Diabetic retinopathy service delivery and integration into the health system in Pakistan-Findings from a multicentre qualitative study.

This paper is based on qualitative research carried out in a diabetic retinopathy (DR) programme in three districts of Pakistan. It analyses the organisation and delivery of DR services and the extent to which the interventions resulted in a fully functioning integrated approach to DR care and treatment. Between January and April 2019, we conducted 14 focus group discussions and 37 in-depth interviews with 144 purposively selected participants: patients, lady health workers (LHWs) and health professionals. Findings suggest that integration of services was helpful in the prevention and management of DR. Through the efforts of LHWs and general practitioners, diabetic patients in the community became aware of the eye health issues related to uncontrolled diabetes. However, a number of systemic pressure points in the continuum of care seem to have limited the impact of the integration. Some components of the intervention, such as a patient tracking system and reinforced interdepartmental links, show great promise and need to be sustained. The results of this study point to the need for action to ensure inclusion of DR on the list of local health departments' priority conditions, greater provision of closer-to-community services, such as mobile clinics. Future interventions will need to consider the complexity of adding diabetic retinopathy to an already heavy workload for the LHWs.

School-based vision screening in Quetta, Pakistan: a qualitative study of experiences of teachers and eye care providers.

BACKGROUND: Visual impairment in children is a significant public health problem affecting millions of children globally. Many eye problems experienced by children can be easily diagnosed and treated. We conducted a qualitative study with teachers and optometrists involved in a school-based vision screening programme in Quetta district of Pakistan to explore their experiences of training, vision screening and referrals and to identify factors impacting on the effectiveness of the programme. METHODS: Between April 2018 and June 2018, we conducted semi-structured in-depth interviews with 14 teachers from eight purposefully selected schools with high rates of inaccurate (false positive) referrals. Interviews were also conducted with three optometrists from a not-for profit private eye care hospital that had trained the teachers. Interviews were audio recorded and professionally transcribed. NVIVO software version 12 was used to code and thematically analyze the data. RESULTS: Findings suggest that the importance of school-based vision screening was well understood and appreciated by the teachers and optometrists. Most participants felt that there was a strong level of support for the vision screening programme within the participating schools. However, there were a number of operational issues undermining the quality of screening. Eight teachers felt that the duration of the training was insufficient; the training was rushed; six teachers said that the procedures were not sufficiently explained, and the teachers had no time to practice. The screening protocol was not always followed by the teachers. Additionally, many teachers reported being overburdened with other work, which affected both their levels of participation in the training and the time they spent on the screening. CONCLUSIONS: School-based vision screening by teachers is a cost-effective strategy to detect and treat children's vision impairment early on. In the programme reviewed here however, a significant number of teachers over referred children to ophthalmic services, overwhelming their capacity and undermining the efficiency of the approach. To maximise the effectiveness and efficiency of school-based screening, future initiatives should give sufficient attention to the duration of the teacher training, experience of trainers, support supervision, refresher trainings, regular use of the screening guidelines, and the workload and motivation of those trained.

Understanding the role of lady health workers in improving access to eye health services in rural Pakistan - findings from a qualitative study.

BACKGROUND: In 1994, the Lady Health Workers (LHWs) Programme was established in Pakistan to increase access to essential primary care services and support health systems at the household and community levels. In Khyber Pakhtunkhwa (KPK) province in northern Pakistan, eye care is among the many unmet needs that LHWs were trained to address, including screening and referral of people with eye conditions to health facilities. However, despite an increase in referrals by LHWs, compliance with referrals in KPK has been very low. We explored the role of LHWs in patient referral and the barriers to patient compliance with referrals. METHODS: Qualitative methodology was adopted. Between April and June 2019, we conducted eight focus group discussions and nine in-depth interviews with 73 participants including patients, LHWs and their supervisors, district managers and other stakeholders. Data were analysed thematically using NVivo software version 12. RESULTS: LHWs have a broad understanding of basic health care and are responsible for a wide range of activities at the community level. LHWs felt that the training in primary eye care had equipped them with the skills to identify and refer eye patients. However, they reported that access to care was hampered when referred patients reached hospitals, where disorganised services and poor quality of care discouraged uptake of referrals. LHWs felt that this had a negative impact on their credibility and on the trust and respect they received from the community, which, coupled with low eye health awareness, influenced patients' decisions about whether to comply with a referral. There was a lack of trust in the health care services provided by public sector hospitals. Poverty, deep-rooted gender inequities and transportation were the other reported main drivers of non-adherence to referrals. CONCLUSIONS: Results from this study have shown that the training of LHWs in eye care was well received. However, training alone is not enough and does not result in improved access for patients to specialist services if other parts of the health system are not strengthened. Pathways for referrals should be agreed and explicitly communicated to both the health care providers and the patients.

Chromium retention potential of two contrasting Solanum lycopersicum Mill. cultivars as deciphered by altered pH dynamics, growth, and organic acid exudation under Cr stress.

Chromium (Cr), being a persistent toxic heavy metal, triggered the retardation of plant's metabolic processes by initiating changes in rhizospheric zone. Current study focused the Cr accumulation potential of two tomato (Solanum lycopersicum Mill.) cultivars through alterations of rhizospheric pH and exudation of organic acids together with plant's ionomics and morpho-physiological responses. Four-week-old seedlings of tomato cultivars (cv. Nakeb and cv. Nadir) were maintained in hydroponic solutions supplemented with 0, 100, 200, and 300 mg/L K2Cr2O7 and a start pH of 6.0. The pH of the growth medium was monitored twice a day up to 6 days as well as mineral contents and morpho-physiological attributes were recorded by harvesting half of plants after 1 week. The remaining half plants were shifted to rhizoboxes for the collection of root exudates. After 6 days, cv. Nakeb exhibited medium acidification by 0.7 units while cv. Nadir showed basification by 0.6 units under 300 mg/L treatment. Increase in applied Cr levels enhanced the root and shoot Cr accumulation in both cultivars with concomitant reduction in growth and accumulation of nutrients (Fe, Zn, K, Mg, and Ca). However, this reduction in biomass and nutrient acquisition was predominant in cv. Nakeb as compared to cv. Nadir. The release of organic acid exudates (citric, acetic, maleic, tartaric, and oxalic acids) was also recorded higher in cv. Nadir at 300 mg/L applied Cr level. This enhanced production of organic acids caused greater retention of mineral nutrients and Cr in cv. Nadir, probably due to growth medium basification. Enhanced exudations of di- and tri- carboxylic organic acids together with accumulation of mineral nutrients are the physiological and biochemical indicators which confer this genotype a better adaptation to Cr polluted biotic systems. Furthermore, it was perceived that organic acid and rhizospheric pH variation response by studied tomato cultivars under Cr stress is an important factor to be considered in food safety and metal remediation programs.

Knowledge of personal and sexual development amongst young people in Pakistan.

Pakistan has one of the largest cohorts of young people in its history, yet research on their circumstances and needs is still relatively new. In this study, twenty four focus group discussions were conducted to explore young peoples' experiences of gaining knowledge of personal and sexual development. Young women typically gained information from a limited number of sources within the home, while young men accessed a wide variety of information sources outside the home. Gaining information was frequently event-based, whereby specific events (i.e. puberty, marriage) trigger information provision to young people, however often too late to be educative. Overall, young people were critical of the quality of information they received, which often led to confusion and stress in understanding sexual development. Findings highlight a gap in formal systems of information provision. Although young people highlighted the merits of school-based information delivery, low school attendance and high drop-out rates amongst girls mean that alternative mechanisms of reaching young Pakistani women need to be identified.