Explore the vast range of titles available.

Pakistan has been experiencing several immunization related challenges. The supply chain management information system (MIS) is considered an important component of immunization services as it can improve visibility in key areas such as vaccine shortages or wastage. This study assessed the effectiveness of the Visibility and Analytics Network (VAN) approach in improving vaccine supply and availability of stocks by comparing the situation in intervention and non-intervention districts in Sindh province of Pakistan. We utilized a quantitative and qualitative approach to collect data to assess the VAN approach in two districts of Sindh province in Pakistan. The data were collected between August and October 2017. VAN is a systematic monitoring system which measures the performance of vaccine supply chain management based on a set of indicators. We assessed storage facilities of the Expanded Programme on Immunization (EPI) in Sindh and interviewed personnel involved using a pre-tested data collection tool. We also conducted in depth interviews with senior management to assess performance of VAN, adoption mechanism and needs to scale up the VAN approach. We assessed 52 EPI facilities of Sindh province government. In the intervention district 83.3% managers were using MIS data for decision making related to vaccine supplies whereas in the non- intervention district no MIS based data were available. Ninety percent of stores were maintaining a stock registry and 100% supplies matched with requisitions in the intervention district compared to 40% and 35% in the non-intervention district for the same variables. Vaccine wastage was high in the non- intervention district (BCG 46.7% vs 33.9; OPV 13.5% vs 9.5%; pneumococcal 11.4% vs 7.4%). In-depth interview findings suggested that the VAN approach provided data guided monitoring in Pakistan for the first time. The approach also enabled district managers to make timely decisions. The VAN approach improves vaccine supply chain management. It should be scaled up and implemented at national or sub national especially in countries struggling with vaccine supply chain management.

Embedded implementation research (IR) can play a critical role in health systems strengthening by tackling systems and implementation bottlenecks of a program. To achieve this aim, with the financial support of GAVI, the Vaccine Alliance, in 2016, the Government of Pakistan, UNICEF and the Alliance for Health Policy and Systems Research (AHPSR) launched an Embedded IR for Immunisation Initiative (the Initiative) to explore health systems and implementation bottlenecks, and potential strategies to tackle such bottlenecks in the Expanded Programme on Immunisation (EPI) in Pakistan. In total, 10 research teams were involved in the Initiative, which was the first of its kind in the country. In this paper, we provided a brief overview of the Initiative's approach as well as the key learnings including challenges and successes of the research teams which could inform future embedded IR Initiatives. Data were collected from members of the IR teams through an online survey. In addition, in-depth interviews were conducted via phone and in-person from IR team members to explore further the challenges they faced while conducting IR in Pakistan and recommendations for future IR initiatives. The qualitative information obtained from these sources was collated and categorized into themes reflecting some of the challenges, successes, and lessons learned, as well as teams' recommendations for future initiatives. The embedded IR Initiative in Pakistan followed several steps starting with a desk review to compile information on key implementation challenges of EPI and ended with a dissemination workshop where all the research teams shared their IR results with policymakers and implementers. Key factors that facilitated the successful and timely completion of the studies included appreciation by and leadership of implementers in generation and use of local knowledge, identification of research priorities jointly by EPI managers and researchers and provision of continuous and high-quality support from in-country research partners. Participants in the Initiative indicated that challenges included a lack of clarity on the role and responsibilities of each partner involved and need for further support to facilitate use and dissemination of research findings. The Initiative established that an immunisation programme in a lower middle-income country can use small and time-bound embedded IR, based on partnerships between programme managers and local researchers, to generate information and evidence that can inform decision-making. Future embedded IR initiatives should strive to ensure effective coordination and active participation of all key stakeholders, a clear research utilisation plan from the outset, and efforts to strengthen research teams' capacity to foster utilisation of research findings.

Sindh, one of the provinces of Pakistan, has been showing a consistently low coverage of immunization. Evidence supports the independent role of supportive supervision in improving the performance of immunization services. However, there is a dearth of evidence regarding the implementation of supportive supervision by the Expanded Programme on Immunization (EPI) Sindh and factors affecting its implementation in the local context. An exploratory case study was conducted in two districts of the province, Sindh ie, Hyderabad and Thatta. In total, 11 key informant interviews (KII) and 5 focus group discussions (FGDs) were conducted to obtain perspectives of various stakeholders of EPI, who play different roles in implementation of supportive supervision. Observations of EPI Checklist and review of current EPI policy and Module-4 of 'Mid-Level Manager training' by World Health Organization (WHO) for supportive supervision was also conducted. This study reveals a lack of clarity regarding the potential role of supportive supervision amongst the stakeholders. Lack of human resources, limited competencies of supervisors, lack of specific training of concerned personnel and feedback mechanisms are major bottlenecks affecting the implementation of supportive supervision by EPI Sindh. The study concludes that supportive supervision is severely affected by challenges such as a lack of comprehensive EPI policy, unavailability of selection criteria for supervisors, training guidelines and proper logistic support to supervisors. There is a lack of training, motivation, and accountability amongst EPI personnel.

Endemic polio in Pakistan is threatening the Global Polio Eradication Initiative (PEI). In recent years, vaccine refusals have surged, spiking polio cases. The current study was conducted to understand the ethnic, religious and cultural roots of vaccine refusals in Charsadda District and explore the remedial options. We conducted 43 in-depth interviews with parents who had refused polio vaccines for their children and the PEI staff. Interviews were audio-recorded, written in verbatim and analysed with Atlis.ti. We conducted a thematic analysis of our data. The fear of American and Jewish conspiracies was the primary cause of vaccine refusals. Militant groups like Tehrek-i-Taliban Pakistan capitalised on this fear, through social media. The Pashtun ethnic group considers itself at the centre of conspiracies. They are suspicious of mass investment and mobilisation behind the polio campaign. Our respondents feared that polio vaccines were making children vulgar. They also feared a reduction in the male to female ratio in childbirth. In Pashtun communities, the iconic conventional community gatherings [\"Hujras\"] are being replaced by provocative digital Hujra [social media], which the PEI and the Government of Pakistan (GOP) are failing to influence or regulate. The PEI uses the misleading term 'religious refusal'. Some factions in the clergy are maligning people from vaccinations, but not through religious dictum. The anti-state elements have stirred sentiments to weaken the state initiative. Fear of adverse effects, attitudinal barriers of health care providers, unmet basic needs and alleged haram composition of the vaccine were among the reasons for vaccine refusals. The PEI needs to revise its misleading nomenclature and ensue open discussion to dispel the myths of infertility, vulgarity and gender ratio related to the vaccines. Simultaneously, the GOP should stop disinformation on social media and rebrand polio vaccination with popular initiatives like the government-sponsored health insurance schemes. The ethnic, cultural and religious dispositions of community members shape polio vaccine refusals in Charsadda District, in different ways. In synch with existing conspiracy theories and medical misconceptions, these three factors make refusals harder to counter. Awareness campaigns with content addressing these three dimensions can improve the situation.

Pakistan has a decent network of community-based workers including lady health workers (LHWs) and vaccinators. However, a major section of the population is not covered by LHWs/vaccinators, labeled here as hard-to-reach (HTR) areas, where immunization coverage is also considerably low. This study explored the feasibility of engagement of traditional birth attendants (TBAs) to improve EPI vaccination coverage in HTR areas in rural Sindh, Pakistan. This implementation research was conducted in two sub-districts of Sukkur (a district in Sindh Province). In an HTR selected intervention arm, TBAs were trained for vaccination and monetary incentives were provided to counsel and refer mothers for vaccination. While LHWs covered areas in the adjacent sub-district were provided with refresher training for vaccination only without any monetary incentive, and were considered as control arm. Considering the inherent differences in intervention and comparison group (HTR intervention area being worse regarding infrastructure and access), between groups and within group change in knowledge of TBA/LHWs and vaccination coverage was assessed before and after the intervention. Furthermore, focus group discussions were conducted with vaccinators, TBAs and LHWs and in-depth interviews with supervisors of vaccinators. TBAs and LHWs' vaccine related knowledge increased significantly after training (pretest vs post test score: 10.5 to 15.4). The BCG coverage improved 74.1% (percentage change) in TBA arm. While completion of vaccination (ie, Penta-3 coverage) increased by 147% from baseline following the intervention. The TBAs, LHWs, vaccinators and their supervisors all welcomed the initiative and considered it as a feasible option. Involvement of TBAs' to form a referral system has potential to improve vaccine coverage and completion in HTR areas in Pakistan. The system is acceptable to the population and implementation is feasible due to availability of TBAs. However, in order to sustain the initiative minimal incentive need to be provided to TBAs to improve the vaccination coverage. Compared to establishing the infrastructure in HTR the intervention seems less costly however, it requires formal cost-effective or cost-benefit analysis.

Immunization hesitancy is a delay in acceptance or refusal of vaccines despite availability of vaccination services. If people are not engaged appropriately via communication and social mobilization, doubts about the trade-offs between the benefits and potential side effects persist. The objective of this study was to explore strategies for improved social mobilization to reduce immunization hesitancy. Mix of quantitative and qualitative approaches was applied to collect data from a diverse group of respondents in Sargodha and Khushab districts. Quantitative data were collected from 329 community health workers, including vaccinators, lady health workers and lady health supervisors, and school health and nutrition supervisors. In addition, qualitative data were collected from top management of Expanded Programme on Immunization (EPI) through key informant interviews (KIIs) and focus group discussions (FGDs) were conducted with parents. Analysis has been done using SPSS software and detailed transcriptions. Advocacy meetings with local influencers, community group sessions, door-to-door visits by community health workers and mosque announcements are considered the most relevant and appropriate interventions for social mobilization. Community Health Workers (CHWs), cognizant of local culture, are being trusted, though optimum performance is achievable with adequate redressal of hesitancy concerns. However, in some cases negative attitudes of people towards immunization hinder trust towards mobilizers or CHWs. Hence, they leverage active participation of local influencers, teachers and health department officials to convince such stubborn parents. Active community involvement through leveraging support from local religious and non-religious influencers in social mobilization activities increases its acceptance. Community engagement is most effective in rural and hard-to-reach areas when community health workers are skilled in interpersonal communication and information education communication. Communication committees as oversight mechanism should be established or reactivated to regularly monitor and support mobilization activities through managing affairs like speedy liaison with local administration and local influencers, mobilizers' service related concerns, community-specific hurdles, and deficiencies of awareness-material provision that eventually improves mobilization performance. Resistant community's needs can be redressed through rigorous conduct of men's and women's education sessions by CHWs while giving more time and space to mobilizers to take on board local religious and non-religious influencers to convince conservative/illiterate parents. Higher management should fix policy implementation slippages like training needs assessment of mobilizers and Civil Society Organizations' involvement framework.

Among all provinces of Pakistan, immunization coverage is poorest in Balochistan. There is no provincial immunization policy for Balochistan including a lack of human resource management policy. Maladministration and lack of accountability leading to health workforce demotivation and poor performance can be a crucial reason behind an inefficient and ineffective immunization program in Balochistan. The objective of this study was to better understand the accountability issues of EPI workforce at provincial and district level leading to poor program performance and to identify governance strategies for management of inefficiency, demotivation and absenteeism. An exploratory qualitative study was carried out to explore issues related to human resource (HR) accountability within immunization program of Balochistan for developing strategies to improve performance of the program. Five districts were selected using purposive sampling based on the comparative poor and good routine immunization coverages and Human Development Index (HDI). Interviews were conducted with EPI Staff and District Health Officers (DHOs) in each district including provincial EPI Staff. A semi-structured and open-ended questionnaire was used. Thematic analysis was used to analyze the qualitative data. Major barriers to HR accountability included lack of a written HR policy, proper service structure including promotions and benefits and understanding of accurate job description coupled with inadequate HR development budget and activities. Most important demotivating factors were inadequate number of vaccinators, deficient budget with delayed wage and salary disbursements resulting in poor immunization coverage and a lack of appreciation/feedback from senior management for the frontline workers. Key challenge for vaccinators was poor community orientation and mobilization. Although, the participants proposed some solutions based on their perspective, none were elaborate or precise. Adaptation of National Immunization Policy tailored to the provincial context and proper implementation is much needed. Review of current allocations of vaccinators and need based relocation along with recruitment of new vaccinators with clear job description and terms of reference is desirable. Review of current incentive structure is required. Finally, trust building between community and the vaccination program and social mobilization about the benefits of vaccinations through community influential is vital.

The aim of this study was to measure the growth of scientific research, authors' productivity, affiliation with the institute and geographic locations published in the Pakistan Journal of Medical Sciences during the period of 2001 - 2010. This numerical analysis was conducted during mid-August 2016 to mid-October, 2016. The data for the study was downloaded from websites of e-journal of Pakistan Journal of Medical Sciences (PJMS) and Pak Medi-Net Com. A total number of 1199 articled were covered by PJMS in 10 volumes and 40 issues with contribution of 3798 (3%) authors during 2001 - 2010. The average number of papers per issue is 30%. A gender wise contribution of males was higher 3050 (80%) than the females 748 (20%). A majority of articles were multi-authored 1052 (87%) as opposed to single author contribution 147 (13%). All 1199 articles were covered under four major disciplines i.e Basic medical sciences, medicine & allied, surgery & allied and radiological sciences and 39 sub-specialties according to medical subject headings (MeSH). It observed that 467 (39%) articles were published in Pakistan and 732 (61%) articles produced by other 32 countries. The Karachi city of Pakistan has produced 199 (16%) articles as highest as its national level and followed by Tehran (Iran) 77 (6%) as followed internationally. This study reveals that the participation of 32 countries in the PJMS publications proves it to be an internationally circulated journal to support research with the constant approach of publishing articles to each volume in basic medical sciences, biomedical, clinical and public health sciences. DOAJ: Directory of Open Access Journals IMEMR: Index Medicus Eastern Mediterranean Region HEC: Higher Education Commission (Pakistan) PJMS: Pakistan Journal of Medical Sciences MeSH: Medical Subject Headings PMDC: Pakistan Medical & Dental Council SCIE: Science Citation Index Expanded.

Maximizing visibility by using academic profiling sites is very crucial in the academic world to improve the readership of research papers published and constant evaluation of research quality. In this article, the authors focused on the visibility of Pakistani University scholars on Google Scholar (GS). An intelligent Web Bot (MAKGBOT) was developed to collect the scholarly data of all Pakistani scholars, whose data is publicly available on Google Scholar. The findings of this research show that 87% of Pakistani universities have a presence on Google Scholar. It analyzes the research performance of scholars based on the last five years’ data from 2016 to 2020. Furthermore, the analysis reports the level of scholarly activities of all provinces and autonomous areas of Pakistan. This paper concludes by discussing the ethical issue of misrepresentation of information on the public profile and its consequences on the rankings of legitimate scholars.