Considering Risks to Researchers and Staff in Low-Resource Settings during Public Health Crises: A Proposed Conceptual Model.

Human subjects research protections have historically focused on mitigating risk of harm and promoting benefits for research participants. In many low-resource settings (LRS), complex and often severe challenges in daily living, poverty, geopolitical uprisings, sociopolitical, economic, and climate crises increase the burdens of even minimal risk research. While there has been important work to explore the scope of ethical responsibilities of researchers and research teams to respond to these wider challenges and hidden burdens in global health research, less attention has been given to the ethical dilemmas and risk experienced by frontline researcher staff as they perform research-related activities in LRS. Risks such as job insecurity, moral distress, infection, or physical harm can be exacerbated during public health crises, as recently highlighted by the COVID-19 pandemic. We highlight the layers of risk research staff face in LRS and present a conceptual model to characterize drivers of this risk, with particular attention to public health crises. A framework by which funders, institutions, principal investigators, and/or research team leaders can systematically consider these additional layers of risk to researchers and frontline staff is an important and needed addition to routine research proposals and protocol review.

Exploring Caregivers' Perspectives and Perceived Acceptability of a Mobile-Based Telemonitoring Program to Support Pregnant Women at High-Risk for Preeclampsia in Karachi, Pakistan: A Qualitative Descriptive Study.

Very little is known about the perspectives of the caregivers on the use of telemonitoring (TM) interventions in low-middle-income countries. Understanding caregivers' perspectives on TM interventions is crucial, given that caregiving activities are correlated with the social, emotional, and clinical outcomes among pregnant women. This study aims to explore caregivers' perspectives and perceived acceptability of a mobile phone-based TM program to support pregnant women at high-risk for preeclampsia. A qualitative description design was used to conduct and analyze 28 semi-structured interviews with a diverse group of caregivers. The study was conducted at the Jinnah Post Graduate Medical Center, Karachi, Pakistan. The caregivers were identified through purposive sampling and additional caregivers were interviewed until the point of data saturation. The conventional content analysis technique was used to analyze digital audio recordings of the caregiver interviews. All caregivers embraced the proposed mobile phone-based TM program because they perceived many benefits, including a reduction in caregivers' anxiety and workload, increased convenience, and cost-effectiveness. However, the caregivers cited several caveats to the future implementation of the TM program including the inability of some women and caregivers to use the TM program and the poor acceptance of the TM system among less educated and non-tech savvy families. Our study recommends developing a TM program to reduce the caregiver stress and workload, designing a context-specific TM program using a user-centric approach, training caregivers on the use of the TM program, sensitizing caregivers on the benefits of the TM program, and developing a low-cost TM program to maximize access.

COVID-19 antibody positivity over time and pregnancy outcomes in seven low-and-middle-income countries: A prospective, observational study of the Global Network for Women's and Children's Health Research.

OBJECTIVES: To determine COVID-19 antibody positivity rates over time and relationships to pregnancy outcomes in low- and middle-income countries (LMICs). DESIGN: With COVID-19 antibody positivity at delivery as the exposure, we performed a prospective, observational cohort study in seven LMICs during the early COVID-19 pandemic. SETTING: The study was conducted among women in the Global Network for Women's and Children's Health's Maternal and Newborn Health Registry (MNHR), a prospective, population-based study in Kenya, Zambia, the Democratic Republic of the Congo (DRC), Bangladesh, Pakistan, India (two sites), and Guatemala. POPULATION: Pregnant women enrolled in an ongoing pregnancy registry at study sites. METHODS: From October 2020 to October 2021, standardised COVID-19 antibody testing was performed at delivery among women enrolled in MNHR. Trained staff masked to COVID-19 status obtained pregnancy outcomes, which were then compared with COVID-19 antibody results. MAIN OUTCOME MEASURES: Antibody status, stillbirth, neonatal mortality, maternal mortality and morbidity. RESULTS: At delivery, 26.0% of women were COVID-19 antibody positive. Positivity increased over the four time periods across all sites: 13.8%, 15.4%, 21.0% and 40.9%. In the final period, positivity rates were: DRC 27.0%, Kenya 33.1%, Pakistan 32.8%, Guatemala 37.0%, Zambia 37.8%, Bangladesh 47.2%, Nagpur, India 57.4% and Belagavi, India 62.4%. Adjusting for site and maternal characteristics, stillbirth, neonatal mortality, low birthweight and preterm birth were not significantly associated with COVID-19. The adjusted relative risk (aRR) for stillbirth was 1.27 (95% CI 0.95-1.69). Postpartum haemorrhage was associated with antibody positivity (aRR 1.44; 95% CI 1.01-2.07). CONCLUSIONS: In pregnant populations in LMICs, COVID-19 antibody positivity has increased. However, most adverse pregnancy outcomes were not significantly associated with antibody positivity.

Knowledge, attitudes, and practices of pregnant women regarding COVID-19 vaccination in pregnancy in 7 low- and middle-income countries: An observational trial from the Global Network for Women and Children's Health Research.

OBJECTIVES: We sought to determine the knowledge, attitudes and practices of pregnant women regarding COVID-19 vaccination in pregnancy in seven low- and middle-income countries (LMIC). DESIGN: Prospective, observational, population-based study. SETTINGS: Study areas in seven LMICs: Bangladesh, India, Pakistan, Guatemala, Democratic Republic of the Congo (DRC), Kenya and Zambia. POPULATION: Pregnant women in an ongoing registry. METHODS: COVID-19 vaccine questionnaires were administered to pregnant women in the Global Network's Maternal Newborn Health Registry from February 2021 through November 2021 in face-to-face interviews. MAIN OUTCOME MEASURES: Knowledge, attitude and practice regarding vaccination during pregnancy; vaccination status. RESULTS: No women were vaccinated except for small proportions in India (12.9%) and Guatemala (5.5%). Overall, nearly half the women believed the COVID-19 vaccine is very/somewhat effective and a similar proportion believed that the COVID-19 vaccine is safe for pregnant women. With availability of vaccines, about 56.7% said they would get the vaccine and a 34.8% would refuse. Of those who would not get vaccinated, safety, fear of adverse effects, and lack of trust predicted vaccine refusal. Those with lower educational status were less willing to be vaccinated. Family members and health professionals were the most trusted source of information for vaccination. CONCLUSIONS: This COVID-19 vaccine survey in seven LMICs found that knowledge about the effectiveness and safety of the vaccine was generally low but varied. Concerns about vaccine safety and effectiveness among pregnant women is an important target for educational efforts to increase vaccination rates.

Health care in pregnancy during the COVID-19 pandemic and pregnancy outcomes in six low- and-middle-income countries: Evidence from a prospective, observational registry of the Global Network for Women's and Children's Health.

OBJECTIVE: To assess, on a population basis, the medical care for pregnant women in specific geographic regions of six countries before and during the first year of the coronavirus disease 2019 (COVID-19) pandemic in relationship to pregnancy outcomes. DESIGN: Prospective, population-based study. SETTING: Communities in Kenya, Zambia, the Democratic Republic of the Congo, Pakistan, India and Guatemala. POPULATION: Pregnant women enrolled in the Global Network for Women's and Children's Health's Maternal and Newborn Health Registry. METHODS: Pregnancy/delivery care services and pregnancy outcomes in the pre-COVID-19 time-period (March 2019-February 2020) were compared with the COVID-19 time-period (March 2020-February 2021). MAIN OUTCOME MEASURES: Stillbirth, neonatal mortality, preterm birth, low birthweight and maternal mortality. RESULTS: Across all sites, a small but statistically significant increase in home births occurred between the pre-COVID-19 and COVID-19 periods (18.9% versus 20.3%, adjusted relative risk [aRR] 1.12, 95% CI 1.05-1.19). A small but significant decrease in the mean number of antenatal care visits (from 4.1 to 4.0, p = <0.0001) was seen during the COVID-19 period. Of outcomes evaluated, overall, a small but significant decrease in low-birthweight infants in the COVID-19 period occurred (15.7% versus 14.6%, aRR 0.94, 95% CI 0.89-0.99), but we did not observe any significant differences in other outcomes. There was no change observed in maternal mortality or antenatal haemorrhage overall or at any of the sites. CONCLUSIONS: Small but significant increases in home births and decreases in the antenatal care services were observed during the initial COVID-19 period; however, there was not an increase in the stillbirth, neonatal mortality, maternal mortality, low birthweight, or preterm birth rates during the COVID-19 period compared with the previous year. Further research should help to elucidate the relationship between access to and use of pregnancy-related medical services and birth outcomes over an extended period.

Perceptions and experiences of healthcare providers during COVID-19 pandemic in Karachi, Pakistan: an exploratory qualitative study

ObjectiveTo explore healthcare provider’s perspectives and experiences of the barriers and facilitators to treat and manage COVID-19 cases.Design and settingWe conducted an exploratory qualitative study using a purposive sampling approach, at a private tertiary care teaching hospital in Karachi, Pakistan. Study data were analysed manually using the conventional content analysis technique.ParticipantsKey-informant interviews (KIIs) were conducted with senior management and hospital leadership and in-depth interviews (IDIs) were conducted with front-line healthcare providers.ResultsA total of 31 interviews (KIIs=19;IDIs=12) were conducted, between April and May 2020. Three overarching themes emerged. The first was ‘challenges faced by front-line healthcare providers working in COVID-19 wards. Healthcare workers experienced increased anxiety due to the fear of acquiring infection and transmitting it to their family members. They felt overwhelmed due to the exhaustive donning and doffing process, intense work and stigmatisation. The second theme was ‘enablers supporting healthcare providers to deal with the COVID-19 pandemic’. Front liners pointed out several enabling factors that supported hospital staff including a safe hospital environment, adequate training, a strong system of information sharing and supportive management. The third theme was ‘recommendations to support the healthcare workforce during the COVID-19 crisis’. Healthcare workers recommended measures to mitigate current challenges including providing risk allowance to front-line healthcare providers, preparing a backup health workforce, and establishing a platform to address the mental health needs of the healthcare providers.ConclusionThis study provides an initial evidence base of healthcare providers’ experiences of managing patients with COVID-19 in the early stage of the pandemic and highlights measures needed to address the encountered challenges. It offers lessons for hospitals in low-income and middle-income countries to ensure a safe working environment for front-line workers in their fight against COVID-19.

Understanding the Needs of a Mobile Phone-Based Telemonitoring Program for Pregnant Women at High Risk for Pre-Eclampsia: Interpretive Qualitative Description Study.

BACKGROUND: Lack of early risk detection, diagnosis, and treatment of pregnant women at high risk for pre-eclampsia can result in high maternal mortality and morbidity not only in Pakistan but also in other low- to middle-income countries (LMICs). A potential tool for supporting pregnant women at high risk for pre-eclampsia for early detection is telemonitoring (TM). However, there is a limited body of evidence on end-user needs and preferences to inform the design of the TM programs for pregnant women at high risk for pre-eclampsia, specifically in LMICs such as Pakistan. OBJECTIVE: This study aims to explore the needs of TM for pregnant women at high risk for pre-eclampsia in Karachi, Pakistan, to inform a potential future feasibility trial of a mobile phone-based TM program. METHODS: An interpretive qualitative description approach was used to conduct and analyze 36 semistructured interviews with 15 (42%) pregnant women and 21 (58%) key informants, including clinicians; nurses; maternal, neonatal, and child health specialists; and digital health experts to explore the perspectives, needs, and preferences of a mobile phone-based TM program to support pregnant women at high risk for pre-eclampsia. Pregnant women were identified through heterogeneous sampling, whereas key informants were selected through purposive sampling. The interview transcripts were analyzed using a conventional content analysis technique. RESULTS: The following four themes emerged from the analysis of the transcripts: poor use of antenatal care during pregnancy, the value of a TM program in high-risk pregnancy, barriers influencing the adoption of TM programs and potential strategies, and considerations for implementing TM programs. The pregnant women and health care providers were willing to use a TM program as they perceived many benefits, including early identification of pregnancy complications, prompt treatment, convenience, cost-effectiveness, increased sense of empowerment for one's health care, improved care continuity, and reduced clinical workload. However, some providers and pregnant women mentioned some concerns regarding the adoption of a TM program, including malfunctioning and safety concerns, potential inaccuracy of blood pressure machines, increased clinical workload, and resistance to learning new technology. Our study recommends building the capacity of patients and providers on TM program use, sensitizing the community and family members on the usefulness of the TM program, using an approach incorporating user-centered design and phased implementation to determine the clinical workload and whether additional staff for the TM program is required, and ensuring greater levels of co-design and the engagement of consumer representatives. CONCLUSIONS: Our findings highlight the perceived feasibility of a mobile phone-based TM program for pregnant women at high risk for pre-eclampsia and provide insights that can be directly used for the design of future TM programs with the aim of reducing mortality and morbidity from pre-eclampsia and eclampsia in LMICs.

Channels Through which Covid-19 Can Affect School-Going Children: Are we Doing Enough to Minimize the Risks and Impacts?

COVID-19 pandemic has affected every continent of the world. The objective of this technical report is to provide an understanding of the key issues faced by school-going children of Pakistan in this current pandemic and to suggest strategies to help children to cope up with the situation. It has affected children as they are more vulnerable to psychological insult and ill-treatment such as domestic violence and sexual/physical abuse. Social distancing and school closure have increased the risk of poor development and nutrition. Underprivileged children have less or no access to digitization thus causing educational loss. Child nutrition is also a vital concern, also the lockdown has disturbed the food supply chain at local markets. Lockdown also jeopardizes water, sanitation and hygiene (WASH) services causing additional pressure to children's health through water-borne diseases.

When COVID-19 enters in a community setting: an exploratory qualitative study of community perspectives on COVID-19 affecting mental well-being.

OBJECTIVE: The COVID-19 pandemic has resulted in an increased level of anxiety and fear among the general population related to its management and infection spread. Considering the relevance of present circumstances, we explored perceptions and attitudes of community members towards their mental well-being during the COVID-19 pandemic. SETTING: We conducted an exploratory qualitative study using a purposive sampling approach, at two communities of Karachi, Pakistan. PARTICIPANTS: In-depth interviews were conducted with community members including, young adults, middle-aged adults and older adults of both genders. Study data were analysed manually using the thematic analysis technique. PRIMARY OUTCOME: The primary outcome is assessing community perception towards their mental well-being amidst the COVID-19 pandemic. RESULTS: A total of 27 in-depth interviews were conducted, between May and June 2020. Three overarching themes were identified: (1) impact of COVID-19 on the mental health of the general communities; (2) current coping mechanisms to adapt to the new reality and (3) recommendations to address the mental health of communities. Generally, community members underwent increased anxiety and fear due to the contagious nature of the virus. Alongside, social, financial and religious repercussions of the pandemic have also heightened psychological distress among community members. However, community members were able to point out some of the coping mechanisms such as getting closer to God, connecting with family, participating in mental health sessions and resetting lives by indulging in diverse activities. Simultaneously, they also recommended the need for remote mental health services for elders and continuous efforts by the government to address the mental health needs of the community. CONCLUSION: COVID-19-associated mental health consequences have hit every individual in society. The study finding has the potential to guide the development of context-specific innovative mental health programmes to overcome the pandemic repercussions.

Impact of the COVID-19 pandemic on mental health and well-being of communities: an exploratory qualitative study protocol.

INTRODUCTION: The COVID-19 pandemic has certainly resulted in an increased level of anxiety and fear in communities in terms of disease management and infection spread. Due to fear and social stigma linked with COVID-19, many individuals in the community hide their disease and do not access healthcare facilities in a timely manner. In addition, with the widespread use of social media, rumours, myths and inaccurate information about the virus are spreading rapidly, leading to intensified irritability, fearfulness, insomnia, oppositional behaviours and somatic complaints. Considering the relevance of all these factors, we aim to explore the perceptions and attitudes of community members towards COVID-19 and its impact on their daily lives and mental well-being. METHODS AND ANALYSIS: This formative research will employ an exploratory qualitative research design using semistructured interviews and a purposive sampling approach. The data collection methods for this formative research will include indepth interviews with community members. The study will be conducted in the Karimabad Federal B Area and in the Garden (East and West) community settings in Karachi, Pakistan. The community members of these areas have been selected purposively for the interview. Study data will be analysed thematically using NVivo V.12 Plus software. ETHICS AND DISSEMINATION: Ethical approval for this study has been obtained from the Aga Khan University Ethical Review Committee (2020-4825-10599). The results of the study will be disseminated to the scientific community and to the research subjects participating in the study. The findings will help us explore the perceptions and attitudes of different community members towards the COVID-19 pandemic and its impact on their daily lives and mental well-being.

Equipping community health workers with digital tools for pandemic response in LMICs.

BACKGROUND: Community health workers (CHWs) are well-positioned to play a pivotal role in fighting the pandemic at the community level. The Covid-19 outbreak has led to a lot of stress and anxiety among CHWs as they are expected to perform pandemic related tasks along with the delivery of essential healthcare services. In addition, movement restrictions, lockdowns, social distancing, and lack of protective gear have significantly affected CHWs' routine workflow and performance. To optimize CHWs' functioning, there is a renewed interest in supporting CHWs with digital technology to ensure an appropriate pandemic response. DISCUSSION: The current situation has necessitated the use of digital tools for the delivery of Covid-19 related tasks and other essential healthcare services at the community level. Evidence suggests that there has been a significant digital transformation to support CHWs in these critical times such as remote data collection and health assessments, the use of short message service and voice message for health education, use of digital megaphones for encouraging behavior change, and digital contract tracing. A few LMICs such as Uganda and Ethiopia have been successful in operationalizing digital tools to optimize CHWs' functioning for Covid-19 tasks and other essential health services. CONCLUSION: Yet, in most LMICs, there are some challenges concerning the feasibility and acceptability of using digital tools for CHWs during the Covid-19 pandemic. In most cases, CHWs find it difficult to adopt and use digital health solutions due to lack of training on new digital tools, weak technical support, issues of internet connectivity, and other administrative related challenges. To address these challenges, engaging governments would be essential for training CHWs on user-friendly digital health solutions to improve routine workflow of CHWs during the Covid-19 pandemic.