Nuruddin Mohammed

Background: In Pakistan, one-third of under-5 deaths (58/1000 live births) are attributable to the high prevalence of stunting (40%), underweight (23%), and wasting (17.7%). Given the suboptimal prevalence of exclusive breastfeeding (EBF; 48%) and the alarmingly low consumption of a minimum acceptable diet (3.6%), mitigation of early-life nutritional risk provides a critical window of opportunity for intervention. Mobile health (mHealth) provides an innovative and low-cost option to improve infant and young child feeding practices (IYCFPs) among mothers. Objective: This study aims to assess the efficacy of a context-specific mHealth coaching app in promoting EBF and IYCFPs compared to face-to-face (F2F) counseling. Methods: This is a prospective, parallel-arm randomized controlled trial planned at a secondary care hospital in Karachi, Pakistan. The study will enroll 300 booked singleton pregnant women in the third trimester, who plan to stay in their respective areas for at least 1 year postdelivery, are registered for child immunization at the associated Family Health Center, own smartphones with internet access, are able to read Urdu, and provide consent. Participants in the intervention arm will receive the Pehli Ghiza mHealth app along with routine standard-of-care F2F counseling. The app will deliver context-specific educational content on breastfeeding and IYCFPs through short videos and messages sent 3 times per week, tailored to the stage of pregnancy and infant age. Participants in the control arm will receive only routine F2F counseling. The standard of care will be delivered at each follow-up visit, which is scheduled at birth, at 6, 10, and 14 weeks, and at 6, 9, and 12 months of the infant’s age. Data will be collected at enrollment and at each follow-up visit using structured questionnaires. Primary outcomes are EBF and the introduction of age-appropriate complementary feeding. Secondary outcomes include early initiation of breastfeeding, continued breastfeeding at 1 year, minimum dietary diversity, meal frequency, minimum acceptable diet, and child health outcomes. Analysis will follow the intention-to-treat principle to detect a 20% absolute improvement in primary outcomes between the intervention and control groups over time and to evaluate between-group differences in feeding practices. 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 and the National Ethics Committee. Participant recruitment started on February 2, 2026. As of May 18, 2026, 241 participants have been recruited. Follow-ups and outcome assessments are expected to be completed by June 2027. Conclusions: If effective, the Pehli Ghiza intervention could support the integration of digital health tools into standard of care in Pakistan and similar low- and middle-income country settings.

Background: Globally, around 800,000 people die by suicide annually, with 77% of these deaths occurring in low- and middle-income countries. Suicidal ideation, frequently observed among adolescents, is directly linked to suicide attempts. Pakistan has witnessed a marked escalation in suicide rates in recent years, with Gilgit-Baltistan (GB) reporting the highest incidence. Extensive research indicates that tailored suicide prevention strategies can mitigate suicidal ideation, attempts, and related fatalities. Objective: This study aims to validate and evaluate the efficacy of suicide prevention programs, RAAHI (the guide) and safeTALK, tailored to the cultural and social context of GB, Pakistan, in preventing suicidal ideation and improving the mental well-being of school-going adolescents. Methods: The investigation will assess the efficacy of the RAAHI intervention among 267 adolescents across 4 private schools in GB using an interrupted time-series design with a pre-post test framework. The first intervention, RAAHI, a suicide literacy module, is designed to empower participants with the knowledge and skills to recognize signs of suicidal ideation, engage them empathetically, and connect individuals in crisis with appropriate support. The second intervention, safeTALK, a 4-hour educational workshop, incorporates presentations, videos, discussions, and interactive sessions to teach participants the tell, ask, listen, and keep safe steps. Outcome measures include changes in knowledge, confidence, willingness to intervene, and help-seeking behaviors, analyzed using descriptive statistics, 2-tailed paired t tests, and ANOVA. Ethics approval was granted by the Aga Khan University Ethics Review Committee (2023-8509-24844). Results: As of April 2025, 267 participants have been recruited from 2 of the 4 schools; data collection commenced in March 2025 and is projected to conclude in August 2025. Final results are expected to be published by February 2026. Conclusions: This study will offer critical insights into the adaptation and effectiveness of the RAAHI suicide prevention intervention in a low-resource, culturally specific setting. The findings are anticipated to inform scalable suicide prevention initiatives in school settings across Pakistan and similar low- and middle-income contexts, ultimately contributing to reduced suicidal ideation and attempts among adolescents. International Registered Report Identifier (IRRID): DERR1-10.2196/67193

Background: Micronutrient deficiencies in folate, ferritin, calcium, and vitamin D are common during pregnancy in low- and middle-income countries, often due to inadequate diets. Micronutrient supplementation can address this need, whereas innovative awareness strategies in antenatal practices could enhance supplement use compliance. Objective: We evaluated the efficacy of a personalized mobile health (mHealth) intervention, hypothesizing a 30% improvement in supplement use in the intervention group compared to a conventional face-to-face counseling group. Methods: In an unblinded randomized controlled trial, we enrolled 306 first-trimester pregnant women from Aga Khan University Hospital between January 2020 and September 2021 who owned smartphones with internet connection. Women on regular medications or with dietary restrictions or critical illnesses were excluded. The intervention group received personalized micronutrient supplement use coaching through an mHealth app (PurUmeed Aaghaz) as thrice-a-week push messages and tailored recommendations over a 24-week period. The comparison group received standard face-to-face counseling at 6, 12, 18, and 24 weeks after enrollment. Baseline sociodemographic, obstetrics, anthropometric, dietary, and lifestyle data were collected through face-to-face interviews. At each follow-up, participants reported their weekly use of folic acid, iron, calcium, and vitamin D supplements, scored as 0 (daily), 1.5 (4-6 times weekly), and 3 (≤3 times weekly). Scores were summed to calculate the cumulative supplement use score (CSUS; 0-12), with higher scores indicating greater inadequacy. Every fourth woman was invited for biochemical micronutrient assessment. Data were analyzed using Stata (version 14), with random-effects linear and logistic panel regression to compare CSUS and supplement use between the 2 groups from baseline to endline. Results: Of 153 participants per group, 107 (69.9%) in the intervention and 125 (81.7%) in the nonintervention group completed the study. After 24 weeks, the intervention group showed a greater but insignificant reduction in mean CSUS compared to the nonintervention group (β=–.27, 95% CI −0.65 to 0.12; P=.17). Daily supplement use improved by 20% versus 22.4% for folic acid, 11.2 times versus 2.1 times for iron, 1.2 times versus 14.2 times for calcium, and 3 times versus 1.3 times for vitamin D in the intervention versus nonintervention group, respectively. Multivariable analysis showed higher, though insignificant, odds of sufficient folic acid (adjusted odds ratio [aOR] 1.26, 95% CI 0.68-2.36; P=.46) and iron (aOR 1.31, 95% CI 0.95-1.81; P=.10) use in the intervention group, whereas vitamin D use was significantly higher (aOR 1.88, 95% CI 1.43-2.47; P<.001). Calcium intake improved in the nonintervention group (aOR 0.59, 95% CI 0.44-0.79; P<.001). Anemia decreased in the intervention group, whereas ferritin, calcium, and vitamin D deficiencies persisted or worsened, particularly in the nonintervention group. Conclusions: An appropriately implemented mHealth intervention can improve antenatal vitamin D supplementation. Affordable, accessible, and personalized counseling through mHealth could ameliorate micronutrient status during pregnancy. Trial Registration: ClinicalTrials.gov NCT04216446; https://clinicaltrials.gov/study/NCT04216446

Objectives: To compare the INTERGROWTH-21st and the WHO fetal growth chart in detecting term small for gestational age (SGA) neonates and predicting short-term adverse perinatal outcomes. Design: A retrospective cohort study. Setting: Department of Obstetrics and Gynaecology at the Aga Khan University Hospital Karachi. Subjects: Term singleton pregnancies between July and December 2018 with ultrasound growth scan done within 4 weeks of delivery. Pregnancies with structural and chromosomal abnormalities and multiple gestations were excluded. Outcome: The estimated fetal weight (EFW) was calculated using the INTERGROWTH-21st and the WHO fetal growth chart based on ultrasound measurements. Fetuses with EFW below the 10th percentile were classified as SGA. Neonates were confirmed as SGA based on similar postnatal weight percentile. Short-term adverse perinatal outcomes were also analysed. Results: A total of 932 records were screened, and 478 were included in the analysis. The sensitivity of the WHO fetal growth chart (70.2%; 95% CI: 60.4%, 78.8%) was higher than the INTERGROWTH-21st (45.2%; 95% CI: 35.4%, 55.3%) for predicting neonatal SGA. The WHO fetal growth chart predicted more SGA neonates when compared with the INTERGROWTH-21st (AUC=0.75, 95% CI: 0.71, 0.80 and AUC=0.63, 95% CI: 0.58, 0.68, respectively). Both charts were similar in predicting the short-term adverse perinatal outcomes; AUC (95% CI) was 0.77 (0.70, 0.83) for INTERGROWTH-21st and 0.78 (0.72, 0.85) for the WHO fetal growth chart. Conclusion: The WHO fetal growth chart demonstrates significantly better accuracy in predicting term SGA neonates compared with INTERGROWTH-21st. Further, both charts have similar prediction abilities for short-term adverse perinatal outcomes.

BACKGROUND Micronutrient deficiencies in folate, ferritin, calcium, and vitamin D are common during pregnancy in low- and middle-income countries, often due to inadequate diets. Micronutrient supplementation can address this need, whereas innovative awareness strategies in antenatal practices could enhance supplement use compliance. OBJECTIVE We evaluated the efficacy of a personalized mobile health (mHealth) intervention, hypothesizing a 30% improvement in supplement use in the intervention group compared to a conventional face-to-face counseling group. METHODS In an unblinded randomized controlled trial, we enrolled 306 first-trimester pregnant women from Aga Khan University Hospital between January 2020 and September 2021 who owned smartphones with internet connection. Women on regular medications or with dietary restrictions or critical illnesses were excluded. The intervention group received personalized micronutrient supplement use coaching through an mHealth app (PurUmeed Aaghaz) as thrice-a-week push messages and tailored recommendations over a 24-week period. The comparison group received standard face-to-face counseling at 6, 12, 18, and 24 weeks after enrollment. Baseline sociodemographic, obstetrics, anthropometric, dietary, and lifestyle data were collected through face-to-face interviews. At each follow-up, participants reported their weekly use of folic acid, iron, calcium, and vitamin D supplements, scored as 0 (daily), 1.5 (4-6 times weekly), and 3 (≤3 times weekly). Scores were summed to calculate the cumulative supplement use score (CSUS; 0-12), with higher scores indicating greater inadequacy. Every fourth woman was invited for biochemical micronutrient assessment. Data were analyzed using Stata (version 14), with random-effects linear and logistic panel regression to compare CSUS and supplement use between the 2 groups from baseline to endline. RESULTS Of 153 participants per group, 107 (69.9%) in the intervention and 125 (81.7%) in the nonintervention group completed the study. After 24 weeks, the intervention group showed a greater but insignificant reduction in mean CSUS compared to the nonintervention group (β=–.27, 95% CI −0.65 to 0.12; P=.17). Daily supplement use improved by 20% versus 22.4% for folic acid, 11.2 times versus 2.1 times for iron, 1.2 times versus 14.2 times for calcium, and 3 times versus 1.3 times for vitamin D in the intervention versus nonintervention group, respectively. Multivariable analysis showed higher, though insignificant, odds of sufficient folic acid (adjusted odds ratio [aOR] 1.26, 95% CI 0.68-2.36; P=.46) and iron (aOR 1.31, 95% CI 0.95-1.81; P=.10) use in the intervention group, whereas vitamin D use was significantly higher (aOR 1.88, 95% CI 1.43-2.47; P<.001). Calcium intake improved in the nonintervention group (aOR 0.59, 95% CI 0.44-0.79; P<.001). Anemia decreased in the intervention group, whereas ferritin, calcium, and vitamin D deficiencies persisted or worsened, particularly in the nonintervention group. CONCLUSIONS An appropriately implemented mHealth intervention can improve antenatal vitamin D supplementation. Affordable, accessible, and personalized counseling through mHealth could ameliorate micronutrient status during pregnancy. CLINICALTRIAL ClinicalTrials.gov NCT04216446; https://clinicaltrials.gov/study/NCT04216446

BACKGROUND Globally, around 800,000 people die by suicide annually, with 77% of these deaths occurring in low- and middle-income countries. Suicidal ideation, frequently observed among adolescents, is directly linked to suicide attempts. Pakistan has witnessed a marked escalation in suicide rates in recent years, with Gilgit-Baltistan (GB) reporting the highest incidence. Extensive research indicates that tailored suicide prevention strategies can mitigate suicidal ideation, attempts, and related fatalities. OBJECTIVE This study aims to validate and evaluate the efficacy of suicide prevention programs, RAAHI (the guide) and safeTALK, tailored to the cultural and social context of GB, Pakistan, in preventing suicidal ideation and improving the mental well-being of school-going adolescents. METHODS The investigation will assess the efficacy of the RAAHI intervention among 267 adolescents across 4 private schools in GB using an interrupted time-series design with a pre-post test framework. The first intervention, RAAHI, a suicide literacy module, is designed to empower participants with the knowledge and skills to recognize signs of suicidal ideation, engage them empathetically, and connect individuals in crisis with appropriate support. The second intervention, safeTALK, a 4-hour educational workshop, incorporates presentations, videos, discussions, and interactive sessions to teach participants the tell, ask, listen, and keep safe steps. Outcome measures include changes in knowledge, confidence, willingness to intervene, and help-seeking behaviors, analyzed using descriptive statistics, 2-tailed paired t tests, and ANOVA. Ethics approval was granted by the Aga Khan University Ethics Review Committee (2023-8509-24844). RESULTS As of April 2025, 267 participants have been recruited from 2 of the 4 schools; data collection commenced in March 2025 and is projected to conclude in August 2025. Final results are expected to be published by February 2026. CONCLUSIONS This study will offer critical insights into the adaptation and effectiveness of the RAAHI suicide prevention intervention in a low-resource, culturally specific setting. The findings are anticipated to inform scalable suicide prevention initiatives in school settings across Pakistan and similar low- and middle-income contexts, ultimately contributing to reduced suicidal ideation and attempts among adolescents. INTERNATIONAL REGISTERED REPORT DERR1-10.2196/67193

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 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. CLINICALTRIAL ClinicalTrials.gov NCT04216446; https://clinicaltrials.gov/ct2/show/NCT04216446 INTERNATIONAL REGISTERED REPORT DERR1-10.2196/31611

Intrauterine undernutrition may lead to fetal vascular programming. We compared abdominal aortic intima-media thickness (aIMT) and aortic diameter (aD) between appropriate for gestational age (AGA) and growth-restricted fetuses (GRF). We recruited 136 singleton fetuses at 34–37 weeks of gestation from Fetal Medicine Unit of Aga Khan University Hospital, Karachi (January–November 2017). Subjects were classified as AGA (n = 102) and GRF (n = 34) using INTER-GROWTH 21st growth reference and standard ultrasound protocol. Their far- and near-wall aIMT and aD were compared after adjustment of maternal age, first-trimester body mass index, fetal gender, hypertension and hyperglycemia in pregnancy. As the severity of growth restriction increased in GRF, aIMT and aD showed an increasing and a decreasing trend, respectively. Both far- and near-wall aIMT in GRF [(adj. β = 0.082, 95% confidence interval [CI] 0.042–0.123) and (adj. β = 0.049, 95% CI 0.010–0.089)] were significantly greater with reference to AGA fetuses. GRF subgroup analysis into small for gestational age (SGA) fetuses and intrauterine growth restricted (IUGR) revealed highly significant difference between AGA and IUGR for far (0.142 mm, P-value < 0.001) and near-wall aIMT (0.115 mm, P-value < 0.001) and marginally significant aD difference (0.51 mm, P-value 0.05). These findings suggest that the extent of fetal aortic remodelling is influenced by the severity of growth restriction. Hence, the targeted interventions for the cardiovascular health promotion of IUGR and SGA born neonates are desirable during early childhood, particularly in set ups with high prevalence of low birth weight babies.