Building sustainable operational research capacity in Pakistan: starting with tuberculosis and expanding to other public health problems

Figures & data

Figure 1. Flow of Pakistan SORT-IT courses from Inception.

*The UNION and the University of Bergen

Table 1. Details of Pakistan national SORT-IT course.

	2016	2017	2018
Total applicants	14	20	42
Selected participants for the course	8	8	10
Male female ratio	7:1	6:2	8:2
Successfully completed* (submitted papers)	6	6	Ongoing
Papers Published	6	4	Ongoing

*Achieved 4 milestones and submitted a paper

Table 2. Research outcomes of participants who have attended in national and international SORT-IT courses (2010–2017).

Total number of participants enrolled	34
Total participants from completed courses	23
Number of participants successfully completed	18 (78%)
Total papers submitted (all SORT IT Pakistani participants)	18
– First author from Pakistan	100 %*
– Last author from Pakistan	68 %
– Female first authors	36 %
Papers published (up until June, 2018)	15 (83%)
No of institutions represented	21
Journal Impact factor (range)	0.80–2.8

*One of the participant was not a Pakistan national, but an expatriate working for MSF in Pakistan

Table 3. Examples of few SORT- IT Research Projects and their effect on policy and practice in Pakistan.

Project details	Key findings	Effect on policy and practices
Fatima R, Ejaz Q, Enarson DA, Bissell K. Comprehensiveness of primary services in the care of infectious tuberculosis patients in Rawalpindi, Pakistan. Public Health Action. 2011;1(1):13–15.	A cross sectional study was done to assess the initial loss to follow up in Rawalpindi districts, Pakistan. There were 16 145 suspects screened for TB and recorded in the laboratory registers. Of 1698 smear positive patients identified in the laboratory registers, 101 (6%) could not be identified in the treatment registers.	The article highlighted the need to strengthen hospital DOTS linkages as an intervention introduce to minimize loss of TB cases from tertiary care hospital linking various departments of hospitals as well as with the peripheral hospitals. Therefore, a phasic scale up of hospital dots linkages was established from 2011 onwards and further evaluated for increasing case notification especially in children in 2016 Pakistan SORT course ‘Mirza AS, Fatima R, Yaqoob A, Qadeer E, Wali A, Khurshid A, et al. Enhancing Childhood TB Notifications by Strengthening Linkages with Large Hospitals in Pakistan – Childhood TB in Large Hospitals, Pakistan. J Tuberc Res; 2018;6.’
Fatima R, Qadeer E, Yaqoob A, ul Haq M, Majumdar SS, Shewade HD, Stevens R, Creswell J, Mahmood N, Kumar AM. Extending ‘Contact Tracing’ into the Community within a 50-Metre Radius of an Index Tuberculosis Patient Using Xpert MTB/RIF in Urban, Pakistan: Did It Increase Case Detection? PloS one. 2016;11(11): 1–11.	In this study, an intervention was evaluated in which contact tracing was extended from smear positive TB cases household to 50 meter radius by using GIS technique. The overall yield of all forms TB patients among investigated was 22.3% among household and 19.1% in close community. The intervention contributed an increase of case detection of bacteriologically confirmed tuberculosis by 6.8% and all forms TB patients by 7.9%.	Same intervention was tested among DR TB patient through the support of Global Fund. Further scale up is planned in next Global fund applications.
Qadeer E, Fatima R, Haq MU, Yaqoob A, Kyaw NT, Shah S, Das M, Isaakidis P. Yield of facility-based verbal screening amongst household contacts of patients with multi-drug resistant tuberculosis in Pakistan. Journal of Clinical Tuberculosis and Other Mycobacterial Diseases. 2017;7:22–27.	In this cross sectional study, verbal screening was done amongst household contacts of patients with multi-drug resistant tuberculosis in Pakistan. Of total contacts, 56 (3.8%) were diagnosed with TB, among them 54(96%) with MDR-TB and 2(4%) with drug-susceptible TB.	The contact investigation for both sensitive and DR TB patient is given a special focus based on evidence generated and linked to the END TB strategy in revision to the national strategic plan.
Khurshid A, Hinderaker SG, Heldal E, Fatima R, Haq M, Yaqoob A, Ansari A, Anwar K, Qadeer E, Kumar AM. Did ‘Screeners’ Increase Pediatric Tuberculosis Case Notification in Sindh, Pakistan?. Journal of Tuberculosis Research. 2017;5(01):81–86.	To identify missing childhood Tuberculosis (TB) cases, ‘screeners’ (hospital-based health workers trained to screen accompanying contacts of TB patients for symptoms) were introduced in eight tertiary care hospitals of Sindh, Pakistan in 2013. There was a 55% increase in childhood TB notifications in 2014 compared to 2012 in facilities with screeners (n = 8) compared to 40% increase in facilities without screeners (n = 22). Screeners were not associated with increase in pediatric TB case notifications.	Based on evidence, the number of screeners are decreased in new funding request (NFR) grant 2017–20 by Private partners from Global Fund grants. Pediatrician training are conducting all over Pakistan which resulted in 4 times increased child TB notification.
Waheed Y, Khan MA, Fatima R, Yaqoob A, Mirza A, Qadeer E, Shakeel M, Heldal E, Kumar AM. Infection control in hospitals managing drug-resistant tuberculosis in Pakistan: how are we doing?. Public Health Action. 2017;7(1):26–31.	This was a descriptive study conducted between April and October 2016 with three components: 1) non-participant observation of service delivery areas (SDAs) (n = 82) in hospitals (n = 10) using structured checklists; 2) exit interviews with 100 patients (10 per hospital); and 3) interviews with 100 health-care workers (HCWs, 10/hospital). Of the 82 SDAs, posters were displayed in 34 (41%), mechanical ventilation was implemented in 79% and functional ultraviolet germicidal irradiation (UVGI) was available in only 26%. Patient interviews showed 50–65% adherence to triage and use of personal protective measures. Implementation of TB infection control measures in hospitals was suboptimal.	Retraining of HCWs and Improved supervision and monitoring of PMDT sides.
Safdar MA, Fatima R, Khan NM, Yaqoob A, Khurshid A, Haq MU, Wali A. Prevalence of Human Immune Deficiency among Registered Tuberculosis Patients across Pakistan during 2013–2015 – Prevalence of TB-HIV Co-Infection in Pakistan. Journal of Tuberculosis Research. 2018;6(01):96.	It was the cross sectional study assessing the prevalence of Human Immune Deficiency among Registered Tuberculosis Patients across Pakistan during 2013–2015. Among the screened TB patients 145 (0.66%) were found HIV reactive. The prevalence of HIV was higher (1.02%) in extra-pulmonary and male TB patients and B + ve. Only 113 (77.9%) reactive patients were found registered at ARV clinics for further treatment.	Sentinel sites for TB/HIV testing was scaled up from 17 to 40 across Pakistan. Introduction of TB-HIV Indicator in case finding reports (TB 07). Integration of TB-HIV services is in process.
Najmi H, Ahmed H, Halepota GM, Fatima R, Yaqoob A, Latif A, Ahmad W, Khursheed A. Community-based integrated approach to changing women’s family planning behaviour in Pakistan, 2014–2016. Public Health Action. 2018;8(2):85–90.	This study is the evaluation of community-based integrated approach to change the women’s family planning behaviour in Pakistan. Contraceptive prevalence rate was increased upto 10.7 % from the baseline (42.3% vs midline 53.0 %) with an increased in modern contraceptive rate 9.2%. Significant association was found between door-to-door counselling with the use of contraceptive methods, access to of public and private facilities for modern contraceptives. However, support group meeting and 24/7 helpline did not show any association with use of contraceptive method.	Based on the success of intervention, life skill based education modules were included to Secondary School Curriculum for Sind and intervention is scaled up in 10 districts.

Figure 2. Expanding research subjects beyond Tuberculosis during three years of SORT IT courses in Pakistan.

IOM: International Organization for Migration

YCF: Infant and Young Child Feeding