneumonia; intestinal ulcer, stomach, urinary ailments and skin disorders by the methods of decoction and infusion. Traditional knowledge about ethnomedicinal plants is a valuable and essential source for the discovery of allopathic, herbal and homeopathic medicines.

Resumo As samambaias são frequentemente usadas pelos indígenas em Khyber Pakhtunkhwa, Paquistão. Este estudo foi desenhado para coletar o conhecimento etnomedicinal e tradicional desses moradores sobre este grupo de plantas vasculares. Quarenta táxons pertencem a dezenove gêneros, e dez famílias são utilizadas no tratamento de diferentes doenças. Pteridaceae foi a família mais representativa com doze táxons (30%), seguida por Athyriaceae e Dryopteridaceae com seis táxons cada (30%), e Thelypteridaceae com cinco táxons (12,5%). Em relação aos gêneros, Adiantum, Asplenium e Dryopteris ficaram em primeiro lugar com quatro táxons cada (30%), seguidos por Aleuritopteris, Diplazium, Pteris e Equisetum com três táxons cada (30%), e Athyrium, Oeosporangium, Polystichum e Pseudophegopteris com dois táxons cada (20%). Estes táxons foram comumente usados no tratamento de distúrbios respiratórios, isto é, asma, bronquite, enfisema, pneumonia; úlcera intestinal, estômago, doenças urinárias e doenças da pele pelos métodos de decocção e infusão. O conhecimento tradicional sobre plantas etnomedicinais é uma fonte valiosa e essencial para a descoberta de medicamentos alopáticos, fitoterápicos e homeopáticos.

Ethnomedicinal and traditional uses of the Ferns of Khyber Pakhtunkhwa, Pakistan / Usos etnomedicinais e tradicionais das samambaias de Khyber Pakhtunkhwa, Paquistão

Abstract Ferns are often used by indigenous people in Khyber Pakhtunkhwa, Pakistan. This study was designed to collect the ethnomedicinal and traditional knowledge of these locals about this group of vascular plants. Forty taxa belong to nineteen genera and ten families are used in the treatment of different diseases. The Pteridaceae was the most representative family with twelve taxa (30%), followed by Athyriaceae and Dryopteridaceae with six taxa each (30%), and Thelypteridaceae with five taxa (12.5%). Regarding the genera, Adiantum, Asplenium and Dryopteris ranked first with four taxa each (30%), followed by Aleuritopteris, Diplazium, Pteris and Equisetum with three taxa each (30%), followed by Athyrium, Oeosporangium, Polystichum and Pseudophegopteris with two taxa each (20%). These taxa were commonly used in the treatment of respiratory disorders i.e. asthma, bronchitis, emphysema, pneumonia; intestinal ulcer, stomach, urinary ailments and skin disorders by the methods of decoction and infusion. Traditional knowledge about ethnomedicinal plants is a valuable and essential source for the discovery of allopathic, herbal and homeopathic medicines.

Resumo As samambaias são frequentemente usadas pelos indígenas em Khyber Pakhtunkhwa, Paquistão. Este estudo foi desenhado para coletar o conhecimento etnomedicinal e tradicional desses moradores sobre este grupo de plantas vasculares. Quarenta táxons pertencem a dezenove gêneros, e dez famílias são utilizadas no tratamento de diferentes doenças. Pteridaceae foi a família mais representativa com doze táxons (30%), seguida por Athyriaceae e Dryopteridaceae com seis táxons cada (30%), e Thelypteridaceae com cinco táxons (12,5%). Em relação aos gêneros, Adiantum, Asplenium e Dryopteris ficaram em primeiro lugar com quatro táxons cada (30%), seguidos por Aleuritopteris, Diplazium, Pteris e Equisetum com três táxons cada (30%), e Athyrium, Oeosporangium, Polystichum e Pseudophegopteris com dois táxons cada (20%). Estes táxons foram comumente usados ​​no tratamento de distúrbios respiratórios, isto é, asma, bronquite, enfisema, pneumonia; úlcera intestinal, estômago, doenças urinárias e doenças da pele pelos métodos de decocção e infusão. O conhecimento tradicional sobre plantas etnomedicinais é uma fonte valiosa e essencial para a descoberta de medicamentos alopáticos, fitoterápicos e homeopáticos.

Knowledge, attitude, and perceptions of healthcare professionals towards complementary and alternative medicine: a cross-sectional survey from twin cities of Pakistan.

BACKGROUND: The growing popularity and use of complementary and alternative medicine (CAM) products among the general public worldwide has been well documented. This study aimed to investigate the knowledge, attitude, and perceptions (KAP) of Pakistani healthcare professionals (HCP) toward CAM and to document their views on integrating CAM education with the curriculum of undergraduate health science programs. METHOD: A cross-sectional study using simple random sampling was conducted for a duration of ten months among HCPs from Pakistan's twin cities: Islamabad and RawalpindiThe data were collected using a self-administered and validated (Cronbach's alpha: 0.71) questionnaire. This questionnaire consisted of five sections, namely; demographic, attitude, perception, integration and knowledge. RESULT: The response rate was 91.20% (500/456). The participants included 160 physicians, 155 nurses,and 141 pharmacists. The majority of the respondents were females, 67.50%, and unmarried (60.50%).The majority of HCPs participating in this study agreed that CAM modalities may benefit conventional medicine system. Likewise, most HCPs perceived different CAM therapies aseffective treatment options. More than 50% HCPs suggested CAM elective courses in the curriculum of the health sciences program.Overall, 79.17% of the HCPs have poor knowledge of CAM. Physicians have the highest knowledge score 25.63%, followed by pharmacists 21.99%, and nurses 12.26%. Knowledge status was significantly associated with age, profession, and experience of practice (p = 0.001,0.001 & 0.019). CONCLUSION: This study revealed that despite the overall positive attitude of HCPs toward CAM, the score of knowledge is low. Therefore, the survey recommends evidence-based guidelines for the rationale use of CAM and updated syllabi of undergraduate health programs which will assist the future HCPs in increasing professionals' knowledge toachieve better health outcomes for the general public.

Barriers experienced by community midwives to provide basic emergency obstetric and newborn care in rural Pakistan.

BACKGROUND: Considering the high maternal mortality rate, the government of Pakistan has deployed Community Midwives (CMWs) in rural areas of Pakistan. This relatively new cadre of community-based skilled birth attendants has previously reported to experience several challenges in providing maternal and child healthcare. However, what barriers they experience in providing basic emergency obstetric and newborn care needs to be further studied. METHODS: This was a cross-sectional study conducted in twelve districts in Sindh province, Pakistan, with poor maternal and child health indicators. A total of 258 CMWs participated in this study and completed the questionnaire on a pretested, validated tool in their community-based stations. The trained data collectors completed the questionnaires from the respondents. The problems identified were categorized into three major issues: financial, and transport and security related; and were analyzed accordingly. Ethical approval was obtained from the institutional review board (IRB) of Health Services Academy (HSA) Islamabad, Pakistan. RESULTS: The majority (90%) of 258 CMWs had formal training in maternal and neonatal care from the recognized institutions. Financial difficulties faced by CMWs were identified as the most frequent barriers and others were transport, security, and other issues. In univariate analysis, 38.1% and 61.9% of the community midwives who faced financial difficulties had completed a graduation or intermediate level of education, respectively (p = 0.006). Round-the-clock availability for emergencies was inversely associated with having financial difficulties, i.e., 71.4%, in contrast to 28.4% who had financial difficulties were available round-the-clock for emergency calls in their community clinics (p = 0.008). Formal training (p = 0.001), work experience (p = 0.015), longer duration of work (p = 0.003), and liaison with health workers and posting district (p = 0.001) had statistically significantly higher transport related issues. Security difficulties faced by CMWs and a set of correlates such as formal training (p = 0.019), working experience (p = 0.001), longer duration of work (p = 0.023), 24 h of availability on call (p = 0.004), liaison with traditional birth attendants (TBAs) in the community (p = 0.002), and district of posting (p = 0.001) were statistically significantly different. Other issues like working experience (p = < 0.001) and Liaison with TBAs in the community (p = < 0.001) were found statistically significant. CONCLUSION: Financial, transportation and security related barriers were commonly reported by community midwives in the delivery of basic emergency obstetric and newborn care in rural Pakistan.

Midwife-led birthing centres in four countries: a case study.

BACKGROUND: Midwives are essential providers of primary health care and can play a major role in the provision of health care that can save lives and improve sexual, reproductive, maternal, newborn and adolescent health outcomes. One way for midwives to deliver care is through midwife-led birth centres (MLBCs). Most of the evidence on MLBCs is from high-income countries but the opportunity for impact of MLBCs in low- and middle-income countries (LMICs) could be significant as this is where most maternal and newborn deaths occur. The aim of this study is to explore MLBCs in four low-to-middle income countries, specifically to understand what is needed for a successful MLBC. METHODS: A descriptive case study design was employed in 4 sites in each of four countries: Bangladesh, Pakistan, South Africa and Uganda. We used an Appreciative Inquiry approach, informed by a network of care framework. Key informant interviews were conducted with 77 MLBC clients and 33 health service leaders and senior policymakers. Fifteen focus group discussions were used to collect data from 100 midwives and other MLBC staff. RESULTS: Key enablers to a successful MLBC were: (i) having an effective financing model (ii) providing quality midwifery care that is recognised by the community (iii) having interdisciplinary and interfacility collaboration, coordination and functional referral systems, and (iv) ensuring supportive and enabling leadership and governance at all levels. CONCLUSION: The findings of this study have significant implications for improving maternal and neonatal health outcomes, strengthening healthcare systems, and promoting the role of midwives in LMICs. Understanding factors for success can contribute to inform policies and decision making as well as design tailored maternal and newborn health programmes that can more effectively support midwives and respond to population needs. At an international level, it can contribute to shape guidelines and strengthen the midwifery profession in different settings.

Ethnobotany for food security and ecological transition: wild food plant gathering and consumption among four cultural groups in Kurram District, NW Pakistan.

BACKGROUND: In traditional food systems, especially those of rural populations around the world, wild food plants remain crucial. These resources need to be urgently documented to lay the foundations for sustainable livelihoods and food security. METHODS: In the present field study, we gathered information about wild food plants and mushrooms consumed by four ethnic groups (Turis, Khushis, Hazaras, and Christians) living in Kurram District, NW Pakistan, by conducting semi-structured interviews and holding group discussions. RESULTS: A total of 57 wild edible plants and mushrooms were reported, with the documented taxa belonging to 50 genera and 34 families. Turis reported the highest number of wild food plants (41), followed by Hazaras (37), Khushis (35), and then Christians, who reported only 11 plants. The most dominant families were Rosaceae, followed by Polygonaceae, Brassicaceae, Fabaceae, Lamiaceae, Moraceae, and Plantaginaceae. The comparative analysis we conducted with the pre-existing Pakistani ethnobotanical studies revealed that 23 wild edible plants have not been previously reported as food items in the area under study, which included Fragaria nubicola, Lepidium draba, Pinus wallichiana, Podophyllum emodi, Prunus jacquemontii, Sambucus nigra, Sideroxylon mascatense, and Thymus linearis. Four wild edible mushrooms are also reported for the area for the first time: Calvatia gigantea, Morchella esculenta, Pisolithus albus, and Tulostoma squamosum. The cross-cultural analysis of wild edible plants and their uses revealed remarkable similarity between Khushis and Hazaras. The overlapping pattern of wild edible plant use among these two groups, as well as Turis, confirms the existence of cross-cultural interactions among these communities, which have shared the same environmental and socio-cultural space for several decades. Food heritage and some unique dishes are linked to wild edible plants in the area, such as Zamda, prepared by Turis, and Saba, famous among Khushis and Hazaras. CONCLUSION: This study suggests that some wild edible plants could be cultivated to protect a few threatened species from overexploitation, while the overall wild food plant heritage should be promoted and revitalized; for example, within educational platforms aimed at improving the wellbeing of local communities and the global ecological transition we must deal with.

Prevalence and Risk Factors for Iron Deficiency Anemia among Children under Five and Women of Reproductive Age in Pakistan: Findings from the National Nutrition Survey 2018.

INTRODUCTION: Anemia remains a global public health problem, especially in developing countries. It affects primarily children under five (CU5), women of reproductive age (WRA), and pregnant women due to their higher need for iron. The most common form of anemia is iron-deficiency anemia (IDA). IDA is estimated to cause half of all anemia cases and one million deaths per year worldwide. However, there remains a lack of well-documented and biochemically assessed prevalence of IDA based on the representative population-based samples globally and regionally. In this study, we aimed to assess the National Nutrition Survey (NNS) 2018 to identify the prevalence and risk factors of IDA in Pakistani CU5 and WRA. METHODS: Secondary analysis was conducted on the NNS 2018, a cross-sectional survey, which collected data on dietary practices, malnutrition, and food insecurity. Anemia was defined as hemoglobin levels < 11.0 g/dL in children and 12.0 g/dL in women. IDA was defined as low hemoglobin and low ferritin (<12 ng/mL) levels, adjusted for inflammation using AGP and CRP biomarkers in CU5 and WRA. Univariate and multivariable logistic regressions were conducted using Stata statistical software (version 16). We also compared the IDA rates of NNS 2018 and 2011. RESULTS: A total of 17,814 CU5 and 22,114 WRA were included in the analysis. Of the CU5, 28.9% had IDA, while 18.4% of WRA reported to experience IDA. Among the CU5, IDA was most prevalent among male children aged 6-23 months living in rural areas and with the presence of diarrhea and fevers in the last 2 weeks. Children whose mothers had no education, were aged 20-34 years, and employed, had a higher prevalence of IDA. Married WRA, who are employed, living in rural areas, and with no education, had a higher prevalence of IDA. In the multivariable logistic regression, children aged 6-23 months (AOR = 1.19, 95% CI [1.08-1.33], p < 0.001) and with the presence of diarrhea in the last 2 weeks (AOR = 1.32, 95% CI [1.13-1.54], p < 0.001) or fever (AOR = 1.16, 95% CI [1.02-1.32], p = 0.02) had higher odds of IDA. At the household level, the odds of IDA among CU5 were higher in the poorest households (AOR = 1.27, 95% CI [1.08-1.50], p = 0.005), with ≥5 CU5 (AOR = 1.99, 95% CI [1.28-3.11], p = 0.002), and with no access to improved sanitation facilities (AOR = 1.17, 95% CI [1.02-1.34], p = 0.026). For WRA, the multivariable logistic regression found that the odds of IDA were higher among women with vitamin A deficiency (Severe: AOR = 1.26, 95% CI [1.05-1.52], p = 0.013; Mild: AOR = 1.36, 95% CI [1.23-1.51], p < 0.001), zinc deficiency (AOR = 1.42, 95% CI [1.28-1.57], p < 0.001), no education (AOR = 1.53, 95% CI [1.30-1.81], p < 0.001), and from severely food insecure households (AOR = 1.20, 95% CI [1.07-1.34], p = 0.001). The odds of IDA were lower among women whose body mass index was overweight (AOR = 0.77, 95% CI [0.69-0.86], p < 0.001) or obese (AOR = 0.71, 95% CI [0.62-0.81], p < 0.001). CONCLUSIONS: The child's age, presence of diarrhea or fever, place of residence, household size, wealth status, and access to sanitation facilities were significantly associated with IDA among CU5 in Pakistan. For WRA, education, body mass index, vitamin A and zinc status, household food security status, wealth status, and access to sanitation facilities were significantly associated with IDA. Large, well-established, government-funded programmes focused on micronutrient supplementation, food fortification, the diversification of food supplies, and the treatment and prevention of infectious and parasitic diseases are needed to prevent IDA and all forms of anemia among children and women in Pakistan.