Exploring the reasons for defaulting from childhood immunization: a qualitative study in Pakistan.

BACKGROUND: Childhood vaccination is widely recognized as the most effective means to prevent various diseases. However, a considerable amount of children still miss out on their vaccination schedules. Therefore, this study explores the reasons for defaulting from the expanded program on immunization in district Swat, Pakistan. METHODS: A qualitative phenomenological approach was used. Data collection took place from March to September 2022. Thirty-six in-depth interviews were conducted with participants who had defaulter children. The collected qualitative data were analysed thematically to identify key patterns and themes related to the reasons for defaulting from childhood vaccination schedules. RESULTS: Six themes emerged, i.e., illness of the defaulter child at the scheduled time, perceived side effects of the vaccination, factors related to caregivers, myths and misconceptions, vaccinators attitudes and crowed vaccination centres, as well as poor immunization service arrangements. Four subthemes arose related to caregivers, such as lack of clear understanding about completion of vaccination, least priority for child's vaccination, cultural restriction on mothers, and the loss of vaccination card. CONCLUSION: According to the study's findings, caregivers have their own perceptions regarding the non-completion of their children's vaccination schedule. The childhood immunization defaulting arises from various factors including child illness, Adverse Events Following Immunization (AEFIs) concerns, misconceptions, improper injection techniques, and negative vaccinator attitudes. The vaccination completion rate may be increased if the concerns of the caregivers are appropriately addressed.

Comparison of physical activity levels and dietary habits between women with polycystic ovarian syndrome and healthy controls of reproductive age: a case-control study.

BACKGROUND: Polycystic ovarian syndrome (PCOS) is a reproductive hormonal anomaly prevalent among women of reproductive age, with an alarmingly high prevalence of 52% among Pakistani women. This study aims to compare the daily physical activity and dietary habits of women with PCOS with age-matched healthy controls living in Lahore, Pakistan. METHODS: A case-control study design was used to collect data from a private hospital situated in Lahore, Pakistan. Data was collected from 115 participants of reproductive age (18-45 years) using a researcher-administered questionnaire. Demographic variables, reproductive characteristics, anthropometric measurements, and seven days of physical activity levels using the international physical activity questionnaire (IPAQ-Short version) and seven days of dietary intake using the food frequency questionnaire (7 days-FFQ) were used to measure the dietary habits of the participants. Mosby's Nutritac v4.0 software was used to estimate the macronutrients, vitamins, and minerals present in dietary intake. The glycaemic index and glycaemic load were calculated to compare the quality and quantity of carbohydrate consumption between the two groups. RESULTS: The 49 PCOS cases, newly identified using the Rotterdam criteria, mean age 24.63 years (SD ± 4.76), and 66 healthy controls, mean age 23.24 years (SD ± 5.45), were compared. A significant difference (p ≤ 0.05) was found for reproductive characteristics, daily physical activity, and polyunsaturated fat and vitamin intake between the two groups. A binary logistic regression analysis showed that food with a low glycaemic index (GI ≤ 40) reduced the odds of PCOS occurrence by OR = 1.94. Similarly, food nutrients with a low glycaemic load (GL ≤ 10) can reduce PCOS occurrence by OR = 1.60. CONCLUSION: The daily physical activity levels and dietary habits of women of reproductive age can influence their reproductive characteristics and polycystic ovarian morphology. A diet with a low glycaemic load and index can produce beneficial reproductive health effects among women of reproductive age.

Application of the Boruta algorithm to assess the multidimensional determinants of malnutrition among children under five years living in southern Punjab, Pakistan.

BACKGROUND: Malnutrition causes nutrient deficiencies that have both physical and clinical consequences in severe acute malnutrition children. Globally, there were 47 million wasted children under the age of five in 2019. One in four were located in sub-Saharan Africa, with half being in South Asia. This study aims to apply the Boruta algorithm to identify the determinants of undernutrition among children under five living in Dera Ghazi Khan, one of the marginalized districts of densely populated Punjab Province in Pakistan. METHODS: A multicenter cross-sectional study design was used to collect data from 185 children with severe acute malnutrition aged under five years visiting the OTPs centers located in Dera Ghazi Khan, Punjab, Pakistan. A purposive sampling technique was used to collect data using a pretested structured questionnaire from parents/caregivers regarding family sociodemographic characteristics, child nutrition, and biological and healthcare characteristics. Anthropometric measurements, including height, weight, and mid-upper arm circumference, were collected. The Boruta models were used to incorporate the children's anthropometric, nutritional, and household factors to determine the important predictive variables for undernutrition using the Boruta package in R studio. RESULTS: This study included 185 children, with a mean age of 15.36 ± 10.23 months and an MUAC of 10.19 ± 0.96 cm. The Boruta analysis identifies age, mid-upper arm circumference, weaning practices, and immunization status as important predictors of undernutrition. Income per month, exclusive breastfeeding, and immunization status were found to be key factors of undernutrition in children under the age of five. CONCLUSION: This study highlights age, mid-upper arm circumference, weaning practices, and immunization status as key determinants of weight-for-height and weight-for-age in children under five years. It also suggests that economic context may influence undernutrition. The findings can guide targeted strategies for combating undernutrition.

Relationship of stunting with water, sanitation, and hygiene (WASH) practices among children under the age of five: a cross-sectional study in Southern Punjab, Pakistan.

BACKGROUND: Reasons for undernutrition are food insufficiency, impaired child care, limited access to healthcare, and maternal lack of health literacy. In addition, there are several environmental factors, such as drinking water quality, poor sanitation, and hygienic practices that can lead to poor nutritional status in children. The present study aimed to compare household-associated risk factors, including water, sanitation, and hygiene (WASH) practices of mothers, with children's stunting under the age of five. METHODS: A face-to-face cross-sectional survey was conducted with mothers of children under the age of five in the Dera Ghazi Khan district in southern Punjab, Pakistan. World Health Organization criteria for stunting were used to identify the participants. A sociodemographic questionnaire was used to collect information from consented parents/guardians on children's age, feeding, and WASH practices. Pearson's chi-square, simple regression, and hierarchical regression models were applied for data analysis. RESULTS: A total of 204 mothers of children of both genders participated in this study. The children's mean (SD) age was 15.67 (± 10.2) months, their weight was 5.44 (± 1.45) kg, their height was 67.69 (± 10.05), and their mid-upper arm circumference was 9.75 (± 1.30) cm. Children's stunting was mild (z-score > -2) at 17.6%, moderate (z-score - 2 to -3) at 16.7%, and severe (z-score < -3) at 65.7% of participants. A simple regression model showed a strong association, r2 = 0.062, p = 0.013, with age as the most significant sociodemographic factor. The hierarchical regression model showed a combined value of r2 = 0.0128, p = 0.027, with hand pump and tank water as the significant source of drinking water that was related to stunting among children. CONCLUSION: Stunting can be associated with several risk factors, including WASH parameters. This study concluded that children aged under five years are susceptible to stunting in southern Punjab, Pakistan. The contamination of hand pumps and tank water resources was found to be the major contributing factor to stunting.

Benefits of physical activity on reproductive health functions among polycystic ovarian syndrome women: a systematic review.

BACKGROUND: Polycystic ovary syndrome (PCOS) is among the predominant endocrine disorders of reproductive-aged women. The prevalence of PCOS has been estimated at approximately 6-26%, affecting 105 million people worldwide. This systematic review aimed to synthesize the evidence on the effects of physical activity on reproductive health functions among PCOS women. METHODS: The systematic review includes randomization-controlled trials (RCTs) on physical exercise and reproductive functions among women with PCOS. Studies in the English language published between January 2010 and December 2022 were identified via PubMed. A combination of medical subject headings in terms of physical activity, exercise, menstrual cycle, hyperandrogenism, reproductive hormone, hirsutism, and PCOS was used. RESULTS: Overall, seven RCTs were included in this systematic review. The studies investigated interventions of physical activity of any intensity and volume and measured reproductive functions and hormonal and menstrual improvement. The inclusion of physical activity alone or in combination with other therapeutic interventions improved reproductive outcomes. CONCLUSION: The reproductive functions of women with PCOS can be improved with physical activity. Furthermore, physical activity can also reduce infertility, as well as social and psychological stress among women. PROSPERO SYSTEMATIC REVIEW REGISTRATION: CRD42020213732.

Double-Blind Parallel Treatment Randomized Controlled Trial of Prebiotics' Efficacy for Children Experiencing Severe Acute Malnutrition in Southern Punjab, Pakistan.

The prevalence of malnutrition among children under five is alarmingly high in Pakistan. However, there are ready-to-use therapeutic foods (RUTF) available which may be used to treat children with severe acute malnutrition (SAM). This study aims to assess the efficacy of prebiotics as a synergistic additive to RUTF to enhance blood parameters and anthropometric measurements in children with uncomplicated SAM living in Southern Punjab, Pakistan. A double-blind parallel treatment randomized controlled trial was conducted on 204 children aged 6-59 months. Participants were randomized and allocated to the placebo (n = 102) or experimental arms (n = 102) in a 1:1 ratio. One group of children was provided with RUTF and 4 g prebiotics, while the other group was given RUTF and starch as a placebo. Participants recruited for both arms were given treatment for eight weeks, and then their biochemical and anthropometric outcomes were evaluated. A substantial difference between the mean weight, mid-upper-arm circumference, haemoglobin, haematocrit, platelet count, mean corpuscular volume, mean corpuscular haemoglobin, and albumin was revealed. During the two-month follow-up phase of the trial, children who were enrolled in the treatment group gained about 20% of their initial weight (pre-study mean weight = 5.44 ± 1.35 kg; post-study mean weight = 6.53 ± 1.45 kg). The analysis showed a significant difference (p < 0.005) between the control and treatment groups for MUAC and complete blood counts. Conclusively, supplementation with RUTF and prebiotics has proven to be an efficient, effective, and safe therapy for children suffering from SAM to improve their growth and development indicators and reduce the dangers of malnutrition in comparison to RUTF alone.

Oral health perceptions and practices of caregivers at children's religious schools and foster care centers: a qualitative exploratory study in Lahore, Pakistan.

BACKGROUND: Oral diseases are one of the major public health problems worldwide and affect the population of all age groups. This qualitative study aimed to explore the perceptions and practices of caregivers at care centres and boarding religious schools responsible for managing children's oral health. METHODS: A qualitative ethnomethodological approach was used to collect data from the caregivers at the children's religious schools and foster care centres. A purposive sampling technique was used to conduct focus group discussions comprising 4-7 caregivers from five foster care centres and religious schools located in Lahore, Pakistan. An interview guide was developed based on results from previous studies. An inductive approach was used to analyse data on broader oral health concepts to generate themes in this qualitative research. A three-step thematic analysis was applied to develop codes that were merged to generate categories and to conclude into themes from the transcribed data. Five focus group discussions were conducted at two foster care centres (FG1 & FG2) and three religious schools (FG3, FG4 & FG5). Foster care centres had children of both gender within the same premises; however, religious schools had segregated settings. RESULTS: The following four themes emerged from the thematic analysis: development of the desired living environment and responsibilities of the caregivers, preexisting traditional personal knowledge of the caregivers determine children's oral health, use of religio-cultural driven and convenience-based oral hygiene practices, and ethnomedicine, spiritual healing, and self-medication. Development and the existing living environment of the foster care centres and religious schools appeared important to manage the matters of the boarding children. CONCLUSIONS: This qualitative study concludes that the oral health of the children at foster care centres and at religious schools depends upon the personal reasoning and pre-existing religio-cultural knowledge of the caregivers rather than on specialized oral health-oriented approaches. The foster care centres are more involved in supervising the children to maintain oral hygiene and oral health compared to religious schools.

Serum anti-Müllerian hormone as a predictor of polycystic ovarian syndrome among women of reproductive age.

BACKGROUND: Polycystic ovarian syndrome (PCOS) affects up to one-fifth of women of reproductive age and causes anovulatory subfertility. Some studies have recommended that an anti-Müllerian hormone (AMH) level greater than 3.8-5 ng/mL can be used for diagnosing PCOS. This study aims to analyse serum AMH levels among PCOS women of reproductive age to use AMH as a biomarker predictor along with other Rotterdam criteria. METHODS: In this cross-sectional study, a total of 98 women visiting the fertility center of a private hospital in Lahore, Pakistan, were screened. Data were obtained from 51 PCOS newly diagnosed women aged 28.24 years (SD ± 4.84 years) meeting at least two of the Rotterdam criteria and specific inclusion criteria. Baseline variables, menstrual cycle length, ovarian morphology on ultrasound, hirsutism, sex hormones, gonadotropin, and serum AMH levels were analysed during the follicular phase (1-5 days) of the menstrual cycle. Serum AMH was measured by an enzyme-linked immunosorbent assay. RESULTS: A high serum AMH level (7.23 ± 4.67 ng/ml) was recorded with normal sex hormone levels. Women with oligo-/amenorrhea had a significant mean difference for luteinizing hormone (p = 0.02) and AMH levels (p = 0.03) when compared with women of normal menstrual cycle length. PCOS women with high AMH levels (≥ 3.9 ng/ml) showed a significant difference in ovarian morphology (p < 0.05) when compared with the normal AMH group. CONCLUSIONS: An elevated serum AMH level can be used as a strong predictor to reflect the certainty of PCOS diagnosis among women of reproductive age when study concurrently with the other Rotterdam criteria.

Effectiveness of Ready-to-Use Therapeutic Food in Improving the Developmental Potential and Weight of Children Aged under Five with Severe Acute Malnourishment in Pakistan: A Pretest-Posttest Study.

The objective of this study was to assess whether the standard therapy of ready-to-use therapeutic food in the treatment of uncomplicated severe acute malnutrition (SAM) is effective in improving developmental potential and weight gain in children aged under five years. A multicenter pretest-posttest study was conducted among 91 children aged under five with uncomplicated SAM in Pakistan. Study participants completed their eight weeks' therapy of ready-to-use therapeutic food according to the World Health Organization's (WHO) standard guidelines. The study outcome was the proportion of children with improved developmental potential in all domains in comparison with the pretreatment status and children gaining >15% of their baseline weight; mean weight-for-height/length z-score after completing eight weeks' therapy of ready-to-use therapeutic food. The Denver Development Screening Tool II was used for developmental screening. Significant changes (p < 0.05) were observed for developmental status milestones in terms of gross motor, fine motor, and personal/social milestones, as well as language and global development milestones. There was a strong positive correlation (r = 0.961) between initial weight and weight at the last visit (p < 0.001). Ready-to-use therapeutic food is effective in improving development potential as well as promoting weight gain in children aged under five with uncomplicated SAM if provided according to WHO guidelines.

Nutritional and lifestyle changes required for minimizing the recovery period in home quarantined COVID-19 patients of Punjab, Pakistan.

The COVID-19 pandemic has introduced a new battle in human history for a safe and fearless life. Therefore, this cross-sectional survey was conducted (Punjab, Pakistan) on healthy recovered, home quarantined COVID-19 patients to draw conclusive health support guidelines in the fight against this pandemic. COVID-19 recovered patients (n = 80) of age ≥14 years were randomly selected during the period November 2020 to February 2021. A nutrition and lifestyle changes questionnaire, containing ten sections and seventy questions, was completed through the telephone/WhatsApp. Data were transferred into an Excel spreadsheet and statistically analyzed by applying chi-square, correlation, and a t test of independent values using SPSS-16 software. The patients had an age range of 14 to 80 years, of which 52 (65%) were male and 28 (35%) were female, and 32 (40%) had a normal BMI. The patients had a peak COVID-19 recovery period of 2 weeks, and a mean recovery period of 2.8 ± 1.4 weeks. Certain variables, including gender (males), age (>40 years), sleep (≤5 hr), less/no physical activity, obesity, diabetes mellitus, and autoimmune diseases, were significantly associated with delayed recovery. Poor nutritional outcomes, including lower intakes of water, legumes, nuts, meat, and milk/yogurt; and higher consumption of fast/fried/junk/spicy foods and cold water/drinks, were also significantly associated with a longer recovery period. The results were similar for not taking daily doses of multivitamins, and vitamins C, D, E, and zinc. This study identified that staying physically active, maintaining sensible body weight, having a sleep of 7 hr, consuming more foods of plant origin especially plant-based proteins from nuts and legumes, taking supplemental doses of multivitamins, vitamin D, E, and zinc, along with drinking ≥2 L of water daily can provide a significant role in early and safe recovery from COVID-19.

Comparative analysis of developmental profile between normal and severe acute malnourished under-five children in Pakistan: a multicentre cross-sectional study.

OBJECTIVES: This study aims to compare the developmental profile of severe acute malnourished (SAM) and normal under-five children and to find sociodemographic determinants accountable for their developmental disabilities. SETTING: We conducted a multi-centre cross-sectional study in three basic health units and one rural health centre in Pakistan. PARTICIPANTS: 200 children (SAM and healthy) aged 6-59 months. PRIMARY AND SECONDARY MEASURES: We screened for nutritional status and clinical complications. Children underwent for developmental assessment by Denver Development Screening Tool II. A pretested structured questionnaire on sociodemographic characteristics and nutrition was used for collecting data about determinants of developmental delay. RESULTS: We observed statistically significant differences in anthropometric measurements among SAM compared with normal nourished in weight, height, mid-upper arm circumference and weight-for-height z-scores. SAM serves as a significant risk factors (p<0.001) for delayed personal or social development (69% vs 11%; OR (95% CI)=18.01 (8.45 to 38.37)), delayed fine motor development (39% vs 8%; OR (95% CI)=7.35 (3.22 to 16.81)), delayed language development (32% vs 8%; OR (95% CI)=5.41 (2.35 to 12.48)), delayed gross motor development (34% vs 10%; OR (95% CI)=4.64 (2.14 to 10.05)) and delayed global development (66% vs 20%; OR (95% CI)=7.77 (4.09 to 14.74)). Applying logistic regression, personal or social development (p<0.001) and language development (p<0.05), under-five siblings was a risk factor, while among gross motor development, mother's educational status (p<0.05) was a significant risk factor for developmental delay. CONCLUSIONS: Our analysis indicates that children with malnutrition have a high frequency of developmental delays. Missing maternal education and a higher number of under-five siblings are also potential risk factors for developmental delay.

Developmental delay and its predictors among children under five years of age with uncomplicated severe acute malnutrition: a cross-sectional study in rural Pakistan.

BACKGROUND: In developing countries, malnutrition in children and developmental delays are two major challenges for public health. To achieve the vision of the Sustainable Development Goals from the broader perspective of child health, early identification of developmental delays and timely intervention are crucial. The aim of this study is to assess the prevalence of suspected developmental delay and their predictors in children under the age of 5 years with uncomplicated severe acute malnutrition in rural areas of Pakistan. METHODS: A multicentre cross-sectional study was conducted among 185 children with uncomplicated severe acute malnutrition. We screened children aged 6-59 months for their nutritional status and clinical complications. Children fulfilling the inclusion criteria underwent the Denver Development Screening Tool II (DDST-II). The children's global developmental profile was calculated according to the established protocols of DDST-II, which are based on four important domains of development: personal and social behaviour, language, gross motor adaptive skills and fine motor adaptive skills. A pretested questionnaire was used to collect data on socio-demographic and nutritional factors for assessing predictors of developmental delay, which were analysed using a multivariate logistic regression model. RESULTS: Out of 177 children with severe acute malnutrition, 69 (38.9%) had normal global development and 108 (61.1%) had delayed global development. Significant associations were found between global developmental delay and younger children (6-24 months vs. 25-59 months; AOR = 4.53, 95% CI: 1.56-13.10, p < 0.01), children who were not exclusively breastfed (AOR = 3.07, 95% CI: 1.24-7.56, p = 0.01), and a history of contact with a tuberculosis smear-positive adult (AOR = 2.67, 95% CI: 1.30-5.49, p < 0.01). CONCLUSION: About two thirds of the study participants showed delayed or unstable global development. Thus, according to DDST-II-established protocols, there is a high prevalence of suspected developmental delay among children under the age of five years with uncomplicated severe acute malnutrition in rural areas of Pakistan. Children in their first 2 years of life were at particularly high risk due to insufficient breastfeeding. This emphasizes the need to provide adequate infrastructure and information to parents for the prevention of developmental delay in remote areas.

Experiences of frontline Pakistani emigrant physicians combating COVID-19 in the United Kingdom: a qualitative phenomenological analysis.

BACKGROUND: This study aims to explore the experiences, beliefs, feelings, and challenges faced by Pakistani migrant doctors working in the United Kingdom in times of the COVID-19 pandemic. The qualitative study aims to explore the lived experiences, beliefs, feelings, and challenges faced by Pakistani migrant physicians working in the United Kingdom during the COVID-19 pandemic. METHODS: An exploratory phenomenological approach was used to collate data on experiences expressed during the COVID-19 pandemic. Purposive and snowball sampling was used to target participants, which were doctors of Pakistani origin involved in the direct care and management of COVID-19 patients in different NHS hospitals of the United Kingdom. Semi-structured, in-depth telephonic interviews were conducted with study participants in May 2020. Data analysis was done parallel with data collection by using an inductive qualitative approach. RESULTS: We recruited ten frontline physicians. Four theme categories emerged from the data analysis: 1) Working across borders and cultures, 2) Role of beliefs for coping with stress and fear, 3) Passion and profession, and 4) Scaffolding the Pakistani health system. Overall, the results show that the participants received limited professional support, in terms of counseling and psychological rehabilitation. Instead, they had to use self-management strategies to cope with the situation. CONCLUSION: The intensive work exhausted participants physically and emotionally. They were holding a lot of grief and hurt inside, but still, healthcare professionals showed the spirit of professional dedication to overcome difficulties. Although currently coping with their emotional problems, comprehensive professional support should be made available to cater to the wellbeing of frontline physicians.

High-dose vitamin D3 in the treatment of severe acute malnutrition: a multicenter double-blind randomized controlled trial.

Background: Vitamin D deficiency is common in children with severe acute malnutrition, in whom it is associated with severe wasting. Ready-to-use therapeutic food (the standard treatment) contains modest amounts of vitamin D that do not reliably correct deficiency. Objective: The aim of this study was to determine whether high-dose oral vitamin D3 enhances weight gain and development in children with uncomplicated severe acute malnutrition. Design: We conducted a randomized placebo-controlled trial of high-dose vitamin D3 supplementation in children aged 6-58 mo with uncomplicated severe acute malnutrition in Pakistan. Participants were randomly assigned to receive 2 oral doses of 200,000 IU vitamin D3 or placebo at 2 and 4 wk after starting ready-to-use therapeutic food. The primary outcome was the proportion of participants gaining >15% of baseline weight at 8 wk after starting ready-to-use therapeutic food (the end of the study). Secondary outcomes were mean weight-for-height or -length z score and the proportion of participants with delayed development at the end of the study (assessed with the Denver Development Screening Tool II), adjusted for baseline values. Results: Of the 194 randomly assigned children who started the study, 185 completed the follow-up and were included in the analysis (93 assigned to intervention, 92 to control). High-dose vitamin D3 did not influence the proportion of children gaining >15% of baseline weight at the end of the study (RR: 1.04; 95% CI: 0.94,1.15, P = 0.47), but it did increase the weight-for-height or -length z score (adjusted mean difference: 1.07; 95% CI: 0.49,1.65, P < 0.001) and reduce the proportion of participants with delayed global development [adjusted RR (aRR): 0.49; 95% CI: 0.31, 0.77, P = 0.002], delayed gross motor development (aRR: 0.29; 95% CI: 0.13, 0.64, P = 0.002), delayed fine motor development (aRR: 0.59; 95% CI: 0.38, 0.91, P = 0.018), and delayed language development (aRR: 0.57; 95% CI: 0.34, 0.96, P = 0.036). Conclusions: High-dose vitamin D3 improved the mean weight-for-height or -length z score and developmental indexes in children receiving standard therapy for uncomplicated severe acute malnutrition in Pakistan. This trial was registered at clinicaltrials.gov as NCT03170479.