Tuberculosis (TB) is a significant global health threat, particularly in high-burden countries like Pakistan. The incidence of diabetes mellitus among TB patients is rising and this bidirectional relationship between TB and DM not only increases disease burden but also complicates diagnosis, management, and outcomes. While the World Health Organization and International Union Against Tuberculosis and Lung Disease has called for integrated care models, the implementation of such strategies and integrated TB diabetes care in Pakistan’s health systems remains inconsistent and challenged. This protocol outlines a planned mixed-methods study designed to examine the implementation determinants of an integrated TB–diabetes care package within Pakistan’s Provincial TB Control Program. The study guided by the Consolidated Framework for Implementation Research (CFIR), will focus on both inner-setting determinants (organizational structures, resources, and readiness) and outer-setting determinants (policy, inter-organizational networks, and external influences). Quantitative and qualitative data will be collected from stakeholders, including policymakers, healthcare providers, and TB site staff. Quantitative and qualitative data will be analysed using statistical and thematic approaches, respectively, guided by CFIR, to identify implementation determinants. Qualitative findings will be transformed into quantitative ratings to assess both the direction (barrier vs. facilitator) and the relative strength of influence of each determinant. Scores ranging from − 2 to + 2 will indicate whether a determinant exerts a negative or positive influence and the magnitude of its influence on implementation outcomes. The study has received ethical approval from the Ethics Review Committee of Khyber Medical University. Study findings will be submitted for publication in peer-reviewed journals and will be presented at relevant conferences.

Diabetes is a rapidly growing non-communicable disease globally, with 360 million out of 537 million affected adults residing in urban centres in 2021. In Pakistan, the situation is alarming, with diabetes prevalence alone exceeding 28.3

Background: Tuberculosis (TB) and diabetes mellitus (DM) represent a growing syndemic in low- and middle-income countries (LMICs), particularly across South Asia. The bidirectional relationship between these diseases exacerbates health outcomes and increases system burdens. Although the World Health Organization has advocated for integrated management of TB and DM, implementation remains inconsistent across the SAARC region. This systematic review aims to identify and analyse implementation determinants of integrated TB and DM care in SAARC countries. Methods: We conducted a systematic review following PRISMA 2020 guidelines. searching MEDLINE (via Ovid), EMBASE, Web of Science, Cochrane CENTRAL, and CINAHL for peer-reviewed studies. Grey literature was sourced from Google Scholar and citation search. Four reviewers independently screened title, abstract and full text using Rayyan. Using a structured Excel form, two reviewers extracted data. Quality assessment was conducted by using Mixed Methods Appraisal Tool (MMAT). A narrative synthesis was conducted in line with SWiM guidelines to categorize implementation determinants as barriers or facilitators. Results: Ten studies met the inclusion criteria and were conducted across five SAARC countries: India (n = 7), Pakistan (n = 1), Bangladesh (n = 1), and Sri Lanka (n = 1). Identified facilitators included political commitment, use of digital tools, and training of healthcare workers. Barriers encompassed inadequate infrastructure and finances, workforce shortages, lack of standardized guidelines and fragmented vertical health systems. Conclusion: Integrated TB-DM care in the SAARC region remains at an early developmental stage, with most efforts limited to pilot projects or small-scale screenings. Despite political and institutional recognition of the dual burden, scale-up is constrained by systemic barriers, resource gaps, and lack of evidence-informed implementation strategies. Future efforts should prioritize system-wide integration guided by implementation frameworks, standardized protocols, and investment in workforce and infrastructure to achieve sustainable impact. Systematic review registration PROSPERO registration number: CRD42025644263.

Background Tuberculosis with co-morbid diabetes mellitus presents a substantial public health challenge, necessitating immediate and coordinated interventions. Such interventions should be sustainable and have a high acceptance rate in real-world settings. Applying the principles of implementation science is essential to enhance the existing system. This research study aims to assess the influence of innovation characteristics on the implementation of an Optimised TB-diabetes integrated care package. Objectives The main objectives of this study are to explore the perceptions and experiences of intervention developers; to understand the experiences of health professionals and patients regarding the Opt TBD integrated care package; assess the content validity of the innovation characteristics instrument; and evaluate the influence of intervention characteristics on the implementation process of the Opt TBD integrated care package. Methods The study will be conducted at thirteen selected TB healthcare facilities across Khyber Pakhtunkhwa and Punjab over a period of 18 months, in three phases. Evaluation will involve qualitative exploration of intervention development, followed by feasibility testing, and finally the definitive implementation of the intervention. The participants will include key stakeholders: intervention developers, TB health professionals, and patients. Conclusion This study will generate critical insights for the Opt TBD integrated care package, focusing on enhancing contextual relevance and improving adoption rates in practical, real-world settings. Specifically, this research study seeks to identify key implementation challenges, evaluate the fidelity of the intervention, and validate the causal relationships between the characteristics of the innovation and its implementation success.

OBJECTIVE: To evaluate dental professionals' knowledge, attitudes, and practices regarding dental indemnity insurance (PII) at teaching institutions in Peshawar. METHODOLOGY: A cross-sectional study was conducted from July 2019 to March 2020 among 276 dentists holding a Bachelor's in Dentistry degree and practising in either government or private teaching institutions in Peshawar. Initially, proportionate sampling was used to allocate samples required across the seven study sites, and a random sampling technique was used to recruit samples from the sites. Data were collected using a validated questionnaire covering socio-demographic characteristics, awareness of PII, and perceptions regarding compensation for dental negligence, and were analyzed using SPSS version 23.0. Ethical approval was obtained, and written informed consent was secured from all participants. RESULTS: Out of 274 respondents (99.8% response rate), 93.8% lacked knowledge of PII, and only 6.2% had insurance coverage. While 64.2% believed PII should be mandatory, 73% were unaware of its existence. Gender, age, and experience did not significantly influence awareness. The majority of participants (77%) had never been asked for compensation, but opinions on compensation amounts for negligence varied widely. CONCLUSION: The study highlights a significant knowledge gap and low uptake of PII among dental professionals in Peshawar. Addressing barriers such as awareness, affordability, and regulatory enforcement is essential to ensure financial protection for practitioners and enhance patient trust.

Tobacco use is a leading cause of morbidity and mortality globally, with South Asia carrying a significant burden. Dentists are well placed to deliver cessation intervention because of the clear link between tobacco use and oral diseases. However, evidence on the reported outcomes and feasibility of such interventions in South Asian contexts has not been systematically synthesized. This review aimed to map and describe the characteristics, delivery approaches, and reported outcomes of tobacco cessation interventions implemented in dental or related healthcare settings within South Asian populations. We conducted the scoping review following the Joanna Briggs Institute (JBI) framework and reported according to PRISMA-ScR. A comprehensive search of PubMed, Embase, PsycINFO, Medline (via Ovid), Scopus, and CINAHL was conducted from database inception until March 2025. Eligible studies included quantitative, qualitative, and mixed methods designs reporting non-pharmacological cessation interventions delivered by dentists. Data were synthesised narratively with subsequent thematic synthesis examining effectiveness, cultural adaptations, resource limitations, and therapeutic adaptations within South Asian contexts. Five studies from India and Pakistan met the inclusion criteria of this review. Interventions included brief health education (BHE), cognitive-behavioural therapy (CBT), motivational interviewing (MI), and theory-based counselling approaches. Reported cessation-related outcomes varied across studies, with quit or abstinence rates ranging from 4

Pakistan faces a substantial burden of tuberculosis (TB) and comorbid depression. Although the TB control programme has made progress, it lacks personalised care for patients with both conditions. Therefore, we aim to explore the health system's readiness and challenges in effectively addressing TB-depression comorbidity. We conducted a multi-site focused ethnography in TB centres in Peshawar and Haripur, Khyber Pakhtunkhwa, Pakistan, involving observations and semi-structured interviews (SSIs). We purposively selected 15 TB centres for observation. For 29 SSIs, we recruited seven TB healthcare providers, 12 patients, and 10 caregivers. An inductive-deductive thematic analysis was performed using the framework method. We identified factors within Pakistan's TB care framework that influence the system's capacity to address TB-depression comorbidity. We organised findings into four themes: the first focusing on accessibility, location, and infrastructure of TB centres; the second highlighting patients' fears, psychological distress, and their past and current experiences; the third examining the working environment of healthcare providers, their behaviour, and interactions with patients; and the final theme emphasising opportunities to address TB-depression comorbidity within the system. Integrating mental health services into Pakistan's TB care is crucial. Training providers, fostering patient engagement, and involving stakeholders can enhance support systems and help address TB-depression comorbidity.

Severe mental illness (SMI) is a major contributor to disease burden in low- and middle-income countries (LMICs), where over 80% of people with mental illness live. Yet evidence on cost-effective interventions remains scarce. This review examined the cost-effectiveness of SMI interventions in LMICs. A systematic search was conducted in Medline, CINAHL, APA PsycINFO, Embase, Cochrane Central, and Global Index Medicus. Eligible studies reported cost-effectiveness of SMI interventions. Data was extracted based on Joanna Briggs Institute (JBI) economic evaluation form, and quality was assessed with ECOBIAS (Bias in Economic Evaluation) and JBI tools. Due to methodological heterogeneity, findings were narratively synthesized. From 6,905 records, 20 studies met inclusion. Most (17/20) used economic models, often Markov model. In upper middle-income countries, atypical antipsychotics with psychoeducation were cost-effective below US$ 25,000 per quality adjusted life year [QALY]. In lower middle-income countries, Olanzapine or Risperidone combined with family therapy were cost-effective at willingness-to-pay (WTP) thresholds ranging from US$ 547 per disability adjusted life year [DALY] to US$ 2,350 per QALY. However, these conclusions may change under more conservative WTP thresholds. Variation in model structure, analytical perspective, and time horizon may further limit the generalizability of the findings.

Alveolar osteitis, also known as dry socket, is a common complication following tooth extraction and is characterized by pain and delayed healing. Compliance with post-extraction instructions may influence healing outcomes; however, quantitative data on compliance and its association with alveolar osteitis are limited in Pakistan. The primary outcome of this study was to assess compliance with post-extraction instructions, and the secondary outcome was to examine its association with the occurrence of alveolar osteitis. A prospective observational study was conducted among 303 patients who underwent surgical or nonsurgical tooth extraction at the Department of Oral and Maxillofacial Surgery, Khyber College of Dentistry, using a non-probability consecutive sampling technique. Ethical approval was obtained, and written informed consent was provided by all participants. Extractions were performed by operators with varying levels of clinical experience, and standardized post-extraction instructions were delivered verbally. Baseline data were collected at the time of extraction, and patients were followed up after one week to assess compliance using a validated ten-item questionnaire (score range 0–10). High compliance was defined as adherence to ≥ 80

Health facility readiness assessment is a foundational element in designing and implementing integrated tuberculosis (TB) and comorbidity interventions, particularly in low- and middle-income countries (LMICs) like Pakistan. The integration of TB care with management of comorbid conditions like diabetes mellitus, depression, and tobacco use is complicated and challenged by diverse, multifaceted barriers at the health system, organizational, and individual levels. Evidence-based frameworks, such as Consolidated Framework for Implementation Research (CFIR), Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, the Exploration, Preparation, Implementation, Sustainment (EPIS) framework, and related tools, help researchers to systematically evaluate service system capacity for service delivery, determine operational gaps and shortcomings, and understand socio-cultural and infrastructural constraints. This ensures that subsequent interventions are not only scientifically grounded but also tailored and well-suited to local capacities, thereby enhancing the sustainability and overall effectiveness of integration. In this perspective paper, we argue that readiness assessment should be institutionalized that is, formally embedded within service delivery structure, routine policy, planning, and decision-making processes, as a strategic prerequisite for integrating tuberculosis and comorbidity care, and we highlight how implementation science frameworks can support context-sensitive planning and scale-up in Pakistan and other similar health system settings.

Introduction Nicotine pouches are gaining popularity among young people. Within 5 years of their introduction, Pakistan has become the third-largest market for Velo, a leading brand among nicotine pouches. However, more information is needed to know about the availability and marketing of these products at point-of-sale (POS).Aims and Methods In August 2023, we surveyed 711 POS across nine districts covering all four provinces of Pakistan. We collected data on the availability of different brands of nicotine pouches and their flavors, nicotine strengths, prices, and pack features. Furthermore, we recorded any POS advertising in a subsample of 382 POS.Results In Pakistan, nicotine pouches were available in all four provinces, eight of nine surveyed districts, and 56 of 711 (7.9%) POS. Urban settings had wider availability and more variety than rural settings. Velo, available in six flavors and three different strengths, captured 85% of the market. On average, nicotine pouches cost 133 Pakistani Rupees (standard deviation 18.9, range 100-190 PKR) or 0.44 US dollars. Display stands advertising nicotine pouches were observed in 12.3% (46/382) POS.Conclusions Nicotine pouches are widely available across Pakistan. A range of flavors and strengths are being sold at an affordable price, making it attractive, particularly for young people. Continued surveillance of these products is needed. Their perceptions and use, and their impact on the tobacco uptake in youth, also need further research.Implications We observed the widespread availability of Velo and the growing nicotine pouch market in Pakistan, underscoring the urgent need for regulation. These products appeal to youth with diverse flavors and affordability, raising concerns about experimentation leading to addiction. Policymakers must prioritize regulating manufacturing, sales, and marketing to limit youth access. Limited research in Asia necessitates longitudinal studies to explore the oral health impact of using these products. Continued monitoring of promotions at POS, along with studies on youth perceptions, usage patterns, and influence on tobacco uptake, is critical for effective policy development.

ABSTRACT OBJECTIVES This study aimed to assess TB staff readiness to integrate diabetes care within TB services in selected basic medical units in Pakistan using the R = MC² implementation framework. METHODOLOGY We conducted a cross-sectional study to assess staff readiness across 13 TB Basic Management Units in 5 districts of Pakistan from November 2024 to April 2025. We conceptualized readiness in three different domains, that is, Motivation, General Capacity, and Capacity for Change, rather than in one composite index, and we measured it at the construct level. DOTS facilitators directly involved in TB service delivery completed a structured questionnaire measuring motivation (12 items), General Capacity (5 items), and Capacity for Change (4 items). We performed reliability analysis using Cronbach’s alpha. Although composite scores were calculated to provide descriptive information, interpretation focused on domain-specific results to maintain theoretical consistency and construct validity. RESULTS Thirteen DOTS facilitators from primary (n=4), secondary (n=5), and tertiary (n=4) TB facilities participated. Reliability was acceptable for motivation (α = 0.802) and excellent for General Capacity (α = 0.918), while Capacity for Change showed moderate reliability (α = 0.548). Motivation was high (mean = 4.2), whereas General Capacity was lowest (mean = 2.9), reflecting resource, training, and coordination gaps. Capacity for change was moderate (mean = 3.3). A strong correlation was observed between General Capacity and Capacity for Change (r = 0.69, 95% CI 0.20–0.90, p < 0.009). CONCLUSION The study findings highlighted that staff in TB BMUs were greatly motivated to incorporate TB–DM care, yet the capacity limitations constrain the readiness. Scaling up integrated care should be preceded by strengthening operational resources, coordination, and implementation support.

Objectives Tuberculosis (TB) remains a significant global health challenge, ranking among the top ten causes of death worldwide. Pakistan is the fifth-highest burden country for TB globally. Patients with TB often develop depression, where cultural factors play a profound role. This study explores the cultural perceptions and beliefs that influence TB-depression comorbidity among the Pashtun ethnic population of Pakistan and Afghan refugees, with a broader aim of developing a culturally appropriate intervention for the treatment of depression in TB. Study design We conducted a qualitative study across TB treatment centres in the Haripur and Peshawar districts of Khyber Pakhtunkhwa, Pakistan. Methods The study comprised 29 in-depth interviews and 11 focus group discussions, involving 101 participants across three groups: healthcare providers, TB patients, and carers. We analyzed the data using a deductive-inductive thematic analysis approach and employed the Southampton framework for cultural adaptation of interventions. Results We identified four central themes. The first theme described the cultural norms of the region, which influence physical and psychological conditions related to TB and depression. The second theme highlighted the role of the belief system in relation to the TB-depression comorbidity. The third theme explained the existing stigma associated with TB and depression. The last theme informed the development of a culturally appropriate psychotherapy-based intervention. Conclusion Gender disparities, social stigma, family dynamics, lack of social support, and belief systems are culturally driven issues linked to TB-depression comorbidity. Psychosocial interventions must consider and integrate the socio-cultural context of the target population. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement Yes ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The study has received ethical approval from Keele University Ethical Review Panel (Ref: REC Project Reference 0599), Khyber Medical University Ethical Review Board (Ref: DIR/KMU-EB/CT/000999-2), and National Bioethics Committee Pakistan (Ref: 4-87/NBC-998/23/1517). Written permission was obtained from the Directorate of TB Control Program, KP-Pakistan. All ethical considerations were appropriately followed, including obtaining informed consent, ensuring participant anonymity, and maintaining confidentiality. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All relevant data are within the manuscript and its Supporting Information files.

Health systems aim to meet populations' needs and to spur their satisfaction, requiring to first understand what drives this satisfaction, and whether these drivers come from the health system or not. In this empirical study, we use survey data from 666 patients exiting outpatient services of 60 public and 62 private health facilities in four districts of the province of Khyber Pakhtunkhwa, Pakistan. The survey tool assessed patients' socio-economic status, satisfaction with health service provision, and experiences of care (respect of privacy, out-of-pocket expenditures, availability of drugs). First, we synthesized the 16 items relating to satisfaction into a 12-item scale Patient Satisfaction score, relying on a Principal Component Analysis. Second, we used this score as the outcome in a linear model to identify its determinants. We found a generally high level of satisfaction regarding outpatient services within the sample, with an average satisfaction score of 76.37 out of 100. We did not find any association between satisfaction characteristics of the environment (type of facility, district). Women displayed significantly lower (-16%) and insured patients significantly higher (+6%) satisfaction scores. Indicators of healthcare experiences were found to be the strongest determinants of satisfaction, namely: satisfaction scores were 12% higher when privacy was respected, 5% higher when prescribed drugs were available and they also varied with the amount of healthcare expenses (positively and then negatively). Our results highlight the importance of designing policies that address the needs of specific population sub-groups and of ensuring access to core aspects of healthcare delivery, as reflected in patients' experiences, across all facility types.

Providing mental health services for transgender individuals within primary care is imperative due to the unique challenges they face. Transgender people experience elevated discrimination, stigma, and social exclusion, increasing mental health risks especially in low- and middle-income countries such as Pakistan. Primary care offers accessible, inclusive platforms to address these needs, enabling supportive environments for timely interventions. Early identification can mitigate psychological distress, depression, and anxiety. Integrating services within primary care promotes holistic care and fosters safe spaces where transgender individuals feel understood, validated, and empowered. This study aims to estimate levels of depression, anxiety, and suicidal ideation among transgender individuals, and to pilot a mental health gap action program (mhGAP)-based intervention for common mental disorders in primary healthcare settings in Peshawar, Pakistan. We will conduct an 18-month mixed-methods pilot feasibility study employing a single-arm pre–post design in primary care, including general practitioner (GP) clinics in Peshawar, Khyber Pakhtunkhwa. A sample of 144 transgender participants scoring ≥ 3 on both PHQ-2 and GAD-2 at screening will be enrolled. Participants will be referred to GPs trained in mhGAP to diagnose depression, anxiety, and suicidal ideation, and to deliver focused cognitive behavioral therapy sessions. Outcomes will be assessed at baseline, 2nd months, and 4th month. Fidelity to mhGAP protocols will be monitored through supervision, checklists, and refresher training for GPs. Pre and post-intervention anxiety and depression scores will be compared using SPSS version 29.0. Findings will offer an evidence-based pathway for integrating mental health care for transgender individuals in primary care, improving detection and management of common mental disorders, and informing scale-up in similar low-resource contexts. We anticipate improved symptoms, reduced suicidal ideation, and enhanced engagement with inclusive, supportive services. This pilot feasibility trial is registered with the ISRCTN registry (ISRCTN12146586).

Background: The dual burden of tuberculosis (TB) and diabetes mellitus (DM) presents a growing challenge for health systems in low- and middle-income countries (LMICs), including Pakistan. Despite global and national policies advocating for integrated care, evidence on health facility readiness to operationalize integration remains scarce. This study assessed the readiness of TB basic management units (BMUs) to deliver integrated TB-DM care and explored implementation barriers using the Consolidated Framework for Implementation Research (CFIR).Methods: We conducted an explanatory sequential mixed-methods study from September 2024 to February 2025 across 13 TB BMUs in five districts of Pakistan. Quantitative readiness data were collected using a structured tool adapted from the WHO Service Availability and Readiness Assessment (SARA), generating a composite score across four domains. Subsequently, qualitative data were gathered through multi-stakeholder focus group discussions with healthcare providers, facility managers, patients, caregivers, and policymakers. Reflexive thematic analysis was conducted and mapped to CFIR Inner Setting constructs to contextualize quantitative findings.Results: Only one facility demonstrated high readiness, while 12 showed low readiness. Facilities lacked routine comorbidity screening, trained staff, diagnostic capacity, and essential medicines. Key barriers included inadequate infrastructure, workforce shortages, fragmented information systems, and low prioritisation of integrated care. Financial constraints and limited coordination further hindered implementation.Conclusion: This study highlights critically low readiness among TB facilities in different districts of Pakistan to deliver integrated TB-DM care, reflecting systemic weaknesses across core domains. Strengthening systems, building capacity, and improving integration strategies are essential to bridge gaps between policy and practice.

OBJECTIVES:Non-adherence to tuberculosis (TB) treatment remains a major challenge in high-burden regions. However, few studies have qualitatively examined the sociocultural and emotional barriers to adherence, particularly among Afghan refugees in Pakistan. This study explores the patient-related, sociocultural and treatment-related barriers to treatment adherence among patients with TB of Pakistani and Afghan origin living in Pakistan. DESIGN:We conducted an exploratory qualitative study consisting of semistructured focus group discussions (FGDs) and in-depth interviews (IDIs) with purposively selected multisectoral stakeholders. The data were analysed thematically using a combination of inductive and deductive approaches. SETTINGS:We employed a qualitative study design in the TB DOTS (Directly Observed Treatment Short course) centres in the Haripur and Peshawar districts of Khyber Pakhtunkhwa province, Pakistan. PARTICIPANTS:We conducted IDIs (n=29) and FGDs (n=11) with three categories of participants: TB healthcare providers, patients with TB and their carers. RESULTS:We identified several contributors to lower treatment adherence. These included patient-related barriers (eg, lack of awareness about TB and its treatment), sociocultural barriers (eg, stigma, refugee status of Afghan patients, gender roles and reliance on traditional and spiritual healing) and treatment-related barriers (eg, demanding treatment regimen and TB-induced depression). CONCLUSION:Several personal, sociocultural and treatment-related barriers contribute to lower treatment adherence in patients with TB. A significant contributing factor to treatment non-adherence in patients is the high prevalence of anxiety and depression related to TB and its treatment, for which there is no treatment or counselling available at the DOTS level in Pakistan, warranting the need for mental health interventions that could improve adherence and treatment outcomes for both TB and depression. TRIAL REGISTRATION NUMBER:ISRCTN10761003.

Objective To determine the prevalence and severity of anxiety and depression among health care professionals in Khyber Pakhtunkhwa and the impact of gender and professional roles on mental health outcomes.Methodology A cross-sectional study was conducted between March and November 2023 using stratified random sampling among health care professionals, including doctors, nurses, paramedics, and emergency staff, across multiple hospitals. The Generalized Anxiety Disorder-7 (GAD-7) and Patient Health Questionnaire-9 (PHQ-9) were used to assess anxiety and depression. Data were analyzed using R/RStudio, employing descriptive statistics, chi-square tests, independent t-tests, Mann-Whitney U tests, and Pearson's correlation coefficient.Results Among 651 participants, 65% were male. Anxiety prevalence was significant, with 42% experiencing minimal anxiety, 35% mild, 16% moderate, and 7.7% severe. Depression prevalence included 10% with no depression with 7.8% moderately severe and 5.9% severe depression. Nurses (40%) and doctors (34%) had the highest depression rates. Females exhibited significantly higher anxiety and depression scores. Anxiety prevalence varied across hospitals (P = 0.024). A strong positive correlation was observed between GAD-7 and PHQ-9 scores.Conclusion Mental health challenges among frontline health care workers in Khyber Pakhtunkhwa are substantial, with anxiety and depression particularly prevalent among nurses and doctors. Female workers experience greater psychological distress. We recommend implementation of hospital-based mental health support systems, prioritizing interventions for female staff and high-burden departments. Policies ensuring regular psychological screening and peer support mechanisms are urgently needed.

In Pakistan, every third adult is suffering from diabetes. Community-based approaches have the potential to be effective in preventing diabetes. We aim to evaluate the effectiveness of a Participatory Learning and Action (PLA) intervention in the prevention and control of diabetes. We will conduct a two-arm cluster randomised controlled-trial in two rural tehsils of district Swabi and district Peshawar in Pakistan. We will recruit 72 randomly selected clusters (the smallest official administrative unit in a tehsil) from two districts of the Khyber Pakhtunkhwa Province of Pakistan. From each cluster, 177 participants will be randomly selected for baseline and follow-up assessments, constituting a total sample size of 12,744. Following the baseline survey, the 72 clusters will be randomly allocated (1:1) to the intervention and control arms. The intervention arm will receive an 18-month long PLA intervention, including monthly community meetings where group members will identify, prioritise, and address problems associated with diabetes and the related risk factors. The primary outcomes of the trial are the prevalence of Type II Diabetes Mellitus (TIIDM), prevalence of Intermediate Hyperglycaemia (IHG), and 2-year cumulative incidence of TIIDM. Secondary outcomes include prevalence of hypertension, body mass index, abdominal obesity, prevalence of overweight obesity, body fat composition, fruit and vegetable intake, physical activity, quality of life, psychological distress, knowledge of TIIDM risk factors, symptoms, complications and self-awareness of diabetic status. Embedded economic and process evaluations will also be conducted. The trial has received ethics approval from the National Bioethics Committee of Pakistan, and the ethics committees of The Aga Khan University, and Khyber Medical University. We will use a variety of channels, conferences, social media, dissemination events, and scientific publications to share the study findings with all the relevant stakeholders. The trial is registered with clinicaltrials.gov—NCT06561126. Date of registration: 23rd August 2024.