Objective: To learn about household maternal and newborn health knowledge and practices to aid the design of newborn programming within Save the Children's Haripur Program.Study Design: In April, we conducted 43 semi-structured interviews (SSIs) and 34 focus group discussions among men, women of reproductive age and health service providers; in September, we added 21 SSIs among new mothers, new fathers and dais. Two investigators analyzed the findings according to themes within six care types: antenatal, delivery, immediate newborn, routine postpartum, special maternal and special newborn.Result: Findings indicated poor maternal diet and antenatal careseeking. Home delivery with an untrained dai was the norm. Respondents knew about benefits of clean delivery, but rarely put knowledge into practice. Knowledge and practices for maintaining the newborn's warmth were good. Delayed initiation of breastfeeding, avoidance of colostrum and prelacteal feeding were almost universal. Unhygienic cord care, including an unclean cut and application of ghee on the cord-stump, was the norm. After delivery, mothers often maintained low fluid intake but otherwise reported healthy nutritional practices. Knowledge of some danger signs in newborns was common, but timely action upon recognition was not. Conclusion:Although the findings illustrate some beneficial practices, many reported practices are harmful to the newborn. These findings, consistent with the sparse existing data in Pakistan, inform program interventions for household-level behavioral change.

SummaryO O BJECTIVE BJECTIVE To identify risk factors associated with HCV infection in Islamabad±Rawalpindi.METHODS METHODS Fifty-seven cases and 180 controls were enrolled from various departments of the nine major hospitals of the Rawalpindi±Islamabad during July±September 1998. Cases were enzyme-linked immunosorbent assay (ELISA) positive for antibodies to HCV (anti-HCV), aged 20±70 years, and residents of Islamabad or Rawalpindi division. Controls were anti-HCV ELISA negatives of the same age range and from the same area. A structured questionnaire was used to collect data on demographic variables and potential risk factors, which was analysed by logistic regression to calculate crude and adjusted odds ratios (OR) and corresponding 95% con®dence intervals (CI) for risk factors. RESULTS RESULTSThe ®nal multivariate logistic regression model revealed that after adjusting for age, cases were more likely to have received therapeutic injections in the past 10 years (1±10 vs. 0 therapeutic injections; adjusted OR 2.8, 95% CI: 1.1±7.1; > 10 vs. 0 therapeutic injections; adjusted OR 3.1, 95% CI: 1.2±7.9) and were signi®cantly more likely to have daily face (adjusted OR 5.1, 95% CI: 1.5±17.0) and armpit shaves (adjusted OR 2.9, 95% CI: 1.3±6.5) by a barber.CONCLUSIO N CONCLUSION HCV control and prevention programs in this region should include safe injection practices and educate men about the risk of HCV infection from contaminated instruments used by barbers.keywords case±control study, hepatitis C virus, hepatitis C, viral hepatitis, risk factors, Pakistan

Background First dose oral cotrimoxazole and referral is the recommended treatment for WHO-defined severe pneumonia. Difficulties with referral compliance are reported from many low resource settings resulting in low access to appropriate treatment. Methods In a cluster-randomized equivalence trial in Haripur District, Pakistan 28 clusters were randomized equally to intervention and control clusters. In 14 intervention clusters children 2-59 months of age with severe pneumonia were treated with oral amoxicillin by community-based Lady Health Workers (LHW). In 14 control clusters LHWs gave first dose of oral cotrimoxazole and referred to a health facility for appropriate treatment, which was standard of care. The objective was to determine whether community case-management (CCM) of severe pneumonia by LHW using oral amoxicillin was equivalent to current standard of care. Primary outcome was treatment failure on day 6 of treatment. Participants, care givers, and assessors were not blinded to study therapy. Per-protocol analysis was conducted adjusting for clustering within arms using generalized estimating equations. Findings 1995 children were randomized to intervention and 1477 to control clusters. We analysed 1857 children randomized to intervention and 1354 randomized to control clusters. They were similar in sex, age, and clinical characteristics. Treatment failure was 8·9% (165/1857) in intervention and 17·8% (241/1354) in control clusters. Cluster adjusted failure rates, the primary outcome, were significantly reduced in intervention clusters (risk difference (RD) -8·9%; 95% CI:-12.4% to -5.4%) by day 6. Further adjusting for baseline covariates made little difference (RD: -7·3%, CI: -10·1% to -4·5%). Three deaths occurred, only one in the intervention arm. Two deaths were before day 6, while one occurred between day 6 and 14. Most reduction in risk was in fever and lower chest indrawing on day 3 (RD -6·38%; 95% CI: -8·3% to -4·5%). Age, gender and very fast breathing were predictive of treatment failure. Interpretation CCM of severe pneumonia by LHWs resulted in reduced treatment failure versus current standard of care. CCM could result in standardized therapy for severe pneumonia, reduce delay in treatment initiation and costs for families and health systems. Funding United States Agency for International Development.

A positive deviance (PD) inquiry identifies uncommon, model practices that a follow-on program can spread. PD has been used to rehabilitate malnourished children, but not for improving newborn health. Save the Children Federation/US (SC) conducted newborn PD cycles in communities (total population about 5,000 each) in two project areas in Haripur District, Pakistan among Afghan refugees and among local Pakistanis. Each PD cycle included planning, community orientation, situation analysis, PD inquiries, and community feedback with action planning. PD inquiries were in-depth interviews to identify uncommon behaviors among surviving asphyxiated newborns, thriving low birthweight babies, surviving newborns who had danger signs, and normal newborns. The Afghan caregivers showed better use of services and some household practices than their Pakistani counterparts, consistent with duration of SC presence (15 years vs. 18 months, respectively). The practices of both groups for clean delivery, thermal control, immediate and exclusive breastfeeding, and fathers' involvement were weak. But PD individuals, families, and/or birth attendants modeled good maternal care and immediate, routine and special newborn care. Communities enthusiastically committed to change behavior and form neighborhood support groups for better newborn care, including a demand for hygienic delivery. The PD approach for the newborn is more complex than for child nutrition. Yet this pilot-test proposed a conceptual framework for household newborn care, suggested tools and methods for information gathering, identified PDs in two settings of different risk, galvanized SC staff to the potential of the approach, mobilized communities for better newborn health, and drafted a newborn PD training curricula.

BackgroundThere is a growing interest in using pay-for-performance mechanisms in low and middle-income countries in order to improve the performance of health care providers. However, at present there is a dearth of independent evaluations of such approaches which can guide understanding of their potential and risks in differing contexts. This article presents the results of an evaluation of a project managed by an international non-governmental organisation in one district of Pakistan. It aims to contribute to learning about the design and implementation of pay-for-performance systems and their impact on health worker motivation.MethodsQuantitative analysis was conducted of health management information system (HMIS) data, financial records, and project documents covering the period 2007-2010. Key informant interviews were carried out with stakeholders at all levels. At facility level, in-depth interviews were held, as were focus group discussions with staff and community members.ResultsThe wider project in Battagram had contributed to rebuilding district health services at a cost of less than US$4.5 per capita and achieved growth in outputs. Staff, managers and clients were appreciative of the gains in availability and quality of services. However, the role that the performance-based incentive (PBI) component played was less clear--PBI formed a relatively small component of pay, and did not increase in line with outputs. There was little evidence from interviews and data that the conditional element of the PBIs influenced behaviour. They were appreciated as a top-up to pay, but remained low in relative terms, and only slightly and indirectly related to individual performance. Moreover, they were implemented independently of the wider health system and presented a clear challenge for longer term integration and sustainability.ConclusionsChallenges for performance-based pay approaches include the balance of rewarding individual versus team efforts; reflecting process and outcome indicators; judging the right level of incentives; allowing for very different starting points and situations; designing a system which is simple enough for participants to comprehend; and the tension between independent monitoring and integration in a national system. Further documentation of process and cost-effectiveness, and careful examination of the wider impacts of paying for performance, are still needed.