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Background: Biofortified Zinc Flour to Eliminate Deficiency in Pakistan (BiZiFED) is a nutritional research program that evaluates the impact of consuming zinc biofortified wheat flour on zinc status and associated health outcomes of vulnerable communities in northwest Pakistan. Measuring zinc status from blood samples is fraught with problems. This feasibility study evaluated whether metabolite changes in tear biofluids could be used to understand zinc status. Methods: Zinc deficiency is particularly prevalent amongst the female population in Pakistan. Therefore, a crossover trial was developed in which 25 women of reproductive age received standard, wheat flour, and another 25 received zinc-biofortified wheat flour for 8 weeks. At the end of this period, the nutritional intervention was switched between the groups for another 8 weeks. Tear biofluid was collected using Schirmer strips at baseline and after 8 and 16 weeks. Metabolomic analysis was conducted using the MxP® Quant 500 kit on the tear biofluid from a subset of the study participants. Results: Two metabolites had a significantly negative correlation with plasma zinc concentration: tiglylcarnitine and valine. Compared to baseline metabolite concentrations, acetylcarnitine, glutamine, two lysophosphatidylcholines (lysoPC a C16:0 and lysoPC a C18:1), and four sphingomyelins (SM (OH) C16:1, SM C16:0, SM C16:1, and SM C24:0) were all significantly decreased post-zinc intervention, whilst a ceramide (Cer(d18:1/18:0) was significantly increased. Conclusion: These results highlight the potential of using tear biofluids as an alternative source for metabolomic biomarkers, both for the assessment of the zinc status of individuals enrolled in nutritional studies and for indicating physiological changes that arise from nutritional supplementation.

The aim of this study was to determine whether x-ray fluorescence spectrometry (XRF) could be used to detect changes in hair zinc concentration in response to a modest daily increase in zinc from the consumption of zinc biofortified wheat flour. This study was conducted as part of an effectiveness trial (BiZiFED2) exploring the potential for zinc biofortified wheat to alleviate zinc deficiency in adolescent girls aged 10-16 years in Pakistan (trial registration ID ISRCTN17107812). A randomised controlled design was used. Participants received either control flour or zinc biofortified flour for 6 months. Consumption of biofortified flour resulted in an average daily increase in dietary zinc intake of 1.5 mg per day above that of the control flour. At baseline and at the end of the intervention, individual hair samples (control: n= 59, intervention: n=64) were analyzed for zinc and sulphur content by XRF. Data were analysed using linear mixed effects models to contrast between trial groups the changes from baseline to end point and also to compare baseline and end point values within each trial group. Increases from baseline to endpoint in both sulphur and zinc were significantly greater in the intervention group compared to control (Sulphur counts. Control: baseline = 119.87±20.33 & endpoint = 121.58±23.58 / intervention: baseline = 122.67±24.19 & endpoint = 131.60±21.34); (Zinc counts. Control: baseline = 50.88±14.33 & endpoint = 54.82±14.61 / intervention: baseline = 49.61±10.77 & endpoint = 58.79±12.20). For these parameters, there were also significant increases from baseline to endpoint in the intervention group but not in control. Furthermore, for Zn:S count ratio there were no differences in terms of the magnitude of the change from baseline to endpoint in the control group, although significant increases from baseline to endpoint were evident in the intervention group. (Zn:S count ratio. Control: baseline = 0.42±0.10 & endpoint = 0.45±0.08 / intervention: bas

Malnutrition is associated with reduced learning aptitude and growth during childhood. We examined the impact of providing two school lunch variants, a standard school meal (school feeding, n = 70), or the standard meal with additional micronutrients (school feeding + micronutrient powder (MNP), n = 70), in children attending two schools in northwest Pakistan. A third local government school, where no lunch was provided (no school feeding, n = 70), served as the control. The primary outcome, cognitive function, was assessed using the Raven’s Coloured Progressive Matrices (RCPM) test, alongside haemoglobin, at three-time points: T1 (baseline, before the initiation of the school lunch programme), T2 and T3 (5 and 12 months, respectively, after the introduction of the school lunch). Data were analysed using linear mixed-effects models to contrast between trial groups, the changes from T1 to T2 and T3. Adjusted for T1 and other co-variates, improvements in the RCPM scores were significantly greater in the school feeding group at T2 (b = 1.61, (95% CI = 0.71–2.52), t = 3.52, p = 0.001) and T3 (b = 1.28, (95% CI = 0.22–2.35), t = 2.38, p = 0.019) compared with no school feeding. In addition, at T2 (b = 1.63, (95% CI = −0.10–3.37), t = 1.86, p = 0.065), there were no significant differences between school feeding + MNP and no school feeding groups. However, improvements in the RCPM scores were significantly greater in the school feeding + MNP group at T3 (b = 2.35, (95% CI = 0.51–4.20), t = 2.53, p = 0.013) compared with no school feeding. The findings indicate an improvement in cognitive performance in children who received a school meal with and without MNP, over a 12-month period. Currently there is no operational school feeding programme at the national or provincial level in Pakistan. Our findings, therefore, highlight the need for school feeding programmes to improve learning opportunities for children from underprivileged communities.

BACKGROUND AND OBJECTIVE: For many health outcomes, there are an array of published methods, however not all have been validated in the target population. So, it is better to first pilot the selected tools and research strategies thus can reduce cost, effort and time in a larger project. The objective of this study was to present the significance of the pilot study by using an example of an observational study in a tertiary care hospital in Pakistan. METHODOLOGY: This pilot study was carried out in a tertiary hospital located in Peshawar, Pakistan. The data (Socio-demographics, anthropometric measurements, biochemical tests, blood pressure measurement and diet intake) was collected from the un-paid female caregivers looking after hemodialysis-dependent family members The caregiver experience was assessed using the Zarit burden interview (ZBI) scale. Pregnant and lactating caregivers were excluded. RESULTS: Data were collected from 20 participants. The decision to participate in the study was based on male family members. Females were reluctant for providing anthropometric measurements and were not aware of monthly income. The majorities were interested in blood pressure measurement and blood tests as offered free of cost. Almost all participants reported positive aspects of caregiving, thus ZBI was not found suitable in the selected sample. CONCLUSION: The results of the pilot study highlighted the strengths and limitations of the selected data collection tools. The results of the survey can be useful for the healthcare professionals involved in researching on South Asian family caregivers.

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

Biofortification of wheat is potentially a sustainable strategy to improve zinc intake; however, evidence of its effectiveness is needed. A household-based, double-blind, cluster-randomized controlled trial (RCT) was conducted in rural Pakistan. The primary objective was to examine the effects of consuming zinc-biofortified wheat flour on the zinc status of adolescent girls aged 10−16 years (n = 517). Households received either zinc-biofortified flour or control flour for 25 weeks; blood samples and 24-h dietary recalls were collected for mineral status and zinc intake assessment. Plasma concentrations of zinc (PZC), selenium and copper were measured via inductively coupled plasma mass spectrometry and serum ferritin (SF), transferrin receptor, alpha 1-acid glycoprotein and C-reactive protein by immunoassay. Consumption of the zinc-biofortified flour resulted in a moderate increase in intakes of zinc (1.5 mg/day) and iron (1.2 mg/day). This had no significant effect on PZC (control 641.6 ± 95.3 µg/L vs. intervention 643.8 ± 106.2 µg/L; p = 0.455), however there was an overall reduction in the rate of storage iron deficiency (SF 15 µg/L; control 11.8% vs. 1.0% intervention). Consumption of zinc-biofortified flour increased zinc intake (21%) but was not associated with an increase in PZC. Establishing a sensitive biomarker of zinc status is an ongoing priority.

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.

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

Consuming a diverse diet is essential to ensure an adequate intake of micronutrients. The aim of this study was to assess the nutritional status and dietary diversity of women of reproductive age (WRA) living in a marginalized community in rural Pakistan. Forty-seven WRA (35 ± 7 years old) who were not pregnant or lactating at enrollment, were recruited to participate in the study. Twenty-four-hour dietary recall interviews were conducted by the study nutritionist, and the data collected were used to create a minimum dietary diversity for women score (MDD-W) on five occasions during the monsoon and winter seasons (October to February). Nutritional status was assessed using anthropometry and biochemical markers of micronutrient status. Height and weight were used to determine body mass index (BMI), and mid-upper-arm circumference was measured. Plasma zinc, iron, and selenium concentrations were measured using inductively coupled mass spectrometry, and iron status was assessed using serum ferritin and blood hemoglobin concentrations. The mean (±SD) food group diversity score was 4 ± 1 with between 26% and 41% of participants achieving an MDD-W of 5. BMI was 27.2 ± 5.5 kg/m2 with 28% obese, 34% overweight, and 6% underweight. The prevalence of zinc deficiency, based on plasma zinc concentration, was 29.8%; 17% of the participants had low plasma selenium levels; 8.5% were iron deficient; and 2% were suffering from iron deficiency anemia. The findings indicate that the women living in this community consume a diet that has a low diversity, consistent with a diet low in micronutrients, and that zinc deficiency is prevalent. Public health interventions aimed at increasing the dietary diversity of WRA are needed to improve the micronutrient intake, particularly of zinc, in this population.

Background: Biofortification of wheat with zinc (Zn) through breeding and agronomy can reduce Zn deficiencies and improve human health. ‘High-Zn’ wheat varieties have been released in India and Pakistan, where wheat is consumed widely as a dietary staple. The aim of this study was to quantify the potential contribution of a ‘high-Zn’ wheat variety (Triticum aestivum L. var. Zincol-2016) and Zn fertilisers to improving dietary Zn supply under field conditions in Pakistan. Methods: Grain Zn concentration of Zincol-2016 and local reference varieties were determined at three sites of contrasting soil Zn status: Faisalabad (Punjab Province; diethylenetriamine pentaacetate- (DTPA-)extractable Zn, 1.31 mg kg-1 soil; gross plot size 13.3 m2; n=4; reference var. Faisalabad-2008), Islamabad (Capital Territory; 0.48 mg kg-1; 4.6 m2; n=5; reference var. NARC-2011), and Pir Sabak (Khyber Pakhtunkhwa, KPK, Province; 0.12 mg kg-1 soil; 9.1 m2; n=4; reference vars. Pirsabak-2015, Wadhan-2017). Eight Zn fertiliser treatment levels were tested using a randomised complete block design: control; soil (5 or 10 kg ha-1 ZnSO4.H2O; 33% Zn applied at sowing); foliar (0.79 or 1.58 kg of ZnSO4.H2O ha-1 applied as a 250 L ha-1 drench at crop booting stage); three soil  foliar combinations. Results: At the Faisalabad site, the grain Zn concentration of Zincol-2016 was greater than Faisalabad-2008, with no yield penalty. Zincol-2016 did not have larger grain Zn concentrations than reference varieties used at Islamabad or Pir Sabak sites, which both had a lower soil Zn status than the Faisalabad site. Foliar Zn fertilisation increased grain Zn concentration of all varieties at all sites. There were no significant effects of soil Zn fertilisers, or variety·fertiliser interactions, on grain Zn concentration or yield. Conclusions: Environment and management affect the performance of ‘high-Zn’ wheat varieties, and these factors needs to be evaluated at scale to assess the potential nutritional impac

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

Consuming a diverse diet is essential to ensure an adequate intake of micronutrients. The aim of this study was to assess the nutritional status and dietary diversity of women of reproductive age (WRA) living in a marginalized community in rural Pakistan. Forty-seven WRA (35 ± 7 years old) who were not pregnant or lactating at enrollment, were recruited to participate in the study. Twenty-four-hour dietary recall interviews were conducted by the study nutritionist, and the data collected were used to create a minimum dietary diversity for women score (MDD-W) on five occasions during the monsoon and winter seasons (October to February). Nutritional status was assessed using anthropometry and biochemical markers of micronutrient status. Height and weight were used to determine body mass index (BMI), and mid-upper-arm circumference was measured. Plasma zinc, iron, and selenium concentrations were measured using inductively coupled mass spectrometry, and iron status was assessed using serum ferritin and blood hemoglobin concentrations. The mean (±SD) food group diversity score was 4 ± 1 with between 26% and 41% of participants achieving an MDD-W of 5. BMI was 27.2 ± 5.5 kg/m2 with 28% obese, 34% overweight, and 6% underweight. The prevalence of zinc deficiency, based on plasma zinc concentration, was 29.8%; 17% of the participants had low plasma selenium levels; 8.5% were iron deficient; and 2% were suffering from iron deficiency anemia. The findings indicate that the women living in this community consume a diet that has a low diversity, consistent with a diet low in micronutrients, and that zinc deficiency is prevalent. Public health interventions aimed at increasing the dietary diversity of WRA are needed to improve the micronutrient intake, particularly of zinc, in this population.

We explored the personal food environment through the consumption of biofortified and non-biofortified wheat flour provided as part of a community-based intervention study in rural Pakistan. Participants reported that the taste, kneading qualities and digestibility of the flour provided to participants were important factors affecting its desirability and their willingness to engage in the study. Fears that consumption of the flour might negatively affect fertility were alleviated through effective engagement with village elders. The results clearly illustrate the importance of cultural context when considering data-collection approaches. This study offers novel insights into the views and perspectives of community members. There was no evidence of negative views towards biofortified flour, provided it remains affordable.

Zinc deficiency is a global public health problem, affecting ~17% of the world’s population, with the greatest burden in low and middle-income countries. An increasing body of evidence suggests that biofortification may be a cost-effective and sustainable approach to reducing zinc and other micronutrient deficiencies. Biofortification enhances the nutritional quality of food crops through conventional plant breeding techniques and agronomic practices. This paper presents our ongoing research on biofortification in Pakistan, where over 40% of women are zinc deficient. The Biofortified Zinc Flour to Eliminate Deficiency (BiZiFED) project aims to investigate the impact of biofortification as a strategy to alleviate zinc deficiency in Pakistan. The project is supported by the Biotechnology and Biological Sciences Research Council (BBSRC) Global Challenges Research Fund from May 2017 to April 2019. This paper outlines the four objectives and work packages within the BiZiFED project: 1) a doubleblind, randomised controlled trial to examine the effect of consuming flour made from a high zinc variety of biofortified wheat (Zincol- 2016/NR-421) on dietary zinc intake and status; 2) a cost-effectiveness study to assess the health and economic impact of agronomic biofortification of wheat; 3) a mixed methods study to explore the cultural acceptability and sustainability of biofortification in Pakistan; 4) capacity building and development of long-term research partnerships in Pakistan. The findings will contribute to the evidence base for the potential impact of biofortification to alleviate zinc deficiency among the poorest communities.

Objective: To improve maternal health and reduce child mortality through developing health service delivery in a poor and marginalised community in North West Pakistan. Methodology: A multifaceted intervention to extend and strengthen the range and quality of services provided at an existing health centre, in a rural community in Peshawar District, Khyber Pakhtunkhwa Province. The intervention was developed with community involvement and had four main components: service development, staff capacity development, community engagement and the introduction of a micro-credit scheme. The evaluation assessed the efficiency and effectiveness of project implementation, including a survey of maternal and child health indicators. Results: Between 2014 and 2017, a range of new health services were developed at the health centre. Local volunteers were trained to promote health awareness in the community and refer pregnant women to the health centre. The survey indicated health improvements, such as increased vaccination rates for women and children, and a dramatic reduction in unskilled deliveries. Conclusions: Community engagement was essential to achieve much needed maternal and child health improvements in this poor and marginalised community. Sustainability was achieved by training local volunteers as community health workers.

Introduction: Dietary zinc (Zn) deficiency is a global problem, particularly in low and middle-income countries where access to rich, animal-source foods of Zn is limited due to poverty. In Pakistan, Zn deficiency affects over 40% of the adult female population, resulting in sub-optimal immune status and increased likelihood of complications during pregnancy. Methods and analysis: We are conducting a double blind, randomised controlled feeding study with crossover design, in a low resource setting in Pakistan. Households were provided with flour milled from genetically and agronomically biofortified grain (Zincol-2016/NR-421) or control grain (Galaxy-2013. Fifty households were recruited. Each household included a female aged 16-49 years who is neither pregnant nor breastfeeding, and not currently consuming nutritional supplements. These women were the primary study participants. All households were provided with control flour for an initial 2-week baseline period, followed by an 8-week intervention period where 25 households receive biofortified flour (Group A) and 25 households receive control flour (Group B). After this eight-week period, Group A and B crossed over, receiving control and biofortified flour respectively for eight weeks. Tissue (blood, hair and nails) have been collected from the women at five time points: baseline, mid and end of period 1, mid and end of period 2. Ethics and dissemination: Ethical approval was granted from the lead University (reference number: STEMH 697 FR) and the collaborating institution in Pakistan. The final study methods (including any modifications) will be published in peer reviewed journals, alongside the study outcomes on completion of the data analysis. In addition, findings will be disseminated to the scientific community via conference presentations and abstracts and communicated to the study participants through the village elders at an appropriate community forum.

Iodine deficiency is still prevalent in parts of Pakistan, despite the introduction of a national Iodine Deficiency Disorder Control Programme in 1994. The purpose of this study was to gain an understanding of the knowledge, attitudes and practice regarding the use of iodised salt in a brick kiln community, and to use this information to design an intervention to increase its consumption. A cross-sectional survey was used to assess the use of iodised salt and focus group discussions explored the attitudes and barriers to its use. Thematically analysed transcripts informed the design of a 4-month intervention. Iodised salt sales and urine iodine concentration (UIC) were monitored to assess the effectiveness of the intervention. At baseline, 2.6% of households reported use of iodised salt and barriers included its higher cost and belief about a negative impact on reproduction. During the intervention, sales of salt labelled as iodised increased by 45%, however this was not reflected in an increase in UIC. This study highlighted the positive impact of education and awareness raising on iodised salt consumption in a hard to reach, marginalised community. However, issues regarding adequate iodisation by local producers and appropriate storage also need to be urgently addressed at a provincial level.

Maternal and infant malnutrition is prevalent in rural regions of NW Pakistan. This article reports on the use of a combination of a realist Context–Mechanism–Outcome framework and participatory appraisal methods to facilitate the development of a locally sensitive and responsive nutritional intervention programme. Data were gathered through a series of focus group (FG) discussions with local lady health workers, as well as pregnant and breastfeeding women attending an Emergency Field Hospital in North West Pakistan between May 2008 and March 2009. A nutrition intervention programme was implemented that involved cookery demonstration kitchens and free food supplements, coupled with nutrition and healthcare information and advice for pregnant and breastfeeding women. Subsequent FG discussions revealed that the programme had a positive impact on knowledge gained by women in the community and generated an openness to receiving and spreading knowledge. The framework, which rested on the use of a double feedback loop, involving local women, lady health workers, local researchers and UK-based researchers, has enabled not only the establishment of the programme, but has also given the local team the tools to apply for, and gain, further funding for the development of nutrition support services. The development of such methodological tools, which empower local researchers and service providers (wherever located) to operationalize local knowledge and assess interventions, is particularly relevant in international financially-constrained contexts.