The Bangladesh paradox: exceptional health achievement despite economic poverty

Distribution and disparities of healthy lifestyles and noncommunicable diseases risk factors between men and women aged 20-59 years in Bangladesh: Evidence from a nationwide survey

Background

Noncommunicable diseases (NCDs) are public health threats globally and recognized impediments to socioeconomic development. This study aimed to identify the prevalence and clustering of NCDs risk factors among Bangladeshi men and women aged 20-59 years using nationally representative data.

Methods

This study was conducted in 82 rural, nonslum urban, and slum clusters across all eight administrative divisions of Bangladesh using multistage cluster sampling. A total of 4917 men and 4905 women aged 20-59 years were included in the study. Descriptive analyses were performed to report the prevalence and distribution of behavioral and clinical risk factors. Multivariable binary logistic regression was performed to identify factors associated with the coexistence of three or more NCD risk factors.

Results

The prevalence of tobacco use (any form), insufficient physical activity, inadequate fruit and vegetable consumption, overweight and obesity, and central obesity were 38.3%, 13.6%, 87.1%, 42.3%, and 36.0%, respectively. Furthermore, 21.9% and 4.9% participants had hypertension and self-reported diabetes, respectively. Regarding the clustering of risk factors, 37.1% men and 50.8% women had at least three NCD risk factors. Only 3.0% men and 1.8% women reported no NCD risk factors. Age, place of residence, education, and wealth status were associated with the presence of at least three risk factors for both sexes.

Conclusion

Since a large proportion of Bangladeshi 20-59 years old population had multiple risk factors, population-based programs with multisectoral approaches are essential to reduce NCDs among Bangladeshi women and men.

On the interpretability of the SVM model for predicting infant mortality in Bangladesh

BACKGROUND

Although machine learning (ML) models are well-liked for their outperformance in prediction, greatly avoided due to the lack of intuition and explanation of their predictions. Interpretable ML is, therefore, an emerging research field that combines the performance and interpretability of ML models to create comprehensive solutions for complex decision-making analysis. Conversely, infant mortality is a global public health concern affecting health, social well-being, socio-economic development, and healthcare services. The study employs advanced interpretable ML techniques to anticipate and understand the factors affecting infant mortality in Bangladesh, overcoming the shortcomings of the conventional logistic regression (LR) model.

METHODS

By utilizing the global surrogate model and local individual conditional expectation (ICE) interpretability technique, the interpretable support vector machine (SVM) has been used in this study to reveal significant characteristics of infant mortality using data from the Bangladesh Demographic and Health Survey (BDHS) 2017-18. To investigate intricate decision-making analysis of infant mortality, we adapted SVM and LR techniques with the hyperparameter tuning parameters. These models' performances were initially assessed using the receiver operating characteristics (ROC) curve, run-time, and confusion matrix parameters with 100 permutations. Afterward, the SVM model's model-agnostic explanation and the LR model's interpretation were compared to enhance advanced comprehension for further insights.

RESULTS

The results of the 100 permutations demonstrated that the LR model (Average: accuracy = 0.9105, precision = NaN, sensitivity = 0, specificity = 1, F1-score = 0, area under the ROC curve (AUC) = 0.6780, run-time = 0.0832) outperformed the SVM model (Average: accuracy = 0.8470, precision = 0.1062, sensitivity = 0.0949, specificity = 0.9209, F1-score = 0.1000, AUC = 0.5632, run-time = 0.0254) in predicting infant mortality, but the LR model had a slower run-time and it was unable to predict any positive cases. The interpretation of LR analysis revealed that infant mortality rates decrease when mothers give birth after over two years, with higher educational attainment, overweight or obese mothers, working mothers, and families with polluted cooking fuel having lower rates. The local ICE interpretability technique, which depicts individual influences on the average likelihood of dying within the first birthday, explores the interpretable SVM model that mothers with normal BMIs, giving birth within two years, using less polluted cooking fuel, working mothers, and having male infant were more likely to experience infant death. The interpretable SVM model based on the global surrogate model also reveals that working mothers who used polluted cooking fuel at home and working women who used less polluted cooking fuel but had a longer period between pregnancies than two years would have higher infant death rates. Even among non-working mothers who used polluted cooking fuel and gave birth within two years of the preceding one, infant death rates were higher.

CONCLUSIONS

The interpretable SVM model reveals global interpretations help clinicians understand the entire conditional distribution, while local interpretations focus on specific instances, providing different insights into model behavior. Interpretable ML models aid policymakers, stakeholders, and families in understanding and preventing infant deaths by improving policy-making strategies and establishing effective family counseling services.

Bangladesh: 50 Years of Advances in Health and Challenges Ahead

Bangladesh has inspired the rest of the world with its remarkable health achievements over the past half-century. A considerably stronger government investment in health care is now needed to achieve universal health coverage and “Health for All” in Bangladesh.

Strengthening health service delivery and governance through institutionalizing 'Urban Health Atlas'-A geo-referenced Information Communication and Technology tool: Lessons learned from an implementation research in three cities in Bangladesh

INTRODUCTION

Urban health governance in Bangladesh is complex as multiple actors are involved and no comprehensive data are currently available on infrastructure, services, or performance either in public and private sectors of the healthcare system. The Urban Health Atlas (UHA)-a novel and interactive geo-referenced, web-based visualization tool was developed in Bangladesh to provide geospatial and service information to decision makers involved in urban health service planning and governance. Our objective was to study the opportunities for institutionalization of the UHA into government health systems responsible for urban healthcare delivery and document the facilitators and barriers to its uptake.

METHODS

This implementation research was carried out during 2017-2019 in three cities in Bangladesh: Dhaka, Dinajpur and Jashore. During the intervention period, six hands-on trainings on UHA were provided to 67 urban health managers across three study sites. Thirty in-depth and twelve key informant interviews were conducted to understand user experience and document stakeholder perceptions of institutionalizing UHA.

RESULTS

Capacity building on UHA enhanced understanding of health managers around its utility for service delivery planning, decision making and oversight. Findings from the IDIs and KIIs suggest that UHA uptake was challenged by inadequate ICT infrastructure, shortage of human resources and lack of ICT skill among managers. Motivating key decision makers and stakeholders about the potential of UHA and engaging them from its inception helped the institutionalization process.

CONCLUSION

While uptake of UHA by government health managers appears possible with dedicated capacity building initiatives, its use and regular update are challenged by multiple factors at the implementation level. A clear understanding of context, actors and system readiness is foundational in determining whether the institutionalization of health ICTs is timely, realistic or relevant.

Effective strategies for increasing the uptake of modern methods of family planning in South Asia: a systematic review and meta-analysis

BACKGROUND

Family planning (FP) interventions have improved the use of modern contraceptives, yet a high unmet need for contraception still exists in South Asia. This systematic review of existing research was conducted to identify effective FP interventions that led to an increase in the uptake of modern methods of contraception in South Asia.

METHODS

Five electronic databases were searched for relevant studies published between January 1st, 2000 and May 4, 2023. Experimental studies that reported data on the impact of FP interventions on modern contraceptive use among women of reproductive age (15-49 years) in the South Asian region were included. A random-effects Inverse Variance weighted model was employed to pool the adjusted odds ratio (OR) on modern contraceptive use and unmet need for contraception. In addition, we computed subgroup meta-estimates based on intervention type and the urban-rural divide.

RESULTS

Among 643 studies identified, 21 met the inclusion criteria. The overall pooled odds ratio for modern contraceptive use was significantly higher (OR 1.51; 95% CI 1.35-1.70; heterogeneity; I2 = 81%) for FP interventions with a significant reduction in unmet need for contraception (OR 0.86; 95% CI 0.78-0.94, I2 = 50%). The subgroup analysis revealed demand-generation (OR 1.61; 95% CI 1.32-1.96), health system integrated (OR 1.53; 95% CI 1.07-2.20), and franchised FP clinic interventions (OR 1.32; 95% CI 1.21-1.44) had promoted the modern contraceptive uptake. Further, FP interventions implemented in urban settings showed a higher increase in modern contraceptive use (OR 1.73; 95% CI 1.44-2.07) compared to rural settings (OR 1.46; 95% CI 1.28-1.66). Given the considerable heterogeneity observed across studies and the low degree of certainty indicated by the GRADE summary for the primary outcome, caution is advised when interpreting the results.

CONCLUSION

The review collated experimentally evaluated FP interventions that increased modern contraception use and reduced the unmet need in South Asia. The demand generation interventions were the most effective in increasing the uptake of modern contraceptive methods. Furthermore, the urban environment provides a conducive environment for interventions to improve contraceptive usage. However, further studies should assess which aspects were most effective on attitudes towards contraception, selection of more effective methods, and contraceptive behaviors.

What does it take to make a wrong decision? A qualitative study from Pakistan's health sector

Background

Pakistan's health system over the past three decades has experienced social, economic, geopolitical instability, and notwithstanding man-made and natural catastrophes. Since 2001, the health system in Pakistan has undergone three phases of organizational and management reforms and does not have a unified national health policy since then. The aim of this research was to assess the factors behind the decision-making by policy planners in the health system of Pakistan.

Methods

An exploratory qualitative study based on grounded theory was designed where in-depth interviews conducted with 20 representatives of the political constituencies, civil bureaucracy, health planners and managers, research and educational institutions, NGOs providing technical support in the health sector, development partners and media.

Results

There leading reason cited was the dearth of leadership in health sector, which is compounded by a range of factors such as "institutional monopoly", "contextual deterrents", "power for turf"; "inadequate knowledge", and "design faults". Such factors were perceived to have a serious effect on the competencies, roles and responsibilities, use of knowledge for decision making. The behavioral aspects of decision makers include the "mindset," and "conflicting interests".

Conclusions

The multitude of factors and complexities within the health sector of Pakistan continue to widen the vacuum in the leadership echelons. Hence, there is a high probability of taking wrong decisions not based on evidence, and resulting in a grossly under-performing health system.

The burden of diseases and risk factors in Bangladesh, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Bangladesh has made substantial progress in improving socioeconomic and health indicators over the past 50 years, but data on national disease burden are scarce. We used data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 to estimate the burden of diseases and risk factors in Bangladesh from 1990 to 2019.

METHODS

For this systematic analysis, we analysed data from vital registration systems, surveys, and censuses using multistage modelling processes to estimate life expectancy at birth, mortality rate, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs). Additionally, we compared the health status of Bangladesh with that of the other countries in the GBD south Asia region-Bhutan, India, Nepal, and Pakistan.

FINDINGS

Life expectancy at birth in Bangladesh increased from 58·2 years (95% uncertainty interval 57·1-59·2) in 1990 to 74·6 years (72·4-76·7) in 2019. Between 1990 and 2019, the age-standardised mortality rate decreased from 1509·3 (1428·6-1592·1) to 714·4 (604·9-838·2) deaths per 100 000 population. In 2019, non-communicable diseases represented 14 of the top 20 causes of death; the leading three causes were stroke, ischaemic heart disease, and chronic obstructive pulmonary disease. High blood pressure, high fasting plasma glucose, and smoking were the top three risk factors. From 1990 to 2019, the rate of all-cause DALYs decreased by 54·9% (48·8-60·4). In 2019, the leading causes of DALYs and YLLs were neonatal disorders, stroke, and ischaemic heart disease, whereas musculoskeletal disorders, depressive disorders, and low back pain were the leading causes of YLDs. Bangladesh has the lowest age-standardised rates of mortality, YLDs, and YLLs and the highest life expectancy at birth in south Asia.

INTERPRETATION

Over the past 30 years, mortality rates have reduced by more than half in Bangladesh. Bangladesh must now address the double burden of communicable and non-communicable diseases. Cost-effective, multisectoral efforts are needed to prevent and control non-communicable diseases, promote healthy lifestyles, and prevent premature mortality and disabilities.

FUNDING

Bill & Melinda Gates Foundation.

TRANSLATION

For the Bangla translation of the abstract see Supplementary Materials section.

Beyond the regulatory radar: knowledge and practices of rural medical practitioners in Bangladesh

BACKGROUND

Informal and unregulated rural medical practitioners (RMPs) provide healthcare services to about two-thirds of people in Bangladesh, although their service is assumed to be substandard by qualified providers. As the RMPs are embedded in the local community and provide low-cost services, their practice pattern demands investigation to identify the shortfalls and design effective strategies to ameliorate the service.

METHODS

We conducted a cross-sectional study in 2015-16 using a convenient sample from all 64 districts of Bangladesh. Personnel practising modern medicine, without any recognized training, or with recognized training but practising outside their defined roles, and without any regulatory oversight were invited to take part in the study. Appropriateness of the diagnosis and the rationality of antibiotic and other drug use were measured as per the Integrated Management of Childhood Illness guideline.

RESULTS

We invited 1004 RMPs, of whom 877 consented. Among them, 656 (74.8%) RMPs owned a drugstore, 706 (78.2%) had formal education below higher secondary level, and 844 (96.2%) had informal training outside regulatory oversight during or after induction into the profession. The most common diseases encountered by them were common cold, pneumonia, and diarrhoea. 583 (66.5%) RMPs did not dispense any antibiotic for common cold symptoms. 59 (6.7%) and 64 (7.3%) of them could identify all main symptoms of pneumonia and diarrhoea, respectively. In pneumonia, 28 (3.2%) RMPs dispensed amoxicillin as first-line treatment, 819 (93.4%) dispensed different antibiotics including ceftriaxone, 721 (82.2%) dispensed salbutamol, and 278 (31.7%) dispensed steroid. In diarrhoea, 824 (94.0%) RMPs dispensed antibiotic, 937 (95.4%) dispensed ORS, 709 (80.8%) dispensed antiprotozoal, and 15 (1.7%) refrained from dispensing antibiotic and antiprotozoal together.

CONCLUSIONS

Inappropriate diagnoses, irrational use of antibiotics and other drugs, and polypharmacy were observed in the practising pattern of RMPs. The government and other stakeholders should acknowledge them as crucial partners in the healthcare sector and consider ways to incorporate them into curative and preventive care.

Factors affecting practices of recently delivered women on maternal and neonatal health care in selected rural areas of Bangladesh

Bangladesh has made laudable progress in maternal and child health (MCH). Maternal and child mortalities have reduced substantially accompanied by stellar rise in immunization and contraceptive prevalence rate (CPR). However, such success is distributed unevenly throughout and the country is among one of the top ten countries with highest number of neonatal and under-five children mortalities. Rural Bangladesh is home to more than half of the country's total population. Yet, disparity in access to healthcare services and information are overt in these areas. Utilization of maternal health services (MHS) is low whereas maternal and child mortalities are high in the rural areas. Thus, this cluster randomized cross sectional study was conducted with the aim to observe the practices that rural women followed in regards to maternal and child health and factors that affected these practices. Primary data was collected from 550 respondents using a structured questionnaire within the time period September-October 2019. All our participants were recently delivered women (RDW), defined in our study as women of reproductive age (15-49 years) who had delivered a child recently, i.e. 12 months prior (September 2018 - August 2019) the data collection. We conducted logistic regression and multivariate analysis to analyze data. Results from this study depict that while 96.3% of RDW opted for ANC visits and 99.1% fed colostrum to their newborn, fewer have had institutional deliveries and the number of RDW who had PNC was only 64.7%. Education was found to be the most prominent factor that affected practices employed by RDW. The more educated a respondent was, the greater the chance was of her engaging in appropriate maternal and child health practices. The RDW preferred and visited private facilities the most to obtain healthcare services with private medical doctors being one of the prime sources of healthcare information for the respondents. On the contrary, monthly expenditure exerted no statistically significant impact on the aforementioned practices. Thus, results of our study imply that interventions enhancing education and health knowledge of women and engaging private sector be designed for improving maternal and neonatal health care in rural areas of Bangladesh.

Village doctors: a national telephone survey of Bangladesh's lay medical practitioners

BACKGROUND

Bangladesh outperforms its Least Developed Country (LDC) status on a range of health measures including life expectancy. Its frontline medical practitioners, however, are not formally trained medical professionals, but instead lightly-trained 'village doctors' able to prescribe modern pharmaceuticals. This current study represents the most complete national survey of these practitioners and their informal 'clinics'.

METHODS

The study is based on a national Computer Assisted Telephone Interviewing (CATI) of 1,000 informal practitioners. Participants were sampled from all eight divisions and all 64 districts of Bangladesh, including 682 participants chosen from the purposively recruited Refresher Training program conducted by the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), supplemented with 318 additional participants recruited through snowball sampling.

PRIMARY AND SECONDARY OUTCOME MEASURES

In addition to demographics, village doctors were asked about the characteristics of their 'clinics' including their equipment, their training, income and referral practices.

RESULTS

Three quarters of the wholly male sample had not completed an undergraduate program, and none of the sample had received any bachelor-level university training in medicine. Medical training was confined to a range of short-course offerings. Village doctor 'clinics' are highly dependent on the sale of pharmaceuticals, with few charging a consultation fee. Income was not related to degree of short-course uptake but was related positively to degree of formal education. Finally, practitioners showed a strong tendency to refer patients to the professional medical care system.

CONCLUSIONS

Bangladesh's village doctor sector provides an important pathway to professional, trained medical care, and provides some level of care to those who cannot afford or otherwise access the nation's established healthcare system. However, the degree to which relatively untrained paramedical practitioners are prescribing conventional medicines has concerning health implications.

Influence of sanitation facilities on diarrhea prevalence among children aged below 5 years in flood-prone areas of Bangladesh: a multilevel analysis

Although the improvement of sanitation facilities has been a major contributor to improving public health, it is not guaranteed to prevent negative health outcomes. This is especially true in areas affected by severe natural disasters, such as flooding or extreme rainfall. Previous studies have examined the association between catastrophic natural disasters and negative health outcomes. However, studies on disaster-prone areas are limited. This study focused on the impact of flood risks and examined whether the improvement of sanitation facilities would be sufficient to suppress the prevalence of diarrhea in flood-prone areas. Two secondary datasets including geodata on flood-prone areas were used for the analysis: one each was obtained from the Bangladesh Demographic and Health Survey and Bangladesh Agricultural Research Council. Two models with categorizations of sanitation facilities based on containment type and excreta flow were applied for analysis. Results showed that the severe flood-prone areas and "diffused" type of sanitation, where the feces are diffused without any containment, had significant positive associations with diarrhea prevalence; however, the interaction between them was negative. Moderate flood-prone areas had a significant positive association with diarrhea prevalence; however, the interaction with unimproved sanitation, which includes containment without clear partition from feces, was significantly negative. These findings indicate that improved sanitation or containment type of sanitation may not positively contribute to the prevention of diarrhea in these severe- and moderate-flood prone areas. The urgent need for alternative sanitation technologies should be addressed in flood-prone regions.

Exploring the factors contributing to increase in facility child births in Bangladesh between 2004 and 2017-2018

Background

Although Bangladesh has gained rapid improvement in births at health facilities, yet far behind to achieve the SDG target. Assessing the contribution of factors in increased use of delivery at facilities are important to demonstrate.

Objective

To explore the determinants and their contribution in explaining increased use of facility child births in Bangladesh.

Participants

Reproductive-aged women (15-49 years) of Bangladesh.

Methods and materials

We used the latest five rounds (2004, 2007, 2011, 2014, 2017-2018) of Bangladesh Demographic and Health Surveys (BDHSs). The regression based classical decomposition approach has been used to explore the determinants and their contribution in explaining the increased use of facility child birth.

Results

A sample of 26,686 reproductive-aged women were included in the analysis, 32.90% (8780) from the urban and 67.10% (17,906) from the rural area. We observed a 2.4-fold increase in delivery at facilities from 2004 to 2017-2018, in rural areas it is more than three times higher than the urban areas. The change in mean delivery at facilities is about 1.8 whereas, the predicted change is 1.4. In our full sample model antenatal care visits contribute the largest predicted change of 22.3%, wealth and education contributes 17.3% and 15.3% respectively. For the rural area health indicator (prenatal doctor visit) is the largest drivers contributing 42.7% of the predicted change, hereafter education, demography and wealth. However, in urban area education and health contributed equally 32.0% of the change followed by demography (26.3%) and wealth (9.7%). Demographic variables (maternal BMI, birth order, age at marriage) contributing more than two-thirds (41.2%) of the predicted change in the model without the health variables. All models showed more than 60.0% predictive power.

Conclusion

Health sector interventions should focus both coverage and quality of maternal health care services to sustain steady improvements in child birth facilities.

How is parental education associated with infant and young child feeding in Bangladesh? a systematic literature review

BACKGROUND

Education is expected to bring about positive behavioral changes which could lead to improved health behaviors. Parental education is a primary determinant of child health and development. However, some evidence showed inverse associations between high parental education and recommended infant and young child feeding (IYCF) in Bangladesh. How the association of parental education differs with specific IYCF components has not been reviewed. Therefore, the role of parental education on optimal IYCF practices in Bangladesh appears to be inconclusive. The objective of this review is to summarize how parental education is associated with IYCF practices in Bangladesh.

METHOD

This review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. A systematic literature search was conducted in PubMed, Web of Science, Embase, and Google Scholar. Record searching, study selection, and data extraction was performed using Endnote online and Covidence tool, respectively. The Newcastle-Ottawa scale was used for quality assessment of the included studies.

RESULTS

Out of 414 initial hits, 34 studies were included for this review. Of the included studies, 32 were cross-sectional, one was a randomized controlled trial, and one was a retrospective cohort. Most of the studies (n = 24) were nationally representative whereas 10 studies had populations from district and sub-district level. Included studies considered different IYCF-related indicators, including breastfeeding (n = 22), complementary feeding (n = 8), both breastfeeding and complementary feeding (n = 2), both breastfeeding and bottle feeding (n = 1), and pre-lacteal feeding (n = 1). Parental education was found to be positively associated with complementary feeding practices. However, the role of parental education on breastfeeding, in general, was ambiguous. High parental education was associated with bottle-feeding practices and no initiation of colostrum.

CONCLUSION

Public health interventions need to focus not only on non- and/or low-educated parents regarding complementary feeding but also on educated mothers for initiation of colostrum and proper breastfeeding practices.

TRIAL REGISTRATION

This systematic review is registered to PROSPERO ( https://www.crd.york.ac.uk/prospero/ ) with registration ID: CRD42022355465.

The capacity of primary healthcare facilities in Bangladesh to prevent and control non-communicable diseases

BACKGROUND

The rapid rise of non-communicable diseases (NCDs) has become a significant public health concern in Bangladesh. This study assesses the readiness of primary healthcare facilities to manage the following NCDs: diabetes mellitus (DM), cervical cancer, chronic respiratory diseases (CRIs), and cardiovascular diseases (CVDs).

METHODS

A cross-sectional survey was conducted between May 2021 and October 2021 among 126 public and private primary healthcare facilities (nine Upazila health complexes (UHCs), 36 union-level facilities (ULFs), 53 community clinics (CCs), and 28 private hospitals/clinics). The NCD-specific service readiness was assessed using the World Health Organization's (WHO) Service Availability and Readiness Assessment (SARA) reference manual. The facilities' readiness was assessed using the following four domains: guidelines and staff, basic equipment, diagnostic facility, and essential medicine. The mean readiness index (RI) score for each domain was calculated. Facilities with RI scores of above 70% were considered 'ready' to manage NCDs.

RESULTS

The general services availability ranged between 47% for CCs and 83% for UHCs and the guidelines and staff accessibility were the highest for DM in the UHCs (72%); however, cervical cancer services were unavailable in the ULFs and CCs. The availability of basic equipment was the highest for cervical cancer (100%) in the UHCs and the lowest for DM (24%) in the ULFs. The essential medicine for CRI was 100% in both UHCs and ULFs compared to 25% in private facilities. The diagnostic capacity for CVD and essential medicine for cervical cancer was unavailable at all levels of public and private healthcare facilities. The overall mean RI for each of the four NCDs was below the cut-off value of 70%, with the highest (65%) for CRI in UHCs but unavailable for cervical cancer in CCs.

CONCLUSION

All levels of primary healthcare facilities are currently not ready to manage NCDs. The notable deficits were the shortage of trained staff and guidelines, diagnostic facilities, and essential medicine. This study recommends increasing service availability to address the rising burden of NCDs at primary healthcare levels in Bangladesh.

Achieving MDG of reducing maternal mortality ratio: A comparative study of selected South Asian countries

Reducing the maternal mortality ratio (MMR) by three quarters by 2015 was one of the major Millennium Development Goals (MDGs). I performed a comparative study of policy tools and outcomes for reducing the MMR in five major South Asian Countries-Bangladesh, India, Nepal, Pakistan, and Sri Lanka. I observed that countries with a greater focus on achieving gender parity and equal health access and having specific healthcare policies to promote maternal care were more successful in achieving the MDG of reducing the MMR. Thus, any healthcare policy targeting women should also consider gender parity and women empowerment policies of a country.

Relations between indoor rehabilitation and basic health services in a developing country

Background

and Introduction: Physical rehabilitation is vital for patients to regain maximum function. Approximately 80% of people with a disability live in developing countries, where they face multiple challenges in rehabilitation. The goal of the study was to conduct an analysis of indoor rehabilitation programs based on the demographics and medical conditions of the admitted patients and to relate to the available basic health and rehabilitation facilities.

Methods

This was a mixed method study conducted in an inpatient rehabilitation ward of a tertiary level academic university hospital in a developing country. All admitted patients who stayed for a period of minimum two weeks were included in the study. Demographic and clinical data were obtained by means of a retrospective medical record review utilizing a standardized data extraction form. The study was further strengthened by an online literature search for the available documents for analysis, relation, and discussion.

Results

Among the 1,309 admitted patients was male- female ratio was 10:7, with the majority (31.4%) cases falling between the ages of 46 and 60yrs. Rehabilitation outpatient department was the principal mode of admission (78%), and musculoskeletal and neurological conditions represented the maximum number (79.8%). Majority of patients (60.8%) were discharged home on completion of the rehabilitation program with a large number of patients who were absconded. Poor health budget allocation and lack of prioritization of the rehabilitation sector face multiple challenges, including the rehabilitation team functioning resources, space crisis for expansion which was further impacted by the COVID-19 pandemic.

Conclusions

The country's current health-related rehabilitation process and socio-demographic variables have a negative relationship. There was a large number of missing data in the medical records and many patients were lost prematurely from the indoor rehabilitation program. Musculoskeletal disorders were common, and the majority of patients were discharged home once the program was completed.

Health system challenges and opportunities in organizing non-communicable diseases services delivery at primary healthcare level in Bangladesh: A qualitative study

Introduction

The weak health system is viewed as a major systematic obstacle to address the rising burden of non-communicable diseases (NCDs) in resource-poor settings. There is little information about the health system challenges and opportunities in organizing NCD services. This study examined the health system challenges and opportunities in organizing NCD services for four major NCDs (cervical cancer, diabetes mellitus, cardiovascular diseases, and chronic respiratory illnesses) at the primary healthcare (PHC) level in Bangladesh.

Methods

Using a qualitative method, data were collected from May to October 2021 by conducting 15 in-depth interviews with local healthcare providers, 14 key informant interviews with facility-based providers and managers, and 16 focus group discussions with community members. Based on a health system dynamics framework, data were analyzed thematically. Information gathered through the methods and sources was triangulated to validate the data.

Results

Organization of NCD services at the PHC level was influenced by a wide range of health system factors, including the lack of using standard treatment guidelines and protocols, under-regulated informal and profit-based private healthcare sectors, poor health information system and record-keeping, and poor coordination across healthcare providers and platforms. Furthermore, the lack of functional referral services; inadequate medicine, diagnostic facilities, and logistics supply; and a large number of untrained human resources emerged as key weaknesses that affected the organization of NCD services. The availability of NCD-related policy documents, the vast network of healthcare infrastructure and frontline staff, and increased demand for NCD services were identified as the major opportunities.

Conclusion

Despite the substantial potential, the health system challenge impeded the organization of NCD services delivery at the PHC level. This weakness needs be to addressed to organize quality NCD services to better respond to the rising burden of NCDs at the PHC level.

Trends and determinants of taking tetanus toxoid vaccine among women during last pregnancy in Bangladesh: Country representative survey from 2006 to 2019

Background

Tetanus occurring during pregnancy is still an important cause of maternal and neonatal mortality in developing countries. This study estimated the trend of tetanus toxoid (TT) immunization coverage from 2006 to 2019 in Bangladesh, considering socio-demographic, socio-economic, and geospatial characteristics.

Methods

The dataset used in this study was extracted from Multiple Indicator Cluster Surveys (2006, 2012–13, and 2019) including 28,734 women aged between 15–49 years. Data analysis was performed using cross-tabulation and logistic regression methods. Further, the spatial distribution of TT immunization coverage was also depicted.

Results

The trend of TT immunization (81.8% in 2006 to 49.3% in 2019) and that of taking adequate doses of TT (67.1% in 2006 to 49.9% in 2019) has gradually decreased throughout the study period. Among the administrative districts, North and South-West regions had lower coverage, and South and West regions had relatively higher coverage of both TT immunization and that of adequate doses. Antenatal TT immunization (any dosage, inadequate or adequate) was significantly associated with lower age (AOR = 3.13, 1.55–6.34), higher education (AOR = 1.20, 1.03–1.40), living in urban areas (AOR = 1.17, 1.03–1.34), having immunization card (AOR = 5.19, 4.50–5.98), using government facilities for birth (AOR = 1.41, 1.06–1.88), and receiving antenatal care (ANC) (AOR = 1.51, 1.35–1.69). In addition, living in urban areas (AOR = 1.31, 1.10–1.55), having immunization cards (AOR = 1.62, 1.36–1.92), and choosing others’ homes for birth (AOR = 1.37, 1.07–1.74) were significantly associated with adequate TT immunization. However, higher education (AOR = 0.57, 0.44–0.74), having poor wealth index (AOR = 0.65, 0.50–0.83), and receiving ANC (AOR = 0.76, 0.63–0.92) had lower likelihood of taking adequate TT immunization.

Conclusions

The gradual decline in the TT immunization rate in the present study suggests the presence of variable rates and unequal access to TT immunization, demanding more effective public health programs focusing on high-risk groups to ensure adequate TT immunization.

Under the regulatory radar: Unregulated rural healthcare in Bangladesh and Australia

This study examines health regulation under conditions of geographical constraint in two strikingly different settings, one on a remote island in Bangladesh and the other in an impoverished rural region in Australia. Both suffer from an absence of medically qualified professionals, which means that in the resultant vacuum, patients access alternative healthcare. The concept of regulation (or lack of regulation) is explored in terms of unconventional new responses to rural health deficits. The two cases show unexpected commonality, with policymakers facing shared challenges beyond physical remoteness. The difference in the degree of enforcement of regulation offers the greatest point of difference. This comparative study revealed a weak health regulatory system in the remote Bangladesh area of Bhola Island where 'alternatives' to formal clinical approaches have become the default choice. Brazen stop-gap servicing is commonplace on Bhola Island, but in The Gemfields such practices only occur in the shadows or as a last resort. Each isolated location, one in a developing country and the other in a developed setting, exemplifies how geographical remoteness can present an opportunity for innovations in supply to emerge. Surprisingly, it is the developing world case that better leverages a regulatory void to respond to local healthcare needs.

A Qualitative Assessment of the Essential Health and Nutrition Service Delivery in the Context of COVID-19 in Bangladesh: The Perspective of Divisional Directors

Bangladesh suffered disruptions in the utilization of essential health and nutrition services (EHNS) during the COVID-19 pandemic. The magnitude of the pandemic has been documented, but little is known from the perspectives of health administrators. A rapid qualitative assessment of division-level capacity identified successes and bottlenecks in providing EHNS- and COVID-19-related services during the first months of the pandemic in Bangladesh. Semi-structured interviews were held with the Health and Family Planning Divisional Directors of the Ministry of Health and Family Welfare. The Primary Health Care System Framework guided the content analysis, focusing on (i) service delivery, (ii) communication and community outreach, and (iii) surveillance and service monitoring. Our findings identified low care seeking due to fears of getting infected and unawareness that EHNS were still available. Adaptations to telemedicine were highly heterogeneous between divisions, but collaboration with NGOs were fruitful in reinstating outreach activities. Guidelines were centered on COVID-19 information and less so on EHNS. The inflexibility of spending capacities at divisional and clinic levels hindered service provision. Misinformation and information voids were difficult to handle all around the country. Community health workers were useful for outreach communication. EHNS must be guaranteed during sanitary emergencies, and Bangladesh presented with both significant efforts and areas of opportunity for improvement.

Health care services use, stillbirth, and neonatal and infant survival following implementation of the Maternal Health Voucher Scheme in Bangladesh: A difference-in-differences analysis of Bangladesh Demographic and Health Survey data, 2000 to 2016

BACKGROUND

Starting in 2006 to 2007, the Government of Bangladesh implemented the Maternal Health Voucher Scheme (MHVS). This program provides pregnant women with vouchers that can be exchanged for health services from eligible public and private sector providers. In this study, we examined whether access to the MHVS was associated with maternal health services utilization, stillbirth, and neonatal and infant mortality.

METHODS AND FINDINGS

We used information on pregnancies and live births between 2000 to 2016 reported by women 15 to 49 years of age surveyed as part of the Bangladesh Demographic and Health Surveys. Our analytic sample included 23,275 pregnancies lasting at least 7 months for analyses of stillbirth and between 15,125 and 21,668 live births for analyses of health services use, neonatal, and infant mortality. With respect to live births occurring prior to the introduction of the MHVS, 31.3%, 14.1%, and 18.0% of women, respectively, reported receiving at least 3 antenatal care visits, delivering in a health institution, and having a skilled birth attendant at delivery. Rates of neonatal and infant mortality during this period were 40 and 63 per 1,000 live births, respectively, and there were 32 stillbirths per 1,000 pregnancies lasting at least 7 months. We applied a difference-in-differences design to estimate the effect of providing subdistrict-level access to the MHVS program, with inverse probability of treatment weights to address selection into the program. The introduction of the MHVS program was associated with a lagged improvement in the probability of delivering in a health facility, one of the primary targets of the program, although associations with other health services were less evident. After 6 years of access to the MHVS, the probabilities of reporting at least 3 antenatal care visits, delivering in a health facility, and having a skilled birth attendant present increased by 3.0 [95% confidence interval (95% CI) = -4.8, 10.7], 6.5 (95% CI = -0.6, 13.6), and 5.8 (95% CI = -1.8, 13.3) percentage points, respectively. We did not observe evidence consistent with the program improving health outcomes, with probabilities of stillbirth, neonatal mortality, and infant mortality decreasing by 0.7 (95% CI = -1.3, 2.6), 0.8 (95% CI = -1.7, 3.4), and 1.3 (95% CI = -2.5, 5.1) percentage points, respectively, after 6 years of access to the MHVS. The sample size was insufficient to detect smaller associations with adequate precision. Additionally, we cannot rule out the possibility of measurement error, although it was likely nondifferential by treatment group, or unmeasured confounding by concomitant interventions that were implemented differentially in treated and control areas.

CONCLUSIONS

In this study, we found that the introduction of the MHVS was positively associated with the probability of delivering in a health facility, but despite a longer period of follow-up than most extant evaluations, we did not observe attendant reductions in stillbirth, neonatal mortality, or infant mortality. Further work and engagement with stakeholders is needed to assess if the MHVS has affected the quality of care and health inequalities and whether the design and eligibility of the program should be modified to improve maternal and neonatal health outcomes.

Barriers to male condom use in Rohingya refugee camps in Bangladesh: A qualitative study

Background

Rohingya people are often called the most persecuted minority in the world. Currently, almost 800,000 Rohingya refugees live in temporary shelters in Cox's Bazar, Bangladesh. More than one-quarter of them are women and girls of reproductive age who are at increased risk of unplanned pregnancies, unsafe abortions and related complications. However, the use of contraception remains inadequate, and particularly use of condoms and male participation is scarce. This study examines the barriers to condom use as a contraceptive method among married Rohingya couples.

Methods

We conducted in-depth qualitative interviews of married Rohingya men and women and thematically analysed the data.

Findings

Depo Provera injections and pills are the dominant forms of contraception. Men's participation in family planning and contraceptive use is rare, and so is the use of condoms. Participants identified several barriers to condom use, including contraception being the responsibility of the women, socio-cultural issues, the stigma attached to condoms, unfamiliarity with condoms, the limitations of condoms, and issues of security in conjugal life. Health workers do not promote condoms in the same way as other contraceptive methods.

Interpretation

Condom use and men's participation in contraception use are rare in Rohingya camps. The involvement of family planning workers who are males may help to promote the use of condoms and increase the method-mix options of contraceptives.

Funding

La Trobe University, Melbourne, Australia.

Depressive Symptoms Among Adolescents in Bangladesh

Adolescent mental well-being hardly took precedence in Bangladesh, which is reflected in both policies and literature. This study assessed the common symptoms of depression among school-going adolescents (aged 10–19 years) in Bangladesh. Primary data were collected during October–November 2019 from 289 participants in four schools using a questionnaire based on the WHO global school-based student health survey and WHO stepwise approach to NCD (Tools version 9.5). Sadness (45.3%) and aggression (40.5%) were the most common depressive symptoms found in the study, followed by confusion (27.7%), worthlessness (21.8%), fatigue (21.5%), and insomnia (18.0%). The sex of the student, grade of study, and duration of daily sleep showed differential associations with these symptoms. These findings indicate a crucial stage of adolescence, where the different societal pressures often ignored by primary carers, could have detrimental effect on children. There is an urgent need to address the growing adolescent mental health issue in Bangladesh and a need for health system to recognize its precedence.

Key Challenges to Optimal Therapeutic Coverage and Maternal Utilization of CMAM Program in Rural Southern Pakistan: A Qualitative Exploratory Study

Severe Acute Malnutrition (SAM) is a serious public health problem in many low- and middle-income countries (LMICs). Therapeutic programs are often considered the most effective solution to this problem. However, multiple social and structural factors challenge the social inclusion, sustainability, and effectiveness of such programs. In this article, we aim to explore how poor and remote households face structural inequities and social exclusion in accessing nutrition-specific programs in Pakistan. The study specifically highlights significant reasons for the low coverage of the Community Management of Acute Malnutrition (CMAM) program in one of the most marginalized districts of south Punjab. Qualitative data are collected using in-depth interviews and FGDs with mothers and health and nutrition officials. The study reveals that mothers’ access to the program is restricted by multiple structural, logistical, social, and behavioral causes. At the district level, certain populations are served, while illiterate, and poor mothers with lower cultural capital from rural and remote areas are neglected. The lack of funding for nutrition causes the deprioritization of nutrition by the health bureaucracy. The subsequent work burden on Lady Health Workers (LHWs) and the lack of proper training of field staff impact the screening of SAM cases. Moreover, medical corruption in the distribution of therapeutic food, long distances, traveling or staying difficulties, the lack of social capital, and the stigmatization of mothers are other prominent difficulties. The study concludes that nutrition governance in Pakistan must address these critical challenges so that optimal therapeutic coverage can be achieved.

Determinants of multimorbidity of infectious diseases among under-five children in Bangladesh: role of community context

Background

The presence of more than one morbid condition among children has become a global public health concern. Studies carried out in Bangladesh have primarily focused on diarrhoea and acute respiratory tract infections independently without considering their co-occurrence effect. The present study examines the multimorbid conditions of infectious diseases in under-five Bangladeshi children. It explores multimorbidity determinants and the role of community context, which are often overlooked in previous literature.

Methods

Utilizing the most recent Demographic and Health Survey of Bangladesh (2017–18), we used mixed-effects random-intercept Poisson regression models to understand the determinants of multimorbidity of infectious diseases in under-five Bangladeshi children considering the community-level characteristics.

Results

The present study found that 28% of the children experienced multimorbidity two weeks prior to the survey. Community-level variability across all the statistical models was statistically significant at the 5% level. On average, the incidence rate of multimorbidity was 1.34 times higher among children from high-risk communities than children from low-risk communities. Moreover, children residing in rural areas and other urban areas involved 1.29 [CI: 1.11, 1.51] and 1.28 [CI: 1.11, 1.47] times greater risk of multimorbidity respectively compared to children from city corporations. Additionally, the multimorbidity incidence was 1.16 times [CI: 1.03, 1.30] higher among children from high-altitude communities than children living in low-altitude communities.

Conclusion

The significant effect of public handwashing places suggests community-based interventions among individuals to learn hygiene habits among themselves, thus, the severity of coexistence nature of infectious diseases. A higher incidence of coexistence of such infectious diseases in the poor and semi-urban populace further recommends a targeted awareness of a clean environment and primary healthcare programmes.

Inequalities in full vaccination coverage based on maternal education and wealth quintiles among children aged 12-23 months: further analysis of national cross-sectional surveys of six South Asian countries

OBJECTIVE

This study was conducted to compare full vaccination coverage and its inequalities (by maternal education and household wealth quintile).

DESIGN

This further analysis was based on the data from national-level cross-sectional Demographic and Health Survey (DHS) from six countries in South Asia.

SETTING

We used most recent DHS data from six South Asian countries: Nepal, India, Pakistan, Bangladesh, Afghanistan and the Maldives. The sample size of children aged 12-23 months ranged from 6697 in the Maldives to 628 900 in India.

PRIMARY AND SECONDARY OUTCOME MEASURES

To measure absolute and relative inequalities of vaccination coverage, we used regression-based inequality measures, slope index of inequality (SII) and the relative index of inequality (RII), respectively, by maternal education and wealth quintile.

RESULTS

Full vaccination coverage was the highest in Bangladesh (84%) and the lowest in Afghanistan (46%), with an average of 61.5% for six countries. Pakistan had the largest inequalities in coverage both by maternal education (SII: -50.0, RII: 0.4) and household wealth quintile (SII: -47.1, RII: 0.5). Absolute inequalities were larger by maternal education compared with wealth quintile in four of the six countries. The relative index of inequality by maternal education was lower in Pakistan (0.5) and Afghanistan (0.5) compared with Nepal (0.7), India (0.7) and Bangladesh (0.7) compared with rest of the countries. By wealth quintiles, RII was lower in Pakistan (0.5) and Afghanistan (0.6) and higher in Nepal (0.9) and Maldives (0.9).

CONCLUSIONS

The full vaccination coverage in 12-23 months old children was below 85% in all six countries. Inequalities by maternal education were more profound than household wealth-based inequalities in four of six countries studied, supporting the benefits of maternal education to improve child health outcome.

Determinants of life expectancy in most polluted countries: Exploring the effect of environmental degradation

BACKGROUND

Better understanding of the determinants of national life expectancy is crucial for economic development, as a healthy nation is a prerequisite for a wealthy nation. Many socioeconomic, nutritional, lifestyle, genetic and environmental factors can influence a nation's health and longevity. Environmental degradation is one of the critical determinants of life expectancy, which is still under-researched, as the literature suggests.

OBJECTIVES

This study aims to investigate the determinants of life expectancy in 31 world's most polluted countries with particular attention on environmental degradation using the World Bank annual data and British Petroleum data over the period of 18 years (2000-2017).

METHODS

The empirical investigation is based on the model of Preston Curve, where panel corrected standard errors (PCSE) and feasible general least square (FGLS) estimates are employed to explore the long-run effects. Pairwise Granger causality test is also used to have short-run causality among the variables of interest, taking into account the cross-sectional dependence test and other essential diagnostic tests.

RESULTS

The results confirm the existence of the Preston Curve, implying the positive effect of economic growth on life expectancy. Environmental degradation is found as a threat while health expenditure, clean water and improved sanitation affect the life expectancy positively in the sample countries. The causality test results reveal one-way causality from carbon emissions to life expectancy and bidirectional causalities between drinking water and life expectancy and sanitation and life expectancy.

CONCLUSION

Our results reveal that environmental degradation is a threat to having improved life expectancy in our sample countries. Based on the results of this study, we recommend that: (1) policy marker of these countries should adopt policies that will reduce carbon emissions and thus will improve public health and productivity; (2) environment-friendly technologies and resources, such as renewable energy, should be used in the production process; (3) healthcare expenditure on a national budget should be increased; and (4) clean drinking water and basic sanitation facilities must be ensured for all people.

A stakeholder analysis of noncommunicable diseases' multisectoral action plan in Bangladesh

Evidence shows that noncommunicable diseases (NCDs) are highly preventable by addressing the common risk factors embedded within and outside the health sector. Bangladesh's Ministry of Health and Family Welfare has adopted a multisectoral action plan for NCD control and prevention. This research aims at examining to what extent was the multisectoral engagement achieved. The stakeholder analysis method comprises two steps: (1) identifying the actors and (2) determining their roles, power, and positions to the policy. The study revealed seven main NCD stakeholder categories: policymakers, development partners (DPs), service providers, industry, research and academia, the media, and civil societies. The government, DPs, and civil societies hold the highest power and supportive position. However, the tobacco and food industries have an opposing position. Furthermore, there was a clear gap in the participation of nonhealth ministries.

Mental Health and Community-Based Rehabilitation: A Qualitative Description of the Experiences and Perspectives of Service Users and Carers in Bangladesh

Since 2016, Promotion of Human Rights of Persons with Disabilities in Bangladesh (PHRPB) has been working to include people with psychosocial disabilities in their community-based inclusive development work, and to increase access to formal mental health care. Field visits were carried out to PHRPBD catchment areas in Dhaka and Chittagong for a case study on the integration of mental health into community-based rehabilitation (CBR). This paper synthesizes the results of twenty-five semi-structured interviews carried out as part of the case study. Participants included people with psychosocial disabilities, intellectual disabilities, epilepsy or other cognitive impairments and their carers as needed. Interviews were audio-recorded, transcribed and translated from Bangla to English, then hand-coded for content analysis. Results were organized into five overarching categories: (1) explanatory models, (2) help-seeking behaviors, (3) impact of services, (4) challenges and barriers to improving mental health, (5) recommendations of users and carers. Respondents either had no explanation for why service users had become unwell or attributed it to physically and/or emotionally traumatic events or supernatural causes. Before attending PHRPBD's mental health services, most had visited formal or informal health care providers, often with disappointing results. Despite positive feedback on PHRPBD's services, participants identified ongoing challenges. Stigma, discrimination and human rights abuses persist and are compounded by issues of gender inequality. Participants also identified barriers and made recommendations specific to the program itself, mainly regarding accessibility (e.g., cost, distance, frequency). This study adds to the limited body of qualitative research on mental health in Bangladesh, reinforcing previous findings on explanatory models and health-seeking behaviors while providing new insights into the impact of a CBR program in this context. Feedback of service users and carers suggests that CBR may indeed be a useful approach to increase access to services in Bangladesh for people with psychosocial or intellectual disabilities, epilepsy or other cognitive impairments. However, this program is not without its limitations, some of which are the product of broader issues within the mental health system and others of the social and cultural context. More research is needed to formally evaluate this and other CBR programs in the Global South.

Cost-effectiveness analysis of a large-scale crèche intervention to prevent child drowning in rural Bangladesh

Background

Drowning is the leading cause of death among children 12–59 months old in rural Bangladesh. This study evaluated the cost-effectiveness of a large-scale crèche (daycare) intervention in preventing child drowning.

Methods

The cost of the crèches intervention was evaluated using an ingredients-based approach and monthly expenditure data collected prospectively throughout the study period from two agencies implementing the intervention in different study areas. The estimate of the effectiveness of the crèches intervention was based on a previous study. The study evaluated the cost-effectiveness from both a program and societal perspective.

Results

From the program perspective the annual operating cost of a crèche was $416.35 (95% CI: $221 to $576), the annual cost per child was $16 (95% CI: $8 to $23), and the incremental-cost-effectiveness ratio (ICER) per life saved with the crèches was $17,008 (95% CI: $8817 to $24,619). From the societal perspective (including parents time valued) the ICER per life saved was − $166,833 (95% CI: − $197,421 to − $141,341)—meaning crèches generated net economic benefits per child enrolled. Based on the ICER per disability-adjusted-life years averted from the societal perspective (excluding parents time), $1978, the crèche intervention was cost-effective even when the societal economic benefits were ignored.

Conclusions

Based on the evidence, the crèche intervention has great potential for generating net societal economic gains by reducing child drowning at a program cost that is reasonable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40621-021-00351-9.

Understanding the Performance of County Health Service Delivery in Kenya: A Mixed Method Analysis

To better understand the wide variation of performance among county health systems in Kenya, this study investigated their performance determinants. We selected five counties with varied performance and examined their performance across five domains containing 10 thematic areas. We conducted a stakeholder analysis, consisting of focus group discussions and key informant interviews, and administered a quantitative survey to quantify the magnitude of inefficiency. The study found that a shortage of funding was one of the most common complaints from counties, leading to inefficiency in the health system. Another major reason for inefficiencies was the delay in disbursing funding to health facilities, which affected the procurement of medical supplies and commodities essential for delivering healthcare to the population. In addition, lack of autonomy in procuring commodities and equipment was repeatedly mentioned as a barrier to delivering quality health services. Other reported common concerns contributing to the performance of county health systems were the lack of lab tests and equipment, low willingness to join health insurance, rigid procurement policies and lengthy procurement process, lack of motivation and incentives for service delivery, and poor economic status. Despite the common concerns among the five counties, they differed in some schematic areas, such as the county’s commitment to health and community mobilization. In summary, this study suggests various factors that determine county health system performance. Given the multifaceted nature of inefficiency drivers, it is necessary to adopt a holistic approach to address the causes of inefficiencies and improve the county health systems

Demand for Information on Environmental Health Risk, Mode of Delivery, and Behavioral Change: Evidence from Sonargaon, Bangladesh

Millions of villagers in Bangladesh are exposed to arsenic by drinking contaminated water from private wells. Testing for arsenic can encourage switching from unsafe wells to safer sources. This study describes results from a cluster randomized controlled trial conducted in 112 villages in Bangladesh to evaluate the effectiveness of different test selling schemes at inducing switching from unsafe wells. At a price of about US0.60, only one in four households purchased a test. Sales were not increased by informal inter-household agreements to share water from wells found to be safe, or by visual reminders of well status in the form of metal placards mounted on the well pump. However, switching away from unsafe wells almost doubled in response to agreements or placards relative to the one in three proportion of households that switched away from an unsafe well with simple individual sales.

Child mortality in Bangladesh - why, when, where and how? A national survey-based analysis

Background

Updated information on the cause of childhood mortality is essential for developing policies and designing programmes targeting the major burden of disease. There is a paucity of evidence regarding the current estimates of the cause of death in Bangladesh, which is essential for reinvigorating the current policies and reshaping existing strategies to avert preventable deaths. This paper aims to address this critical evidence gap and report the cause, timing and place of death among children under-five years of age using a nationally representative sample.

Methods

The present study was undertaken to provide updated estimates of causes of death among children under-five years of age using data from the 2017-18 round of the Bangladesh Demographic and Health Survey (BDHS). The verbal autopsy (VA) questionnaire of the 2017-18 BDHS was adapted from the standardised WHO 2016 instruments. Specially trained physicians reviewed the responses of the VA questionnaire and assigned the cause of death based on the online-2016-version of the International Classification of Diseases (ICD-10). We included 456 deaths among children under-five years of age in our analysis. Descriptive statistics were used to present the causes, timing and places of death with uncertainty ranges (UR).

Results

Pneumonia is the major killer (19%), accounting for approximately 24 268 (UR = 21 626-26 695) under-five deaths per-year. It is followed by birth asphyxia (16%), prematurity and low-birth-weight (11%), serious infections including sepsis (8%) causing 20 882 (UR = 18 608-22 970), 14 956 (UR = 13 327-16,452), and 10 723 (UR = 9555-11,795) deaths per-year, respectively. Drowning (8%) caused 10 441 (UR = 9304-11 485) deaths and congenital anomaly (7%) resulted in d 8748 (UR = 7795-9623) deaths per-year. Around 29% of all deaths occurred on the first day, 52% within the first week, and 66% within the first month of life. Around 70% of birth asphyxia, prematurity, and low birth weight-related deaths happen on the day of birth. Approximately 43% of pneumonia-related deaths occur in age 1-11 months, and around 51% of drowning-related deaths happen in age 12-23 months.

Conclusions

Pneumonia with other serious infections, birth asphyxia, prematurity and low-birth-weight are responsible for more than half of all deaths among children under-five years of age. Strengthening the existing maternal, neonatal and child health programmes may be helpful in averting the majority of these preventable deaths. A multisectoral approach is required for the prevention of childhood deaths, especially drowning-related fatalities. Special measures need to be taken to prevent and control emerging public health challenges like birth defects and congenital anomalies.

Effects of the COVID-19 pandemic on caregiver mental health and the child caregiving environment in a low-resource, rural context

Early child development has been influenced directly and indirectly by the COVID‐19 pandemic, and these effects are exacerbated in contexts of poverty. This study estimates effects of the pandemic and subsequent population lockdowns on mental health, caregiving practices, and freedom of movement among female caregivers of children 6–27 months (50% female), in rural Bangladesh. A cohort (N = 517) was assessed before and during the pandemic (May–June, 2019 and July–September, 2020). Caregivers who experienced more food insecurity and financial loss during the pandemic reported larger increases in depressive symptoms (0.26 SD, 95% CI 0.08–0.44; 0.21 SD, 0.04–0.40) compared to less affected caregivers. Stimulating caregiving and freedom of movement results were inconsistent. Increases in depressive symptoms during the pandemic may have consequences for child development.

Primary healthcare system readiness to prevent and manage non-communicable diseases in Bangladesh: a mixed-method study protocol

INTRODUCTION

The burden of non-communicable diseases (NCDs) is rapidly increasing in Bangladesh. Currently, it contributes to 67% of annual deaths, and accounts for approximately 64% of the disease burden. Since 70% of the Bangladeshi population residing in the rural area rely on the primary healthcare system, assessment of its capacity is crucial for guiding public health decisions to prevent and manage NCDs. This protocol is designed to recognise and assess the Bangladeshi health system's readiness for NCDs at the primary level.

METHODS AND ANALYSIS

The study will use a mixed-method design. Numerical data will be collected using households and health facilities surveys, while qualitative data will be collected by interviewing healthcare providers, policy planners, health administrators and community members. The WHO's Service Availability and Readiness Assessment (SARA) methodology and Package of Essential Non-communicable (PEN) Disease Interventions for Primary Healthcare reference manuals will be used to assess the readiness of the primary healthcare facilities for NCD services. Furthermore, Health System Dynamics Framework will be used to examine health system factors. Using the supportive items outlined in the WHO PEN package, and indicators proposed in WHO SARA methodology, a composite score will be created to analyse facility-level data. Two independent samples t-test, analysis of variance and χ2 test methods will be used for bivariate analysis, and multiple regression analysis will be used for multivariable analysis. Complementarily, the thematic analysis approach will be used to analyse qualitative data.

ETHICS AND DISSEMINATION

The project has been approved by the Monash University Human Research Ethics Committee (Project ID: 27112), and Bangladesh Medical Research Council (Ref: BMRC/NREC/2019-2022/270). The research findings will be shared through research articles, conference proceedings or in other scientific media. The reports or publications will not have any information that can be used to identify any of the study participants.

A national assessment of elective cesarean sections in Bangladesh and the need for health literacy and accessibility

There has been a gradual rise in the number of cesarean sections (CSs) in Bangladesh. The present study identified the cohort of women, who were more likely to opt for an elective CS based on their sociodemographic characteristics, pre-delivery care history, and media exposure, using the Bangladesh Multiple Indicator Cluster Survey-2019. The survey stratification adjusted logistic regression model and interpretable machine learning method of building classification trees were utilized to analyze a sample of 9202 women, alongside district-wise heat maps. One-in-five births (20%) were elective CSs in the 2 years prior to the survey. Women residing in affluent households with educated house-heads, who accessed antenatal care prior to delivery (AOR 4.12; 95% CI 3.06, 5.54) with regular access to media (AOR 1.31; 95% CI 1.10, 1.56) and who owned a mobile phone (AOR 1.25; 95% CI 1.04, 1.50) were more likely to opt for elective CSs, which suggests that health access and health literacy were crucial factors in women's mode of delivery. Spatial analyses revealed that women living in larger cities had more elective CS deliveries, pointing towards the availability of better health and access to multiple safe delivery options in peripheral areas.

The Influence of Women's Empowerment on Poverty Reduction in the Rural Areas of Bangladesh: Focus on Health, Education and Living Standard

Women’s empowerment has a great influence on health, nutrition, education, and the overall well-being of societies as well as of the children and households. This study investigates the effect of women’s empowerment on poverty reduction and focuses on household deprivation, in terms of education, health, and standard of living. Primary data was collected from 914 married women from rural areas of Bangladesh using a well-structured questionnaire and a random sampling technique. Descriptive statistics, logistic regression, and ordinary least squares models were used in this study. The results indicate that increased women’s access to education, asset ownership, decision-making power on children’s health and education, and access to medical facilities, have caused a significant decline in income poverty and multidimensional poverty. However, gender violence, taking resources against women’s will, and preventing women from working outside, have caused a considerable decline in per capita income and an increase in income poverty and multidimensional poverty. Overall, it is found that women’s empowerment has a great impact on the reduction of income poverty and multidimensional poverty in society. The findings of the study can assist and guide policymakers to initiate appropriate strategies for women’s empowerment to reducing poverty in Bangladesh while making progress towards other social and developmental goals.

Does membership in women's group advance health and empowerment? Evidence from India

Objectives:

Women's self-help groups (SHGs) are actively promoted to advance women's empowerment. SHGs are estimated to cover 112 million households in 2017; more than 90% are women. This article answers if membership in women's group is associated with better health and women's empowerment.

Methods:

Data on district level health and empowerment indicators were obtained from the fourth round of the National Family Health Survey 2015–16. Data on SHG activity, defined as concentration of SHG at district, was obtained from publicly available data. Twelve indicators were clubbed to measure four domains: maternal health, women's empowerment, child health, and health protection. Binary logistic regressions were computed with education and wealth as control in each model to analyze the change in 12 indicators with the presence of SHG.

Results:

Districts with higher concentration of SHG members were associated with higher odds of women delivering their babies in an institution (OR: 1.53), taking iron pills, sprinklers, or syrup (OR: 1.11), using family planning methods (OR: 1.03), having knowledge of ovulatory cycle (OR: 1.10), owning house or land (either alone or jointly) (OR: 1.18) and lower odds of women suffering from anemia (OR: 0.92). The odds improve when districts with higher concentration of SHG members were compared with those with lower concentration.

Conclusion:

Membership in women's group is associated with better health measures as well as asset ownership; higher the concentration of SHG, higher is the impact.

Factors associated with mobile phone usage to access maternal and child healthcare among women of urban slums in Dhaka, Bangladesh: a cross-sectional study

INTRODUCTION

With the acute shortage of human resources and infrastructure, mobile phones can be a critical tool for accessing health services and strengthening health systems in Bangladesh. Yet, there is a scarcity of evidence on the use of mobile phones in this context for accessing health services. In this study, we sought to explore the current use of mobile phones for accessing maternal and child healthcare and its determinants among recently delivered women in urban slums of Bangladesh.

METHODS

The data were collected through interviewing 800 recently delivered women from eight slums of Dhaka city of Bangladesh during May and June 2018. The study followed a cross-sectional design and a two-stage cluster random sampling procedure was followed. A pretested structured questionnaire was employed to collect information. Chi square tests were performed for descriptive analyses and a multilevel binary logistic regression model was executed to explore the determinants of mobile phone usage for accessing maternal and childcare among the participants.

RESULTS

Overall, 73.8% of study participants used mobile phones for accessing maternal and child healthcare. After adjusting for potential confounders, participants' age, husband's occupation, sex of household head, women's ownership of mobile phones and household wealth status were found to be significantly associated with higher odds of using mobile phones to access maternal and child healthcare.

CONCLUSION

The study highlighted the possibility of implementing large-scale mobile health (mHealth) interventions in slum settlements for accessing maternal and child healthcare and is a sustainable mitigation strategy for the acute health worker crisis in Bangladesh. The findings of this study are particularly crucial for policymakers and practitioners while they revise the health policy to incorporate mHealth interventions as highlighted in the recently initiated Digital Health Strategy of Bangladesh.

A Policy Analysis Regarding Education, Career, and Governance of the Nurses in Bangladesh: A Qualitative Exploration

Nurses, short in production and inequitable in the distribution in Bangladesh, require the government's efforts to increase enrolment in nursing education and a smooth career progression. Given the importance of an assessment of the current nursing scenario to inform the decision makers and practitioners to implement the new policies successfully, we analyzed relevant policies on education, career, and governance of nurses in Bangladesh. We used documents review and qualitative methods such as key informant interviews (n = 13) and stakeholder analysis. We found that nursing education faced several backlashes: resistance from diploma nurses while attempting to establish a graduate (bachelor) course in 1977, and the reluctance of politicians and entrepreneurs to establish nursing institutions. Many challenges with the implementation of nursing policies are attributable to social, cultural, religious, and historical factors. For example, Hindus considered touching the bodily excretions as the task of the lower castes, while Muslims considered women touching the body of the men immoral. Nurses also face governance challenges linked with their performance and reward. For example, nurses have little voice over the decisions related to their profession, and they are not allowed to perform clinical duties unsupervised. To improve the situation, the government has made new policies, including upliftment of nurses' position in public service, the creation of an independent Directorate General, and improvement of nursing education and service. New policies often come with new apprehensions. Therefore, nurses should be included in the policy processes, and their capacity should be developed in nursing leadership and health system governance.

Making information and communications technologies (ICTs) work for health: protocol for a mixed-methods study exploring processes for institutionalising geo-referenced health information systems to strengthen maternal neonatal and child health (MNCH) service planning, referral and oversight in urban Bangladesh

INTRODUCTION

Disparities in health outcomes and access to maternal neonatal and child health (MNCH) are apparent among urban poor compared with national, rural or urban averages. A fundamental first step in addressing inequities in MNCH services is knowing what services exist in urban areas, where these are located, who provides them and who uses them. This study aims to institutionalise the Urban Health Atlas (UHA)-a novel information and communications technology (ICT) tool-to strengthen health service delivery and oversight and generate critical evidence to inform health policy and planning in urban Bangladesh.

METHODS AND ANALYSIS

This mixed-method implementation research will be conducted in four purposively selected urban sites representing larger and smaller cities. Research activities will include an assessment of information needs and task review analysis of information users, stakeholder mapping and cost estimation. To document stakeholder perceptions and experiences, key informant interviews and in-depth interviews will be conducted along with desk reviews to understand MNCH planning and referral decisions. The UHA will be refined to increase responsiveness to user needs and capacities, and hands-on training will be provided to health managers. Cost estimation will be conducted to assess the financial implications of UHA uptake and scale-up. Systematic documentation of the implementation process will be undertaken. Policy decision-making and ICT health policy process flowcharts will be prepared using desk reviews and qualitative interviews. Thematic analysis of qualitative data will involve both emergent and a priori coding guided by WHO PATH toolkit and Policy Engagement Framework. Stakeholder analysis will apply standard techniques and measurement scales. Descriptive analysis of quantitative data and cost estimation analysis will also be performed.

ETHICS AND DISSEMINATION

The study has been approved by the Institutional Review Board of icddr,b (# PR-16057). Study findings will be disseminated through national and international workshops, conferences, policy briefs and peer-reviewed publications.

Postneonatal under-5 mortality in peri-urban and rural Eastern Uganda, 2005-2015

INTRODUCTION

Community and individual sociodemographic characteristics play an important role in child survival. However, a question remains how urbanisation and demographic changes in sub-Saharan Africa affect community-level determinants for child survival.

METHODS

Longitudinal data from the Iganga/Mayuge Health and Demographic Surveillance Site was used to obtain postneonatal under-5 mortality rates between March 2005 and February 2015 in periurban and rural areas separately. Multilevel survival analysis models were used to identify factors associated with mortality.

RESULTS

There were 43 043 postneonatal under-5 children contributing to 116 385 person years of observation, among whom 1737 died. Average annual crude mortality incidence rate (IR) differed significantly between periurban and rural areas (9.0 (8.1 to 10.0) per 1000 person-years vs 18.1 (17.1 to 19.0), respectively). In periurban areas, there was evidence for decreasing mortality from IR=11.3 (7.7 to 16.6) in 2006 to IR=4.5 (3.0 to 6.9) in 2015. The mortality fluctuated with no evidence for reduction in rural areas (IR=19.0 (15.8 to 22.8) in 2006; IR=15.5 (13.0 to 18.6) in 2015). BCG vaccination was associated with reduced mortality in periurban and rural areas (adjusted rate ratio (aRR)=0.45; 95% CI 0.30 to 0.67 and aRR=0.56; 95% CI 0.41 to 0.76, respectively). Maternal education level within the community was associated with reduced mortality in both periurban and rural sites (aRR=0.83; 95% CI 0.70 to 0.99; aRR=0.90; 95% CI 0.81 to 0.99). The proportion of households in the poorest quintile within the community was associated with mortality in rural areas only (aRR=1.08; 95% CI 1.00 to 1.18). In rural areas, a large disparity existed between the least poor and the poorest (aRR=0.50; 95% CI 0.27 to 0.92).

CONCLUSION

We found evidence for a mortality decline in peri-urban but not rural areas. Investments in the known key health (eg, vaccination) and socio-economic interventions (education, and economic development) continue to be crucial for mortality declines. Focused strategies to eliminate the disparity between wealth quintiles are also warranted. There may be equitable access to health services in peri-urban areas but improved metrics of socioeconomic position suitable for peri-urban residents may be needed.

A systematic assessment on COVID-19 preparedness and transition strategy in Bangladesh

RATIONALE, AIMS, AND OBJECTIVES

The COVID-19 pandemic of 2020 has overpowered the most advanced health systems worldwide with thousands of daily deaths. The current study conducted a situation analysis on the pandemic preparedness of Bangladesh and provided recommendations on the transition to the new reality and gradual restoration of normalcy.

METHOD

A complex adaptive system (CAS) framework was theorized based on four structural dimensions obtained from the crisis and complexity theory to help evaluate the health system of Bangladesh. Data sourced from published reports from the government, non-governmental organizations, and mainstream media up to June 15, 2020 were used to conduct a qualitative analysis and visualize the spatial distribution of countrywide COVID-19 cases.

RESULTS

The findings suggested that Bangladesh severely lacked the preparedness to tackle the spread of COVID-19 with both short- and long-term implications for health, the economy, and good governance. Absence of planning and coordination, disproportionate resource allocations, challenged infrastructure, adherence to bureaucratic delay, lack of synchronized risk communication, failing leadership of concerned authorities, and incoherent decision-making have led to a precarious situation that will have dire ramifications causing many uncertainties in the coming days.

CONCLUSIONS

Implementation of response protocols addressing the needs of the community and the stakeholders from the central level is urgently needed. The development of mechanisms for dynamic decision-making based on regular feedback and long-term planning for a smooth transition between the new reality and normalcy should also be urgently addressed in Bangladesh.

Predictors of health facility readiness for diabetes service delivery in low- and middle-income countries: The case of Bangladesh

AIMS

We aimed to evaluate the readiness and predictors of diabetes service capability at the level of primary care in Bangladesh as an illustrative instance of readiness for diabetes care in low- and middle-income countries (LMICs).

METHODS

We used data from the 2014 Bangladesh Health Facility Survey (BHFS), a cross-sectional, nationally representative survey (n = 1596 health facilities). We constructed a diabetes-specific readiness index to assess diabetes service readiness in facilities with outpatient capability and used multivariable regression analysis to evaluate contextual predictors of diabetes service readiness.

RESULTS

Three-hundred and forty-five facilities with outpatient and diabetes service capability were included. Mean readiness for diabetes service capability on a scale of 0-100 was 24.9 (95%CI: 20.8-28.9) and was lowest in rural settings, districts with high social deprivation, and public facilities, where diabetes diagnostic equipment and medications were largely unavailable. Facility type was the strongest, independent predictor of diabetes service readiness.

CONCLUSIONS

Diabetes service readiness in outpatient facilities in Bangladesh was low, particularly in public facilities, rural settings, and districts with high social deprivation. .These findings could inform policies aimed at improving diabetes care in areas of high unmet need and may serve as a model to assess diabetes service readiness in other LMICs.

Effect of unintended pregnancy on skilled antenatal care uptake in Bangladesh: analysis of national survey data

Background

Around 48% of all pregnancies in low- and middle-income countries are unintended. Unintended pregnancy may contribute to lower use of antenatal care (ANC); however, current research in the area is largely inconclusive due to the methodological approaches applied.

Methods

Responses from 4493 women extracted from the 2014 Bangladesh Demographic and Health Survey (BDHS) were used to assess the association between unintended pregnancy and subsequent uptake of at least one and at least four skilled ANC visits. For this, Bayesian multilevel logistic regression models with informative priors (representing a range of values within which the researcher is certain the true effect of the parameters included lies) were used, adjusting for other factors that affect ANC uptake. Informative priors were selected from the BDHS data collected in 2004, 2007, and 2011.

Results

Around 64% of women in Bangladesh who had at least one pregnancy within 3 years prior to the survey (that ended in a live birth) received ANC at least once, and of these around 32% used ANC at least four times. Mistimed (aOR, 0.73, 95% Cred I, 0.66–0.81) and unwanted (aOR, 0.69, 95% Cred I, 0.64–0.75) pregnancy were associated with reduced odds of attending the recommended minimum of four skilled ANC visits compared with wanted pregnancy. These likelihoods were even lower for at least one skilled ANC visit among women with a mistimed (aOR, 0.59, 95% Cred I, 0.53–0.65) or an unwanted pregnancy (aOR, 0.67, 95% Cred I, 0.61–0.74) than women with a wanted pregnancy.

Conclusions

In Bangladesh, more than one-quarter of women who report an unintended pregnancy at conception and do not terminate the pregnancy are at high risk of not using ANC. It is important for policies to include women with unintended pregnancy in mainstream healthcare services. This will increase the use of ANC and reduce associated adverse consequences.