Developing health service delivery in a poor and marginalised community in North West Pakistan

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

Dietary Calcium Intake, Vitamin D Status, and Bone Health in Postmenopausal Women in Rural Pakistan

The high prevalence of osteoporosis in Pakistan is of public-health concern. However, there is a paucity of information regarding nutrition and bone density in rural communities. The purpose of this study was to evaluate the dietary and lifestyle factors that impact bone health in Nahaqi. Data were collected from 140 postmenopausal women using an interviewer-administered 24-hour dietary recall questionnaire. Bone mineral density was estimated using the quantitative ultrasound index (QUI). Serum 25(OH)D was measured in fasting blood samples. The QUI scores revealed that 42% and 29% of the women had T-scores, indicative of osteopaenia and osteoporosis respectively. The mean calcium intake was 346 mg/d, which is less than 50% of the recommended daily intake. The QUI correlated with 25(OH)D after controlling for age (p=0.021, r=0.41, r2=0.168). Vitamin D deficiency and low intake of dietary calcium are two key factors contributing to poor bone health in this population

Increasing Awareness and Use of Iodised Salt in a Marginalised Community Setting in North-West Pakistan

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

Dietary Calcium Intake, Vitamin D Status, and Bone Health in Postmenopausal Women in Rural Pakistan

The high prevalence of osteoporosis in Pakistan is of public-health concern. However, there is a paucity of information regarding nutrition and bone density in rural communities. The purpose of this study was to evaluate the dietary and lifestyle factors that impact bone health in Nahaqi. Data were collected from 140 postmenopausal women using an interviewer-administered 24-hour dietary recall questionnaire. Bone mineral density was estimated using the quantitative ultrasound index (QUI). Serum 25(OH)D was measured in fasting blood samples. The QUI scores revealed that 42% and 29% of the women had T-scores, indicative of osteopaenia and osteoporosis respectively. The mean calcium intake was 346 mg/d, which is less than 50% of the recommended daily intake. The QUI correlated with 25(OH)D after controlling for age (p=0.021, r=0.41, r2=0.168). Vitamin D deficiency and low intake of dietary calcium are two key factors contributing to poor bone health in this population

The Importance of Cultural and Socioeconomic Context in Health Research Design--- Lessons Learnt from a Pilot Study in Pakistan

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

The BiZiFED project: Biofortified Zinc Flour to Eliminate Deficiency in Pakistan

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

Site-specific factors influence the field performance of a Zn-biofortified wheat variety

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 impact of Zn biofortified crops. Designing studies to detect realistic effect sizes for new varieties and crop management strategies is therefore an important consideration. The current study indicated that nine replicate plots would be needed to achieve 80% power to detect a 25% increase in grain Zn concentration

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

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

Examining the effectiveness of consuming flour made from agronomically biofortified wheat (Zincol-2016/NR-421) for improving Zn status in women in a low resource setting Pakistan: Study protocol for a randomised, double blind, controlled cross over trial (BiZiFED)

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