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Background: Pakistan has subpar childhood immunization rates and immunization activities have faced several challenges over the past years. We evaluated the social-behavioral and cultural barriers and risk factors for refusal of polio, Routine Immunization (RI), or both in high-risk areas of poliovirus circulation. Methods: A matched case-control study was conducted from April to July 2017 in eight super high-risk Union Councils of five towns in Karachi, Pakistan. A total of 3 groups, each with 250 cases, including refusals for the Oral Polio Vaccine (OPV) in campaigns (national immunization days and supplementary immunization activities), RI, and both, were matched with 500 controls and identified using surveillance records. Sociodemographic characteristics, household information, and immunization history were assessed. Study outcomes included social-behavioral and cultural barriers and reasons for vaccine refusal. Data were analyzed in STATA using conditional logistic regression. Results: RI refusal was associated with illiteracy and fear of the vaccine’s adverse effects, while OPV refusals were linked to the mother’s decision authority and the assumption that the OPV caused infertility. Conversely, higher socioeconomic status (SES) and knowledge of and willingness to vaccinate with Inactivated Polio Vaccine (IPV) were inversely associated with RI; and lower SES, walking to the vaccination point, knowledge of IPV, and an understanding of contracting polio were inversely associated with OPV refusals, with the latter two also inversely associated with complete vaccine refusal. Conclusion: Education, knowledge and understanding of vaccines, and socioeconomic determinants influenced OPV and RI refusals among children. Effective interventions are needed to address knowledge gaps and misconceptions among parents.

Background Adequate intake of macro- and micronutrients and adoption of an active lifestyle during pregnancy are essential for optimum maternal and fetal health and offspring development. Dietary counseling and advice regarding adequate physical activity are integral components of antenatal care. Personalized coaching through the use of mobile health (mHealth) that supports behavior modification is an innovative approach that needs exploration. Objective Our primary aim is to assess the efficacy of an mHealth program in improving diet, supplement use, and physical activity during pregnancy. Secondary objectives include evaluation of the program’s effect on maternal and offspring health outcomes and assessment of its compliance and usability. Methods A randomized controlled trial was initiated at the Aga Khan University Hospital in Karachi, Pakistan, in January 2020. We aim to recruit 300 pregnant women in their first trimester who have smartphones, do not have comorbidities, and are not taking medications. The intervention group will be trained to use an mHealth app called PurUmeed Aaghaz. Through this app, the subjects will report information about their diet, supplement use, and physical activity and will receive personalized advice and three push messages as weekly reminders. The research assistant will obtain similar information from the control group via a paperless questionnaire; this group will receive standard face-to-face counseling regarding diet, supplement use, and physical activity. Data will be collected at enrollment and during four follow-up sessions scheduled 6 weeks apart. Primary study outcomes include improvements in diet (ie, change in mean dietary risk score from baseline to each follow-up), supplement use (ie, changes in mean supplement use score and biochemical levels of folic acid, iron, calcium, and vitamin D on a study subset), and mean duration of reported physical activity (minutes). Secondary study outcomes relate to maternal health (ie, gestational diabetes mellitus, gestational hypertension, pre-eclampsia, and gestational weight gain), newborn health (ie, birth weight and length and gestational age at delivery), and infant health (ie, BMI and blood pressure at 1 year of age). Compliance will be determined by the proportion of participants who complete the 6-month coaching program. Usability will be assessed based on features related to design, interface, content, coaching, perception, and personal benefit. Results The study was approved by the Ethics Review Committee of the Aga Khan University in 2017. The recruitment of study participants was completed in September 2021. All follow-ups and outcome assessments are expected to be completed by March 2023 and analysis is expected to be completed by June 2023. We expect the results to be published by the end of 2023. Conclusions This study will be an important step toward evaluating the role of mHealth in improving behaviors related to a healthy diet, supplement use, and promotion of physical activity during pregnancy, as well as in influencing maternal and offspring outcomes. If proven effective, mHealth interventions can be scaled up and included in antenatal care packages at tertiary care hospitals of low- and middle-income countries. Trial Registration ClinicalTrials.gov NCT04216446; https://clinicaltrials.gov/ct2/show/NCT04216446 International Registered Report Identifier (IRRID) DERR1-10.2196/31611

BACKGROUND Adequate intake of macro and micronutrients and adoption of an active lifestyle during pregnancy are essential for optimum maternal and fetal health and offspring development. Dietary counselling and advice for adequate physical activity make integral components of antenatal care. Personalized coaching through the use of mobile health (m-Health) which supports behaviour modification is an innovative approach that needs exploration. OBJECTIVE Our primary objective is to assess the efficacy of an m-Health program in improving diet, supplement use and physical activity during pregnancy. Secondary objectives include evaluation of its effect on maternal and offspring health outcomes and assessment of its compliance and usability. METHODS A randomized control trial is initiated at the Aga Khan University Hospital, Karachi in January 2020. We aim to recruit 300 pregnant women in their first trimester having smartphones and without co-morbid or on medications. The intervention group would be trained to use an m-Health application named as PurUmeed Aaghaz. Through this application, the subjects would report information about their diet, supplement use and physical activity and would receive personalized advice and 3 push messages as weekly reminders. Research Assistant would obtain similar information from the non-intervention group on a paperless questionnaire who would receive standard face-to-face counselling on diet, supplement use and physical activity. Data would be collected at enrolment and on 4 follow-ups scheduled 6 weeks apart. Primary study outcomes include improvement in the diet (change in mean Dietary Risk Score (DRS) from baseline to each follow-up), supplement use (change in mean supplement use score and biochemical levels of folic acid, iron, calcium and vitamin D on a study subset) and mean duration of reported physical activity (minutes). Secondary study outcomes relate to maternal (gestational diabetes mellitus, gestational hypertension, preeclampsia and gestational weight gain), newborn (birth weight and length and gestational age at delivery) and infant health (body mass index and blood pressure at 1 year of age). Compliance would be determined by proportion completing coaching program at 6 months and usability would be assessed based on features related to design, interface, content, coaching, perception and personal benefit. RESULTS The study is approved by the Ethical Review Committee in 2017. As of June 01, 2021, 258 participants have been enrolled. Recruitment will be completed by July 2021 and results are expected to be released by early 2023. CONCLUSIONS This study will be an important step towards evaluating the role of m-Health in improving behaviours related to the consumption of healthy diet and supplement use, for promoting physical activity during pregnancy and in influencing maternal and offspring outcomes. If proven effective, m-health intervention can be scaled up and included in antenatal care package at tertiary care hospitals of Low Middle-Income Countries. CLINICALTRIAL Clinicaltrials.gov NCT04216446. Registered January 2, 2020.