Background: Coronavirus disease (COVID-19) has accentuated the need for speedy access to information. Digital divide and socio-demographic disparity create an information hiatus and therefore unhealthy practices with regard to dealing with COVID-19, particularly in low- and middle-income countries. Aims: We assessed knowledge, attitudes, practices and their determinants regarding COVID-19 in Pakistan during March-April 2020. Methods: 905 adults >= 18 years (males and females) participated: 403 from a web-based survey; 365 from an urban survey; and 137 from a rural survey. Frequency of adequate knowledge, attitudes and practices for the three populations was determined based on available global guidelines. Multivariable logistic regression analysis determined factors of adequacy of knowledge, attitudes, practices, and association of knowledge with attitudes and practices. Results: Mean age of the participants was 33.5 (+ SD 11.1) years, 51% were females. More females and young adults (18-30 years) participated in the web-based survey. The urban survey and web-based survey participants had significantly higher adequate knowledge (2-7 times) and practices (4-5 times) towards COVID-19. Adequate knowledge had a significant influence on healthy attitudes and practices for COVID-19, after adjustment for covariates. Overall, two-thirds of the population had high levels of fear about COVID-19, which was highest among the rural survey population. Conclusion: Substantial gaps exist in adequate knowledge, attitudes and practices, particularly among rural populations, and underscores the variation in access to information according to level of education and access to the internet. Thus, a comprehensive, contextually congruent awareness raising strategy is urgently needed to confront COVID-19 among these populations.

Background: People with disabilities deal with widespread exclusion from healthcare services, including sexual and reproductive health (SRH) rights. Studies analyzing the relationship between disability and key SRH utilization outcomes have often reported mixed findings. In Pakistan, very little to no literature is available on this topic, therefore we aim to determine inequalities in the utilization of essential maternal and reproductive health services between women with and without disabilities in Pakistan. Methods: This was a secondary analysis of Pakistan Demographic Health Survey 2017–18 performed on a weighted sample of 6,711 women aged 15–49 years with a live birth in the 5 years preceding the survey. Six types of disabilities were assessed i.e. vision, hearing, communication, cognition, walking and self-care. Utilization of essential maternal and reproductive health services was assessed through a set of four outcome variables: (i) modern contraceptive use; (ii) skilled antenatal care (ANC); (iii) skilled birth attendance (SBA); and (iv) skilled postnatal care (PNC). Multivariate Cox regression analysis was performed to determine the association between dependent and independent variables. Data were analyzed using Stata MP Version 16.0. Results: A total of 6,711 women were included out of which 14.1% (n = 947) live with at least one form of disability. Mean age was 29.4 (S.E = 0.13) years. The most prevalent form of disability was vision (7.0%), followed by walking (4.8%), cognition (4.8%) and hearing (1.8%). Women with disabilities were comparatively less educated, belonged to older age group, and had higher parity than their non-disabled counterparts. With the exception of modern contraceptive use, which was more prevalent in the group with disabilities, women with disabilities were less likely to utilize skilled ANC, SBA and PNC in bivariate analysis. However, these associations turned insignificant in the adjusted model. Overall, no statistically significant differences were observed in the utilization of essential reproductive health services between women with and without disabilities after adjusting for important covariates. Conclusion: Our analyses did not find any statistically significant differences in the utilization of essential maternal and reproductive health services between women with and without disabilities. In-depth research utilizing qualitative or mixed methods is required to understand how well the healthcare system in Pakistan is responsive to the different needs of disabled women.

Background: Decentralization of a health system is a complex and multidimensional phenomenon that demands thorough investigation of its process logistics, predisposing factors and implementation mechanisms, within the broader socio-political environment of each nation. Despite its wide adoption across both high-income countries (HICs) and low-and-middle-income countries (LMICs), empirical evidence of whether decentralization actually translates into improved health system performance remains inconclusive and controversial. This paper aims to provide a comprehensive description of the decentralization processes in three countries at different stages of their decentralization strategies – Pakistan, Brazil and Portugal. Main body: This study employed a systematic analysis of peer-reviewed academic journals, official government reports, policy documents and publications from international organizations related to health system decentralization. A comprehensive search was conducted using reputable databases such as PubMed, Google Scholar, the WHO repository and other relevant databases, covering the period up to the knowledge cutoff date in June 2023. Information was systematically extracted and organized into the determinants, process mechanics and challenges encountered during the planning, implementation and post-decentralization phases. Although decentralization reforms have achieved some success, challenges persist in their implementation. Comparing all three countries, it was evident that all three have prioritized health in their decentralization reforms and aimed to enhance local decision-making power. Brazil has made significant progress in implementing decentralization reforms, while Portugal and Pakistan are still in the process. Pakistan has faced significant implementation challenges, including capacity-building, resource allocation, resistance to change and inequity in access to care. Brazil and Portugal have also faced challenges, but to a lesser extent. The extent, progress and challenges in the decentralization processes vary among the three countries, each requiring ongoing evaluation and improvement to achieve the desired outcomes. Conclusion: Notable differences exist in the extent of decentralization, the challenges faced during implementation and inequality in access to care between the three countries. It is important for Portugal, Brazil and Pakistan to address these through reinforcing implementation strategies, tackling inequalities in access to care and enhancing monitoring and evaluation mechanism. Additionally, fostering knowledge sharing among these different countries will be instrumental in facilitating mutual learning.

Background: According to global estimates for 2017, nearly 295,000 maternal deaths occurred worldwide. Thus, approximately 810 women die every day due to pregnancy-related complications. This burden of maternal deaths in LMICs is primarily due to poor healthcare service utilization, as indicated by relatively low rates of institutional deliveries and skilled-birth attendance (SBA). We conducted this study with an aim to assess the factors associated with home delivery and its subsequent effect on the pregnancy outcome in rural Sindh, Pakistan. Methods: Data for this study were taken from The Global Network’s Maternal Newborn Health Registry (MNHR), which is a prospective, population-based observational cohort study. Registry data for 2018–2019 for District Thatta, Pakistan was retrieved for the analysis. Multivariable logistic regression models were used to determine the effect of each independent variable on the place of delivery by including all predictors and covariates. Results of the regression analyses are presented with crude odds ratios (OR) and adjusted odds ratios (aOR) with 95% confidence intervals (CIs). Results: A total of 4649 women were included in the study, of these, 1286 (27.7%) women had delivered at home. Of those who delivered at home, a larger proportion was illiterate (90%), had a BMI of less than 18.5 kg/m² (26.0%), had parity of 3 or more (48.1%), and had a history of pregnancy loss as compared to women who had institutional delivery. In addition, two-thirds of women (63.4%) who had delivered at home had less than 4 ANC visits, whereas 15.6% did not receive any ANC. On multivariable logistic regression we found that home delivery was significantly associated with being illiterate (aOR = 1.60; [95% CI: 1.34, 2.04]), having high parity (aOR = 1.91; [95% CI: 1.58, 2.32]), and no ANC visit (aOR = 14.8; [95% CI: 10.2, 21.5]). Conclusions: More than a quarter of our study sample women delivered at home. These women were illiterate, multiparous, and did not receive antenatal care during pregnancy. It is essential to conduct extensive educational interventions for the women and their family members regarding the potential benefits of delivering in a safe and skilled environment. Moreover, the provision of comprehensive and quality antenatal care should be ensured as it improves the mothers' health-seeking behavior and helps them make informed decisions about their health and well-being.

Background: The high prevalence of adverse events (AEs) globally in health care delivery has led to the establishment of many guidelines to enhance patient safety. However, patient safety is a relatively nascent concept in low- and middle-income countries (LMICs) where health systems are already overburdened and underresourced. This is why it is imperative to study the nuances of patient safety from a local perspective to advocate for the judicious use of scarce public health resources. Objective: This study aims to assess the status of patient safety in a health care system within a low-resource setting, using a multipronged, multimethod approach of standardized methodologies adapted to the local setting. Methods: We propose purposive sampling to include a representative mix of public and private, rural and urban, and tertiary and secondary care hospitals, preferably those ascribed to the same hospital quality standards. Six different approaches will be considered at these hospitals including (1) focus group discussions on the status quo of patient safety, (2) Hospital Survey on Patient Safety Culture, (3) Hospital Consumer Assessment of Healthcare Providers and Systems, (4) estimation of incidence of AEs identified by patients, (5) estimation of incidence of AEs via medical record review, and (6) assessment against the World Health Organization’s Patient Safety Friendly Hospital Framework via thorough reviews of existing hospital protocols and in-person surveys of the facility. Results: The abovementioned studies collectively are expected to yield significant quantifiable information on patient safety conditions in a wide range of hospitals operating within LMICs. Conclusions: A multidimensional approach is imperative to holistically assess the patient safety situation, especially in LMICs. Our low-budget, non–resource-intensive research proposal can serve as a benchmark to conduct similar studies in other health care settings within LMICs.