Exploring gestational age, and birth weight assessment in Thatta district, Sindh, Pakistan: Healthcare providers' knowledge, practices, perceived barriers, and the potential of a mobile app for identifying preterm and low birth weight.

INTRODUCTION: Reliable methods for identifying prematurity and low birth weight (LBW) are crucial to ending preventable deaths in newborns. This study explored healthcare providers' (HCPs) knowledge, practice, perceived barriers in assessing gestational age and birth weight and their referral methods for preterm and LBW infants. The study additionally assessed the potential of using a mobile app for the identification and referral decision of preterm and LBW. METHODS: This qualitative descriptive study was conducted in Thatta District, Sindh, Pakistan. Participants, including doctors, nurses, lady health visitors, and midwives, were purposefully selected from a district headquarter hospital, and private providers in the catchment area of Global Network's Maternal and Newborn Health Registry (MNHR). Interviews were conducted using an interview guide after obtaining written informed consent. Audio recordings of the interviews were transcribed and analyzed using NVIVO® software with an inductive approach. RESULTS: The HCPs had extensive knowledge about antenatal and postnatal methods for assessing gestational age. They expressed a preference for antenatal ultrasound due to the perceived accuracy, though accept practical barriers including workload, machine malfunctions, and cost. Postnatal assessment using the Ballard score was only undertaken sparingly due to insufficient training and subjectivity. All HCPs preferred electronic weighing scales for birth weight Barriers encountered included weighing scale calibration and battery issues. There was variation in the definition of prematurity and LBW, leading to delays in referral. Limited resources, inadequate education, and negative parent past experiences were barriers to referral. Foot length measurements were not currently being used. While mobile apps are felt to have potential, unreliable electricity supply and internet connectivity are barriers. CONCLUSION: The HCPs in this study were knowledgeable in terms of potential tools, but acknowledged the logistical and parental barriers to implementation.

Exploring Caregivers' Perspectives and Perceived Acceptability of a Mobile-Based Telemonitoring Program to Support Pregnant Women at High-Risk for Preeclampsia in Karachi, Pakistan: A Qualitative Descriptive Study.

Very little is known about the perspectives of the caregivers on the use of telemonitoring (TM) interventions in low-middle-income countries. Understanding caregivers' perspectives on TM interventions is crucial, given that caregiving activities are correlated with the social, emotional, and clinical outcomes among pregnant women. This study aims to explore caregivers' perspectives and perceived acceptability of a mobile phone-based TM program to support pregnant women at high-risk for preeclampsia. A qualitative description design was used to conduct and analyze 28 semi-structured interviews with a diverse group of caregivers. The study was conducted at the Jinnah Post Graduate Medical Center, Karachi, Pakistan. The caregivers were identified through purposive sampling and additional caregivers were interviewed until the point of data saturation. The conventional content analysis technique was used to analyze digital audio recordings of the caregiver interviews. All caregivers embraced the proposed mobile phone-based TM program because they perceived many benefits, including a reduction in caregivers' anxiety and workload, increased convenience, and cost-effectiveness. However, the caregivers cited several caveats to the future implementation of the TM program including the inability of some women and caregivers to use the TM program and the poor acceptance of the TM system among less educated and non-tech savvy families. Our study recommends developing a TM program to reduce the caregiver stress and workload, designing a context-specific TM program using a user-centric approach, training caregivers on the use of the TM program, sensitizing caregivers on the benefits of the TM program, and developing a low-cost TM program to maximize access.

Understanding the mental health impact and needs of public healthcare professionals during COVID-19 in Pakistan : a qualitative study.

OBJECTIVES: A dearth of qualitative studies constrains in-depth understanding of health service providers' perspectives and experiences regarding the impact of COVID-19 on their mental health. This study explored the mental health impact and needs of of public sector healthcare workers during COVID-19 who working in secondary-level and tertiary-level healthcare settings of Pakistan. DESIGN: An exploratory qualitative study. SETTING: Twenty-five secondary-level and eight tertiary-level public hospitals of Sindh and Punjab provinces of Pakistan. PARTICIPANTS: In-depth interviews were conducted with 16 health service providers and 40 administrative personnel. Study data were analysed on NVivo V.11 using the conventional content analysis technique. RESULTS: The study identified three overarching themes: (1) mental health impact of COVID-19 on health service providers that included the fear of acquiring the infection and transmitting it to their family members, fear of social isolation and stigma, anxiety related to the uncertainty of COVID-19, nervousness due to media exaggeration and stress associated with excessive workload; (2) mental health needs of health service providers involved in the COVID-19 crisis and available support from the healthcare system, including the expression of the need for counselling services and safe working conditions, the need for paid rest periods, and the need for appreciation and motivation to work in the pandemic; and (3) suggestions to address mental health needs of healthcare workers, including provision of specialised mental healthcare/services, formal training of health managers on managing mental health needs of health facility staff, and assessment and addressing of these needs of the health workforce. CONCLUSION: The study emphasises the need to strengthen health system preparedness for recognising and addressing the needs of healthcare professionals. At the system level, there is a need for a specialised unit to provide mental health services and better communication strategies. At the staff level, continuous motivation and appreciation should be given to healthcare professionals either through monetary incentives or formal acknowledgement of their performance.

Facilitators and barriers influencing utilization of services provided by community midwives in district Thatta, Pakistan: a qualitative exploratory study.

BACKGROUND: To address the issue of high maternal mortality, the Government of Pakistan initiated a community midwifery program in 2006 to provide skilled birth attendance to women living in rural areas. Despite a large investment in the community midwifery program, research evidence from rural districts of Pakistan suggests that the utilization of maternal and newborn services through community midwives is very low. This exploratory study aimed to understand the facilitators and barriers influencing community midwives' services utilization in district Thatta. METHODS: A qualitative study was conducted in the rural district Thatta, Pakistan. Key-informant interviews (KIIs) were conducted with district officials of the Health department (Thatta), Maternal and Newborn Child Health Program, and Midwifery Association of Pakistan (MAP). In-depth Interviews (IDIs) were conducted with midwifery students who were currently enrolled in the midwifery program of the district; trained community midwives providing services in district Thatta, and trained community midwives not continuing their profession. IDIs were also conducted with community women to explore their views about the scope of midwifery practice and the factors influencing the utilization of community midwives' services in district Thatta, Pakistan. Data were analyzed using qualitative thematic analysis. RESULTS: A total of 25 interviews (KIIs = 5; IDIs = 20) were conducted. Two overarching themes were identified: (I) community midwives' skills and competencies; and (II) ownership and supportive supervision. The major hindering factors for community midwives' service utilization included deficiencies in community midwives' training particularly in clinical hands-on training, lack of ownership of community midwifery program, and lack of service structure by the CMWs regulatory body. CONCLUSION: The study has identified serious gaps in the CMWs program at the level of training and supervision of midwives in Pakistan. The study has also identified factors related to the training of CMWs that could facilitate the program in the context of Pakistan and similar settings.

Role of COVID-19 pandemic in the academic life and well-being of private sector university students: an exploratory qualitative study.

OBJECTIVE: The advent of the COVID-19 pandemic has caused a drastic impact on students' life, causing physical and emotional sufferings. Considering the relevance of unprecedented conditions, we explored perceptions and attitudes of students towards their academic life and well-being amid the COVID-19 pandemic. SETTING: We conducted an exploratory qualitative study using a purposive sampling approach conducted at a single-centre private nursing institution in Karachi, Pakistan. PARTICIPANTS: The current study used in-depth interviews with female university students. Study data were analysed manually using the thematic analysis approach. PRIMARY OUTCOME: The primary outcome is to explore perception of students on academic life and well-being amidst the COVID-19 pandemic. RESULTS: A total of 10 in-depth interviews were conducted between August and September 2020. Four overarching themes were identified: (1) impact of COVID-19 on students' well-being; (2) effect of COVID-19 on students' academic life; (3) current coping mechanisms adopted by students and (4) recommendations to address students' concerns. The pandemic-related stressors served as a major impediment on students' motivation, concentration span and socioeconomic conditions which negatively influenced their well-being and academic life. However, students have adopted diverse coping mechanisms to combat unstable circumstances that include connecting with family and relatives, indulging in diverse activities, and getting academic support from faculty, senior students, and university administration. Students also recommended the need for arranging online mental health services, integrating e-learning mediums in existing academia, and constant efforts by the government to address electricity and internet connectivity issues to promote virtual learning. CONCLUSION: University students have been struck hard due to rapid pandemic-related transitions in their life. The study finding served as the potential guide for educational institutions and government officials to employ appropriate psychological interventions and provide infrastructure and technical facilities to provide support with their academic journey and overcoming the ongoing pandemic repercussions.

Understanding the Needs of a Mobile Phone-Based Telemonitoring Program for Pregnant Women at High Risk for Pre-Eclampsia: Interpretive Qualitative Description Study.

BACKGROUND: Lack of early risk detection, diagnosis, and treatment of pregnant women at high risk for pre-eclampsia can result in high maternal mortality and morbidity not only in Pakistan but also in other low- to middle-income countries (LMICs). A potential tool for supporting pregnant women at high risk for pre-eclampsia for early detection is telemonitoring (TM). However, there is a limited body of evidence on end-user needs and preferences to inform the design of the TM programs for pregnant women at high risk for pre-eclampsia, specifically in LMICs such as Pakistan. OBJECTIVE: This study aims to explore the needs of TM for pregnant women at high risk for pre-eclampsia in Karachi, Pakistan, to inform a potential future feasibility trial of a mobile phone-based TM program. METHODS: An interpretive qualitative description approach was used to conduct and analyze 36 semistructured interviews with 15 (42%) pregnant women and 21 (58%) key informants, including clinicians; nurses; maternal, neonatal, and child health specialists; and digital health experts to explore the perspectives, needs, and preferences of a mobile phone-based TM program to support pregnant women at high risk for pre-eclampsia. Pregnant women were identified through heterogeneous sampling, whereas key informants were selected through purposive sampling. The interview transcripts were analyzed using a conventional content analysis technique. RESULTS: The following four themes emerged from the analysis of the transcripts: poor use of antenatal care during pregnancy, the value of a TM program in high-risk pregnancy, barriers influencing the adoption of TM programs and potential strategies, and considerations for implementing TM programs. The pregnant women and health care providers were willing to use a TM program as they perceived many benefits, including early identification of pregnancy complications, prompt treatment, convenience, cost-effectiveness, increased sense of empowerment for one's health care, improved care continuity, and reduced clinical workload. However, some providers and pregnant women mentioned some concerns regarding the adoption of a TM program, including malfunctioning and safety concerns, potential inaccuracy of blood pressure machines, increased clinical workload, and resistance to learning new technology. Our study recommends building the capacity of patients and providers on TM program use, sensitizing the community and family members on the usefulness of the TM program, using an approach incorporating user-centered design and phased implementation to determine the clinical workload and whether additional staff for the TM program is required, and ensuring greater levels of co-design and the engagement of consumer representatives. CONCLUSIONS: Our findings highlight the perceived feasibility of a mobile phone-based TM program for pregnant women at high risk for pre-eclampsia and provide insights that can be directly used for the design of future TM programs with the aim of reducing mortality and morbidity from pre-eclampsia and eclampsia in LMICs.

Virtual Primary Care Implementation During COVID-19 in High-Income Countries: A Scoping Review.

Background: The purpose of this scoping review was to map the challenges, strategies, and lessons learned from high-income countries that can be mobilized to inform decision-makers on how to best implement virtual primary care services during and after the COVID-19 pandemic. Findings of our scoping review identified the barriers and strategies within the Quadruple Aim components, which may prove to be an effective implementation strategy for virtual care adoption in primary care settings. Materials and Methods:The two concepts of virtual care and COVID-19 were searched in MEDLINE, EMBASE, and CINAHL on August 10, 2020, and Scopus was searched on August 15, 2020. The database searches returned 10,549 citations and an additional 766 citations were retrieved from searching the citations from the reference lists of articles that met all inclusion criteria. A total of 1,260 full-text articles were reviewed of which 38 articles met the eligibility criteria for inclusion in the review. Results: Seven key barriers and strategies were identified for the implementation of virtual primary care. Of the 38 articles included, the key barriers identified were equitable access to care (n = 20; 53%), lack of funding for virtual care (n = 14; 37%), negative patient and clinician perception (n = 11, 29%), lack of regulatory policies (n = 10, 26%), inadequate clinical workflows (n = 9, 21), lack of virtual care infrastructure (n = 8, 21%), and insufficient virtual care training and education (n = 5, 13%). Strategies included the following: increased funding (n = 15, 39%), improving clinical workflows (n = 13, 34%), appropriate education and training (n = 11, 29%), improving virtual care infrastructure and patient equity (n = 7, 18%), establishing regulatory policies (n = 5, 13%), and improving patient and clinician perceptions (n = 3, 7%). Conclusions: As many countries enter potential subsequent waves of the COVID-19 pandemic, applying early lessons learned to mitigate implementation barriers can help with the transition to equitable and appropriate virtual primary care services.

Impact of COVID-19 on mental health of primary healthcare workers in Pakistan: lessons from a qualitative inquiry.

OBJECTIVES: The existing literature regarding the mental health consequences of COVID-19 among healthcare workers revolves predominantly around specialised hospital settings, while neglecting primary healthcare workers (PHCW) who are the first point of contact for patients. In view of negligible evidence, this study explored the mental health impact of COVID-19 and health system response, and sought suggestions and recommendations from the PHCWs to address their mental health needs during the pandemic crisis. DESIGN: We employed a qualitative exploratory design. SETTING: A total of 42 primary healthcare facilities across 15 districts in Sindh and Punjab provinces of Pakistan. PARTICIPANTS: We telephonically conducted 47 in-depth interviews with health service providers and hospital managers. A combination of inductive and deductive approach was used for data analyses using NVivo V.11.0. RESULTS: There was immense fear, stress and anxiety among PHCWs being infected and infecting their families at the beginning of this outbreak and its peak which tapered off over time. It was triggered by lack of information about the virus and its management, false rumours, media hype, lack of personal protective measures (personal protective equipment, PPE) and non-cooperation from patients and community people. Trainings on awareness raising and the PPEs provided by the healthcare system, with emotional support from coworkers and supervisors, were instrumental in addressing their mental health needs. Additionally, they recommended appreciation and recognition, and provision of psychosocial support from mental health professionals. CONCLUSION: Primary healthcare system should be prepared to provide timely informational (eg, continuous updates in training and guidelines), instrumental (eg, provision of PPE, appreciation and recognition), organisational (eg, safe and conducive working environment) and emotional and psychosocial support (eg, frequent or needs-based session from mental health professionals) to PHCWs in order to mitigate the mental health impact of pandemic crisis.

Changing Perceptions of Rural Frontline Workers and Caregivers About Management of Childhood Diarrhea and Pneumonia Despite Several Inequities: The Nigraan Plus Trial in Pakistan.

PURPOSE: Diarrhea and pneumonia greatly contribute to high childhood mortality in Pakistan. Frontline community health workers or the Lady Health Workers (LHWs) provide care at the doorstep of over 60% of Pakistan's rural residents. Difficult terrain, lack of supplies, and inadequate supervision put these LHWs at an added disadvantage in the timely diagnosis and delivery of known treatment options to community caregivers (CCGs). This study aims to assess whether a supportive supervision intervention through Lady Health Supervisors (LHSs) using enhanced mentorship and written feedback cards have the potential to improve case management of childhood diarrhea and pneumonia. STUDY SETTING AND DESIGN: This perception-based qualitative inquiry nested within the Nigraan Plus trial included LHSs, LHWs, and CCGs as the participants. Twenty-two in-depth interviews (IDIs) and 16 focus group discussions (FGDs) were conducted before a supportive supervision intervention in 2017, and 10 FGDs were conducted in 2019 once the intervention concluded. Data were analyzed using manual content analysis. RESULTS: The perceived ability of LHWs and LHSs to describe the danger signs of diarrhea and pneumonia, classify dehydration and relate respiratory rate to the severity of pneumonia improved over time. Appropriate prescription of zinc in diarrhea and antibiotics in pneumonia was noted. Furthermore, CCGs' trust in LHWs increased following the intervention, and they reported a growing inclination to contact LHWs as their first point of care. LHWs in the intervention arm were more satisfied with their job due to frequent supervisory visits and continuous feedback by LHSs. CONCLUSION: Despite geographic, social, and economic inequities, supportive supervision has the potential to improve knowledge, practice, and skills of frontline health workers related to CCM of childhood diarrhea and pneumonia in disadvantaged rural communities. Additionally, the trust of CCGs in the health workers' ability to manage such cases is also enhanced.

Exploring digital health interventions to support community health workers in low-and-middle-income countries during the COVID-19 pandemic: a scoping review protocol.

INTRODUCTION: COVID-19 has significantly affected community health workers' (CHWs) performance as they are expected to perform pandemic-related tasks along with routine essential healthcare services. A plausible way to optimise CHWs' functioning during this pandemic is to couple the efforts of CHWs with digital tools. So far, no systematic evidence is available on the use of digital health interventions to support CHWs in low-middle-income countries (LMICs) amid the COVID-19 pandemic. The article describes a protocol for a scoping review of primary research studies that aim to map evidence on the use of unique digital health interventions to support CHWs during COVID-19 in LMICs. METHODS AND ANALYSIS: Our methodology has been adapted from scoping review guidelines provided by Arksey and O'Malley, Levac et al. and the Joanna Briggs Institute. Our search strategy has been developed for the following four main electronic databases: Excerpta Medica Database, Medical Literature Analysis and Retrieval System Online, Cochrane Central Register of Controlled Trials and Cumulated Index to Nursing and Allied Health Literature. Google Scholar and reference tracking will be used for supplementary searches. Each article will be screened against eligibility criteria by two independent researchers at the title and abstract and full-text level. The review will include studies that targeted digital health interventions at CHWs' level to provide support in delivering COVID-19-related and other essential healthcare services. A date limit of 31 December 2019 to the present date will be placed on the search and English language articles will be included. ETHICS AND DISSEMINATION: Formal ethical approval is not required, as primary data will not be collected in this study. The results from our scoping review will provide valuable insight into the use of digital health interventions to optimise CHWs' functioning and will reveal current knowledge gaps in research. The results will be disseminated through journal publications and conference presentations.

Health Systems Approach to Ensure Quality and Safety Amid COVID-19 Pandemic in Pakistan.

Ensuring quality and safe care during the coronavirus disease 2019 (COVID-19) pandemic offers a challenge to already strained health systems in low and middle-income countries (LMICs), such as Pakistan with less shock-absorbing capacities. There is a dearth of evidence on mechanisms to provide optimum quality care to COVID-19 patients in the resource-constrained healthcare environment. The lessons learned from the Ebola virus outbreak for the deficient health systems and quality improvement are considered to propose strengthening the health systems response to deliver quality-assured care to patients during the current pandemic. In this regard, the World Health Organization (WHO) health systems framework can serve as a guiding principle towards providing quality-assured and safe healthcare services during the ongoing pandemic in Pakistan by ensuring the availability of an adequate workforce, medical supplies and equipment, strong governance, active information system, and adequate health financing to effectively manage COVID-19. Research evidence is needed to be better prepared for an effective and coordinated health systems response to offer quality and safe care to patients. Key Words: Health systems approach, COVID-19 pandemic, Quality of healthcare, Safe care.

When COVID-19 enters in a community setting: an exploratory qualitative study of community perspectives on COVID-19 affecting mental well-being.

OBJECTIVE: The COVID-19 pandemic has resulted in an increased level of anxiety and fear among the general population related to its management and infection spread. Considering the relevance of present circumstances, we explored perceptions and attitudes of community members towards their mental well-being during the COVID-19 pandemic. SETTING: We conducted an exploratory qualitative study using a purposive sampling approach, at two communities of Karachi, Pakistan. PARTICIPANTS: In-depth interviews were conducted with community members including, young adults, middle-aged adults and older adults of both genders. Study data were analysed manually using the thematic analysis technique. PRIMARY OUTCOME: The primary outcome is assessing community perception towards their mental well-being amidst the COVID-19 pandemic. RESULTS: A total of 27 in-depth interviews were conducted, between May and June 2020. Three overarching themes were identified: (1) impact of COVID-19 on the mental health of the general communities; (2) current coping mechanisms to adapt to the new reality and (3) recommendations to address the mental health of communities. Generally, community members underwent increased anxiety and fear due to the contagious nature of the virus. Alongside, social, financial and religious repercussions of the pandemic have also heightened psychological distress among community members. However, community members were able to point out some of the coping mechanisms such as getting closer to God, connecting with family, participating in mental health sessions and resetting lives by indulging in diverse activities. Simultaneously, they also recommended the need for remote mental health services for elders and continuous efforts by the government to address the mental health needs of the community. CONCLUSION: COVID-19-associated mental health consequences have hit every individual in society. The study finding has the potential to guide the development of context-specific innovative mental health programmes to overcome the pandemic repercussions.

Health Systems Approach to Ensure Quality and Safety Amid COVID-19 Pandemic in Pakistan.

Ensuring quality and safe care during the coronavirus disease 2019 (COVID-19) pandemic offers a challenge to already strained health systems in low and middle-income countries (LMICs), such as Pakistan with less shock-absorbing capacities. There is a dearth of evidence on mechanisms to provide optimum quality care to COVID-19 patients in the resource-constrained healthcare environment. The lessons learned from the Ebola virus outbreak for the deficient health systems and quality improvement are considered to propose strengthening the health systems response to deliver quality-assured care to patients during the current pandemic. In this regard, the World Health Organization (WHO) health systems framework can serve as a guiding principle towards providing quality-assured and safe healthcare services during the ongoing pandemic in Pakistan by ensuring the availability of an adequate workforce, medical supplies and equipment, strong governance, active information system, and adequate health financing to effectively manage COVID-19. Research evidence is needed to be better prepared for an effective and coordinated health systems response to offer quality and safe care to patients. Key Words: Health systems approach, COVID-19 pandemic, Quality of healthcare, Safe care.

Using mobile phones to improve young people sexual and reproductive health in low and middle-income countries: a systematic review to identify barriers, facilitators, and range of mHealth solutions.

BACKGROUND: Globally, reproductive health programs have used mHealth to provide sexual and reproductive health (SRH) education and services to young people, through diverse communication channels. However, few attempts have been made to systematically review the mHealth programs targeted to improve young people SRH in low-and-middle-income countries (LMICs). This review aims to identify a range of different mHealth solutions that can be used for improving young people SRH in LMICs and highlight facilitators and barriers for adopting mHealth interventions designed to target SRH of young people. METHODS: Databases including PubMed, CINAHL Plus, Science Direct, Cochrane Central, and grey literature were searched between January 01, 2005 and March 31, 2020 to identify various types of mHealth interventions that are used to improve SRH services for young people in LMICs. Of 2948 titles screened after duplication, 374 potentially relevant abstracts were obtained. Out of 374 abstracts, 75 abstracts were shortlisted. Full text of 75 studies were reviewed using a pre-defined data extraction sheet. A total of 15 full-text studies were included in the final analysis. RESULTS: The final 15 studies were categorized into three main mHealth applications including client education and behavior change communication, data collection and reporting, and financial transactions and incentives. The most reported use of mHealth was for client education and behavior change communication [n = 14, 93%] followed by financial transactions and incentives, and data collection and reporting Little evidence exists on other types of mHealth applications described in Labrique et al. framework. Included studies evaluated the impact of mHealth interventions on access to SRH services (n = 9) and SRH outcomes (n = 6). mHealth interventions in included studies addressed barriers of provider prejudice, stigmatization, discrimination, fear of refusal, lack of privacy, and confidentiality. The studies also identified barriers to uptake of mHealth interventions for SRH including decreased technological literacy, inferior network coverage, and lower linguistic competency. CONCLUSION: The review provides detailed information about the implementation of mobile phones at different levels of the healthcare system for improving young people SRH outcomes. This systematic review recommends that barriers to uptake mHealth interventions be adequately addressed to increase the potential use of mobile phones for improving access to SRH awareness and services. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018087585 (Feb 5, 2018).

Equipping community health workers with digital tools for pandemic response in LMICs.

BACKGROUND: Community health workers (CHWs) are well-positioned to play a pivotal role in fighting the pandemic at the community level. The Covid-19 outbreak has led to a lot of stress and anxiety among CHWs as they are expected to perform pandemic related tasks along with the delivery of essential healthcare services. In addition, movement restrictions, lockdowns, social distancing, and lack of protective gear have significantly affected CHWs' routine workflow and performance. To optimize CHWs' functioning, there is a renewed interest in supporting CHWs with digital technology to ensure an appropriate pandemic response. DISCUSSION: The current situation has necessitated the use of digital tools for the delivery of Covid-19 related tasks and other essential healthcare services at the community level. Evidence suggests that there has been a significant digital transformation to support CHWs in these critical times such as remote data collection and health assessments, the use of short message service and voice message for health education, use of digital megaphones for encouraging behavior change, and digital contract tracing. A few LMICs such as Uganda and Ethiopia have been successful in operationalizing digital tools to optimize CHWs' functioning for Covid-19 tasks and other essential health services. CONCLUSION: Yet, in most LMICs, there are some challenges concerning the feasibility and acceptability of using digital tools for CHWs during the Covid-19 pandemic. In most cases, CHWs find it difficult to adopt and use digital health solutions due to lack of training on new digital tools, weak technical support, issues of internet connectivity, and other administrative related challenges. To address these challenges, engaging governments would be essential for training CHWs on user-friendly digital health solutions to improve routine workflow of CHWs during the Covid-19 pandemic.

A comparison of MITS counseling and informed consent processes in Pakistan, India, Bangladesh, Kenya, and Ethiopia.

Globally, more than 5 million stillbirths and neonatal deaths occur annually. For many, the cause of death (CoD) is unknown. Minimally invasive tissue sampling (MITS) has been increasingly used in postmortem examinations for ascertaining the CoD in stillbirths and neonates. Our study compared the counseling and consent methods used in MITS projects in five countries in Africa and south Asia. Key informant interviews were conducted with researchers to describe the characteristics and backgrounds of counselors, the environment and timing of consent and perceived facilitators and barriers encountered during the consent process. Counselors at all sites had backgrounds in social science, psychology and counseling or clinical expertise in obstetrics/gynecology or pediatrics. All counsellors received training about techniques for building rapport and offering emotional support to families; training duration and methods differed across sites. Counselling environments varied significantly; some sites allocated a separate room, others counselled families at the bedside or nursing stations. All counsellors had a central role in explaining the MITS procedure to families in their local languages. Most sites did not use visual aids during the process, relying solely on verbal descriptions. In most sites, parents were approached within one hour of death. The time needed for decision making by families varied from a few minutes to 24 h. In most sites, extended family took part in the decision making. Because many parents wanted burial as soon as possible, counsellors ensured that MITS would be conducted promptly after receiving consent. Barriers to consent included decreased comprehension of information due to the emotional and psychological impact of grief. Moreover, having more family members engaged in decision-making increased the complexity of counselling and achieving consensus to consent for the procedure. While each site adapted their approach to fit the context, consistencies and similarities across sites were observed.

Rigorous Hand Hygiene Practices Among Health Care Workers Reduce Hospital-Associated Infections During the COVID-19 Pandemic.

The experiences of these recent months have left us with as many new questions as they have given us new solutions. The main question that infection prevention and control department is having these days is "Why have hospital-associated infections (HAIs) reduced during COVID-19 pandemic?" What is the one unique strategy that has brought decline in increasing HAIs? Would it be appropriate to say that rigorous hand hygiene practices among health care workers (HCWs) have reduced HAIs in a tertiary care hospital of Pakistan? This commentary is written to understand the effect of rigorous hand hygiene among HCWs on number of HAIs during COVID-19 pandemic. Given the seriousness of this outbreak, it was observed that the hand hygiene has occupied a new place of importance in the minds of HCWs. We observed 4 times increase in the consumption of hand sanitizers after COVID-19 outbreak. The increased consumption of hand sanitizers was reflected in improved hand hygiene practices. A reduction was observed in the number of HAIs after the COVID-19 outbreak, and we assume that the dip in HAIs is associated with the improvement in hand hygiene practices in the recent months. In the wake of COVID-19 pandemic, these trends reassure us that hand hygiene compliance by HCWs alone can be effective in reducing HAIs in a hospital setting.

Assessing mobile phone access, usage, and willingness among women to receive voice message-based mobile health intervention to improve antenatal care attendance in district Thatta, Sindh, Pakistan.

BACKGROUND: Pakistan has one of the highest maternal mortality ratios worldwide at 276/100,000 live births and only 51% percent of women receive four or more ANC visits. This means that there are missed opportunities for almost half of the women who were not able to seek the recommended antenatal visits. In Thatta district, the maternal mortality ratio is estimated at 313/100,000 live births. Various studies reported that mHealth interventions have proven to be effective to improve antenatal care and postnatal care services. However, the feasibility and effectiveness of mobile health interventions to increase uptake of preventive maternal healthcare services among pregnant women in different settings may be different due to differing patient demographics, cultural diversity, environmental and behavioral factors, availability and accessibility to mobile phones, and budgetary constraints. Prior to implementing a similar intervention in Thatta District, it is crucially important to assess the mobile phone access, usage and willingness among women to receive voice-message based mHealth intervention to improve antenatal care attendance. METHODS: A cross-sectional quantitative study will be used to assess mobile phone access, usage and willingness among women to receive voice-message based mHealth intervention to improve antenatal care attendance in district Thatta. The study will be conducted in Thatta district of Sindh province. Married women of reproductive age (MWRA), who are residing in selected villages of Mirpur Sakro and willing to participate will be included in the study. Multistage sampling technique will be used to recruit the 415 study participants. A structured questionnaire has been designed on Epicollect to collect data from 415 women. Data will be analyzed using IBM SPSS Statistics version 23, with a level of significance as < 0.05. DISCUSSION: This research project will provide invaluable information on the current access, usage of mobile phones among women of district Thatta and their willingness to receive voice messages to improve the antenatal care services. The study will also highlight demographic, sociocultural and economic factors associated with women willingness and readiness to receive voice messages regarding antenatal care.