Impact of educational intervention on hypertension management by primary care physician: A randomized control trial.

Objective: The current study aimed to observe hypertension educational intervention's effect on general physicians (GPs) to improve blood pressure control and patient outcomes indirectly. Methods: This randomized control trial includes 42 GPs divided into 2 groups. GPs in group 1 receive face-to-face education with structured educational material on hypertension management strategies by a senior cardiologist. GPs in group 2 receive the print version of education material. The data was collected from six major cities in Pakistan. GPs with at least three years of experience in the broad primary care disciplines, with ages above 18 years, were included in the study. Results: A total of 42 physicians (21 from each group) completed questionnaires, while out of 420 hypertension patients, 105 newly diagnosed and already diagnosed patients enrolled under physicians of both groups. The educational material did just as well at informing clinicians as the face-to-face group intervention did and both the interventions had a significant effect on knowledge and BP control. Conclusion: After the 3-month follow-up, both interventions, including face-to-face and educational approaches, demonstrated significant effectiveness in improving knowledge and blood pressure control. Innovation: The study shows that hypertension educational intervention's effect on general physicians indirectly improves blood pressure control and patient outcomes. And emphasize for developing a hypertension educational program targeted at general physicians.

Temperature-dependent heterojunction ternary nanocomposite: Assessing photocatalytic and antibacterial applications.

Heterojunction nanocomposites (ZnO:NiO:CuO) were synthesized via a hydrothermal method and annealed at three different temperatures (400 °C, 600 °C, and 800 °C). The structural, optical, and electrical properties were examined by employing XRD, SEM, UV-Vis, FTIR, and LCR meter techniques to investigate the effects of annealing. Increasing the annealing temperature resulted in the nanocomposites (NCPs) exhibiting enhanced crystallinity, purity, optical properties, and improved electrical and dielectric behavior. The calculated crystalline sizes (Debye-Scherrer method) of the NCPs were determined to be 21, 26 and 34 nm for annealing temperature 400 °C, 600 °C, and 800 °C, respectively. The calculated bandgaps of synthesized samples were found in the range of 2.92-2.55 eV. This temperature-dependent annealing process notably influenced particle size, morphology, band-gap characteristics, and photocatalytic efficiency. EDX analysis affirmed the sample purity, with elemental peaks of Zn, Cu, Ni, and O. These NCPs demonstrated exceptional photocatalytic activity against various dyes solutions (Methyl orange (MO), Methylene Blue (MB), and mixed solution of dyes) under sunlight and also showed good antibacterial properties assessed by the disc diffusion method. Notably, the nanocomposite annealed at 400 °C exhibited a particularly high degradation efficiency by degrading 96% MB and 91% MO in just 90 min under sunlight.

Fabrication of ternary metal oxide (ZnO:NiO:CuO) nanocomposite heterojunctions for enhanced photocatalytic and antibacterial applications.

In this article, ZnO:NiO:CuO nanocomposites (NCPs) were synthesized using a hydrothermal method, with different Zn : Ni : Cu molar ratios (1 : 1 : 1, 2 : 1 : 1, 1 : 2 : 1, and 1 : 1 : 1). The PXRD confirmed the formation of a NCP consisting of ZnO (hexagonal), NiO (cubic), and CuO (monoclinic) structures. The crystallite sizes of NCPs were calculated using Debye Scherrer and Williamson-Hall methods. The calculated crystalline sizes (Scherrer method) of the NCPs were determined to be 21, 27, 23, and 20 nm for the molar ratios 1 : 1 : 1, 2 : 1 : 1, 1 : 2 : 1, and 1 : 1 : 2, respectively. FTIR spectra confirmed the successful formation of heterojunction NCPs via the presence of metal-oxygen bonds. The UV-vis spectroscopy was used to calculate the bandgap of synthesized samples and was found in the range of 2.99-2.17 eV. SEM images showed the mixed morphology of NCPs i.e., irregular spherical and rod-like structures. The dielectric properties, including AC conductivity, dielectric constant, impedance, and dielectric loss parameters were measured using an LCR meter. The DC electrical measurements revealed that NCPs have a high electrical conductivity. All the NCPs were evaluated for the photocatalytic degradation of Methylene blue (MB), methyl orange (MO), and a mixture of both of these dyes. The NCPs with a molar ratio 1 : 1 : 2 (Zn : Ni : Cu) displayed outstanding photocatalytic activity under sunlight, achieving the degradation efficiency of 98% for methylene blue (MB), 92% for methyl orange (MO) and more than 87% in the case of a mixture of dyes within just 90 minutes of illumination. The antibacterial activity results showed the more noxious nature of NCPs against Gram-negative bacteria with a maximum zone of inhibition revealed by the NCPs of molar ratio 1 : 2 : 1 (Zn : Ni : Cu). On the basis of these observations, it can be anticipated that the NCPs can be successfully employed for the purification of contaminated water by the degradation of hazardous organic compounds and in antibacterial ointments.

Physical properties of multifunctional TM-doped ZnO nanorods and their photocatalytic and anti-bacterial activities.

Dilute magnetic semiconductor Zn1-xCuxO (x = 0, 1.5, 3.0, and 4.5%) nanorods were prepared by hydrothermal method. The impact of dopant concentration on the physical properties was investigated along with the anti-bacterial and photocatalytic activities. Synthesis of ZnO nanorods was confirmed by the characteristic band at 380 nm in UV-Visible spectra of the synthesized samples. A red shift in absorbance spectra was observed from 380 to 465 nm with an increase in dopant concentration. The hexagonal wurtzite geometry and rod-like morphology of Cu-doped ZnO nanorods having an average size of 29 nm were confirmed by X-ray diffraction analysis (XRD) and scanning electron microscopy (SEM), respectively. An increase in the crystallinity of the material was observed with an increase in the dopant (Cu) ratio without any alteration in geometry. EDX analysis was used to confirm the purity of samples. FTIR spectra were recorded to explore the functional group present in samples. The hysteresis loop drawn by a vibrating-sample magnetometer (VSM) was utilized to analyze the ferromagnetic behavior. As-synthesized pure and Cu-ZnO nanorods were evaluated for their photocatalytic behavior for the photodegradation of methyl orange (MO) dye. Zn1 - xCuxO with x = 4.5%, pH 3, and catalyst dosage of 0.5 g has shown the maximum efficiency. Results elucidated > 81% degradation of MO dye with a rate constant (k) value of - 1.930 × 10-2 min-1 in just 90 min of exposure to a visible light source. ZnO nanorods have also exhibited anti-bacterial potential against gram-positive and gram-negative strains of bacteria. However, smaller size nanorods were found more effective to suppress the growth of gram-negative bacteria. A slight decrease (11%) in catalytic potential was observed in the 5th cycle during recycling and reuse experiments.

Correction: Ishaque et al. Iriflophenone-3-C-ß-d Glucopyranoside from Dryopteris ramosa (Hope) C. Chr. with Promising Future as Natural Antibiotic for Gastrointestinal Tract Infections. Antibiotics 2021, 10, 1128.

At the request of Dr. Markus Bacher, Dr. Johann Schinnerl, and Dr. Karin Valant-Vetschera, they have been removed as authors of the paper [...].

Pharmacological properties and preliminary phytochemical analysis of Pseudocaryopteris foetida (D.Don) P.D. Cantino leaves.

Medicinal plants have significant contribution in pharmaceutical industries being producers of compounds utilized as precursors for drug development. A plant of Lamiaceae family; Pseudocaryopteris foetida had not been investigated for its biomedical potential. Current research was aimed to investigate phytochemical analysis, cytotoxic potential and antioxidant activity of crude methanolic extract and fractions of Pseudocaryopteris foetida (leaves). The preliminary phytochemical analysis of crude methanolic extracts and fractions of Pseudocaryopteris foetida revealed that plant is rich in phenolic and flavonoid classes of secondary metabolites while presence of tannin was observed only in crude methanolic extract. The cytotoxicity was determined using brine shrimp lethality test. Different concentrations (25, 50, 100, 150, 200 and 250 µg/mL) of crude methanolic extract and fractions exhibited dose dependent cytotoxicity. However, The LD50 for all the extracts was more than 200 µg/mL indicating weak cytotoxic potential of Pseudocaryopteris foetida. The antioxidant capabilities of crude methanolic extract and fraction of Pseudocaryopteris foetida were analyzed by in vitro bio assays including DPPH, ABTS, Reducing power and phosphomolybdate antioxidant assays using ascorbic acid as standard. The crude methanolic extract showed IC50 (256.38 ± 0.6 and 314.95 ± 1.1 µg/mL) for DPPH and ABTS respectively, while total antioxidant capacity was calculated as 55.79 ± 0.5 µg/mL for crude methanolic extract of Pseudocaryopteris foetida while ascorbic acid indicated total antioxidant capacity of 71.89 ± 2.3 µg/mL. Study concluded that leaves of Pseudocaryopteris foetida were the rich source of antioxidant phytochemicals. Based on preliminary investigations further research should be focused to isolate bioactive phytochemicals as leading source of clinical medicines in future.

Xanthone C-glycosides isomers purified from Dryopteris ramosa (Hope) C. Chr. with bactericidal and cytotoxic prospects.

Xanthones C-glycosides are plants secondary metabolites with diverse biological activities. Among the C-glycoside xanthones, the mangiferin (MF) is of widespread occurrence in plants while isomangiferin (IsoMF) is not very common. For the present study mangiferin (MF) and isomangiferin (IsoMF) were isolated from Dryopteris ramosa. The antibacterial potential of MF and IsoMF was evaluated by using agar well diffusion method while cytotoxic properties of MF and IsoMF were assessed by brine shrimp lethality test (BSLT). The antibacterial potential of MF and IsoMF increases in dose dependent manner. The minimum inhibitory concentration (MIC) indicated strong antibacterial potential of MF against Salmonella setubal (125 µg/mL) and Bacillus subtilis (125 µg/mL) while MF showed weak antibacterial potential against Escherichia coli (500 µg/mL). On the other hand the IsoMF showed better antibacterial potential against all the tested strain including Escherichia coli (MIC = 250 µg/mL). The MF and IsoMF showed poor cytotoxicity towards Brine shrimp nauplii as indicated by their LD50 (969.77 ± 0.67 and 768.92 ± 0.81 µg/mL respectively). The present study has highlighted the antibacterial potential of MF and IsoMF. Further evaluation of these two isomeric compounds may prove to be the future remedies for various bacterial infections and other human ailments.

Outcome of Post-intubation Tracheal Stenosis (PITS) with Primary Resection and Anastomosis.

OBJECTIVE: To ascertain the outcome of primary resection anastomosis in patients of post-intubation tracheal stenosis (PITS) and the associated morbidity. STUDY DESIGN: A case series. PLACE AND DURATION OF STUDY: Department of Thoracic Surgery, Combined Military Hospital, (CMH) Rawalpindi, Lahore and Multan from January 2010 to August 2018. METHODOLOGY: Patients with tracheal stenosis due to prolonged intubation with functional were included. Exclusion criteria were patients having stenosis due to malignant cause, trauma and glottic stenosis involving vocal cords. Clinical examination, computerised tomography (CT) of neck plus chest and fiberoptic bronchoscopy were done in all the patients, while virtual bronchoscopy were done in 35 cases. Sharp dissection, aided by loupes, was the preferred technique. Thyroid tissue and strap muscle were used as flap for high cricoid lesion. Guardian stitch was applied to all cases. Postoperative elective bronchoscopy was performed after a fortnight. RESULTS: Among 43 patients, [26 (60.5%) men and 17 (39.5) women] 18 patients were intubated for days >10 ,18 for <10 and 7 for <3 days. Thirty-four (79.1%) patients were under 40 years of age, while 23 patients had tracheostomy incorporated in surgery. Bronchoscopy evaluation of distance from vocal cords showed involvement of the first ring in six patients, 1st ring normal in 1, 2 rings normal in 17, while 3 or more rings spared in 19 patients. Length of stenotic segment was <2 cm in 17, between 2-3 cm in 21, and between 3-5 cm in five patients. All patients were successfully extubated. Two patients had twin lesions. Seven patients required hyoid bone excision and release. There was one recurrent stenosis managed successfully with dilatation and granulation removal. CONCLUSION: Post-intubation tracheal stenosis (PITS) is curable disease. Primary resection and anastomosis remain the gold standard with acceptable morbidity and mortality. Key Words: Tracheal stenosis, Intubation, Resection, Primary anastomosis.

Determination of ROS Scavenging, Antibacterial and Antifungal Potential of Methanolic Extract of Otostegia limbata (Benth.) Boiss.

Wide spectrum medicinal significance augments plant utilization as the primary source of significant pharmaceutical agents. In vitro investigation of antioxidant and antimicrobial activity highlights the therapeutic potential of Otostegia limbata. Methanol extract of the plant (MEP) shows considerable dose dependent antioxidant ability at six concentrations (7.81 µg/mL to 250 µg/mL) in 2.2-diphenyl-1-picrylhydrazyl (DPPH) assay, phosphomolybdate assay (PMA) and reducing power assay (RPA). The plant capability to scavenge free radicals in the mixture ranged from 37.89% to 63.50% in a concentration-dependent manner. MEP was active against five tested bacterial strains in the agar-well diffusion method. Staphylococcus aureus, gram-positive bacteria was found to be most susceptible followed by S. epidermidis with 18.80 mm and 17.47 mm mean zone of inhibition. The mean inhibition zone against gram-negative strains Klebsiella pneumonia, Pseudomonas spp. and Escherichia coli were 15.07 mm, 14.73 mm, and 12.17 mm. MEP revealed potential against Alternaria spp. and Aspergillus terreus fungal strains evaluated through agar-tube dilution assay. Aspergillus terreus was more sensitive than Alternaria spp. with an average 78.45% and 68.0% inhibition. These findings can serve as a benchmark for forthcoming scrutiny such as bioactive components discovery and drug development.

Effectiveness of community-based interpersonal communication for generating family planning demand in key groups.

OBJECTIVE: The study aimed to document the impact of interpersonal communication (IPC) activities on increasing volume of family planning clients, new users, long term contraceptive uptake, post-partum, and post abortion family planning uptake at the associated health facilities of the Sabz Sitara Network. METHODOLOGY: A comparative secondary analysis of retrospective programme service delivery data from two groups of providers was performed. The exposure variable is defined as receipt of IPC. The six outcome variables are volume of: family planning (FP) clients, FP clients less < 25 years, intra-uterine device (IUD) insertions, post-partum FP clients (PPFP), users, and post-abortion FP (PAFP) clients. RESULTS: The increase in client volume in IPC supported providers is significant for all the FP outcomes when adjusted for provider qualification and location. The adjusted model shows a significant increase of 10 more FP clients, 2 more youth clients and IUD insertions each, 3 more new users, and 1 more client for post abortion services. CONCLUSIONS: The IPC intervention has a positive and significant impact on increasing client volume for all related FP outcomes at the associated provider facilities. Location and qualification of providers seem to moderate the impact. Considering qualification, and geo-social demographics of the area to tweak intervention intensity and design will help amplify the associated beneficial outcomes and minimize underperformance. To maximize return on investment, subsequent evaluations should help determine the ideal time frame required to achieve and sustain the positive results.

Predictors of postpartum family planning uptake in Sindh and Punjab provinces of Pakistan.

OBJECTIVE: Combination of beneficiary and supply side factors for determining what influences Postpartum family planning use in Sindh and Punjab provinces of Pakistan. METHODS: A facility-based survey was conducted among 1690 married women of reproductive age (MWRA - i.e. married women between the ages of 15 and 49 years) visiting public facilities in six districts across Sindh and Punjab provinces of Pakistan. RESULTS: Half (53%) of the interviewed women used postpartum contraceptives. Participants who used PPFP were: 55% more likely to be from Punjab than Sindh, 39% more likely to be between 25 to 34 year of age than under 25 years. After adjusting for all variables in the model, women who delivered in the private sector remained to have lower odds of PPFP use compared to those who delivered in public facilities. Women who had four or more sons were nearly 20 time more likely to use PPFP compared to women with no sons, and the PPFP use increases with the number of sons. On the contrary, women who had four or more daughters were 16 times less likely to use PPFP compared with women with no daughters. CONCLUSIONS: Postpartum women are among those with the greatest unmet need as a result of a combination of beneficiary and supplier side factors. The health system's response to meet the contraceptive needs of postpartum women should work along the continuum of care from pregnancy to postpartum, with expanded method choice and alternative service delivery outlets.

Using HPLC-DAD and GC-MS Analysis Isolation and Identification of Anticandida Compounds from Gui Zhen Cao Herbs (Genus Bidens): An Important Chinese Medicinal Formulation.

Gui Zhen Cao is an herbal formulation that has been documented in Chinese traditional medicine as a remedy for diarrhea, dysentery, inflammation, and toxicity. The sources of this formulation (Bidens pilosa L., Bidens biternata (Lour.) Merr. & Sherff, Bidens bipinnata L.) are also listed in ethnomedicinal reports all over the world. In this study, all these plants are tested for in vitro anticandida activity. A quantitative evaluation of the phytochemicals in all these plants indicated that their vegetative parts are rich in tannins, saponins, oxalates, cyanogenic glycoside and lipids; moreover, the roots have high percentages of alkaloids, flavonoids, and phenols. The results indicated significant anticandida activity, especially for the hexane extract of B. bipinnata leaves which inhibited C. albicans (42.54%), C. glabrata (46.98%), C. tropicalis (50.89%), C. krusei (40.56%), and C. orthopsilosis (50.24%). The extract was subjected to silica gel chromatography and 220 fractions were obtained. Purification by High Performance Liquid Chromatography with Diode-Array Detection (HPLC-DAD) and Gas Chromatography tandem Mass Spectrometry (GC-MS/MS) analysis led to the identification of two anticandida compounds: dehydroabietic and linoleic acid having an inhibition of 85 and 92%, respectively.

Iriflophenone-3-C-ß-d Glucopyranoside from Dryopteris ramosa (Hope) C. Chr. with Promising Future as Natural Antibiotic for Gastrointestinal Tract Infections.

Ethnopharmacological approaches provide clues for the search of bioactive compounds. Dryopteris ramosa (Hope) C. Chr. (plant family: Dryopteridaceae) is an ethnomedicinal plant of the Galliyat region of Pakistan. The aqueous fraction (AqF) of D. ramosa is being used by inhabitants of the Galliyat region of Pakistan to treat their gastrointestinal tract ailments, especially those caused by bacteria. The aims of the present study were as follows: (i) to justify the ethnomedicinal uses of the AqF of D. ramosa; (ii) to isolate a bioactive compound from the AqF of D. ramosa; and (iii) to evaluate the antibacterial and cytotoxic potential of the isolated compound. Column chromatography (CC) techniques were used for the isolation studies. Spectroscopic techniques (UV-Vis, MS, 1&2D NMR) were used for structural elucidation. The agar-well diffusion method was used to evaluate the antibacterial potential of "i3CßDGP" against five bacterial strains, and compare it with the known antibiotic "Cefixime". The brine shrimp lethality test (BSLT) was used for cytotoxic studies. The AqF of D. ramosa afforded "iriflophenone-3-C-ß-D glucopyranoside (i3CßDGP)" when subjected to LH20 Sephadex, followed by MPLC silica gel60, and purified by preparative TLC. The "i3CßDGP" showed a strong potential (MIC = 31.1 ± 7.2, 62.5 ± 7.2, and 62.5 ± 7.2 µg/mL) against Klebsiella pneumoniae, Staphylococcus aureus, and Escherichia coli, respectively. On the other hand, the least antibacterial potential was shown by "i3CßDGP" (MIC = 125 ± 7.2 µg/mL), against Bacillus subtilis, in comparison to Cefixime (MIC = 62.5 ± 7.2 µg/mL). The cytotoxicity of "i3CßDGP" was significantly low (LD50 = 10.037 ± 2.8 µg/mL) against Artemia salina nauplii. This study not only justified the ethnomedicinal use of D. ramosa, but also highlighted the importance of ethnomedicinal knowledge. Further studies on AqF and other fractions of D. ramosa are in progress.

Development and validation of a psychometric scale to assess attitude towards safe abortions in Pakistan.

Despite severe health and economic consequences that women face because of the negative attitude of healthcare providers towards safe abortion and post-abortion care (SA/PAC), no psychometric tool has yet been validated for assessing the attitude towards SA/PAC. Only a handful of studies have attempted to assess healthcare providers' attitude towards safe abortions in Pakistan. Therefore, this study aimed to develop and validate a psychometric scale to assess attitude towards safe abortions in Pakistan. The study collected data from 106 workers of an NGO that provides SA/PAC through an online and anonymous survey using the organisation's network. The study used factor analytic techniques and structural equation modelling to validate the factor structure and a final hierarchical model. A final scale of seven items relating to attitude towards elective abortions and moral attitude towards safe abortions was validated. The scales were highly reliable with both factors having reliability indicators greater than 0.7. The scale can be easily implemented to assess providers' attitude towards safe abortions. This will allow programmers to screen healthcare providers with a negative attitude, and evaluate the efficacy of their Value Clarification and Attitude Transformation (VCAT) programmes that are aimed at transforming providers' attitude towards safe abortions.

Evaluation of Mast Cell Density using CD117 antibody and Microvessel Density Using CD34 Antibody in Different Grades of Oral Squamous Cell Carcinoma.

OBJECTIVE: To compare mast cell and microvessel densities among histologic grades of oral squamous cell carcinoma. SETTING: Armed Forces Institute of Pathology. MATERIALS AND METHODS: A total of 60 specimens of OSCC comprising 20 each of well, moderately and poorly differentiated were evaluated. Immunohistochemical analysis was performed to measure MCD and MVD by applying monoclonal CD117 antibody and monoclonal CD34 antibody, on formalin fixed and paraffin embedded sections. ANOVA and Post Hoc Tukey test was employed to assess the densities and to compare the differences between different grades of OSCC. A p-value.

Does courtesy bias affect how clients report on objective and subjective measures of family planning service quality? A comparison between facility- and home-based interviews.

PURPOSE: Despite a general understanding that exit interviews being conducted at service providers' facilities may influence clients' responses favorably to health professionals, there is very little evidence available that demonstrates the extent to which this problem exists. This study aimed at assessing and comparing clients' perceptions of the quality of family planning services and their satisfaction levels between facility- and home-based interviews. METHODS: A cross-sectional survey was conducted among clients receiving family planning services across three service delivery channels - nongovernmental organization (NGO) clinics, social franchise (SF) centers, and outreach camps. The survey took place from December 2015 to January 2016 in 70 districts across all four provinces of Pakistan. A total of 2,807 clients were interviewed, of whom 1,404 clients were interviewed at health facilities after receiving services and 1,403 were interviewed at their homes within 3 days of method uptake. RESULTS: Overall, we found no significant differences between the characteristics of study participants interviewed at health facilities or at home. The findings suggested that experiences reported in exit surveys at facilities were strongly biased positively. This was true for both experiential (service quality) and perception-based (satisfaction) questions in the context of SF centers, while at NGO clinics the interview location only affected clients' responses regarding service quality. However, in outreach settings, clients are more likely to share bad experiences in exit interviews than in home-based interviews on objectively asked questions (service quality). CONCLUSION: Our study indicates signs of courtesy bias and possibly the Hawthorne effect in exit interviews. Program implementers could opt for home-based interviews for women receiving services at NGO clinics or SF center, whereas exit interviews could be used in outreach settings.

Comparing Effectiveness of Active and Passive Client Follow-Up Approaches in Sustaining the Continued Use of Long Acting Reversible Contraceptives (LARC) in Rural Punjab: A Multicentre, Non-Inferiority Trial.

BACKGROUND: The use of long-acting reversible contraceptive (LARC) methods is very low in Pakistan with high discontinuation rates mainly attributed to method-related side effects. Mixed evidence is available on the effectiveness of different client follow-up approaches used to ensure method continuation. We compared the effectiveness of active and passive follow-up approaches in sustaining the use of LARC-and within 'active' follow-up, we further compared a telephone versus home-based approach in rural Punjab, Pakistan. METHODS: This was a 12-month multicentre non-inferiority trial conducted in twenty-two (16 rural- and 6 urban-based) franchised reproductive healthcare facilities in district Chakwal of Punjab province, between November 2013 and December 2014. The study comprised of three groups of LARC clients: a) home-based follow-up, b) telephone-based follow-up, and c) passive or needs-based follow-up. Participants in the first two study groups received counselling on scheduled follow-up from the field workers at 1, 3, 6, 9, and 12 month post-insertion whereas participants in the third group were asked to contact the health facility if in need of medical assistance relating to LARC method use. Study participants were recruited with equal allocation to each study group, but participants were not randomized. The analyses are based on 1,246 LARC (intra-uterine contraceptive device and implant) users that completed approximately 12-months of follow-up. The non-inferiority margin was kept at five percentage points for the comparison of active and passive follow-up and six percentage points for telephone and home-based approach. The primary outcome was cumulative probability of method continuation at 12-month among LARC users. RESULTS: Women recruited in home-based, telephone-based, and passive groups were 400, 419 and 427, respectively. The cumulative probability of LARC continuation at 12 month was 87.6% (95% CI 83.8 to 90.6) among women who received home-based follow-up; 89.1% (95% CI 85.7, 91.8) who received telephone-based follow-up; and 83.8% (95% CI 79.8 to 87.1) who were in the passive or needs-based follow-up group. The probability of continuation among women who were actively followed-up by field health educators-either through home-based visit or telephone-based follow-up was, 88.3% (95% CI 85.9 to 90.0). An adjusted risk difference of -4.1 (95% CI -7.8 to -0.28; p-value = 0.035) was estimated between active and passive follow-up. Whereas, within the active client follow-up, the telephone-based follow-up was found to be as effective as the home-based follow-up with an adjusted risk difference of 1.8 (95% CI -2.7 to 6.4; p-value = 0.431). CONCLUSION: A passive follow-up approach was 5% inferior to an active follow-up approach; whereas telephone-based follow-up was as effective as the home-based visits in sustaining the use of LARC, and was far more resource efficient. Therefore, active follow-up could improve method continuation especially in the critical post-insertion period.

Engaging with community-based public and private mid-level providers for promoting the use of modern contraceptive methods in rural Pakistan: results from two innovative birth spacing interventions.

BACKGROUND: Family planning (FP) interventions aimed at reducing population growth have negligible during the last two decades in Pakistan. Innovative FP interventions that help reduce the growing population burden are the need of the hour. Marie Stopes Society--Pakistan implemented an operational research project--'Evidence for Innovating to Save Lives', to explore effective and viable intervention models that can promote healthy timing and spacing of pregnancy in rural and under-served communities of Sindh, Punjab and Khyber Pakhtunkhwa provinces of Pakistan. METHODS: We conducted a quasi-experimental (pre- and post-intervention with control arm) study to assess the effectiveness of each of the two intervention models, (1) Suraj model (meaning 'Sun' in English), which uses social franchises (SF) along with a demand-side financing (DSF) approach using free vouchers, and (2) Community Midwife (CMW) model, in promoting the use of modern contraceptive methods compared to respective controls. Baseline and endline cross-sectional household surveys were conducted, 24 months apart, by recruiting 5566 and 6316 married women of reproductive age (MWRA) respectively. We used Stata version 8 to report the net effect of interventions on outcome indicators using difference-in-differences analysis. Multivariate Cox proportional hazard regression analysis was used to assess the net effect of the intervention on current contraceptive use, keeping time constant and adjusting for other variables in the model. RESULTS: The Suraj model was effective in significantly increasing awareness about FP methods among MWRA by 14% percentage points, current contraceptive use by 5% percentage points and long term modern method--intrauterine device (IUD) use by 6% percentage points. The CMW model significantly increased contraceptive awareness by 28% percentage points, ever use of contraceptives by 7% percentage points and, IUD use by 3% percentage points. Additionally the Suraj intervention led to a 35% greater prevalence (prevalence ratio: 1.35, 95% CI: 1.22-1.50) of contraceptive use among MWRA. CONCLUSION: Suraj intervention highlights the importance of embedding subsidized FP services within the communities of the beneficiaries. The outcomes of the CMW intervention also improved the use of long-term contraceptives. These findings indicate the necessity of designing and implementing FP initiatives involving local mid-level providers to expand contraceptive coverage in under-served areas.

Determinants of Method Switching among Social Franchise Clients Who Discontinued the Use of Intrauterine Contraceptive Device.

Introduction. Women who do not switch to alternate methods after contraceptive discontinuation, for reasons other than the desire to get pregnant or not needing it, are at obvious risk for unplanned pregnancies or unwanted births. This paper examines the factors that influence women to switch from Intrauterine Contraceptive Device (IUCD) to other methods instead of terminating contraceptive usage altogether. Methods. The data used for this study comes from a larger cross-sectional survey conducted in nine (9) randomly selected districts of Sindh and Punjab provinces of Pakistan, during January 2011. Using Stata 11.2, we analyzed data on 333 women, who reported the removal of IUCDs due to reasons other than the desire to get pregnant. Results. We found that 39.9% of the women do not switch to another method of contraception within one month after IUCD discontinuation. Use of contraception before IUCD insertion increases the odds for method switching by 2.26 times after removal. Similarly, postremoval follow-up by community health worker doubles (OR = 2.0) the chances of method switching. Compared with women who received free IUCD service (via voucher scheme), the method switching is 2.01 times higher among women who had paid for IUCD insertion. Conclusion. To increase the likelihood of method switching among IUCD discontinuers this study emphasizes the need for postremoval client counseling, follow-up by healthcare provider, improved choices to a wider range of contraceptives for poor clients, and user satisfaction.

Family Planning Knowledge, Attitudes, and Practices among Married Men and Women in Rural Areas of Pakistan: Findings from a Qualitative Need Assessment Study.

This paper presents the findings of a qualitative assessment aimed at exploring knowledge, attitudes, and practices regarding family planning and factors that influence the need for and use of modern contraceptives. A descriptive exploratory study was conducted with married women and men aged between 15 and 40. Overall, 24 focus group discussions were conducted with male and female participants in three provinces of Pakistan. The findings reveal that the majority knew about some modern contraceptive methods, but the overall contraceptive use was very low. Knowledge and use of any contraceptive method were particularly low. Reasons for not using family planning and modern contraception included incomplete family size, negative perceptions, in-laws' disapproval, religious concerns, side-effects, and lack of access to quality services. The majority preferred private facilities over the government health facilities as the later were cited as derided. The study concluded the need for qualified female healthcare providers, especially for long term family planning services at health facilities instead of camps arranged occasionally. Addressing issues around access, affordability, availability, and sociocultural barriers about modern contraception as well as involving men will help to meet the needs and ensure that the women and couples fulfill their childbearing and reproductive health goals.