Usability and Acceptability of a Mobile App for Behavior Change and to Improve Immunization Coverage among Children in Pakistan: A Mixed-Methods Study.

BACKGROUND: Pakistan's immunization uptake rates are still significantly lower than anticipated despite several initiatives. Lack of awareness, forgetting about vaccination schedule, and vaccine misconception/misinformation are a few of the major drivers that mitigate the rates of immunization. The current COVID-19 pandemic emphasizes the importance of immunization. The significant reductions in regular childhood vaccination during pandemic have increased the risk of outbreaks of vaccine-preventable diseases. Concerns among parents over possibly exposing their children to COVID-19 during child visits may have contributed to the reported declines. Innovative and cost-effective mHealth interventions must be implemented in order to address the problem of inadequate immunization rates. In addition, it is also critical to understand the end user needs in order to reflect on the highly relevant essence of the customized healthcare experience. OBJECTIVE: The aim of this study was to learn about caregivers' attitudes toward the usability and acceptability of behavior-change smartphone applications (mobile phones) for improving immunization coverage in Pakistan. METHODS: A mixed-method design was employed for this study. The study was conducted at Aga Khan University, Hospital. Parents visiting the Community Health Center for 6-week vaccination of their children were recruited. The study was conducted in two stages. Stage 1 consisted of qualitative interviews that grasped the parent's attitudes and challenges to immunization, as well as their acceptability and accessibility of the smartphone-based behavior-change application to increase vaccine uptake. Stage 1 was followed by stage 2, in which data were collected through a questionnaire designed by using data from qualitative interviews. RESULTS: The majority of participants agreed that immunization serves an important role in protecting their child from illnesses that cause morbidity and mortality. Almost all of them emphasized the importance of using a pre-appointment method at vaccination center in order to reduce the waiting time. Furthermore, participants were also interested in AI-based behavior modification applications related to immunization. They also wanted to have applications in their native language for better understanding and communication of related information. In our study, approximately 95.2 percent of participants agreed to accept SMS immunization updates, which was also reasonably high. Lastly, the majority of them identified forgetfulness as a significant contributor to regular immunization. CONCLUSION: To enhance the uptake of childhood vaccines, overall vaccination rates, and overcome barriers related to vaccination coverage, cost-effective and user-friendly mHealth AI-based smart phone applications are required to raise awareness regarding the continuation of vaccination service and the importance of timely vaccination. Parents' experiences and attitudes must be considered while designing and evaluating the efficacy of mHealth-based interventions.

The Influence of Person-Environment Fit on the Turnover Intention of Nurses in Jordan: The Moderating Effect of Psychological Empowerment.

There is an acute shortage of nurses worldwide, including in Jordan. The nursing shortage is considered to be a crucial and complex challenge across healthcare systems and has stretched to a warning threshold. High turnover among nurses in Jordan is an enduring problem and is believed to be the foremost cause of the nurse shortage. The purpose of this study was to investigate the multidimensional impact of the person-environment (P-E) fit on the job satisfaction (JS) and turnover intention (TI) of registered nurses. The moderating effect of psychological empowerment (PE) on the relationship between JS and TI was also investigated. Based on a quantitative research design, data were collected purposively from 383 registered nurses working at private Jordanian hospitals through self-administered structured questionnaires. Statistical Package for Social Sciences (SPSS) 25 and Smart Partial Least Squares (PLS) 3.2.8 were used to analyze the statistical data. The results showed that there is a significant relationship between person-job fit (P-J fit), person-supervisor fit (P-S fit), and JS. However, this study found an insignificant relationship between person-organization fit (P-O fit) and JS. Moreover, PE was also significantly moderate between JS and TI of nurses. This study offers an important policy intervention that helps healthcare organizations to understand the enduring issue of nurse turnover. Additionally, policy recommendations to mitigate nurse turnover in Jordan are outlined.

An Artificial Intelligence-Based, Personalized Smartphone App to Improve Childhood Immunization Coverage and Timelines Among Children in Pakistan: Protocol for a Randomized Controlled Trial.

BACKGROUND: The immunization uptake rates in Pakistan are much lower than desired. Major reasons include lack of awareness, parental forgetfulness regarding schedules, and misinformation regarding vaccines. In light of the COVID-19 pandemic and distancing measures, routine childhood immunization (RCI) coverage has been adversely affected, as caregivers avoid tertiary care hospitals or primary health centers. Innovative and cost-effective measures must be taken to understand and deal with the issue of low immunization rates. However, only a few smartphone-based interventions have been carried out in low- and middle-income countries (LMICs) to improve RCI. OBJECTIVE: The primary objectives of this study are to evaluate whether a personalized mobile app can improve children's on-time visits at 10 and 14 weeks of age for RCI as compared with standard care and to determine whether an artificial intelligence model can be incorporated into the app. Secondary objectives are to determine the perceptions and attitudes of caregivers regarding childhood vaccinations and to understand the factors that might influence the effect of a mobile phone-based app on vaccination improvement. METHODS: A mixed methods randomized controlled trial was designed with intervention and control arms. The study will be conducted at the Aga Khan University Hospital vaccination center. Caregivers of newborns or infants visiting the center for their children's 6-week vaccination will be recruited. The intervention arm will have access to a smartphone app with text, voice, video, and pictorial messages regarding RCI. This app will be developed based on the findings of the pretrial qualitative component of the study, in addition to no-show study findings, which will explore caregivers' perceptions about RCI and a mobile phone-based app in improving RCI coverage. RESULTS: Pretrial qualitative in-depth interviews were conducted in February 2020. Enrollment of study participants for the randomized controlled trial is in process. Study exit interviews will be conducted at the 14-week immunization visits, provided the caregivers visit the immunization facility at that time, or over the phone when the children are 18 weeks of age. CONCLUSIONS: This study will generate useful insights into the feasibility, acceptability, and usability of an Android-based smartphone app for improving RCI in Pakistan and in LMICs. TRIAL REGISTRATION: ClinicalTrials.gov NCT04449107; https://clinicaltrials.gov/ct2/show/NCT04449107. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/22996.

Current Challenges of Digital Health Interventions in Pakistan: Mixed Methods Analysis.

BACKGROUND: Digital health is well-positioned in low and middle-income countries (LMICs) to revolutionize health care due, in part, to increasing mobile phone access and internet connectivity. This paper evaluates the underlying factors that can potentially facilitate or hinder the progress of digital health in Pakistan. OBJECTIVE: The objective of this study is to identify the current digital health projects and studies being carried out in Pakistan, as well as the key stakeholders involved in these initiatives. We aim to follow a mixed-methods strategy and to evaluate these projects and studies through a strengths, weaknesses, opportunities, and threats (SWOT) analysis to identify the internal and external factors that can potentially facilitate or hinder the progress of digital health in Pakistan. METHODS: This study aims to evaluate digital health projects carried out in the last 5 years in Pakistan with mixed methods. The qualitative and quantitative data obtained from field surveys were categorized according to the World Health Organization's (WHO) recommended building blocks for health systems research, and the data were analyzed using a SWOT analysis strategy. RESULTS: Of the digital health projects carried out in the last 5 years in Pakistan, 51 are studied. Of these projects, 46% (23/51) used technology for conducting research, 30% (15/51) used technology for implementation, and 12% (6/51) used technology for app development. The health domains targeted were general health (23/51, 46%), immunization (13/51, 26%), and diagnostics (5/51, 10%). Smartphones and devices were used in 55% (28/51) of the interventions, and 59% (30/51) of projects included plans for scaling up. Artificial intelligence (AI) or machine learning (ML) was used in 31% (16/51) of projects, and 74% (38/51) of interventions were being evaluated. The barriers faced by developers during the implementation phase included the populations' inability to use the technology or mobile phones in 21% (11/51) of projects, costs in 16% (8/51) of projects, and privacy concerns in 12% (6/51) of projects. CONCLUSIONS: We conclude that while digital health has a promising future in Pakistan, it is still in its infancy at the time of this study. However, due to the coronavirus disease 2019 (COVID-19) pandemic, there is an increase in demand for digital health and implementation of health outcomes following global social distancing protocols, especially in LMICs. Hence, there is a need for active involvement by public and private organizations to regulate, mobilize, and expand the digital health sector for the improvement of health care systems in countries.

Association Between Low Serum Magnesium Level And Type 2 Diabetes Mellitus In Abbottabad.

BACKGROUND: Magnesium serves as a cofactor for various oxidation reactions in the body and helps in glucose transport across cell membrane. Deficiency of magnesium is a common electrolyte abnormality in type 2 diabetic patients and is linked to development of various diabetic complications. This study was conducted to determine the association between low serum magnesium level and type 2 diabetes mellitus presenting at Medical B ward, BBS Hospital Abbottabad. METHODS: This descriptive study was conducted over a period of 6 months starting July 1, 2017. One hundred & eighty diagnosed diabetic patients aged at least 40 years, were included in the study. Their serum magnesium level was checked after withdrawing blood under strict aseptic conditions. Fasting & random blood glucose and the level of glycosylated haemoglobin were measured and age, gender, duration of illness were recorded on a proforma. RESULTS: Sixty-one patients (33.89%) had hypomagnesemia. There was no significant association between hypomagnesemia and age and sex of patients (p>0.05). However, hypomagnesemia was found to be significantly associated with the duration of diabetes mellitus among study population (p=0.02). CONCLUSIONS: Hypomagnesemia is frequently present in patients with diabetes mellitus and it appears that its prevalence increases with the duration of diabetes mellitus.

Diagnostic Utility Of Pleural Fluid Adenosine Deaminase Level In Tuberculous Pleural Effusion.

BACKGROUND: Early diagnosis and management of tuberculosis is essential for decreasing the disease burden. Pakistan is one of the few countries of world with a very high burden of tuberculosis. Many diagnostic tests are available for detection of tuberculosis but each is fraught with certain limitations of its own. METHODS: This study was a cross sectional validation study that sought to determine the validity of pleural fluid adenosine deaminase levels for diagnosis of tuberculous pleural effusion. RESULTS: A total of 160 patients with exudative lymphocytic pleural effusions were enrolled in this study. The mean pleural fluid ADA level was 52.18±1.98 U/L. The mean pleural fluid ADA level in patients diagnosed to have tuberculosis on pleural biopsy/histopathology was higher as compared to patients who did not have tuberculous pleural effusion 52.16±2.4 U/L vs 38.6±3.14 U/L. The difference was found to be statistically significant between the two groups (p<0.05). The sensitivity, specificity, ppv and npv of pleural fluid ADA level were 88.88%, 77.04%, 86.28% and 81.04% respectively. CONCLUSIONS: Despite wide variations in the reported sensitivity and specificity of pleural fluid ADA level, it can be used as a surrogate for pleural biopsy when the latter is not feasible.

Efficacy Of Local Anaesthesia In Repair Of Inguinal Hernia.

BACKGROUND: Local anaesthesia has been identified as the most favourable anaesthesia for elective inguinal hernia repair with respect to complication rate, cost effectiveness and overall patients' satisfaction. This study was conducted to determine the efficacy of local anaesthesia in inguinal hernia in terms of pain relief, wound infection and hospital stay. METHODS: In this randomized controlled trial (RCT), 60 patients with inguinal hernia were included at the General Surgical 'B' Unit, Ayub Teaching Hospital Abbottabad. RESULTS: The day-case rates were significantly higher when patients underwent surgery under LA compared to GA (82.6% versus 42.6%). The incidence of urinary retention was higher in the GA group (p<0.05). There were 17 (2.9%) re-admissions overall. The reasons for readmission included haematoma (n=6), severe pain (n=4), infection (n=3), fainting (n=2) and urinary retention (n=2). CONCLUSIONS: This study demonstrates that local anaesthesia for inguinal hernia repair has better efficacy as compared to general anaesthesia.

AN EXPERIENCE OF BRONCHOTOMY AND RESECTIONAL PROCEDURES AFTER FAILED BRONCHOSCOPIC FOERIGN BODY RETRIEVAL.

BACKGROUND: Foreign body bronchus is a surgical emergency and is associated with a high mortality if neglected or complicated. The objective of this study was to analyse the outcome of bronchotomy and resectional procedures after failed bronchoscopic foreign body retrieval. METHODS: This study of 24 cases of bronchotomy and resectional procedures after failed bronchoscopic foreign body retrieval was done from June 2008 to June 2009 and March 2010 to Sep 2013. Patients after failed retrieval of foreign body by bronchoscopy either by ENT specialists or thoracic surgeons underwent bronchotomy or resectional procedures were included in the study. We used the posterolateral thoracotomy approach for the surgical procedures. RESULTS: Bronchotomy and resectional procedures were done in 24 cases. Age of patients ranged from 2 years to 51 years. Most patients were children and right side was mostly involved. Bronchotomy procedures were 10 (41%) and resectional surgeries were 13 (58%). Emergency lobectonies were 3 out of 13 resectional surgeries. Right intermedius bronchus was opened up and incision was extended in the direction of foreign body in 6 cases and left bronchus intermedius was opened in 4 cases. Haemoptysis was the main symptom in late presenters. Range of objects retrieved in our study was from pins, needles to whistles. CONCLUSION: Retention causes endobronchial obstruction with stasis leading to irreversible damaged parenchyma. Foreign body with structural changes require resection, others can be offered bronchotomy which is a safe procedure for retained non retrievable foreign bodies.

COMPARISON OF PEAK EXPIRATORY FLOW RATE AND LIPID PROFILE IN ASYMPTOMATIC SMOKERS AND NON-SMOKERS.

BACKGROUND: Tobacco is the major risk factor for chronic obstructive airway disease (COAD), other pulmonary diseases, cancer, cardiovascular and cerebrovascular diseases. The objective of study was to determine the mean Peak Expiratory Flow Rate (PEFR) and serum lipid profile. in apparently healthy male smokers and non-smokers. METHODS: This cross-sectional study was conducted in Ayub Teaching Hospital, Abbottabad from 15th December, 2009 to 15th June, 2010. Apparently healthy smokers and non-smokers from population coming to Hospital as attendants of the patients or as employees of the hospital were inducted in the study. PEFR and lipid profile of all the subjects was accessed. RESULTS: There were total of 300 male subjects, 150 smokers and 150 non-smokers. The mean age of study subjects was 26.6 +/- 5.5 years. The mean PEFR of smokers was 450.621/min and that of non-smokers was 494.81 L/min, the difference being statistically significant (p-value <0.05).The mean total cholesterol of smokers is 5.30 +/- 0.86 mmol/l and it was 3.84 +/- 0.54 mmol/l in non-smokers. Mean serum Triacyl Glycerols (TAGs) and Low Density Lipoproteins (LDL) cholesterol of smokers was 2.04 +/- 0.38 and 3.5 +/- 0.83 mmol/l whereas it was 1.44 +/- 0.52 and 2.02 +/- 0.66 mmol/l in non-smokers. Mean High Density Lipo-protein (HDL) of smokers was 0.86 +/- 0.30 mmol/l and of non-smoke is 1.20 +/- 0.41 mmo/l. There was statistically significant difference between serum lipid profile of smokers and non-smokers (p<0.05). the mean serum Total Cholesterol (TC), TAGs and LDL were significantly higher in smokers as compared to non-smokers. However HDL was significantly lower in smokers in comparison to non-smokers. CONCLUSION: There was statistically significant difference between PEFR of smokers and non-smokers.

DEMOGRAPHICS OF TUBERCULOSIS IN DISTRICT MANSEHRA.

BACKGROUND: Tuberculosis is one of the leading causes of morbidity and mortality across the globe. Pakistan is one of the 22 high tuberculosis burden countries of the world sharing more than 80% of the global burden of tuberculosis. METHODS: This study was a retrospective case-based study that analyzed secondary data obtained from TB-03 form at the office of the District Tuberculosis Control Officer (DTO), Mansehra. Data was entered into SPSS-20 and analysed. RESULTS: A total of 625 patients with a mean age of 32.1 ± 19.1 years were registered at the DTO office during the year 2013. Most of the patients were female (57%) as compared to males (43%). The most common treatment outcome was "treatment completed", recorded against 56% of the patients. The proportion of patients declared "cured" at the end of the treatment was 236 (37.8%). There were only 4 (0.64%) cases of treatment failure during 2013. CONCLUSION: Despite falling incidence of tuberculosis and mortality across the globe, tuberculosis is still a major determinant of disease in our society. Aggressive case detection and treatment is needed to manage this disease.

Frequency of albuminuria in diabetic patients presenting with macrovascular complications.

BACKGROUND: Diabetes mellitus is major cause of morbidity and premature mortality from its long-term complications such as cardiovascular disease, blindness, renal failure, amputation and stroke. The study was conducted to determine the frequency of albuminuria in diabetic patients presenting with macro-vascular complications like myocardial infarction (MI) and stroke. METHODS: This descriptive study was conducted at Ayub Medical College, Abbottabad from December 2010 to May 2011. Total 88 diabetic patients admitted with macro-vascular disease were included in this study. The patients were subjected to two urine specimen's examination, one for routine examination for infection and dipstick analysis for albuminuria. Second was tested for albumin was tested in the urine. RESULTS: Out of 88 patients with a mean 47.12 ± 7.58 years, 39 (44.32%) were female while 49 (55.68%) were male. Overall albuminuria was detected in the urine of 81 out of total 88 patients (92%) when tested by heating method whereas it was detected in 41 (46.6%) cases by the dipstick method. CONCLUSION: Frequency of albuminuria is much.higher in diabetic population with macro-vascular complications; hence albumin in the urine of diabetic patient can be regarded as an indicator for impending macro-vascular complications of diabetes.

Common risk factors for the development of anti tuberculosis treatment induced hepatotoxicity.

BACKGROUND: Tuberculosis is a global pandemic which affects millions of people every year. The treatment of tuberculosis consists of simultaneous use of a number of drugs for a prolonged period of time, therefore anti-tuberculosis treatment induced toxicity is a real problem. Many risk factors which make a tuberculosis patient prone to the development of hepatotoxicity associated with the anti-tuberculosis treatment have been identified. The aim of this study was to determine common risk factors responsible for precipitation of hepatotoxicity following treatment with anti-tuberculosis drugs. METHODS: This cross-sectional study was conducted in the Department of Pulmonary Medicine, Ayub Teaching Hospital, Abbottabad from 20th April 2013 to 19th March 2014. Patients -' , who were newly diagnosed cases of tuberculosis in whom treatment of tuberculosis with first line anti-tuberculosis drugs was initiated and were 20 years or older, were included. The precipitation of drug induced hepatotoxicity was diagnosed with detailed history taking and physical examination followed by laboratory investigations, i.e., Liver Function tests (LFT). RESULTS: Of the total 179 patients included in this study, 100 (55.8 %) were males and 79 (44.2 %) were females. Out of them 23 (12.85%) developed hepatotoxicity. Drug induced hepatotoxicity was observed in the older patients. No relationship was found with the sex, body mass index (BMI), and pre-existing liver disease. CONCLUSION: The study showed that the risk of development of drug-induced hepatotoxicity following treatment with first line anti-tuberculosis treatment increased with the age of the patient.

Kartagener syndrome: a not so rare phenomenon.

BACKGROUND: Kartagener Syndrome is characterized by ciliary dyskinesia and is inherited in autosomal recessive manner. It occurs in 1:20,000-30,000 live births in general population. Its prevalence varies from region to region. METHODS: This case series describes four patients of Kartagener Syndrome who were diagnosed in the departments of medicine and pulmonology between year 2009 and 2013. RESULTS: The age of youngest patient was 15 years while the oldest patient was 19 years old. All of them were males. Mean age was 17.5 years. They had presented with history of shortness of breath and productive cough. One of them had presented with rhinorrhea and nasal blockage as the main symptom. CONCLUSION: Although Kartagener Syndrome is often thought of as a rare disorder, yet it might not be as rare as it is thought of. Considering this and the fact that half of the patients with Kartagener Syndrome do not have situs inversus, large scale studies with family trees are required to trace patients with Kartagener Syndrome.

Primary alveolar proteinosis.

A 35 years old man presented with primary pulmonary alveolar proteinosis who was admitted to chest unit of ATH through casualty department. Before he came to our ward he was treated with different antibiotics including anti-tuberculosis drugs for a month at least. But his symptoms did not improve rather his dyspnoea got worse. He was misdiagnosed till histopathology revealed that he has pulmonary alveolar proteinosis. With this background we briefly review clinical features, diagnosis and treatment of this rare disease.

TB dots strategy in District Rawalpindi: results and lessons.

BACKGROUND: Tuberculosis (TB) is one of the most ancient diseases of mankind. Despite newer modalities for diagnosis and treatment, unfortunately, people are still suffering, and TB is among the top 10 killer infectious diseases in the world. TB is a devastating disease due to its rapid transmission and high rate of mortality causing around 1.8 million deaths annually. This study was conducted to evaluate the effectiveness of the Directly Observed Therapy Short-course (DOTS) in the target population. METHODS: Two Tehsils of District Rawalpindi were selected for the study. All patients under TB treatment attending Basic Health Units (BHUs) and Rural Health Centres (RHCs) were included in the study. The patients with extra pulmonary TB and children under five years of age were excluded from the study. All patients were contacted individually and asked about the DOTS program activity using a preformed questionnaire that mainly contained questions regarding knowledge of the patients about their disease and the role of health facility in treating and following the disease. RESULTS: Out of the 224 patients who were included in the study, 87 (38.8%) were male, and 137 (61.2%) were female. Majority (48.8%) of the patients was in age group of 21-40 years and 62.5% patients had positive family history of TB. Among the patients, 51.8% were illiterate, 31.7% had studied till primary level, and only 16.5% had the educational qualification of Matric or above. In our study 69.2% of patients themselves or through their relatives reported to the health facilities to get treatment, while the rest were picked by community health workers, 62.9% were diagnosed by the public hospitals, 23.2% were diagnosed by general practitioners and 12.9% by the federal public hospitals. In our study 69.6% of the patients were not observed at all or were observed by the family members. CONCLUSION: TB is mainly a disease of the poor and illiterate people. Despite many achievements a bulk of patients are not picked by the community health providers nor are they properly observed. We need to improve the current working of the DOTS personnel. General practitioners are playing a big role in diagnosing the disease, so they need to be integrated in the DOTS to effectively diagnose and control TB.