Asher Feroze

Improvement of perinatal and newborn care in rural Pakistan through community-based strategies: a cluster-randomised effectiveness trial

BACKGROUND Newborn deaths account for 57% of deaths in children younger than 5 years in Pakistan. Although a large programme of trained lady health workers (LHWs) exists, the effectiveness of this training on newborn outcomes has not been studied. We aimed to evaluate the effectiveness of a community-based intervention package, principally delivered through LHWs working with traditional birth attendants and community health committees, for reduction of perinatal and neonatal mortality in a rural district of Pakistan. METHODS We undertook a cluster randomised trial between February, 2006, and March, 2008, in Hala and Matiari subdistricts, Pakistan. Catchment areas of primary care facilities and all affiliated LHWs were used to define clusters, which were allocated to intervention and control groups by restricted, stratified randomisation. The intervention package delivered by LHWs through group sessions consisted of promotion of antenatal care and maternal health education, use of clean delivery kits, facility births, immediate newborn care, identification of danger signs, and promotion of careseeking; control clusters received routine care. Independent data collectors undertook quarterly household surveillance to capture data for births, deaths, and household practices related to maternal and newborn care. Data collectors were masked to cluster allocation; those analysing data were not. The primary outcome was perinatal and all-cause neonatal mortality. Analysis was by intention to treat. This trial is registered, ISRCTN16247511. FINDINGS 16 clusters were assigned to intervention (23,353 households, 12,391 total births) and control groups (23,768 households, 11,443 total births). LHWs in the intervention clusters were able to undertake 4428 (63%) of 7084 planned group sessions, but were only able to visit 2943 neonates (24%) of a total 12,028 livebirths in their catchment villages. Stillbirths were reduced in intervention clusters (39·1 stillbirths per 1000 total births) compared with control (48·7 per 1000; risk ratio [RR] 0·79, 95% CI 0·68-0·92; p=0·006). The neonatal mortality rate was 43·0 deaths per 1000 livebirths in intervention clusters compared with 49·1 per 1000 in control groups (RR 0·85, 0·76-0·96; p=0·02). INTERPRETATION Our results support the scale-up of preventive and promotive maternal and newborn interventions through community health workers and emphasise the need for attention to issues of programme management and coverage for such initiatives to achieve maximum potential. FUNDING WHO; Saving Newborn Lives Program of Save the Children USA, funded by the Bill & Melinda Gates Foundation.

Evaluation of health workforce competence in maternal and neonatal issues in public health sector of Pakistan: an Assessment of their training needs.

BackgroundMore than 450 newborns die every hour worldwide, before they reach the age of four weeks (neonatal period) and over 500,000 women die from complications related to childbirth. The major direct causes of neonatal death are infections (36%), Prematurity (28%) and Asphyxia (23%). Pakistan has one of the highest perinatal and neonatal mortality rates in the region and contributes significantly to global neonatal mortality. The high mortality rates are partially attributable to scarcity of trained skilled birth attendants and paucity of resources. Empowerment of health care providers with adequate knowledge and skills can serve as instrument of change.MethodsWe carried out training needs assessment analysis in the public health sector of Pakistan to recognize gaps in the processes and quality of MNCH care provided. An assessment of Knowledge, Attitude, and Practices of Health Care Providers on key aspects was evaluated through a standardized pragmatic approach. Meticulously designed tools were tested on three tiers of health care personnel providing MNCH in the community and across the public health care system. The Lady Health Workers (LHWs) form the first tier of trained cadre that provides MNCH at primary care level (BHU) and in the community. The Lady Health Visitor (LHVs), Nurses, midwives) cadre follow next and provide facility based MNCH care at secondary and tertiary level (RHCs, Taluka/Tehsil, and DHQ Hospitals). The physician/doctor is the specialized cadre that forms the third tier of health care providers positioned in secondary and tertiary care hospitals (Taluka/Tehsil and DHQ Hospitals). The evaluation tools were designed to provide quantitative estimates across various domains of knowledge and skills. A priori thresholds were established for performance rating.ResultsThe performance of LHWs in knowledge of MNCH was good with 30% scoring more than 70%. The Medical officers (MOs), in comparison, performed poorly in their knowledge of MNCH with only 6% scoring more than 70%. All three cadres of health care providers performed poorly in the resuscitation skill and only 50% were able to demonstrate steps of immediate newborn care. The MOs performed far better in counselling skills compare to the LHWs. Only 50 per cent of LHWs could secure competency scale in this critical component of skills assessment.ConclusionsAll three cadres of health care providers performed well below competency levels for MNCH knowledge and skills. Standardized training and counselling modules, tailored to the needs and resources at district level need to be developed and implemented. This evaluation highlighted the need for periodic assessment of health worker training and skills to address gaps and develop targeted continuing education modules. To achieve MDG4 and 5 goals, it is imperative that such deficiencies are identified and addressed.

Routine EPI coverage: subdistrict inequalities and reasons for immunization failure in a rural setting in Pakistan

High vaccine coverage at the district level may not translate with the same vigor to subdistrict levels; therefore, it is important to understand coverage inequalities. This study underscored vaccine coverage inequalities at subdistrict levels and explored reasons for immunization failure in a high-performing rural district of Pakistan. Parents of children aged 12 to 23 months were randomly selected and interviewed for child’s vaccination history through a cross-sectional survey in 2008. Using secondary data (GIS maps and population census), coverage was plotted in respect to sociodemographic and presence of lady health workers. The proportion of children fully immunized was found notably low (75%) than officially reported (85%). Coverage inequalities were observed at subdistrict levels, ranging from 58% to 85% in rural to urban areas and from 60% to 80% in lower to higher income quintiles. Distance to immunization facility, parental unawareness, and wrong ideas about vaccination were statistically significant for immunization failure. Focus of immunization microplans at the subdistrict level are needed to achieve universal immunization goals.

Home injury risks to young children in Karachi, Pakistan: a pilot study

Objective To pilot an in-home unintentional injury hazard assessment tool and to quantify potential injury risks for young children in a low-income urban setting. Methods Two low-income neighbourhoods in Karachi, Pakistan, were mapped, and families with at least one child between the ages of 12 and 59 months were identified. Using existing available home injury risk information, an in-home injury risk assessment tool was drafted and tailored to the local setting. Home injury assessments were done in June–July 2010 after obtaining informed consent. Results Approximately 75.4% of mothers were educated through at least grade 12. The main risks identified were stoves within the reach of the child (n=279, 55.5%), presence of open buckets in the bathroom (n=240, 47.7%) within the reach of the child, and pedestal fans accessible to the child (n=242, 48.1%). In terms of safety equipment, a first-aid box with any basic item was present in 70% of households, but only 4.8% of households had a fire extinguisher in the kitchen. Conclusions This was the first time that an in-home, all-unintentional injury risk assessment tool was tailored and applied in the context of a low-income community in Pakistan. There was a significant burden of hazards present in the homes in these communities, representing an important opportunity for injury prevention. This pilot may have future relevance to other LMICs where child injury prevention is a critical need.

Burn injury characteristics: findings from Pakistan National Emergency Department Surveillance Study

BackgroundBurn injury is an important yet under-researched area in Pakistan. The objective of this study was to determine the characteristics and associated outcomes of burn injury patients presenting to major emergency departments in Pakistan.MethodsPakistan National Emergency Department Surveillance (Pak-NEDS) was a pilot active surveillance conducted between November 2010 and March 2011. Information related to patient demographics, mode of arrival, cause of burn injury, and outcomes was analyzed for this paper. Data were entered using Epi Info and analyzed using SPSS v.20. Ethical approval was obtained from all participating sites.ResultsThere were 403 burn injury patients in Pak-NEDS, with a male to female ratio 2:1. About 48.9% of the burn injury patients (n = 199) were between 10 - 29 years of age. There was no statistically significant difference between unintentional and intentional burn injury patients except for body part injured (p-value 0.004) and ED disposition (p-value 0.025). Among 21 patients who died, most were between 40 - 49 years of age (61.9%) and suffered from fire burns (81%).ConclusionBurn injuries are a burden on emergency rooms in Pakistan. We were able to demonstrate the significant burden of burn injuries that is not addressed by specialized burn centers.

Effects of the Crises on Child Nutrition and Health in East Asia and the Pacific

Experiences of the 1997 financial crisis in East Asia provide strong evidence that there are serious risks that the current food, fuel, economic and financial crisis will affect child health and nutrition in the region. Using information available on the 1997 crisis, this paper evaluates its effects on nutrition status, reportable diseases, immunization status and child mortality. These results are used to model plausible estimates of the potential health and nutrition impacts of the current crisis across socioeconomic strata. The model results suggest that, if unaddressed, the current crisis could increase maternal anaemia rates by 10—20%, prevalence of low birth weight by 5—10%, childhood stunting by 3—7%, wasting by 8—16% and under-five child mortality in severely affected countries from 3—11%. The paper asserts that a range of low-cost and high-impact interventions exist that, if delivered in primary care settings without further delay, could mitigate or even reverse these adverse health and nutrition consequences. Le Ralentissement Économique Mondial, la Crise Alimentaire et l’Instabilité du Prix des Combustibles: Les Expositions et les Impacts sur la Nutrition et la Santé des Enfants dans les Régions de l’Asie de l’Est et le Pacifique Les expériences de la crise financière en 1997 dans l’Asie de l’Est fournissent des preuves fortes que la crise actuelle des produits alimentaires, des combustibles, et de l’économie risque d’affecter gravement la santé et la nutrition des enfants dans la région. En utilisant les renseignements disponibles sur la crise de 1997, cet article évalue les effets sur la nutrition, les maladies devant être notifiées, les systèmes d’immunisation, et la mortalité des enfants. On utilise ces résultats pour créer des évaluations plausibles quant aux impacts possibles de la crise actuelle sur la santé et la nutrition à travers les couches socioéconomiques. Les résultats du modèle suggèrent que, sans intervention, la crise actuelle pourrait augmenter les taux de l’anémie maternelle entre 10 et 20%; la prévalence du petit poids à la naissance entre 5 et 10%; le retard de croissance chez les enfants entre 3 et 7%; le dépérissement entre 8 et 16%; et la mortalité chez les enfants de moins de 5 ans dans les pays plus affectés entre 3 et 11%. L’article soutient qu’il existe des interventions pas chères mais bien efficaces qui pourraient atténuer, ou bien inverser, les effets négatifs sur la santé et la nutrition, si elles sont implémentées dans les centres d’attention primaire sans délai. La Recesión Económica Mundial, la Crisis de Alimentos y la Inestabilidad del Precio de Combustibles: Exposiciones e Impactos en la Nutrición y la Salud de los Niños en las Regiones de Asia del Este y el Pacífico Las repercusiones de la crisis financiera de 1997 en el Asia del Este proporcionan fuertes pruebas que la crisis actual de alimentos, combustibles y finanzas afectará a la salud y la nutrición de los niños en la región. Usando la información disponible sobre la crisis de 1997, este documento evalúa los efectos sobre la situación nutricional, las enfermedades de declaración obligatoria, los sistemas de inmunización, y la mortalidad infantil. Estos resultados están usados para formar cálculos creíbles de los posibles impactos sobre la salud y la nutrición, a través los estratos socioeconómicos, que podrían ser provocados por la crisis actual. Los resultados del modelo sugieren que la crisis actual, sin intervención, podría aumentar los índices de anemia materna entre el 10 y el 20%; la preponderancia del peso bajo al nacimiento entre el 5 y el 10%; el retraso en el crecimiento entre el 3 y el 7%; las enfermedades debilitantes entre el 8 y el 16%; y la mortalidad de niños menores de 5 años en los países mas afectados entre el 3 y el 11%. Este documento afirma que existe una escala de intervenciones de bajo coste y gran impacto que, si están realizadas en los centros de atención primaria sin retraso, podrían mitigar o invertir estas consecuencias adversas sobre la salud y la nutrición.

The pediatric disease spectrum in emergency departments across Pakistan: data from a pilot surveillance system

BackgroundThere is an increasing number of urgently ill and injured children being seen in emergency departments (ED) of developing countries. The pediatric disease burden in EDs across Pakistan is generally unknown. Our main objective was to determine the spectrum of disease and injury among children seen in EDs in Pakistan through a nationwide ED-based surveillance system.MethodsThrough the Pakistan National Emergency Department Surveillance (Pak-NEDS), data were collected from November 2010 to March 2011 in seven major tertiary care centers representing all provinces of Pakistan. These included five public and two private hospitals, with a collective annual census of over one million ED encounters.ResultsOf 25,052 children registered in Pak-NEDS (10% of all patients seen): 61% were male, 13% under 5 years, while almost 65% were between 10 to < 16 years. The majority (90%) were seen in public hospital EDs. About half the patients were discharged from the EDs, 9% admitted to hospitals and only 1.3% died in the EDs. Injury (39%) was the most common presenting complaint, followed by fever/malaise (19%) and gastrointestinal symptoms (18%). Injury was more likely in males vs. females (43% vs. 33%; p < 0.001), with a peak presentation in the 5-12 year age group (45%).ConclusionsPediatric patients constitute a smaller proportion among general ED users in Pakistan. Injury is the most common presenting complaint for children seen in the ED. These data will help in resource allocation for cost effective pediatric ED service delivery systems. Prospective longer duration surveillance is needed in more representative pediatric EDs across Pakistan.

Pattern of fall injuries in Pakistan: the Pakistan National Emergency Department Surveillance (Pak-NEDS) study.

BackgroundWe aimed to analyse the frequency and patterns of fall-related injuries presenting to the emergency departments (EDs) across Pakistan.MethodsPakistan National Emergency Departments surveillance system collected data from November 2010 to March 2011 on a 24/7 basis using a standardized tool in seven major EDs (five public and two private hospitals) in six major cities of Pakistan. For all patients presenting with fall-related injuries, we analysed data by intent with focus on unintentional falls. Simple frequencies were run for basic patient demographics, mechanism of falls, outcomes of fall injuries, mode of arrival to ED, investigations, and procedures with outcomes.ResultsThere were 3335 fall-related injuries. In cases where intent was available, two-thirds (n = 1186, 65.3%) of fall injuries were unintentional. Among unintentional fall patients presenting to EDs, the majority (76.9%) were males and between 15-44 years of age (69%). The majority of the unintentional falls (n = 671, 56.6%) were due to slipping, followed by fall from height (n = 338, 28.5%). About two-thirds (n = 675, 66.6%) of fall injuries involved extremities, followed by head/neck (n = 257, 25.4%) and face (n = 99, 9.8%). Most of the patients were discharged from the hospital (n = 1059, 89.3%). There were 17 (1.3%) deaths among unintentional fall cases.ConclusionFalls are an important cause of injury-related visits to EDs in Pakistan. Most of the fall injury patients were men and in a productive age group. Fall injuries pose a burden on the healthcare system, especially emergency services, and future studies should therefore focus on safety measures at home and in workplaces to reduce this burden.

Real-Time Patient Satisfaction of Emergency Department Services in a Tertiary- Care Hospital in Karachi, Pakistan

Background: In Emergency Department (ED), patient satisfaction is an important quality indicator. The aim of this study was to assess the patient satisfaction with ED services using real- time patient satisfaction survey. Methods: The study was conducted for two weeks in the ED of Aga Khan University in December 2011. A structured questionnaire was used to capture patient’s feedback on service quality in the ED. Patient response was recorded using five-level Likert scale; strongly agree, agree, neutral, disagree and strongly disagree. Respondents were either patients or their relatives. Results: Total 348 real-time survey forms were completed. Of these 18.6% (n=61) were in P1 triage category, 32.6% (n=107) in P2 and 48.8% (n=160) were P3 patients. An overall satisfaction rate was 4.27 with satisfactory response from 84.6% patients with ED services. About 87.7% of patients were satisfied with time taken to be attended by the triage staff at the counter, Time taken to get an ED bed was 86.8% and time taken until beginning of treatment after getting an ED bed is 84.3%. Conclusion: Patient satisfaction is an important quality indicator which enables to identify areas of improvement in ED so as to provide better care & services to patients.

Dead on arrival in a low-income country: results from a multicenter study in Pakistan

BackgroundThis study assessed the characteristics of dead on arrival (DOA) patients in Pakistan.MethodsData about the DOA patients were extracted from Pakistan National Emergency Department Surveillance study (Pak-NEDS). This study recruited all ED patients presenting to seven tertiary care hospitals during a four-month period between November 2010 and March 2011. This study included patients who were declared dead-on-arrival by the ED physician.ResultsA total of 1,557 DOA patients (7 per 1,000 visits) were included in the Pak-NEDS. Men accounted for two-thirds (64%) of DOA patients. Those aged 20-49 years accounted for about 46% of DOA patients. Nine percent (n = 72) of patients were brought by ambulance, and most patients presented at a public hospital (80%). About 11% of DOA patients had an injury. Factors significantly associated (p < 0.05) with ambulance use were men (adjusted odds ratio [aOR] = 2.72), brought to a private hospital (OR = 2.74), and being injured (aOR = 1.89). Cardiopulmonary resuscitation (CPR) was performed on 6% (n = 42) of patients who received treatment. Those brought to a private hospital were more likely to receive CPR (aOR = 2.81).ConclusionThis study noted a higher burden of DOA patients in Pakistan compared to other resourceful settings (about 1 to 2 per 1,000 visits). A large proportion of patients belonging to productive age groups, and the low prevalence of ambulance and CPR use, indicate a need for improving the prehospital care and basic life support training in Pakistan.