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Background In Pakistan, every third baby is born small for gestational age (SGA). Early antenatal detection of SGA helps with birth planning and initial treatment of mother and baby, thereby reducing complications. Screening and diagnosis of SGA however are challenging, especially in low and middle-income countries where access to technological advances may be limited and there is a lack of routine antenatal screening. Aims To explore the current practices, knowledge, and experiences of caring for SGA infants with women and health professionals in Pakistan. Design A cross-sectional survey with healthcare professionals and focus groups or interviews with health professionals and mothers of SGA babies were undertaken. Survey data were analysed descriptively and integrated with the qualitative data using thematic data analysis. Subjects 78 completed surveys were returned and eight FGDs and five interviews were undertaken with 77 participants – 67 healthcare professionals (gynecologists/obstetricians, neonatologists, Lady Health Workers, and Lady Health Visitors) and 10 mothers of SGA infants aged under 12 months. Results The survey highlighted a general lack of training on SGA for all health care professionals, but particularly amongst community staff who often act as primary caregivers for women. Five qualitative themes described the challenges and issues faced in the management, treatment, and prevention of SGA in Pakistan: Lack of policies and training, Lack of resources, Lack of access to healthcare, Not following the guidance, and Lack of data and reporting. Conclusions A whole system approach to improve service provision and outcomes is needed. This should include epidemiological research, country-specific policies, training for healthcare professionals and awareness raising amongst women and community members.

Perceptions of teachers and students about curriculum viability inhibitors are equally important yet may differ. Divergence can lead to destructive friction and adversely affect curriculum viability. Our team aimed to find the perceptions of teachers and students on inhibitors affecting the viability of an implemented medical curriculum, report their convergence or divergence, and explore approaches to reduce divergence. Through a mixed-method approach, using valid and reliable questionnaires, we found the curriculum under review had no clear inhibitors. Whereas teachers exhibited complete agreement that no educational programme inhibitors existed, students did not fully agree. Upon qualitative inquiry, using focus group discussion with students and teachers, we found that ‘improving the communication gap’, ‘enhancing the role of faculty and students in curriculum’, and ‘improving the assessment process’ can reduce the friction between teachers and students. This study provides an approach that identifies the curriculum viability inhibitors and solutions to address them.

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 t

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 t

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.

BACKGROUND: Curriculum viability is determined by the degree to which quality standards have or have not been met, and by the inhibitors that affect attainment of those standards. The literature reports many ways to evaluate whether a curriculum reaches its quality standards, but less attention is paid to the identification of viability inhibitors in different areas of the curriculum that hamper the attainment of quality. The purpose of this study is to develop and establish the reliability and validity of questionnaires that measure the presence of inhibitors in an undergraduate medical curriculum.METHODS: Teacher and student questionnaires developed by the authors were sent to medical educationalists for qualitative expert validation and to establish their content validity. To establish the response process validity, cognitive interviews were held with teachers and students to clarify any confusion about the meaning of items in the questionnaires. Reliability and construct validity of the questionnaires were established by responses from 575 teachers and 247 final-year medical students.RESULTS: Qualitative expert validation was provided by 21 experts. The initial teacher and student questionnaires containing respectively 62 items to measure 12 theoretical constructs, and 28 items to measure 7 constructs, were modified to improve their clarity and relevance. The overall scale validity index for the questionnaires was, in order, .95 and .94. Following the cognitive interviews, the resultant teacher and student questionnaires were reduced to respectively 52 and 23 items. Furthermore, after the confirmatory analysis, the final version of the teacher questionnaire was reduced to 25 items to measure 6 constructs and the student questionnaire was reduced to 14 items to measure 3 constructs. Good-for-fit indices were established for the final model and Cronbach alphas of, in order, .89 and .81 were found for the teacher and student questionnaire.CO

Curriculum evaluation is typically done by using quality standards defined by accrediting bodies. This does not include inhibitors that hinder the achievement of standards. Hence, to address both standards and inhibitors, we have coined the new concept of “curriculum viability.” This study establishes consensus among experts on curriculum viability indicators, i.e. standards and inhibitors, and aims to provide a framework for evaluating the curriculum viability. The study was done in two phases. In the first phase, a consensus was established on the curriculum viability indicators using the Modified Delphi Technique using two rounds. In the first round of the Delphi process, 25 experts participated, which were reduced to 19 in the second round. After two rounds, experts developed a consensus on 40 out of 44 items. These included 27 standards and 13 inhibitors. In the second phase, 18 experts rank-ordered the indicators according to their relative importance in the areas of educational content and strategies, faculty, leadership, assessment, students, educational/working environment, communication, and technology. The list of indicators provides a framework for evaluating the curriculum viability, and their ordering enables curriculum managers to prioritize them during curriculum evaluation.

OBJECTIVES: To determine the perceptions of senior faculty regarding frame factors influencing curriculum change at undergraduate level in public and private medical and dental schools at Peshawar, Pakistan.  METHODOLOGY: This was qualitative exploratory case study and senior faculty was interviewed regarding the frame factors influencing integration and changes in undergraduate medical curriculum. Data was collected through in-depth interviews. Transcription, thick description was analyzed, coding was done, and similar codes were converted into categories. Finally, themes were created and concluded by thematic analysis. RESULTS: A total of ten interviews were done that identified 52 open codes. These codes were merged into 19 categories that led to development of five themes of frame factors influencing the medical curriculum. The themes and categories were: Lack of proper resources including human, technical, financial and infrastructure (building, equipment); Environmental factors, which included cultural, political and social contexts, which if not supportive could influence the change in curriculum; Lack of supports from regulatory authorities; leadership; legal issues and fragmented assessment approach minimize the dream of the changes in curriculums. CONCLUSION: Intention to change the medical curriculum is the ultimate goal but it is unlikely to grasp better pace due to few bottlenecks such as resources, infrastructure, and cultural, political and legal issues.&nbsp

Introduction Micronutrient deficiencies, commonly referred to as ‘hidden hunger’, affect more than two billion people worldwide, with zinc and iron-deficiency frequently reported. The aim of this study is to examine the impact of consuming zinc biofortified flour (Zincol-2016) on biochemical and functional measures of status in adolescent girls and children living in a low-resource setting in Pakistan. Methods and analysis We are conducting a pragmatic, cluster-randomised, double-blind, controlled trial. A total of 482 households have been recruited from two catchment areas approximately 30–40 km distance from Peshawar. Household inclusion criteria are the presence of both an adolescent girl, aged 10–16 years, and a child aged 1–5 years. The study duration is 12 months, divided into two 6-month phases. During phase 1, all households will be provided with locally procured flour from standard varieties of wheat. During phase 2, clusters will be paired, and randomised to either the control or intervention arm of the study. The intervention arm will be provided with zinc biofortified wheat flour, with a target zinc concentration of 40 mg/kg. The control arm will be provided with locally procured wheat flour from standard varieties with an expected zinc concentration of 20 mg/kg. The primary outcome measure is plasma zinc concentration. Secondary outcomes include anthropometric measurements, biomarkers of iron and zinc status, and the presence and duration of respiratory tract infections and diarrhoea. Ethics and dissemination Ethical approval was granted from the University of Central Lancashire STEMH Ethics Committee (reference number: STEMH 1014) and Khyber Medical University Ethics Committee (DIR/KMU-EB/BZ/000683). The final study methods will be published in peer-reviewed journals, alongside the study outcomes. In addition, findings will be disseminated to the scientific community via conference presentations and abstracts and communicated to the study participants

Background: Biofortification of staple food crops may be a cost-effective and sustainable approach to reducing micronutrient deficiencies in resource-poor settings with low dietary diversity. However, its success depends on uptake by the local population. This paper presents formative research conducted in a remote, rural community in North West Pakistan, prior to commencing a randomised controlled trial to test the effectiveness of consuming zinc-biofortified wheat flour for alleviating zinc deficiency. It explored local community members’ knowledge, understanding and attitudes towards biofortification and views on members of their community taking part in the trial. Methods: Four focus group discussions were conducted with male and female community members (separately for cultural reasons) and four in-depth interviews were conducted with Jirga members—respected male elders. Participation was limited to households that were ineligible for the trial so that we could explore the perspectives of community members who were not influenced by the incentives of the trial. Focus group participants were selected at community events for transparency. Data collection took place at the local school and homes of Jirga members. Thematic analysis was undertaken, using a combination of deductive and inductive approaches to identify key themes. Results: A total of 47 men and women participated in this study. Participants reported clear motivation to access and consume more nutritious flour, believing this would bring health benefits, particularly to women and children. Trusted members of the local community, including Jirga members and female health workers, should be involved in providing information on biofortified flour (and the trial) to increase levels of awareness and acceptance. Without their involvement, there is a risk that biofortified flour would be mistrusted. The cost of flour is the main factor affecting purchasing decisions, and biofortified flour will need to be cos

BACKGROUND: A curriculum is dynamic entity and hence, metaphorically, can be considered 'alive'. Curricular diseases may impair its quality and hence its viability. The quality of a curriculum is typically assessed against certain quality standards only. This approach does not identify the inhibitors impeding the achievement of quality standards. The purpose of this study is to identify not only standards but also inhibitors of curriculum quality, allowing for a more comprehensive assessment of what we coin 'curriculum viability'.METHODS: We performed a scoping review of 'curriculum viability', after which 13 articles were found eligible through a meticulous search and selection process. We first identified 1233 studies based on matching keywords, title and abstract; 36 of which met our inclusion criteria. After application of the Qualsyst criteria, two independent reviewers performed a thematic analysis of the 13 articles that remained.RESULTS: While all studies reported on standards of quality, only two studies described both standards and inhibitors of quality. These standards and inhibitors were related to educational content and strategy, students, faculty, assessment, educational/work environment, communication, technology and leadership.CONCLUSIONS: The framework of curriculum viability thus developed will help identify inhibitors adversely affecting the curriculum viability and remaining hidden or un-noticed when curriculum evaluation is done.

Background: Professionalism is contextual and varies with culture. It has multiple dimensions including individual, inter-personal, organizational, and societal components. The aim of this study was to add some new perspectives to understand professionalism. Professionalism was explored in the context of two different cultures, Scotland and Pakistan, to identify similarities and differences in perceptions of clinical faculty members and medical students. Methodology: The method used was qualitative multiple case studies in a constructivist approach. Cultural Historical Activity Theory (CHAT) was used as a theoretical framework to enhance understanding of the study. Faculty members from three Scottish and three Pakistani medical schools were interviewed. Focus group discussions were arranged with groups of 7-10 medical students from each of the six medical schools. The data was analysed using a thematic analysis to identify reasons for cultural similarities and differences across two countries. Results: The results were divided into nine themes, that is, the nature of the healthcare system, models and process of professionalism, attributes of professional doctors, approach of doctors towards their patients and other healthcare professionals, working in teams, self-regulation, the role of doctors in society and within families, dealing with ethical dilemmas and legally difficult situations, and resolving conflict situations in the work place. Discussion The variance of professionalism found in this study was mainly due to the health professionals working in two different healthcare systems. The cultural differences between the two countries were reflected in these systems and the activity of professionalism included conflicts and dilemmas, self-regulation, and professional attributes. Medical professionals were found to adopt different institutional models of professionalism when they perform their daily activities. Conclusions: This study showed that doctors and medi

Background: Professionalism is contextual and varies with culture. It has multiple dimensions including individual, inter-personal, organizational, and societal components. The aim of this study was to add some new perspectives to understand professionalism. Professionalism was explored in the context of two different cultures, Scotland and Pakistan, to identify similarities and differences in perceptions of clinical faculty members and medical students. Methodology: The method used was qualitative multiple case studies in a constructivist approach. Cultural Historical Activity Theory (CHAT) was used as a theoretical framework to enhance understanding of the study. Faculty members from three Scottish and three Pakistani medical schools were interviewed. Focus group discussions were arranged with groups of 7-10 medical students from each of the six medical schools. The data was analysed using a thematic analysis to identify reasons for cultural similarities and differences across two countries. Results: The results were divided into nine themes, that is, the nature of the healthcare system, models and process of professionalism, attributes of professional doctors, approach of doctors towards their patients and other healthcare professionals, working in teams, self-regulation, the role of doctors in society and within families, dealing with ethical dilemmas and legally difficult situations, and resolving conflict situations in the work place. Discussion The variance of professionalism found in this study was mainly due to the health professionals working in two different healthcare systems. The cultural differences between the two countries were reflected in these systems and the activity of professionalism included conflicts and dilemmas, self-regulation, and professional attributes. Medical professionals were found to adopt different institutional models of professionalism when they perform their daily activities. Conclusions: This study showed that doctors and medi

Background: Professionalism is contextual and varies with culture. It has multiple dimensions including individual, inter-personal, organizational, and societal components. The aim of this study was to add some new perspectives to understand professionalism. Professionalism was explored in the context of two different cultures, Scotland and Pakistan, to identify similarities and differences in perceptions of clinical faculty members and medical students. Methodology: The method used was qualitative multiple case studies in a constructivist approach. Cultural Historical Activity Theory (CHAT) was used as a theoretical framework to enhance understanding of the study. Faculty members from three Scottish and three Pakistani medical schools were interviewed. Focus group discussions were arranged with groups of 7-10 medical students from each of the six medical schools. The data was analysed using a thematic analysis to identify reasons for cultural similarities and differences across two countries. Results: The results were divided into nine themes, that is, the nature of the healthcare system, models and process of professionalism, attributes of professional doctors, approach of doctors towards their patients and other healthcare professionals, working in teams, self-regulation, the role of doctors in society and within families, dealing with ethical dilemmas and legally difficult situations, and resolving conflict situations in the work place. Discussion The variance of professionalism found in this study was mainly due to the health professionals working in two different healthcare systems. The cultural differences between the two countries were reflected in these systems and the activity of professionalism included conflicts and dilemmas, self-regulation, and professional attributes. Medical professionals were found to adopt different institutional models of professionalism when they perform their daily activities. Conclusions: This study showed that doctors and medi