Building on the Health Policy Analysis Triangle: Elucidation of the Elements.

The health policy triangle first presented in the 20th century by Walt and Gilson has been extensively used at local, national, regional, and international levels to assess health policies related to communicable and non-communicable diseases, physical and mental health, antenatal and postnatal care, and human resources, services, and systems. However, the framework lacks intricate details for the four pillars in the triangle viz: 'content,' 'context', 'actors', and 'processes. We propose a checklist of elements to be considered for each pillar; to ease and enhance the process of policy analyses for researchers and policymakers across the globe, including low- and middle-income countries. We suggest using Leichter's categorization of situational, structural, cultural, and environmental factors for comprehensive contextual assessment. Kingdon's multiple streams framework can be applied to determine the 'window of opportunity' allowing the politics, policy, and problem streams to unite, giving birth to the formulation of policies. Lastly, stakeholders' analyses expounding the power, influence, interest, and involvement of intrinsic, extrinsic, implicit, and explicit players should be applied to explore the 'actors' in policy analyses. Robust policy analyses for generating evidence are of paramount importance for policymakers for informed decision-making. Our approach of dis-entangling and elaborating the pillars of the triangle will be helpful for health systems researchers at sub-national, national, regional and global levels to serve as a basis for evidence-based informed decision-making.

Impact Evaluation of a Resident-Driven Research Training Workshop in Idaho: A Feasibility Study.

Objectives: Engagement in research activities is a critical component of clinical residency training. It is vital to build research capacity of residents to help interpret evidence-based medicine and design quality improvement projects. A mixed methods study was conducted to assess the impact of a 1-day research training workshop conducted at Eastern Idaho Regional Medical Centre, Idaho in May 2022. The workshop was targeted to improve the research knowledge of current clinical residents of Internal Medicine and Family Medicine. Methods: Workshop comprised of expert presentations, with assessment of difference in knowledge with a pretest and post-test. The sessions were organized around the core competencies of Institute of Medicine. Suggestions were also gathered from the audience. A pretest and post-test based on 13 questions was administered to the participants to assess change in research-related knowledge. Comments and suggestions of the participants were also recorded. Wilcoxon rank test was applied to determine statistical difference across each question and cumulative knowledge score. Conventional content analysis was applied to explore the comments and feedback. Results: The mean score of participants improved across all 12 questions. Statistically significant results were observed for the questions about types of studies qualifying as qualitative research. The cumulative score of participants increased in the post-test from 8.57 to 9.35. The participants gained new knowledge (94.3%), and felt more comfortable in application of research methods (74.3%). Encouraging feedback was obtained from the audience. They stated that they had benefited from the workshop and felt more prepared and motivated to indulge in scholarly activities. Conclusion: The study shows improvement in research-related knowledge of clinical residents attending a 1-day training workshop. We recommend inclusion of such workshops in the curriculum of residents for skill building and enhanced indulgence in research activities in order to prepare them as future leaders in quality improvement, health policy, and hospital administration.

Individual and community preparedness to disasters and pandemics in Idaho Falls: A cross sectional analysis.

Communities form an integral component of disaster and pandemic preparedness. This study aimed to explore disaster/pandemic preparedness-with a special focus on coronavirus disease 2019 (COVID-19)-at the household and community level among residents within 50 miles of Idaho Falls. A structured online survey questionnaire was distributed, resulting in 924 responses from participants over 18 years of age. The results highlighted that 29 and 10 percent of participants were not prepared to deal with disasters and pandemics, respectively. Most participants trusted healthcare professionals (61 percent) for information about COVID-19, followed by scientists (46 percent) and local health departments (26 percent). The overall preparedness to disasters/pandemics at the community level was 50 percent. Males, participants older than 35 years, and participants with paid employment had higher odds of being prepared for disasters, whereas higher education was associated with higher preparedness for pandemics. This study highlights the need for better household and community disaster and pandemic preparedness.

Engagement of private healthcare sector in reproductive, maternal, newborn, child and adolescent health in selected Eastern Mediterranean countries.

Background: The private healthcare sector in the Eastern Mediterranean Region (EMR) is active and growing, providing curative, preventive, and promotive services related to reproductive, maternal, newborn, child, and adolescent health (RMNCAH). Aims: To understand the contribution of formal for-profit private health-care sector in delivering RMNCAH services and explore best practices for improvement. Methods: Desk review of available literature from Saudi Arabia, Oman, Iraq, Egypt, Sudan, Yemen, Pakistan, and Islamic Republic of Iran, followed by stakeholder interviews in Iraq, Pakistan, and Oman were carried out. Directed content analysis using Maxqda 2020 was performed, and information was triangulated according to a priori themes: governance, health information systems, financing, and service delivery related to RMNCAH. Results: Formal and informal public-private partnerships exist in RMNCAH but lack a strategic roadmap to guide collaboration. The private healthcare sector is minimally represented in the main policy stream at national and subnational levels due to resistance from the private and public sectors. They are weak in collecting, maintaining, and sharing health information. Data on abortion and postabortion complications are scarce. Various models of supply and demand financing (voucher schemes, private and social health insurance) related to antenatal care and contraception have been implemented in the EMR. Despite the higher cost of care in the private sector, limited training of providers, ill-defined service delivery packages, and lack of continuity-of-care and team-based approaches, the private sector remains the predominant sector providing RMNCAH services in the EMR. Conclusion: Partnering with the private sector has huge untapped potential that should be harnessed by national governments for expanding RMNCAH services and progressing towards Universal Health Coverage.

Should we offer disaster preparedness and response training workshops across Idaho? A feasibility study.

INTRODUCTION: It is important for individuals and families to prepare for potential disasters to enable communities to generate a consolidated response. It is estimated that 30 percent of residents of the fourth largest city in Idaho, Idaho Falls, are not prepared to deal with disasters. A 1-day training workshop for healthcare professionals and students at Idaho State University in Pocatello was organized to build their capacity for acute disaster response and preparedness. This study assesses the impact of the workshop in improving knowledge and attitudes of the participants toward disaster management. METHODS: A mixed methods study design was employed. Pre- and post-tests were administered to the participants (n = 18) to examine change in self-perceived understanding of disasters, and disaster preparedness and management. Core competencies encompassing knowledge of disaster preparedness were assessed via 18 multiple-choice questions. Participant attitudes toward disaster training exercises in colleges, universities, and healthcare facilities were recorded, and written feedback regarding the workshop obtained. Chi-square and paired t-tests were used to examine changes in disaster preparedness and cumulative knowledge score. Quantitative variables and comments were analyzed using Stata.v.13 and Maxqda, respectively. RESULTS: Our assessment indicates an improvement in mean knowledge score [pretest: 10.7 (2.8), post-test: 12.5 (2.9); p = 0.007] and self-perceived disaster preparedness and management. The attitude of audience toward training workshops was wholly positive in both the pre- and post-tests. Participants commented that the workshop was "excellent," helped them polish their knowledge and skills, trained them to build emergency kits and communication plans, and perform triage amidst crises. CONCLUSION: Training workshops should be offered to communities to build their capacity to prepare for and respond to disasters.

Diffusion of innovations: a guiding framework for public health.

Exploring the behavior change process has been of interest and importance to public health professionals, to translate research into practice. Diffusion of innovations (DOI) model has been extensively applied in public health to examine the process by which innovation is passively communicated to individuals and groups. It builds on a staged model of awareness, persuasion, decision, implementation, and confirmation; and categorizes communities into innovators (2.5%), early adopters (13.5%), early majority (34%), late majority (34%) and laggards (16%). It reflects on the diversity of strategies to be applied for different cadres of the society to bring about a wholistic change. Nonetheless, DOI suffers from 'pro-innovation' and 'individual blame' bias, as it fails to account for the influence of societal, cultural, and extraneous factors affecting individual behavior change. The social networks theory (SNT) in contrast, explains behavior change based on social networks and their influences. It builds on the constructs of homophily, centralization, reciprocity, transitivity, and density; and fills the void in the DOI model. We suggest public health professionals to combine the constructs of DOI and SNT in rolling out behavior change interventions, to yield a comprehensive approach.

Effectiveness of Simulation-based Clinical Skills Training for Medical Students in Respiratory Medicine: A Pilot Study.

OBJECTIVE: To assess the effectiveness of high-fidelity simulation-based medical education (HF-SBME) in teaching and learning respiratory clinical examination in medical students. STUDY DESIGN: Quasi-experimental pilot study. PLACE AND DURATION OF STUDY: The Aga Khan University, Karachi, from November 2018 to January 2020.   Methodology: This study was conducted amongst third year medical students at the University. Students were assigned to intervention (IG) or control groups (CG). The IG underwent training for the respiratory clinical examination on a high-fidelity simulator mannequin, while the CG received the conventional practice session on standardised patients. Students were assessed on their respiratory clinical examination skills in five domains, and each domain was scored between 1-3 points (poor=1, fair=2, good=3) for a maximum composite score of 15. Feedback on use of SBME was also obtained from students. RESULTS: There were no statistically significant differences in demographics for the CG (n=41) and IG (n=40). Composite score for control and intervention groups was not significantly different (CG: 12.9 ± 1.89 vs. IG: 12.0 ± 2.35; p=0.067). However, a greater percentage of CG students were rated good in all five domains, with the difference being statistically significant for ability to correlate findings with clinical history (CG: 87.8% vs. IG: 67.5%; p=0.028). CONCLUSION: Although medical students perceived HF-SBME as a beneficial teaching modality, it did not translate into improved performance. More research is required to determine the utility of HF-SBME in a developing country, like Pakistan. Key Words: Simulation, High-fidelity, Medical education, Developing country, Clinical skills.

Violence and abuse among working children in urban and suburban areas of lower Sindh, Pakistan.

BACKGROUND: Child labourers are exposed to an insecure environment and higher risk of violence. Violence among child labourers is an under-studied phenomenon which requires contextual assessment. AIMS: We applied Bronfenbrenner's ecological model (micro-, exo- and macro-system) to understand the interplay of individual, community, societal and policy context fuelling violence. METHODS: Focus group discussions and family ethnographies of child-labourers working in common occupational sectors of suburban areas of Sindh were carried out to gain in-depth understanding of their immediate environment and abuse (micro-system). Frequency of emotional, physical and sexual violence (5-14 years; n = 634) was also determined. Indepth interviews with employers (exo-system, n = 4) and key-informant-interviews of prominent stakeholders in Pakistan (macro-system, n = 4) working against labour/violence were carried out Thematic-content analysis was performed using MAXQDA, version 8.0. RESULTS: We estimated that 21%, 19% and 9% of children suffered from emotional, physical and sexual violence respectively. Child labourers' interviews indicated the existence of all forms of abuse at home and in the workplace; sexual violence by grandfathers was highlighted (micro-system). Children reported frequent scolding and insults in the workplace along with physical violence that could be fatal (exo-system). The legal environment of violence in Pakistan was considered deficient as it did not address the hidden forms (touching, kissing, etc.; macro-system). CONCLUSION: We documented that all forms of violence were rampant among the child labourers, and improved efforts and comprehensive legislation is direly needed to alleviate the situation.

Responding To The Covid 19 Pandemic In A Resource Constrained Country: The Case Of Pakistan.

BACKGROUND: Pakistan, like the rest of the world has not been spared by COVID-19, with the cases escalating nationwide. Being a developing country, Pakistan has had meagre resources and weak health systems to tackle the menace. We analysed the national response of Pakistan to the pandemic by critically analysing the interventions taken at community, health systems and multi-sectoral level and identifying the response gaps. The fragile health system of Pakistan performed fairly well according to its ability - the bed capacity was expanded, health professionals' capacity building strategies were adopted, telemedicine was put into practice, indigenous production of required personal protective equipment started, testing capacity was increased, and attempts were made to improve the surveillance mechanisms. However, the strategies adopted at the community level proved in-adequate. The severity of the disease was not communicated clearly to the public, religious leaders were not effectively on board, social distancing measures were not strictly followed specially during religious festivities, contact tracing was not extensively carried out specially in the rural areas - overall awareness of the community to COVID-19 remained low. The educational institutions were closed in time but the intermittent lockdown procedures and easing of transport restrictions led to community spread of the virus. Overall, Pakistan's performance has been acceptable, but community engagement and participation need to be improved.

Prevalence of Emotional and Physical Intimate Partner Violence Among Married Women in Pakistan.

Intimate partner violence (IPV) affects millions of women across the world, and Pakistan is no exception. However, there is wide variance in reported frequencies worldwide and even within the same population. No standardized representative national and subnational estimates were available for IPV in Pakistan. We analyzed 3,666 ever-married women (15-49 years), from the most recent Pakistan Demographic and Health Survey (PDHS; 2012-2013), to determine the prevalence of emotional and physical violence among women in Pakistan and its major subpopulations. The Conflicts Tactics Scale (CTS) was used to ascertain violence. Furthermore, we examined the socioeconomic and demographic characteristics, which have the potential to increase the risk of emotional and physical violence. Weighted multivariate logistic regression was carried out to determine the association of IPV with the potential risk factors using Stata version 13.0. The prevalence of emotional and physical violence was, respectively, 36.4% (95% confidence interval [CI]: [33.8, 39.1]) and 18.4% (95% CI: [16.4, 20.6]) in Pakistan. The frequency of emotional and physical violence was highest in Khyber Pakhtunkhwa (KPK; 54.9% and 36.4%) followed by Balochistan (50.0% and 25.5%), Punjab (35.9% and 15.8%), and Sindh (24.7% and 13.3%) provinces. The prevalence of any form of violence (emotional or physical or both) was higher in rural than in urban areas (45.2% vs. 30.6%). Higher age of the husband and lower socioeconomic status were associated with emotional violence in KPK. Furthermore, alcohol intake by husbands and lower educational status of women or their husbands were associated with greater risk of emotional and physical violence across the provinces. IPV is high in Pakistan and large variations exist in the prevalence of violence across the provinces. The predictors of emotional and physical violence included occupation and education of the husband, alcohol intake, woman's occupation, and wealth index. Further studies are needed to explore the underlying factors of violence and reasons for variation across different regions in the country for contextual interventions.

Brucellosis in Pakistan: a neglected zoonotic disease.

Brucellosis is a zoonotic disease; endemic but neglected in the South Asian countries including Pakistan. It causes economic loss to the livestock sector and leads to systemic infection in humans. Brucellosis was neglected in Pakistan since long. According to the Staged Tool for the Elimination of Brucellosis (STEB), Pakistan carries a grim landscape of the disease with no structured control activities. This article describes the five-year national brucellosis control strategic plan (2018-2023) formulated by the government of Pakistan using the one-health approach for the prevention and control of disease across the country. The plan incorporates components of surveillance, research, diagnostic capacity, awareness and vaccination using a multi-disciplinary approach.

Malnutrition and food insecurity in child labourers in Sindh, Pakistan: a cross-sectional study.

BACKGROUND: Child labour is common in low- and middle-income countries. Although child labour is widespread in Pakistan, no data are available on the health of child labourers. AIMS: This study aimed to assess the food security, food intake and nutritional status of child labourers aged 5-14 years working in lower Sindh, Pakistan. METHODS: Child labourers aged 5-14 years working in agriculture, manufacturing industry, hotels and restaurants, domestic work and migrant child labourers working in vegetable markets were recruited using a respondent-driven sampling technique. Sociodemographic and nutrition information was obtained by an interviewer questionnaire. The children's height and weight were measured to assess stunting (height-for-age z scores less than -2) and wasting (weightfor- height z scores less than -2). RESULTS: A total of 634 child labourers were included: 184 worked in agriculture, 120 in industry, 67 in hotels and restaurants, 63 in domestic work and 200 were migrant child labourers. Overall, 15.5% of the children were stunted and 30.0% were wasted. The prevalence of stunting was highest in children working in agriculture (27.2%) and the prevalence of wasting was highest in migrant child workers (35.0%). About half the children (51.1%) were suffering from food insecurity. Food inadequacy was mainly in consumption of vegetables/potatoes (98% of the children had inadequate intake), legumes (97%), fruits (96%), meat/ poultry (95%) and milk/dairy products (82%). CONCLUSION: The nutritional status and food insecurity of the child labourers of Pakistan are comparable with the general population, highlighting the grave situation of the country with regard to food security.

Recommendations: putting an end to child labour in Pakistan!

Child labour is rampant in Pakistan since ages. Laws, policies, programmes and strategies to eliminate child labour have been in place with little gain. Implementation of laws and sustainability of programmes offer barriers to eliminate the menace. We recommend a new approach of regulating child labour as a strategy to eliminate it in the longer run. Model districts with drop-in-centres offering free education to the working children should be constructed. The key stakeholders should unite on a common platform to formulate guidelines defining the nature and duration of work for children in various sectors such that they have sufficient time to visit the drop-incentres. Once a generation of children is educated, the cycle will start to break itself and gradually we will overcome child labour.

Pakistan's Health System Against COVID-19: Where Do Things Stand?

The national response of Pakistan's health system to COVID-19 was assessed by applying a framework of three distinct tiers. The first tier assessed politico-economic ecosystems: lockdown procedures, contact-screening, monetary/organisational arrangements for economically deprived groups, and travel restrictions. The second tier assessed intervention measures according to six building blocks of WHO: strategic vision highlighted by National Action Plan COVID-19, inadequacy and urban bias of healthcare professionals, expanded bed capacity, enhanced laboratory diagnostic capacity and financial assistance. The third tier of community participation revealed that the majority of the population was abiding by restrictions, but sporadic instances of orthodox religious gatherings were facilitating community spread. We recommend private health sector coordination with public facilities and call for deployment of non-practising health professionals. The neighborhood-warden-system should be introduced at the union council level with the help of community level volunteers to facilitate enforcement of quarantines and responding to emerging community needs. Key Words: COVID-19, Coronavirus disease 2019, Pakistan healthcare delivery.

Worsening of the COVID-19 Pandemic in New York City: Analysis of Response Gaps and Challenges at the Public Policy and Community Levels.

This review was aimed to probe into factors that resulted in worsening of novel coronavirus disease 2019 (COVID-19) pandemic in New York City, USA. Extensive review of available information sources, such as scientific literature, COVID-19 data generating websites, expert opinions as well as government briefings and simultaneous measures, were carried out to fulfil the objectives of this paper. Data was arranged in tabular form. Gaps in responding to the pandemic were identified. There was lack of proactivity in measures taken by governments which is due to neo-liberal capitalism on one hand and lack of coordination among three tiers of government on the other. Cosmopolitan features of the city also made it prone to devastating spread of pandemic. Crowded mega cities with incompetent governments in implementing timely public health measures for prevention of spread of COVID-19 are at potential threat of high disease spread across the globe. Keywords: New York City, COVID-19 pandemic, Response gaps, Metropolitan.