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Khan M.A.,Association for Social Development | Anil S.,Association for Social Development | Ahmed M.,Association for Social Development | Athar A.,Association for Social Development | And 2 more authors.
Annals of Global Health | Year: 2016

Background In Pakistan, many tuberculosis (TB) cases are not reported to the national surveillance system. An active case finding strategy in the form of conventional (simple) or innovative (infotainment) chest camps can contribute to diagnosing these missed cases. Objective To compare the yield in terms of TB patients detected at a simple chest camp (SCC) versus an infotainment chest camp (ICC) in rural areas. Methods A cluster randomized controlled trial with 2 parallel arms was conducted in 4 districts of Pakistan from June 2012 to May 2013. Rural neighborhoods (n = 318) were randomly allocated in a ratio of 1:3 to receive either SCC or ICC. Incidence of TB (all forms and sputum smear positive [SS+]) and number needed to screen (NNS) to diagnose 1 TB case were calculated. Cluster analysis was done according to intention to treat and risk ratio (RR), and 95% confidence intervals (CIs) were calculated. Findings A total of 3086 participants were tested at the SCC and 9029 at the ICC, of whom 38.5% were female. Mean age was 37.4 ± 15.9 years. Incidences of previously undiagnosed TB (all forms) for SCC and ICC were 23.6 (95% CI 20.04-27.4) and 22.1 (95% CI 20.3-24.1) per 100,000 population (P = .42), SS+ TB 22.5 (95% CI 19.3-26.1) and 21.6 (95% CI 19.8-23.6) (P = .67), respectively. NNS to diagnose 1 TB case were 260 (95% CI 234.3-289.6) and 258 (95% CI 233.3-287.9) for SCC and ICC, respectively (P = .9). RRs for all forms of TB and SS+ TB in SCC compared to ICC were 0.94 (95% CI 0.73-1.19) and 0.95 (95% CI 0.74-1.22) and P values were .58 and .71, respectively. Conclusions Both types of chest camps are equally effective in active case finding of previously undiagnosed TB cases in rural areas in 2 provinces in Pakistan. © 2016


PubMed | Association for Social Development, Ministry of Health, National Tuberculosis Control Program and Pakistan Medical Research Council
Type: Journal Article | Journal: JPMA. The Journal of the Pakistan Medical Association | Year: 2015

To assess the knowledge of lady health visitors and midwives working at primary healthcare facilities about neonatal resuscitation.The cross-sectional survey was conducted in District Sheikhupura of Pakistans Punjab province from September to November 2013, and comprised lady health visitors and midwives at primary level healthcare facilities. Datas was gathered using a close-ended questionnaire. SPSS 16 was used for statistical analysis.Of the 103 health workers interviewed, 54(52.4%) were lady health visitors and 49(47.5%) were midwives. Overall, 71(69.90%) health workers had received training on neonatal resuscitation, while 32(30.10%) had no formal training. Basic neonatal resuscitative arrangements were available at all the 54(100%) basic health units and 7(100%) rural health centres. Basic neonatal care knowledge was found adequate but the knowledge of midwives on the subject was poor as only 24(49%) answered correctly.There is a need for regular in-service trainings of lady health visitors and midwives regarding Basic Neonatal Resuscitation.


Khan M.A.,Association for Social Development | Walley J.D.,University of Leeds | Munir M.A.,Association for Social Development | Khan M.A.,Directorate of Malaria Control | And 4 more authors.
Malaria Journal | Year: 2011

Background: Prompt, quality assured laboratory diagnosis is key to effective malaria case management and control, especially since the introduction of the more expensive artemisinin combination therapy (ACT). The malaria programme and its non-government partners, on the basis of WHO recommended Lot Quality Assurance methods, have developed a district level external quality assurance (EQA) system. This study was designed to assess the feasibility, under programme conditions, of an integrated district level external quality assurance and supervision approach for malaria microscopy. Design and Methods. A prospective study conducted over seven months period (May-November 2007). In addition to the standard WHO EQA elements, three operational innovations were introduced, with the a district laboratory supervisor: a) onsite re-checking of slides, b) in ensuring uninterrupted availability of laboratory reagents and supplies at diagnostic centers, and c) supervision of administrative and technical components. The quantitative data for the study came from the service records/documents, whereas the qualitative data came from the key informant interviews. Results: During the seven month period in four districts, a total of 8,118 slides were examined of which 209 (2.6%) were found positive for malaria parasites (slide positivity range between1.6% to 6.0%). The District Laboratory Supervisors in four districts reexamined a total of 1,770 slides (22%). The proportion of slides found discordant ranged from 0.5% to 1%. The quality of smear preparation was found acceptable in 73% slides. Conclusions: A district-based EQA, based on lot quality assurance methods was implemented, using context-specific operational guidelines, tools and training modules, and other inputs from the malaria control programme and partners. This EQA and supervision approach was found to be feasible and acceptable to those involved. Further study is required on the microscopy quality and cost-effectiveness of adding external quality assurance and supervision to district malaria microscopy services. © 2011 Khan et al; licensee BioMed Central Ltd.


PubMed | Health Science University, The Union, Health Services Academy, Association for Social Development and 2 more.
Type: Journal Article | Journal: Public health action | Year: 2015

Xpert() MTB/RIF testing was offered to consecutive patients with presumptive tuberculosis (TB) attending two hospitals in Pakistan during April-May 2012, in addition to routine diagnostic protocol (smear microscopy, chest radiography and clinical judgement). We assessed the relative contribution of each tool in detecting pulmonary TB under routine conditions. Of 606 participants, 121 (20%) were detected as pulmonary TB: 46 (38%) by microscopy, 38 (31%) by Xpert alone and 37 (31%) on clinical and radiological grounds; 41 (65%) were detected by both Xpert and microscopy. One patient had rifampicin resistance. Although Xpert detected approximately twice as many TB cases as microscopy (n = 79, 65%), clinical judgement remained favoured by clinicians even when smear and Xpert were negative.


PubMed | National TB Control Program, Association for Social Development and University of Bergen
Type: Journal Article | Journal: Tanaffos | Year: 2014

Tuberculosis (TB) is a major cause of mortality affecting millions of people in third world countries. In DOTS monitoring of patients is facility-based and treatment supporter-based; by these two ways patients compliance to treatment is monitored. The aim of this study was to evaluate the role of treatment supporters and their impact on patients treatment outcomes.The study was a cross-sectional survey in the routine TB control program operational context. All sputum smear positive TB patients that were diagnosed and registered by the public sector in the urban and rural diagnostic centers in 2008 with available outcomes were included in the study. Data of 451 patients were collected during August-October 2010 from 15 health facilities.The majority of patients (89.6%) were provided with treatment supporters. Of 404 (89.6%) cases with treatment supporters, in 203 (50.2%) the supporters were lady health workers, in 46 (11.4%) were community health workers and health facility workers, and in 155 (38.4%) were family members and community volunteers. A total of 384 (85.1%) were categorized as treatment success, 31 (6.9%), as transferred out, 17 (3.8%), as expired, 16 (3.5%) as defaulted and three (0.7%) as treatment failure. The treatment success rates in patients supervised by Lady health workers, community health workers and health facility workers, and family members and community volunteers were 93.1%, 89.1% and 73.5%, respectively.We found a significantly higher treatment success rate (93.1%) in patients supervised by lady health workers compared to others. The overall treatment success rate was 85.1%.


Siddiqi K.,University of Leeds | Khan A.,Association for Social Development | Ahmad M.,Association for Social Development | Shafiq-Ur-Rehman,Association for Social Development
BMC Public Health | Year: 2010

Background. In many low- and middle-income countries, where tobacco use is common, tuberculosis is also a major problem. Tobacco use increases the risk of developing tuberculosis, secondary mortality, poor treatment compliance and relapses. In countries with TB epidemic, even a modest relative risk leads to a significant attributable risk. Treating tobacco dependence, therefore, is likely to have benefits for controlling tuberculosis in addition to reducing the non-communicable disease burden associated with smoking. In poorly resourced health systems which face a dual burden of disease secondary to tuberculosis and tobacco, an integrated approach to tackle tobacco dependence in TB control could be economically desirable. During TB screening, health professionals come across large numbers of patients with respiratory symptoms, a significant proportion of which are likely to be tobacco users. These clinical encounters, considered to be "teachable moments", provide a window of opportunity to offer treatment for tobacco dependence. Methods/Design. We aim to develop and trial a complex intervention to reduce tobacco dependence among TB suspects based on the WHO 'five steps to quit' model. This model relies on assessing personal motivation to quit tobacco use and uses it as the basis for assessing suitability for the different therapeutic options for tobacco dependence. We will use the Medical Research Council framework approach for evaluating complex interventions to: (a) design an evidence-based treatment package (likely to consist of training materials for health professionals and education tools for patients); (b) pilot the package to determine the delivery modalities in TB programme (c) assess the incremental cost-effectiveness of the package compared to usual care using a cluster RCT design; (d) to determine barriers and drivers to the provision of treatment of tobacco dependence within TB programmes; and (e) support long term implementation. The main outcomes to assess the effectiveness would be point abstinence at 4 weeks and continuous abstinence up to 6 months. Discussion. This work will be carried out in Pakistan and is expected to have relevance for other low and middle income countries with high tobacco use and TB incidence. This will enhance our knowledge of the cost-effectiveness of treating tobacco dependence in patients suspected of TB. © 2010 Siddiqi et al; licensee BioMed Central Ltd.


PubMed | Association for Social Development, University of Leeds, World Health Organization, King Saud University and National Tuberculosis control Program Pakistan.
Type: Journal Article | Journal: JPMA. The Journal of the Pakistan Medical Association | Year: 2016

To develop and evaluate a more structured process for effective tuberculosis control monitoring.The quasi-experimental exploratory study was conducted from April 2007 to January 2008 in the Punjab province of Pakistan. Eight intervention districts were compared with eight control districts. Intervention consisted of managers using performance monitoring guidelines and tools for monitoring meetings at the facility and district levels. Proportion of tuberculosis suspects among outpatients, registered confirmed cases and patients default rate were monitored. Semi-structured interviews were done to assess the experience of the participants.The proportion of TB suspects among outpatient attendees was significantly higher in the intervention districts (95% confidence interval 1.6-1.8%). The pre-registration default also showed difference (p=0.07). The case finding during 9 months of the intervention showed 96.3% increase compared to the 9 months of the preceding year.The new process was effective in improving tuberculosis case finding. The process may be used to improve tuberculosis monitoring systems and other such healthcare services.


PubMed | Association for Social Development, University of Leeds and Public Health Solutions Pakistan
Type: | Journal: Global health action | Year: 2015

Respiratory diseases, namely asthma and chronic obstructive pulmonary disease (COPD), account for one-fourth of the patients at the primary health-care (PHC) facilities in Pakistan. Standard care practices to manage these diseases are necessary to reduce the morbidity and mortality rate associated with non-communicable diseases in developing countries.To develop and measure the effectiveness of operational guidelines and implementation materials, with sound scientific evidence, for expanding lung health care, especially asthma and COPD through PHC facilities already strengthened for tuberculosis (TB) care in Pakistan.A cluster randomized controlled trial with two arms (intervention and control), with qualitative and costing study components, is being conducted in 34 clusters; 17 clusters per arm (428 asthma and 306 COPD patients), in three districts in Pakistan from October 2014 to December 2016. The intervention consists of enhanced case management of asthma and COPD patients through strengthening of PHC facilities. The main outcomes to be measured are asthma and COPD control among the registered cases at 6 months. Cluster- and individual-level analyses will be done according to intention to treat. Residual confounding will be addressed by multivariable logistic and linear regression models for asthma and COPD control, respectively. The trial is registered with ISRCTN registry (ISRCTN 17409338).Currently, only about 20% of the estimated prevalent asthma and COPD cases are being identified and reported through the respective PHC network. Lung health care and prevention has not been effectively integrated into the core PHC package, although a very well-functioning TB program exists at the PHC level. Inclusion of these diseases in the already existent TB program is expected to increase detection rates and care for asthma and COPD.


Dogar O.,University of York | Jawad M.,Imperial College London | Shah S.K.,University of York | Newell J.N.,Nuffield Center for International Health and Development | And 3 more authors.
Nicotine and Tobacco Research | Year: 2014

Introduction: We explored the differential effect of cessation interventions (behavioral support sessions with [BSS+] and without [BSS] bupropion) between hookah and cigarette smokers. Methods: We reanalyzed the data from a major cluster-randomized controlled trial, ASSIST (Action to Stop Smoking In Suspected Tuberculosis), which consisted of 3 conditions: (a) behavioral support sessions (BSS), (b) behavioral support sessions plus 7 weeks of bupropion therapy (BSS+), and (c) controls receiving usual care. The trial originally recruited 1,955 adult smokers with suspected tuberculosis from 33 health centers in the Jhang and Sargodha districts of Pakistan between 2010 and 2011. The primary endpoint was continuous 6-month smoking abstinence, which was determined by carbon monoxide levels. Subgroup-specific relative risks (RRs) of smoking abstinence were computed and tested for differential intervention effect using log binomial regression (generalized linear model) between 3 subgroups (cigarette-only: 1,255; mixed: 485; and hookah-only: 215). Results: The test result for homogeneity of intervention effects between the smoking forms was statistically significant (p-value for BSS+: .04 and for BSS: .02). Compared to the control, both interventions appeared to be effective among hookah smokers (RR = 2.5; 95% CI = 1.3-4.7 and RR = 2.2; 95% CI = 1.3-3.8, respectively) but less effective among cigarette smokers (RR = 6.6; 95% CI = 4.6-9.6 and RR = 5.8; 95% CI = 4.0-8.5), respectively. Conclusions: The differential intervention effects on hookah and cigarette smokers were seen (a) because the behavioral support intervention was designed primarily for cigarette smokers; (b) because of differences in demographic characteristics, behavioral, and sociocultural determinants; or (c) because of differences in nicotine dependency levels between the 2 groups. © Advance Access publication December 27, 2013. © The Author 2013. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved.


PubMed | Association for Social Development
Type: | Journal: BMC cardiovascular disorders | Year: 2013

Cardiovascular diseases (CVDs) are one of the leading causes of death and disability in the world. Over 80% of CVD deaths take place in low-and middle-income countries. One-third of the population aged above 40years suffers from Hypertension (HTN) and this is largely unreported as there is no registry for CVDs. No guidelines are available for use in health care facilities, especially private health facilities where practice among GPs varies considerably. We aim to conduct a Cluster Randomized Controlled trial delivering a quality HTN-CVD care package at strengthened private health facilities as compared to current practice at private health facilities.A pragmatic cluster randomized trial, with qualitative and economic studies, will be conducted in Sargodha district of Punjab, Pakistan, from January 2012 to December 2016. At least 912 hypertensives will be registered in the two arms, six clusters per arm. The proposed cluster randomized controlled trial will evaluate the effects of delivering quality HTN-CVD care, through enabled private health care facilities, to achieve better case registration, adherence and hypertension control also blood glucose and serum cholesterol control. The trial will be conducted through the doctors and paramedics at private health facilities. Main outcomes are mean difference in Systolic blood pressure among the two arms. Secondary outcomes are mean change in total serum cholesterol levels and mean change in glycaemic control achieved in the adult hypertensive patients. Individual and Cluster level analysis will be done according to intention-to-treat.Due to the high burden of disease where 1 in 3 individuals aged above 45 suffers from hypertension, topped with the fact that there is a dearth of a set of available, standardised guidelines for management, the disease is constantly on a hike in Pakistan. The government has made no effort to issue a set of guidelines adapted specifically for our population and this becomes more of a problem when managing CVD in urban population through private practitioners whose practices vary widely.If our set of context sensitive guidelines show an effectiveness in the proposed intervention districts it will be replicated in other such settings.Current Controlled Trials ISRCTN34381594.

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