Aga Khan Development Network

Abstract Farm‐specific profit inefficiency among Basmati rice producers was estimated from a variable‐coefficient profit frontier. The mean level of inefficiency at farm resources and price levels was 28%, with a wide range (5%–87%). Average loss of profit was Rs 1,222 per hectare. Socioeconomic factors related to profit loss were the farm household's education, nonagricultural employment, and a credit constraint. Institutional determinants of profit loss were a water constraint and the late application of fertilizer. Punjab‐wide benefits of increasing farmer's profit efficiency are large; a 25% reduction in profit loss among Basmati rice producers may generate over Rs 240 million in extra profits each rice season.

Objective: To compare the effectiveness of second line injectables containing shorter (duration 9–12 months) and longer treatment regimens (LTR, duration ≥ 20 months) among multidrug-resistant tuberculosis (MDR-TB) patients with no documented resistance and history of treatment with any second-line anti-TB drug (SLD) for ≥ 1 month. Methods: This was an observational cohort study of MDR-TB patients treated at eight PMDT units in Pakistan. Patients’ data from baseline until treatment outcomes were collected from Electronic Nominal Recording and Reporting System. The treatment outcomes of “cured” and “treatment completed” were grouped together as successful, whereas “death,” “treatment failure,” and “lost to follow-up” were collectively grouped as unsuccessful outcomes. Time to sputum culture conversion (SCC) was analyzed using the Kaplan–Meier method and the differences between groups were compared through the log-rank test. Multivariate Cox proportional hazards and binary logistic regression analyses were used to find predictors of time to SCC and unsuccessful treatment outcomes. A p -value < 0.05 was considered statistically significant. Results: A total 701 eligible MDR-TB patients [313 treated with shorter treatment regimen (STR) and 388 treated with LTR at eight centres in Pakistan were evaluated]. Time to achieve SCC was significantly shorter in STR group [mean: 2.03 months, 95% confidence interval (CI):1.79–2.26] than in LTR group (mean: 2.69 months, 95% CI: 2.35–3.03) ( p -value<0.001, Log-rank test). Treatment success was higher in STR (83.7%) than in LTR (73.2%) group ( p -value <0.001) due to high cure (79.9% vs. 70.9%, p -value = 0.006) and low death (9.9% vs. 18.3%, p -value = 0.002) rates with STR. Treatment with STR emerged the only predictor of early SCC [adjusted Hazards ratio (aHR) = 0.815, p -value = 0.014], whereas, patient’s age of 41–60 (OR = 2.62, p -value<0.001) and >60 years (OR = 5.84, p -value<0.001), baseline body weight of 31–60 (OR = 0.36, p -value = 0.001) and >60 kg (OR = 0.23, p -value <0.001), and treatment with LTR (OR = 1.88, p -value = 0.001) had statistically significant association with unsuccessful treatment outcomes. Conclusion: STR exhibited superior anti-microbial activity against MDR-TB. When compared LTR, treatment with STR resulted in significantly early SCC, high cure, and lower death rates among MDR-TB patients who had no documented resistance and history of treatment with any SLD ≥ 1 month.

To determine the prevalence and routes of transmission of hepatitis C virus (HCV) infection in Hafizabad, Pakistan, we collected sera in 1993 from a geographically based random sample of residents, and in 1994 identified 15 HCV-infected individuals (cases) and 67 age and sex matched uninfected individuals (controls). Initially we approached 504 households, and collected serum from a randomly selected household member in 309 (64%). Twenty persons (6.5%) had anti-HCV antibody; 31% percent had hepatitis B core antibodies, and 4.3% had hepatitis B surface antigen. In the case-control study, persons who received more therapeutic injections (categorized as averaging 1, 2-4, 5-9 or > 10 injections per year in the previous 10 years) were more likely to be infected with HCV (odds ratio 0, 1.5, 2.5 and 6.9 respectively, P = 0.008) compared to persons averaging 0 injections per year. Efforts to limit therapeutic injections to only those that are medically indicated and that use sterile equipment are essential in order to prevent transmission of HCV.

BACKGROUND: The effectiveness of mobile technology to improve medication adherence via customized Short Messaging Service (SMS) reminders for stroke has not been tested in resource poor areas. We designed a randomized controlled trial to test the effectiveness of SMS on improving medication adherence in stroke survivors in Pakistan. METHODS: This was a parallel group, assessor-blinded, randomized, controlled, superiority trial. Participants were centrally randomized in fixed block sizes. Adult participants on multiple medications with access to a cell phone and stroke at least 4 weeks from onset (Onset as defined by last seen normal) were eligible. The intervention group, in addition to usual care, received reminder SMS for 2 months that contained a) Personalized, prescription tailored daily medication reminder(s) b) Twice weekly health information SMS. The Health Belief Model and Social Cognitive theory were used to design the language and content of messages. Frontline SMS software was used for SMS delivery. Medication adherence was self-reported and measured on the validated Urdu version of Morisky Medication Adherence Questionnaire. Multiple linear regression was used to model the outcome against intervention and other covariates. Analysis was conducted by intention-to-treat principle. RESULTS: Two hundred participants were enrolled. 38 participants were lost to follow-up. After 2 months, the mean medication score was 7.4 (95 % CI: 7.2-7.6) in the intervention group while 6.7 (95 % CI: 6.4-7.02) in the control group. The adjusted mean difference (Δ) was 0.54 (95 % CI: 0.22-0.85). The mean diastolic blood pressure in the intervention group was 2.6 mmHg (95 % CI; -5.5 to 0.15) lower compared to the usual care group. CONCLUSION: A short intervention of customized SMS can improve medication adherence and effect stroke risk factors like diastolic blood pressure in stroke survivors with complex medication regimens living in resource poor areas. TRIAL REGISTRATION: Clinicaltrials.gov NCT01986023 last accessed at https://clinicaltrials.gov/ct2/show/NCT01986023.

Please cite this paper as: Mobeen N, Durocher J, Zuberi N, Jahan N, Blum J, Wasim S, Walraven G, Hatcher J. Administration of misoprostol by trained traditional birth attendants to prevent postpartum haemorrhage in homebirths in Pakistan: a randomised placebo-controlled trial. BJOG 2011;118:353–361. Objective To determine if misoprostol is safe and efficacious in preventing postpartum haemorrhage (PPH) when administered by trained traditional birth attendants (TBA) at home deliveries. Design A randomised, double-blind, placebo-controlled trial. Setting Chitral, Khyber Pakhtunkhwa Province, Pakistan. Population A total of 1119 women giving birth at home. Methods From June 2006 to June 2008, consenting women were randomised to receive 600 μg oral misoprostol (n = 534) or placebo (n = 585) after delivery to determine whether misoprostol reduced the incidence of PPH (≥500 ml). Main outcome measures The primary outcomes were measured blood loss ≥500 ml after delivery and drop in haemoglobin >2 g/dl from before to after delivery. Results Oral misoprostol was associated with a significant reduction in the rate of PPH (≥500 ml) (16.5 versus 21.9%; relative risk 0.76, 95% CI 0.59–0.97). There were no measurable differences between study groups for drop in haemoglobin >2 g/dl (relative risk 0.79, 95% CI 0.62–1.02); but significantly fewer women receiving misoprostol had a drop in haemoglobin >3 g/dl, compared with placebo (5.1 versus 9.6%; relative risk 0.53, 95% CI 0.34–0.83). Shivering and chills were significantly more common with misoprostol. There were no maternal deaths among participants. Conclusions Postpartum administration of 600 μg oral misoprostol by trained TBAs at home deliveries reduces the rate of PPH by 24%. Given its ease of use and low cost, misoprostol could reduce the burden of PPH in community settings where universal oxytocin prophylaxis is not feasible. Continual training and skill-building for TBAs, along with monitoring and evaluation of programme effectiveness, should accompany any widespread introduction of this drug. Trial registration http://clinicaltrials.gov/NCT00120237 Misoprostol for the Prevention of Postpartum Hemorrhage in Rural Pakistan.

Between 1998 and 2001 I carried out surveys in four areas in the Baltistan district of the Northern Areas of Pakistan to estimate the population of the snow leopard and to examine the threats to its future conservation. I estimate that a total of 36–50 snow leopards are present in the areas surveyed. Based on the availability of suitable snow leopard habitat and of its prey species, I estimate that 90–120 snow leopards are potentially present in Baltistan and 300–420 throughout its range within Pakistan's borders. Although this estimate is higher than extrapolations based on earlier surveys, the long-term future of the snow leopard is under threat. This is mainly due to retaliatory killings by farmers, and poaching for pelts and other body parts. Species-focused conservation policies, particularly those targeting ungulates for the promotion of trophy hunting, may constitute an additional threat to snow leopard conservation in the region. However, all forms of threats to the snow leopard in Baltistan appear to emanate from the relatively poor economic conditions of the local people.

This study explores the health seeking behaviour of poor male and female tuberculosis patients in Bombay, and examines their perceptions of the causes and effects of the disease on their personal lives. Sixteen patients who attended an NGO's tuberculosis clinic were interviewed in-depth. Almost equal numbers of respondents stated 'germs' and 'worry' as the cause of tuberculosis. Men worried about loss of wages, financial difficulties, reduced capacity for work, poor job performance, and the consequences of long absence from work. Women were concerned about rejection by husband, harassment by in-laws, and the reduced chances of marriage (for single women), in addition to their concerns about dismissal from work. During the first two months of symptoms most patients either did nothing or took home remedies. When symptoms continued, private practitioners were the first source of allopathic treatment; they were generally unable to correctly diagnose the disease. Respondents shifted to municipal and NGO health services when private treatment became unaffordable. Respondents shifted again to NGO-based services because of the poor quality of municipal tuberculosis control services. The wage-earning capacity of both men and women was affected, but women feared loss of employment whereas men, being self-employed, lost wages but not employment. Married men and single women perceived a greater level of family support to initiate and complete treatment. Married women tried, often unsuccessfully, to hide their disease condition for fear of desertion, rejection or blame for bringing the disease. Women dropped out from treatment because of the pressure of housework, and the strain of keeping their condition secret particularly when the reasons for their movements outside the home were routinely questioned. Health programmes will have to be sensitive to the different needs and concerns of urban men and women with tuberculosis; in the case of women, health care providers will have to make particular efforts to identify and treat married women with tuberculosis completely.

Abstract. Glacial lake outburst floods (GLOFs) have been intensely investigated in High Mountain Asia (HMA) in recent years and are the most well-known hazard associated with the cryosphere. As glaciers recede and surrounding slopes become increasingly unstable, such events are expected to increase, although current evidence for an increase in events is ambiguous. Many studies have investigated individual events, and while several regional inventories exist, they either do not cover all types of GLOF or are geographically constrained. Further, downstream impacts are rarely discussed. Previous inventories have relied on academic sources and have not been combined with existing inventories of glaciers and lakes. In this study, we present the first comprehensive inventory of GLOFs in HMA, including details on the time of their occurrence, processes of lake formation and drainage involved, and downstream impacts. We document 697 individual GLOFs that occurred between 1833 and 2022. Of these, 23 % were recurring events from just three ephemeral ice-dammed lakes. In combination, the documented events resulted in 6906 fatalities of which 906 can be attributed to 24 individual GLOF events, which is 3 times higher than a previous assessment for the region. The integration of previous inventories of glaciers and lakes within this database will inform future assessments of potential drivers of GLOFs, allowing more robust projections to be developed. The database and future, updated versions are traceable and version-controlled and can be directly incorporated into further analysis. The database is available at https://doi.org/10.5281/zenodo.7271187 (Steiner and Shrestha, 2023), while the code including a development version is available on GitHub.

Purpose The purpose of this study is to investigate the impact of technology orientation (TO) on firm performance (FP). This study also aims to identify the mediating role of firm innovativeness (FI) in the relation between TO and FP. Design/methodology/approach Quantitative approach has been adopted for analyzing the impact of TO on FP in software houses located in two big cities of Pakistan. Mean, standard deviation, correlation and regression analysis were used. Findings Results proved that of TO predicts FP and FI mediate the relationship between TO and FP. Practical implications This study used cross-sectional further studies may be conducted using longitudinal research design for achieving in-depth insights. Social implications Software houses should focus on TO and innovativeness for improving their performance. Originality/value This research guides the way to improve performance TO and innovativeness of software houses based on the empirical results.

BACKGROUND: Global policy regarding optimal umbilical cord care to prevent neonatal illness is an active discussion among researchers and policy makers. In preparation for a large cluster-randomized control trial to measure the impact of 4% chlorhexidine as an umbilical wash versus dry cord care on neonatal mortality in Southern Province, Zambia, we performed a qualitative study to determine local perceptions of cord health and illness and the cultural belief system that shapes umbilical cord care knowledge, attitudes, and practices. METHODS AND FINDINGS: This study consisted of 36 focus group discussions with breastfeeding mothers, grandmothers, and traditional birth attendants, and 42 in-depth interviews with key community informants. Semi-structured field guides were used to lead discussions and interviews at urban and rural sites. A wide variation in knowledge, beliefs, and practices surrounding cord care was discovered. For home deliveries, cords were cut with non-sterile razor blades or local grass. Cord applications included drying agents (e.g., charcoal, baby powder, dust), lubricating agents (e.g., Vaseline, cooking oil, used motor oil) and agents intended for medicinal/protective purposes (e.g., breast milk, cow dung, chicken feces). Concerns regarding the length of time until cord detachment were universally expressed. Blood clots in the umbilical cord, bulongo-longo, were perceived to foreshadow neonatal illness. Management of bulongo-longo or infected umbilical cords included multiple traditional remedies and treatment at government health centers. CONCLUSION: Umbilical cord care practices and beliefs were diverse. Dry cord care, as recommended by the World Health Organization at the time of the study, is not widely practiced in Southern Province, Zambia. A cultural health systems model that depicts all stakeholders is proposed as an approach for policy makers and program implementers to work synergistically with existing cultural beliefs and practices in order to maximize effectiveness of evidence-based interventions.

Background: Despite evidence supporting telehealth provision in developed countries, there is limited evidence regarding its economic benefits for patients living in areas where access and cost present major barriers to health care, particularly in low- and middle-income countries (LMICs). This study explores the economic benefits of telemedicine for patients, in terms of cost and times savings, and its potential role in improving chronic disease outcomes. Methods: This retrospective cross-sectional study compared telemedicine services with hypothetical in-person consultations, with a focus on patient travel time and travel cost savings. A database containing teleconsultation visits ( N = 25,182) conducted at health facilities in remote regions of Afghanistan, Pakistan, Tajikistan, and the Kyrgyz Republic, was analyzed. A two-sample homoscedastic t test was used to determine differences between the two groups. A one-way sensitivity analysis was also conducted, presuming in-person teleconsultations at 90%, 75%, and 50%. Results: The study extracted data from 25,182 teleconsultation visits (12,814 males; 12,368 females). The cumulative patient savings through the program amounted to USD 9,175,132, and 1,876,146 h, or 213.1 years. A significant difference was seen between the two groups in terms of mean time savings ( p-value <0.05), and a nearly significant difference was observed in terms of mean cost savings ( p-value = 0.05). Conclusions: This study suggests that considerable economic benefits imparted to patients in low-resource settings of LMICs via accessing telemedicine. Telemedicine has great potential to improve chronic disease outcomes in low-resource areas by reducing socioeconomic barriers related to cost and access, and increasing uptake of services, thereby enabling early intervention and long-term management.

The snow leopard, Panthera uncia, is an elusive high-altitude specialist that inhabits vast, inaccessible habitat across Asia. We conducted the first range-wide genetic assessment of snow leopards based on noninvasive scat surveys. Thirty-three microsatellites were genotyped and a total of 683 bp of mitochondrial DNA sequenced in 70 individuals. Snow leopards exhibited low genetic diversity at microsatellites (AN = 5.8, HO = 0.433, HE = 0.568), virtually no mtDNA variation, and underwent a bottleneck in the Holocene (∼8000 years ago) coinciding with increased temperatures, precipitation, and upward treeline shift in the Tibetan Plateau. Multiple analyses supported 3 primary genetic clusters: (1) Northern (the Altai region), (2) Central (core Himalaya and Tibetan Plateau), and (3) Western (Tian Shan, Pamir, trans-Himalaya regions). Accordingly, we recognize 3 subspecies, Panthera uncia irbis (Northern group), Panthera uncia uncia (Western group), and Panthera uncia uncioides (Central group) based upon genetic distinctness, low levels of admixture, unambiguous population assignment, and geographic separation. The patterns of variation were consistent with desert-basin "barrier effects" of the Gobi isolating the northern subspecies (Mongolia), and the trans-Himalaya dividing the central (Qinghai, Tibet, Bhutan, and Nepal) and western subspecies (India, Pakistan, Tajikistan, and Kyrgyzstan). Hierarchical Bayesian clustering analysis revealed additional subdivision into a minimum of 6 proposed management units: western Mongolia, southern Mongolia, Tian Shan, Pamir-Himalaya, Tibet-Himalaya, and Qinghai, with spatial autocorrelation suggesting potential connectivity by dispersing individuals up to ∼400 km. We provide a foundation for global conservation of snow leopard subspecies, and set the stage for in-depth landscape genetics and genomic studies.

We report on the first six cases of acquired resistance to bedaquiline in Pakistan. Seventy sequential isolates from 30 drug-resistant-tuberculosis patients on bedaquiline-containing regimens were retrospectively tested for bedaquiline resistance by MIC testing and by the detection of mutations in relevant genes. We documented cases failing therapy that developed specific mutations in Rv0678 and had increased MICs associated with cross-resistance to clofazimine during treatment.

Household members of people with hepatitis C are at increased risk of HCV infection. The prevalence and routes of transmission of HCV to household members in Hafizabad, Pakistan were investigated. Household members of 24 index cases were given a risk factor questionnaire, tested for HCV infection, and the risk factors between the infected and uninfected were compared. Twelve of 74 household members (16.2%) were seropositive for HCV antibody. This was 2(1/2) times the rate of infection in the general population (OR = 2.8; P = 0.01). None of the routes of transmission studied within the household was associated with an increased risk. Household members who received more than 4 injections per year were 11.9 times more likely to be infected than those who had not (P = 0.016). In Hafizabad, the greatest risk for HCV infection to household members of infected people is injections given by health-care workers rather than household contact with infected persons.

BACKGROUND: There is limited evidence from community-based interventions to guide the development of effective maternal, perinatal and newborn care practices and services in developing countries. We evaluated the impact of a low-cost package of community-based interventions implemented through government sector lady health workers (LHWs) and community health workers (CHWs) of a NGO namely Aga Khan Health Services on perinatal and neonatal outcomes in a sub-population of the remote mountainous district of Gilgit, Northern Pakistan. METHODS: The package was evaluated using quasi experimental design included promotion of antenatal care, adequate nutrition, skilled delivery and healthy newborn care practices. Control areas continued to receive the routine standard health services. The intervention areas received intervention package in addition to the routine standard health services. Outcome measures included changes in maternal and newborn-care practices and perinatal and neonatal mortality rates between the intervention and control areas. RESULTS: The intervention was implemented in a population of 283324 over a 18 months period. 3200 pregnant women received the intervention. Significant improvements in antenatal care (92% vs 76%, p < .001), TT vaccination (67% vs 47%, p < .001), institutional delivery (85% vs 71%, p < .001), cord application (51% vs 71%, p < .001), delayed bathing (15% vs 43%, p < .001), colostrum administration (83% vs 64%, p < .001), and initiation of breastfeeding within 1 hour after birth (55% vs 40%, p < .001) were seen in intervention areas compared with control areas. Our results indicate significant reductions in mortality rates in intervention areas as compared to control areas from baseline in perinatal mortality rate (from 47.1 to 35.3 per 1000 births, OR 0.62; 95% CI: 0.56-0.69; P 0.02) and neonatal mortality rates (from 26.0 to 22.8 per 1000 live births, 0.58; 95% CI: 0.48-0.68; P 0.03). CONCLUSIONS: The implementation of a set of low cost community-based intervention package within the health system settings in a mountainous region of Pakistan was found to be both feasible and beneficial. The interventions had a significant impact in reduction of the burden of perinatal and neonatal mortality. TRIAL REGISTRATION: This study is registered, ClinicalTrial.gov NCT02412293 .

for universal health coverage, say Fawzia Rasheed and colleagues

Ownership protection on relational databases--shared with collaborators (or intended recipients)-demands developing a watermarking scheme that must be able to meet four challenges: 1) it should be robust against different types of attacks that an intruder could launch to corrupt the embedded watermark; 2) it should be able to preserve the knowledge in the databases to make them an effective component of knowledge-aware decision support systems; 3) it should try to strike a balance between the conflicting requirements of database owners, who require soft usability constraints, and database recipients who want tight usability constraints that ensure minimum distortions in the data; and 4) last but not least, it should not require that a database owner defines usability constraints for each type of application and every recipient separately. The major contribution of this paper is a robust and efficient watermarking scheme for relational databases that is able to meet all above-mentioned four challenges. The results of our experiments prove that the proposed scheme achieves 100 percent decoding accuracy even if only one watermarked row is left in the database.

INTRODUCTION: Salmonella Typhi is one of the leading health problems in Pakistan. With the emergence of extensively drug resistant (XDR) Salmonella Typhi, treatment options are limited. Here we report the clinical manifestations and the response to treatment of patients with XDR Typhoid fever. The patients were treated with either Meropenem or Azithromycin or a combination of both. METHODS: We reviewed the records of culture confirmed XDR typhoid who visited Aga Khan University Hospital (AKUH), Karachi and Aga Khan Secondary Care Hospital, Hyderabad from April 2017 to June 2018. Symptoms developed during disease, unplanned treatment extension and complications developed while on antimicrobials was recorded. Means with standard deviation were calculated for duration of treatment, time to defervescence, and cost of treatment. RESULTS: Records of 81 culture confirmed XDR typhoid patients admitted at the AKU hospitals were reviewed. Most, (n = 45; 56%) were male. Mean age of the cases was 8.03 years with range (1-40). About three quarter (n = 66) of the patients were treated as inpatient. Fever and vomiting were the most common symptoms at the time of presentation. Oral azithromycin alone (n = 22; 27%), intravenous meropenem alone (n = 20; 25%), or a combination of azithromycin and meropenem (n = 39; 48%) were the options used for treatment. Average (95% confidence interval) time to defervescence was 7.1(5.5-8.6), 6.7(4.7-8.7), and 6.7(5.5-7.9) days for each treatment option respectively whereas there were 1,0 and 3 treatment failures in each treatment option respectively. Average cost of treatment per day for azithromycin was US$5.87 whereas it was US$88.46 for meropenem. CONCLUSION: Patients treated with either Azithromycin, Meropenem alone or in combination showed similar time to defervescence. Because of the lower cost of azithromycin, it is preferable in lower socio-economic areas. Background estimates for power calculation can be made for more robust clinical trials using this observational data.

BACKGROUND: The recent proliferation of digital health technology in low- and middle-income countries has made it possible for community health workers (CHWs) to use mobile health (mHealth) to perform tasks such as data collection and training. Although most studies focus on the prospect of digital apps to motivate and connect CHW, only a few have captured end-user experiences with mobile-based apps. We examined the experience of frontline health workers with a move towards digitalized real-time data to record maternal and childcare services in remote areas of Afghanistan and Pakistan. OBJECTIVE: Our study aimed to explore CHW perceptions on the operability of the mHealth app in a community setting, usefulness of the app in the delivery of assigned maternal and childcare functions, and the task-technology fit with monitoring information systems. METHODS: The Hayat app, designed to digitalize and facilitate electronic record keeping, was evaluated to be embedded into mainstream health systems. The app had 2 components: smartphone app for data entry and web dashboard for visualization of the maternal, newborn, and child health reports. Using a qualitative exploratory study design, we conducted a total of 8 focus group discussions with purposively selected lady health workers (LHWs) and CHWs in 3 districts of Pakistan and 3 hamlets of Afghanistan, respectively. Focus group discussions were conducted in the local language, audio recorded, and converted into expanded notes for thematic analysis. RESULTS: Although a majority of LHWs used the app with ease, some initially faced difficulties in operating it and requested a longer duration of training. Contrary to LHWs, the CHWs were able to use the app without difficulty, as they were using it only to register clients. Overall, use of the mHealth app in both countries resulted in a positive impact on health education sessions, easier communication with parents or clients, tracking of routine immunization defaulters and follow-ups, improved data validity, easily accessible vaccination schedules, and faster registration. In addition to building up their image in the community and personal development, the improved reporting and monitoring mechanisms also set the stage for the LHWs to get recognized for their hard work. CHWs in Afghanistan also reported the app provided immediate access to information when requested by their supervisor. Although the Hayat app eliminates the need to carry multiple registers and helps in recalling client information at the touch of a button, technical issues around connectivity and data inputting tabs were highlighted by the participants. CONCLUSIONS: The digitization of records not only provided CHWs support in their daily routine but also strengthened monitoring mechanisms and improved motivation. We recommend conducting end user experience studies before embedding apps into mainstream health systems as high acceptability does not always result in high uptake of digital technology.

Drawing from past research suggesting that high prior commitment leads to stronger reactions to unfairness in the workplace (Brockner, Tyler, &amp; Cooper‐Schneider, 1992), we predicted that those forming relational as opposed to transactional psychological contracts would exhibit stronger detrimental effects of felt violation on job satisfaction, turnover intentions, and job performance. We also predicted a combined effect of personality and violation on these outcomes. Self‐ and supervisor‐reported data ( N = 331 dyads) collected from a variety of organisations supported our predictions. In general, relational contract terms were associated with stronger violation–outcome relationships, and transactional contract terms were associated with weaker relationships. Similarly, four of the Big Five dimensions (extraversion, neuroticism, agreeableness, and openness to experience) moderated the violation–outcome relationships such that it was stronger for higher levels of these traits.