Virtual patients versus standardized patients for improving clinical reasoning skills in ophthalmology residents. A randomized controlled trial.

BACKGROUND: History taking and clinical reasoning are important skills that require knowledge, cognition and meta-cognition. It is important that a trainee must experience multiple encounters with different patients to practice these skills. However, patient safety is also important, and trainees are not allowed to handle critically ill patients. To address this issue, a randomized controlled trial was conducted to determine the effectiveness of using Virtual Patients (VP) versus Standardized Patients (SP) in acquiring clinical reasoning skills in ophthalmology postgraduate residents. METHODS: Postgraduate residents from two hospitals in Lahore, Pakistan, were randomized to either the VP group or the SP group and were exposed to clinical reasoning exercise via the VP or SP for 30 min after the pretest. This was followed by a posttest. One month after this activity, a follow-up posttest was conducted. The data were collected and analysed using IBM-SPSS version 25. Repeated measures ANOVA was used to track the effect of learning skills over time. RESULTS: The mean age of the residents was 28.5 ± 3 years. The male to female ratio was 1:1.1. For the SP group, the mean scores were 12.6 ± 3.08, 16.39 ± 3.01 and 15.39 ± 2.95, and for the VP group, the mean scores were 12.7 ± 3.84, 16.30 ± 3.19 and 15.65 ± 3.18 for the pretest, posttest and follow-up posttest, respectively (p value < 0.00). However, the difference between the VP and SP groups was not statistically significant (p = 0.896). Moreover, there was no statistically significant difference between the VP and SP groups regarding the retention of clinical reasoning ability. In terms of learning gain, compared with the VP group, the SP group had a score of 51.46% immediately after clinical reasoning exercise as compared to VP group, in which it was 49.1%. After one month, it was 38.01 in SP and 40.12% in VP group. CONCLUSION: VPs can be used for learning clinical reasoning skills in postgraduate ophthalmology residents in a safe environment. These devices can be used repeatedly without any risk to the real patient. Although similarly useful, SP is limited by its nonavailability for repeated exercises.

Challenges faced by teachers of postgraduate health professions blended learning programs: a qualitative analysis.

INTRODUCTION: Blended learning, which integrates classroom face-to-face teaching with both asynchronous and synchronous online learning elements, has swiftly gained acceptance in educational environments. However, the implementation of blended learning presents challenges that impact all stakeholders, necessitating thoughtful consideration. Teachers play a central role in shaping the instructional experience among these stakeholders. To fully realize the potential of comprehensive blended learning, it is imperative to identify the challenges faced by these teachers and develop strategies that sensibly address and overcome them. METHODOLOGY: A qualitative exploratory study was conducted with twelve teachers involved in the postgraduate blended learning health professions program at Khyber Medical University, Peshawar in 2022. One-on-one semi-structured Interviews were conducted via WhatsApp/ZOOM, transcribed by Otter AI, coded on NVivo & analyzed using Braun/Clarke's Thematic Analysis. RESULTS: Three themes of challenges faced by teachers of postgraduate blended learning programs were constructed namely (1) Skills, such as (i) digital, (ii) instructional, and (iii) online class management, and (2) Administrative barriers in terms of (iv) resources (iv) training, and (3) Faculty resistance. CONCLUSION: This study provides profound insights into the daunting challenges that postgraduate blended learning program teachers encounter in terms of skills, administrative barriers, and faculty resistance. These findings offer a valuable opportunity for program directors to identify the critical requirements of these faculties in their pursuit of effective teaching and learning, ultimately transforming the landscape of blended education. This study emphasizes the need for ongoing faculty development and institutional support to address the identified challenges and improve the quality of postgraduate blended-learning programs.

Post-graduate educational environment of two parallel programs in Pediatric Medicine.

Objective: To compare the trainees' perception of the Educational Environment (EE) of the two parallel post-graduate training programs (MD & FCPS) in Pediatric Medicine. Methods: This quantitative cross-sectional study was carried out by Department of Medical Education UOL and Department of Pediatric Medicine KEMU from February to December 2021. Data about the perception of EE was collected from the Pediatric Medicine trainees by purposive sampling using the 40 items PHEEM inventory. The inventory has three perception domains: role autonomy, teaching, and social support. In addition, to mean scores, the inventory also gives interpretation according to the score ranges. The FCPS and MD trainees of both genders and all years of training across the institutions of Punjab were approached using Google Forms. SPSS (v 23.0) was used for descriptive and analytic statistics. Results: A total of 327 trainees' responses were included-188 (57.5%) FCPS and 139 (42.5%) MD trainees. The mean overall score was 92±19.7 for FCSP and 93.88±21.5 for MD trainees (p-value 0.41). The interpretation of the overall score was "more positive than negative but room for improvement" in 67.3%. For the subscales of role autonomy, teaching, and social support, the perception was positive by 71%, 80%, and 45% of trainees, respectively. Except for three individual items, the mean scores of the subscales and the individual items were not statistically different between the two groups. Conclusion: The Pediatric Medicine trainees' perception of the educational environment in the FCPS and MD groups was comparable overall and in all three domains. Individual item analysis showed almost similar areas for improvement in both programs.

Farmers' and millers' experiences and attitudes towards the production and processing of zinc biofortified wheat in Pakistan: a mixed methods study.

Background: Zinc biofortified wheat may be a sustainable strategy to increase zinc intake in areas where fortification and dietary diversification are not feasible or are limited by household purchasing power. This convergent mixed methods study aimed to explore the farmers' and millers' experiences and attitudes towards the production and processing of zinc biofortified wheat in Pakistan. Methods: A telephone survey was conducted with farmers (n = 418) who were provided with Zincol-2016 biofortified wheat seed for the 2019-2020 growing season, as part of a wheat grain micronutrient mapping study across Punjab Province. The survey explored the farmers' experiences of growing Zincol-2016 and whether they opted to grow it again in the subsequent season. Semi-structured focus group discussions were undertaken in a separate group of farmers in Khyber Pakhtunkhwa (KP) province (n = 12) who grew Zincol-2016 for the BiZiFED2 RCT. Millers were also interviewed in KP, both those who had processed Zincol-2016 for the trial (n = 12) and those who had no experience of processing biofortified wheat (n = 12). Survey data were analyzed using descriptive statistics and transcripts of focus groups were analyzed using thematic analysis. Results: Nearly half of farmers who responded to the survey (47%) re-cultivated Zincol-2016 in the following season. The drivers for Zincol-2016 re-cultivation were seed availability (100%), grain yield and growth resistance (98%), quality of the flour from the previous harvest (97%) and nutritional benefit (94.5%). Discussions with farmers suggested that the main motivators for potential scale-up of biofortified wheat were the perceived quality of the grain, wheat, and flour. Millers saw it as an opportunity to expand their business. Farmers and millers valued the health benefits of the wheat. Challenges for scale-up include the need of additional support to produce it, unfamiliarity with the biofortification process, production costs, and external threats to the supply chain. Conclusion: Farmers and millers showed a strong implicit preference for Zincol-2016 over alternative varieties. Crop performance and product yield were the most cited motivators for growing Zincol-2016. Farmers and millers are willing to produce and process biofortified wheat if financial and educational support is provided.

Participatory action research to co-design a culturally appropriate COVID-19 risk communication and community engagement strategy in rural Pakistan.

Background: Community engagement has shown to be fundamental component of the response to previous disease outbreaks. This study aimed co-design and implement a culturally appropriate COVID-19 risk communication and community engagement strategy with a resource-poor rural community in Northwest Pakistan. Methods: Participatory Action Research (PAR) was conducted from January 2021 to March 2022. Five PAR meetings took place with community members (n = 30) to: (1) explore how the COVID-19 pandemic impacted on the community; (2) identify challenges to limit the spread of the virus; (3) identify and implement solutions to these challenges; and (4) highlight the enablers, challenges and knowledge of the cultural context needed to optimize safety during emergencies. Focus group discussions (N = 6) with community members not involved in the PAR meetings (N = 50) and children of the community (N = 26) were conducted following the PAR meetings. Thematic analysis of the PAR and focus group data was conducted. Results: Delivery of messages on how to keep families safe, provision of personal protective equipment and improved water systems were part of the strategies taken by the community to create awareness and reduce the spread of COVID-19. Nine themes were identified: Attitudes to the pandemic: From skepticism to acceptance, Changing attitudes about vaccination: rumors and trust, COVID-19 and Faith, Social impact of the pandemic, Access to water, Resource mobilization: personal protective equipment, Spaces where collaborative effort can bring to solutions, Agents of change, and Empowerment of women. Discussion: The participatory approach of this research allowed understanding of the challenges faced by the community to engage in behavior change strategies to reduce the spread of COVID-19 and enabled the community to find sustainable solutions. Engagement with the community empowered men and women to be agents of change and promoted necessary precautionary actions to reduce the risk of infection within their community. Conclusion: Participatory approach highlighted the importance of engaging with and integrating to local culture and values to overcome challenges such as gender imbalance and distrust. Findings of this study are relevant to others working in diverse cultural settings in similar crises events regardless of particular cultural variations.

Exploring the experiences of struggling undergraduate medical students with formal mentoring program at a private medical college in Rawalpindi.

Objective: To explore the experiences of struggling undergraduate medical students (mentees) with formal mentoring program at a private medical college in Rawalpindi. Methods: A qualitative exploratory study was carried out from March to August 2019. Data was collected from a purposive sample of sixteen struggling undergraduate students. Validated interview guide was utilized to conduct semi-structured one-to-one interviews. Interviews were audio recorded and transcribed accurately. Confidentiality and anonymity were ensured to the participants due to the sensitive nature of the data. Various measures were taken to achieve trustworthiness in the study. Manual thematic analysis was performed and consensus among all authors was built regarding themes and subthemes. Results: Four themes and twelve subthemes emerged from the data. Participants were satisfied with the psychosocial outcomes of the mentoring program such as emotional, moral, and psychological support, and personal and professional development. Mentees told that mentors were their best guides who shared their life experiences. Moreover, mentors provided guidance on Islam, research methods, and case-based learning. Further, mentees said that mentors provide solutions to their problems. Useful suggestions were provided by the mentees regarding betterment in the present mentoring program such as recruitment of committed staff, the need for verbal feedback from mentees about their mentors, need for career counselling and one-to-one mentoring sessions. Conclusions: Majority of the mentees were satisfied with the formal mentoring program. Mentoring focuses on personal and professional development of all medical students. In addition to the useful suggestions provided by the mentees, there is a need for the addition of specific strategies to deal with students struggling with personal or professional problems.

Teaching attentive listening to medical students: need and strategies.

Listening is a primary skill essential for learning and is positively correlated with academic achievement. It also enables a healthcare professional to fully explore patients' concerns in healthcare settings. There has been much discussion on how effective listening practices can facilitate students' learning. A clear understanding of listening as a 'process' and planned listening activities can help exploit listening skills in formal and informal learning contexts. This paper explores strategies through which listening can be taught to undergraduate medical students in a small group setting. A planned tutorial is discussed, including methods that can be used to teach listening skills. The simple guidelines provided here can be used in most small group teaching methods. These teaching strategies are likely to allow undergraduate students to evolve into better listeners and, therefore, better lifelong learners and future physicians.

Impact of Language Barriers in Doctor - Patient Relationship: A Qualitative Study.

Objective: To explore the problems faced by recent medical graduates in communication with their patients due to language barriers and the influence of these language barriers on the doctor-patient relationship. Methods: A basic qualitative study was conducted at Allama Iqbal Memorial Teaching Hospital Sialkot, Services Hospital Lahore and Mayo Hospital Lahore over eight months after receiving approval from the Ethical Review Board of the University of Lahore. Twelve recent medical graduates from different departments were selected via a purposive sampling technique. Data was collected through semi-structured interviews conducted over the phone with prior appointments. Manual qualitative thematic analysis was done by transcribing the interview and then codes, subthemes, and themes were generated. Results: Six themes and thirteen subthemes were identified depicting the influence of language barriers on the doctor-patient relationship, namely: frustration (due to repetition, feeling of inadequacy & disappointment), lack of rapport (difficulty in communication, effective counseling & failure in establishment of comfort level), trust Issues (predilection towards the native speaker & difficulty in getting consent) patient dissatisfaction, compliance issues (difficulty in comprehending medication & nature of disease), and threat to patient safety (misdiagnosis & consequent treatment plan & misinterpretation of treatment). Conclusion: This study establishes the detrimental effects of language barriers on the relationship between physician and patient which can help medical educationists and policymakers in devising a curriculum in such a way that it can minimize the impact of language barriers on the doctor-patient relationship.

Online mentoring: challenges and strategies.

Objectives: To gain insights into the e-mentoring experience, needs of the stakeholders (mentors and mentees) challenges and strategies to overcome the challenges. Methods: Qualitative exploratory study was conducted in Islamic International Medical College, from February 2021 to July 2021. The study duration was six months. Six 'Semi-structured interviews' of mentors and two 'focus group discussions' with mentees were conducted. A purposeful sampling technique was employed to select the respondents. Data were audio taped and transcribed verbatim. After that analysis of data was done by inductive content analysis. Data were coded line by line. Open codes were combined to form categories, which were combined to form themes through abstraction. Results: Data was analyzed by using Atlas.ti. After analyzing data from mentors and mentees, 21 open codes sorted into 15 categories and abstracted to from five major themes. Participants talked about the problems of online sessions like; connectivity issues, impaired interaction, nonspecific goals, unaware of MS Teams use. They suggested strategies to make these sessions more practical; like workshops for training, face to face sessions before online mode, blended approach, careful selection of mentors and mentees. All were satisfied with security and witnessed anonymity and privacy. Conclusion: Online mentoring can help students feel less lonely through social contact. E-mentoring provides flexibility to those who would usually deal with discrimination to being mentored because of their gender, ethnicity, disability or geographical location.

Diagnostic Errors: Association with level of expertise, effect of time taken to reach the diagnosis and utilization of differential diagnosis checklists among postgraduate trainees.

Objectives: The objectives of this study were to evaluate: (1) The association between level of training (expertise) and rate of diagnostic errors. (2) The effect of time taken to reach a diagnosis on the frequency of diagnostic errors. (3) The effect of utilization of differential diagnosis checklists in reducing the frequency of diagnostic errors. Methods: The study was carried out from November 2020 till April 2021 in Peshawar. The participants included FCPS Part-II trainees of Maxillofacial Surgery undergoing training in five centres. Thirty written case scenarios were prepared and validated, ten scenarios for each of the three objectives. To evaluate the association between training level (expertise) and the rate of diagnostic errors, two groups of trainees (1st year group and 4th year group) were formed and given ten same case scenarios for diagnosis. To evaluate the effect of time taken to reach diagnosis on the frequency of diagnostic errors, two groups of 4th year trainees (fast group and slow group) were formed by random allocation of participants to groups and given ten similar case scenarios for diagnosis. Fast group was given 15-minutes whereas slow group was given 30-minutes to respond. To evaluate the effect of utilization of differential diagnosis checklists in reducing diagnostic errors, again two groups of 4th year trainees were formed by random allocation of participants to groups and given ten similar case scenarios for diagnosis. One group was given differential diagnosis checklists for the scenarios and the other none. Results: In this study, participants included were 1st year (n=36) and 4th year (n=36) trainees of Maxillofacial Surgery. The results showed that training level or expertise was significantly associated with the rate of diagnostic errors (p = 0.002). Time taken to reach diagnosis and differential diagnosis checklists have no significant effect on the frequency of diagnostic errors (p = 0.74 and 0.56 respectively). Conclusions: Training level (expertise) has significant effect on the frequency of diagnostic errors whereas no significant effect was recorded for time (time taken to reach diagnosis) and differential diagnosis checklists on the rate of diagnostic errors.

Effect of team-based learning on critical thinking: A quasi-experimental study.

Objectives: To determine the effect of Team-based learning (TBL) on the critical thinking of health professions students. Methods: This quasi-experimental study, was done in paramedical and nursing sciences institutes using the convenience sampling technique. Students included were enrolled in the haematology course of paramedic institute from January to December 2020 and adult health course of the nursing institute of Khyber Medical University. Six dimensions of critical thinking (CT) of the students before and after TBL were determined using the critical thinking disposition inventory. Results: The study participants included 89 students, comprising 58 students from the paramedic's institute and 31 from the nursing institute; 67 (75.28%) males and 22 (24.71%) females. The overall pre-test score of CT was 257.46 ± 21.73, and the post-test score was 274.55 ± 19.36, which was statistically significant (p-value = 0.000). The pre-test score of six dimensions, namely, analyticity, inquisitiveness, systematicity, truth-seeking, self-confidence, and open-mindedness was 41.35 ± 5.15, 44.73 ± 4.77, 41.12±6.87, 43.17± 5.19, 44.94±6.03, 42.38 ± 5.32 respectively, whereas the post-test scores were 44.57± 5.28, 47.11 ± 4.69, 46.12± 5.54, 45.77 ± 5.05, 47.58 ± 5.65, 43.56 ± 4.56 correspondingly. Analyticity (p=.000), inquisitiveness (p=.000), systematicity (p=.000), truth-seeking (p=.000) and self-confidence (p=.000) were statistically significant. However, open-mindedness was statistically insignificant (p=.074). Conclusion: TBL improves five out of six dimensions of students' critical thinking. Besides its established evidence to increase knowledge, TBL can also be used as a teaching methodology for enhancing students' critical thinking.

Analysing trends of Patient Safety Non-Technical Skills among postgraduate trainees through a modified survey tool.

Objective: To analyse practices of patient safety non-technical skills among postgraduate trainees to establish the utility of organised teaching programmes in this regard, and to determine the utilisation of different teaching modes. METHODS: The multicentre, two-phase, cross-sectional study was conducted from February to August 2020 at 27 teaching hospitals across Pakistan which were part of the Patient Safety Friendly Hospital Initiative by the World Health Organisation. The Hospital Survey on Patient Safety Culture was modified with validated additional survey items before using it to gather relevant data. Data was analysed using SPSS 21. RESULTS: In the first phase, 42 additional survey items were developed with content validity ratio >0.66 and item content validity index >0.83. Cronbach's alpha of the modified survey tool was 0.790. The second phase comprised 388 postgraduate trainees; 199(51.3%) males and 189(48.7%) females. Of them, 134(34.5%) were in the third year of training, 215(55.4%) fourth, and 39(10.1%) in the final year. Highest positive response was found for learning Teamwork 216(55.7%) and the lowest for Situational Awareness 62(15.9%). Leadership had highest good practice responses (subscales range: 77.6% to 76.6%) and Communication had the lowest (subscales range: 16.5% to 74.2%). Agreement on Informal Learning mode was the highest 268(69.1%) and the lowest was for Simulator Learning 63(16.2%). Besides, 274(70.6%) and 281(72.4%) subjects agreed on the supportive role of supervisors and hospital administrations. The correlation of the studied variables with the year of training was significant only for Teamwork (p=0.02) and Medication Safety skills (p=0.01). Conclusion: Modified Hospital Survey on Patient Safety Culture could be used as a benchmark for evaluating patient safety teachings and practices. Significance of patient safety non-technical skills was established with limited evidence for the utility of organised teaching programmes.

Medical colleges' challenges and coping strategies in implementing accreditation standards in Pakistan.

Objectives: To explore the challenges faced by medical colleges and coping strategies used in implementing accreditation standards by Pakistan Medical Commission during accreditation inspection 2019. Methods: In this qualitative case study, four medical colleges and their affiliated hospitals from three cities in Khyber Pakhtunkhwa province of Pakistan were selected through purposive sampling. Data was collected through focus group discussions (FGD) through Open-ended questions, based on CIPP (context, input, process, and product) model. Each focus group comprised of Dean, the Director Department of Medical Education (DME) and the Medical Director of the hospital. Data were thematically analyzed and results were based on the CIPP model. Results: Three themes identified were administrative challenges, accreditation challenges and resource challenges. The administrative challenges theme was further explained under subthemes of rules and regulation challenges, documentation and record challenges, and DME-related challenges. The accreditation-related challenges theme was explored in-depth with subthemes of accreditation process-related challenges, accreditation standards-related challenges and curriculum-related challenges. The resource challenges theme was described under sub-themes of infrastructure-related challenges, human resources and financial challenges. The commonest coping strategies adopted by medical colleges were establishing DME, emergency preparatory meetings of staff, and hiring staff on an emergency basis, to overcome administrative, accreditation and resource challenges respectively. Future suggestions for improving the accreditation process in the local context were highlighted. Conclusion: Main challenges identified were administrative challenges, accreditation challenges and resource challenges. Coping strategies by the medical colleges for these challenges are highlighted. The accreditation body should harmonize the process of accreditation with medical colleges and other stakeholders.

The Drudgery of a Doctor's Disciple: Exploring the effects of Negative Role Modelling on medical students' professional development.

INTRODUCTION: Role modelling is considered an essential component of teaching in various educational settings and impact students' professional development. Most studies found in the literature have explored the influence of positive role models and limited data is available about the negative role modelling. This study explores the effects of negative role modelling of teachers on the professional development of future doctors. METHODS: A qualitative exploratory study was done in three medical colleges of Lahore, Pakistan. Fifteen, telephonic, semi-structured interviews were done with fifth-year MBBS students. A thematic analysis was done through manual coding of transcribed interviews. RESULTS: A total of 374 codes were generated in the first cycle of coding, that was merged to 42 in the second cycle. These codes led to 4 subthemes that finally emerged as two themes. The first theme was "Students & patients: In the same boat" highlighting the damaging effects of negative role modelling. The second theme was "Taking the bad with the good" focusing on the ambivalent response of students towards the unprofessional behaviours of their role models. CONCLUSION: Negative role modelling exponentially affects the attitude and behaviour of medical students especially in informal settings and have detrimental effects on patient care. Students lose some degree of humanism while unconsciously observing the unethical behaviours, to become a part of hospital culture whereas some students show determination to channelize their resentment to reforms.

Exploring developmental assignments shaping experience-driven acquisition of leadership competencies in young clinicians.

BACKGROUND: Experiential leadership development is well documented in the corporate sector, but those models cannot be applied as is, in the healthcare domain. The current study proposes a framework for the healthcare sector to enable experiential leadership development for young clinicians. The authors identify developmental assignments (DAs) and explore those characteristics [developmental assignment characteristics; DACs] therein that help develop leadership competencies in young clinicians. METHODS: As part of a qualitative exploratory study in Pakistan, the authors conducted 16 semi-structured interviews with senior clinicians in leadership positions with post-graduate residents under their supervision from different medical specialties. The participants were selected through purposive sampling, ensuring a maximum variation sample. Focusing on participants' experiences and perspectives related to experience-driven leadership development, the authors used a multi-level theoretical framework for analysis. RESULTS: The thematic analysis resulted in 19 subthemes with four overarching themes for both objectives. The authors categorized the developmental assignments (DAs) into clinical, academic, and administrative assignments. These assignments can be utilized for leadership development by ensuring that they have the requisite characteristics built into their context and structure. These developmental assignment characteristics (DACs) can range from learner-driven to supervisor-driven. The learner-driven characteristics include autonomy, high levels of responsibilities, unfamiliar assignments, working across boundaries, managing diversity, making a commitment, and creating change. The supervisor-driven characteristics include briefing, debriefing, accountability, and learner-assignment matching. The authors also developed a learner-assignment matching (LAM) framework to guide supervisors in customizing and adjusting the level of each DAC in a DA. CONCLUSION: A modern healthcare educational system can utilize studies like this to enable supervisors to develop required leadership skills in young clinicians along with clinical skills.

How To Teach 'Listening For Learning' In A Clinical Context?

Active listening skills are an important factor in communication skill set. And for budding doctors they need to be incorporated in the undergraduate medical programs. Studies have shown that patients, prefer the doctors who can listen to them instead of just looking at their signs and symptoms. Listening is related to empathy when strictly talking from patient's perspective. Having better listening skills can also lead to less prescription errors and help the doctor to identify some missing points from the history that can help in the diagnosis. Listening skills can be taught in different ways. Role plays are a safe way to teach them however, while teaching them in a clinical setting; we need to approach it in a different way like bedside teaching, Chairside Dental OPD etc.

How to teach ethics to the undergraduates in clinical context?

Teaching ethics to undergraduates is no more a part of hidden curriculum rather it is a norm to be incorporated in the formal curriculum. Regarding instructional strategies, the consensus is stagerry and mainly based on the institutional choices. To develop moral reasoning and address the social value system, Cognitive part is delivered through lecturing while affection part is discussed via reflective practices in small group settings through deliberate moral case teachings and portfolio note book writings. However the outcome of such practices is yet to be known. However we suggest that the ethical curriculum should base on the reflective practices, social constructivism and experiential learning. Further customization could be done assessing potential ethical conflicts and legal accountability specific to our profession. We cannot merely focus on student preparation but also must focus on the organizational culture to be conducive for ethical practice and quality to match with what is being preached.

How to Teach Professionalism in a Clinical Context?

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Community Perceptions of Zinc Biofortified Flour during an Intervention Study in Pakistan.

Zinc-biofortified flour may be a cost-effective approach to improve zinc status of populations in low-resource settings. The success of biofortification programmes is subject to acceptability and uptake by consumers. This study explored community leaders' and community members' (n = 72) experiences and attitudes towards the flour provided during a cluster randomised controlled trial of zinc biofortified wheat in rural Pakistan (BiZiFED2). Focus group discussions (n = 12) were conducted and thematic analysis applied using an inductive, semantic, contextualist approach. Five themes were identified: (1) Contribution to food security; (2) Better sensory and baking properties than local flour; (3) Perceived health benefits; (4) Willingness to pay for the flour; and (5) Importance of trusted promoters/suppliers. Although the participants were blind to whether they had received control or biofortified flour, referred to collectively as "study flour", the results indicated that the study flour performed well in terms of its taste and bread making qualities, with no adverse reports from participants in either arm of the BIZIFED2 RCT. Participants suggested that they would buy the biofortified wheat if this was available at a fair price due to perceived health benefits, reporting positive sensory characteristics and cooking attributes when compared to the flour available in the local markets. Overall, there was a positive reception of the programme and flour among the participants, and members of the community hoped for its continuation and expansion.