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Sujon H, Sarker MHR, Uddin A, Banu S, Islam MR, Amin MR, Hossain MS, Alahi MF, Asaduzzaman M, Rizvi SJR, Islam MZ, Uzzaman MN. Beyond the regulatory radar: knowledge and practices of rural medical practitioners in Bangladesh. BMC Health Serv Res 2023; 23:1322. [PMID: 38037022 PMCID: PMC10688090 DOI: 10.1186/s12913-023-10317-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 11/14/2023] [Indexed: 12/02/2023] Open
Abstract
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.
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Affiliation(s)
- Hasnat Sujon
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- Directorate General of Health Services, Ministry of Health and Family Welfare, Dhaka, Bangladesh
| | | | - Aftab Uddin
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- Public Health Foundation of Bangladesh, Dhaka, Bangladesh
- faith Bangladesh, Dhaka, Bangladesh
| | - Shakila Banu
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Mohammod Rafiqul Islam
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Md Ruhul Amin
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- Translational Biology, Medicine, and Health Graduate Programme, Virginia Polytechnic Institute and State University, Blacksburg, VA, USA
| | - Md Shabab Hossain
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Md Fazle Alahi
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Mohammad Asaduzzaman
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | | | - Mohammad Zahirul Islam
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- The University of Queensland, Brisbane, Australia
| | - Md Nazim Uzzaman
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- Usher Institute, The University of Edinburgh, Edinburgh, UK
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Muurlink O, Uzzaman N, Boorman RJ, Binte Kibria S, Best T, Taylor-Robinson AW. Village doctors: a national telephone survey of Bangladesh's lay medical practitioners. BMC Health Serv Res 2023; 23:964. [PMID: 37679729 PMCID: PMC10486006 DOI: 10.1186/s12913-023-09972-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 08/26/2023] [Indexed: 09/09/2023] Open
Abstract
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.
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Affiliation(s)
| | | | | | | | | | - Andrew W. Taylor-Robinson
- College of Health Sciences, VinUniversity, Hanoi, 100000 Vietnam
- Center for Global Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104 USA
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Akter K, Kuddus A, Jeny T, Nahar T, Shaha S, Ahmed N, King C, Pires M, Haghparast-Bidgoli H, Azad K, Fottrell E, Morrison J. Stakeholder perceptions on scaling-up community-led interventions for prevention and control of non-communicable diseases in Bangladesh: a qualitative study. BMC Public Health 2023; 23:719. [PMID: 37081438 PMCID: PMC10116471 DOI: 10.1186/s12889-023-15551-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 03/28/2023] [Indexed: 04/22/2023] Open
Abstract
BACKGROUND Engaging communities is an important component of multisectoral action to address the growing burden of non-communicable diseases (NCDs) in low- and middle-income countries. We conducted research with non-communicable disease stakeholders in Bangladesh to understand how a community-led intervention which was shown to reduce the incidence of type 2 diabetes in rural Bangladesh could be scaled-up. METHODS We purposively sampled any actor who could have an interest in the intervention, or that could affect or be affected by the intervention. We interviewed central level stakeholders from donor agencies, national health policy levels, public, non-governmental, and research sectors to identify scale-up mechanisms. We interviewed community health workers, policy makers, and non-governmental stakeholders, to explore the feasibility and acceptability of implementing the suggested mechanisms. We discussed scale-up options in focus groups with community members who had attended a community-led intervention. We iteratively developed our data collection tools based on our analysis and re-interviewed some participants. We analysed the data deductively using a stakeholder analysis framework, and inductively from codes identified in the data. RESULTS Despite interest in addressing NCDs, there was a lack of a clear community engagement strategy at the government level, and most interventions have been implemented by non-governmental organisations. Many felt the Ministry of Health and Family Welfare should lead on community engagement, and NCD screening and referral has been added to the responsibilities of community health workers and health volunteers. Yet there remains a focus on reproductive health and NCD diagnosis and referral instead of prevention at the community level. There is potential to engage health volunteers in community-led interventions, but their present focus on engaging women for reproductive health does not fit with community needs for NCD prevention. CONCLUSIONS Research highlighted the need for a preventative community engagement strategy to address NCDs, and the potential to utilise existing cadres to scale-up community-led interventions. It will be important to work with key stakeholders to address gender issues and ensure flexibility and responsiveness to community concerns. We indicate areas for further implementation research to develop scaled-up models of community-led interventions to address NCDs.
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Affiliation(s)
- Kohenour Akter
- Diabetic Association of Bangladesh - Centre for Health Research and Implementation (BADAS-CHRI), BIRDEM, Ramna, Dhaka, 1000, Bangladesh
| | - Abdul Kuddus
- Diabetic Association of Bangladesh - Centre for Health Research and Implementation (BADAS-CHRI), BIRDEM, Ramna, Dhaka, 1000, Bangladesh
| | - Tasnova Jeny
- Diabetic Association of Bangladesh - Centre for Health Research and Implementation (BADAS-CHRI), BIRDEM, Ramna, Dhaka, 1000, Bangladesh
| | - Tasmin Nahar
- Diabetic Association of Bangladesh - Centre for Health Research and Implementation (BADAS-CHRI), BIRDEM, Ramna, Dhaka, 1000, Bangladesh
| | - Sanjit Shaha
- Diabetic Association of Bangladesh - Centre for Health Research and Implementation (BADAS-CHRI), BIRDEM, Ramna, Dhaka, 1000, Bangladesh
| | - Naveed Ahmed
- Diabetic Association of Bangladesh - Centre for Health Research and Implementation (BADAS-CHRI), BIRDEM, Ramna, Dhaka, 1000, Bangladesh
| | - Carina King
- Karolinska Institutet, K9 Global Folkhälsa, K9 GPH Stålsby Lundborg Alfvén, Stockholm, 171 77, Sweden
| | - Malini Pires
- UCL Institute for Global Health, 30 Guilford Street, London, WC1N 1EH, UK
| | | | - Kishwar Azad
- Diabetic Association of Bangladesh - Centre for Health Research and Implementation (BADAS-CHRI), BIRDEM, Ramna, Dhaka, 1000, Bangladesh
| | - Edward Fottrell
- UCL Institute for Global Health, 30 Guilford Street, London, WC1N 1EH, UK
| | - Joanna Morrison
- UCL Institute for Global Health, 30 Guilford Street, London, WC1N 1EH, UK.
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Coombs NC, Campbell DG, Caringi J. A qualitative study of rural healthcare providers’ views of social, cultural, and programmatic barriers to healthcare access. BMC Health Serv Res 2022; 22:438. [PMID: 35366860 PMCID: PMC8976509 DOI: 10.1186/s12913-022-07829-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 03/21/2022] [Indexed: 11/24/2022] Open
Abstract
Background Ensuring access to healthcare is a complex, multi-dimensional health challenge. Since the inception of the coronavirus pandemic, this challenge is more pressing. Some dimensions of access are difficult to quantify, namely characteristics that influence healthcare services to be both acceptable and appropriate. These link to a patient’s acceptance of services that they are to receive and ensuring appropriate fit between services and a patient’s specific healthcare needs. These dimensions of access are particularly evident in rural health systems where additional structural barriers make accessing healthcare more difficult. Thus, it is important to examine healthcare access barriers in rural-specific areas to understand their origin and implications for resolution. Methods We used qualitative methods and a convenience sample of healthcare providers who currently practice in the rural US state of Montana. Our sample included 12 healthcare providers from diverse training backgrounds and specialties. All were decision-makers in the development or revision of patients’ treatment plans. Semi-structured interviews and content analysis were used to explore barriers–appropriateness and acceptability–to healthcare access in their patient populations. Our analysis was both deductive and inductive and focused on three analytic domains: cultural considerations, patient-provider communication, and provider-provider communication. Member checks ensured credibility and trustworthiness of our findings. Results Five key themes emerged from analysis: 1) a friction exists between aspects of patients’ rural identities and healthcare systems; 2) facilitating access to healthcare requires application of and respect for cultural differences; 3) communication between healthcare providers is systematically fragmented; 4) time and resource constraints disproportionately harm rural health systems; and 5) profits are prioritized over addressing barriers to healthcare access in the US. Conclusions Inadequate access to healthcare is an issue in the US, particularly in rural areas. Rural healthcare consumers compose a hard-to-reach patient population. Too few providers exist to meet population health needs, and fragmented communication impairs rural health systems’ ability to function. These issues exacerbate the difficulty of ensuring acceptable and appropriate delivery of healthcare services, which compound all other barriers to healthcare access for rural residents. Each dimension of access must be monitored to improve patient experiences and outcomes for rural Americans.
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Mahmood SS, Hasan MZ, Hasan AMR, Rabbani MG, Begum F, Yousuf TB, Hanifi SMA, Reidpath DD, Rasheed S. Health system impact of COVID-19 on urban slum population of Bangladesh: a mixed-method rapid assessment study. BMJ Open 2022; 12:e057402. [PMID: 35197355 PMCID: PMC8882639 DOI: 10.1136/bmjopen-2021-057402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVE We aimed to rapidly assess the health system impact of COVID-19 in the urban slums of Bangladesh. DESIGN Setting and participantsA cross-sectional survey among 476 households was conducted during October-December 2020 in five selected urban slums of Dhaka North, Dhaka South and Gazipur City Corporation. In-depth interviews with purposively selected 22 slum dwellers and key informant interviews with 16 local healthcare providers and four policymakers and technical experts were also conducted. OUTCOME MEASURES Percentage of people suffering from general illness, percentage of people suffering from chronic illness, percentage of people seeking healthcare, percentage of people seeking maternal care, health system challenges resulting from COVID-19. RESULTS About 12% of members suffered from general illness and 25% reported chronic illness. Over 80% sought healthcare and the majority sought care from informal healthcare providers. 39% of the recently delivered women sought healthcare in 3 months preceding the survey. An overall reduction in healthcare use was reported during the lockdown period compared with prepandemic time. Mismanagement and inefficient use of resources were reported as challenges of health financing during the pandemic. Health information sharing was inadequate at the urban slums, resulting from the lack of community and stakeholder engagement (51% received COVID-19-related information, 49% of respondents knew about the national hotline number for COVID-19 treatment). Shortage of human resources for health was reported to be acute during the pandemic, resulting from the shortage of specialist doctors and uneven distribution of health workforce. COVID-19 test was inadequate due to the lack of adequate test facilities and stigma associated with COVID-19. Lack of strong leadership and stakeholder engagement was seen as the barriers to effective pandemic management. CONCLUSION The findings of the current study are expected to support the government in tailoring interventions and allocating resources more efficiently and timely during a pandemic.
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Affiliation(s)
| | - Md Zahid Hasan
- Health Systems and Population Studies Division, icddr,b, Dhaka, Bangladesh
| | - A M Rumayan Hasan
- Health Systems and Population Studies Division, icddr,b, Dhaka, Bangladesh
| | - Md Golam Rabbani
- Health Systems and Population Studies Division, icddr,b, Dhaka, Bangladesh
| | - Farzana Begum
- Health Systems and Population Studies Division, icddr,b, Dhaka, Bangladesh
| | - Tariq Bin Yousuf
- Urban Resilience Project, Dhaka North City Corporation, Dhaka, Bangladesh
| | | | - Daniel D Reidpath
- Health Systems and Population Studies Division, icddr,b, Dhaka, Bangladesh
| | - Sabrina Rasheed
- Health Systems and Population Studies Division, icddr,b, Dhaka, Bangladesh
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6
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Lam TT, Dang DA, Tran HH, Do DV, Le H, Negin J, Jan S, Marks GB, Nguyen TA, Fox GJ, Beardsley J. What are the most effective community-based antimicrobial stewardship interventions in low- and middle-income countries? A narrative review. J Antimicrob Chemother 2021; 76:1117-1129. [PMID: 33491090 DOI: 10.1093/jac/dkaa556] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Antimicrobial resistance (AMR) is a major global issue and antimicrobial stewardship is central to tackling its emergence. The burden of AMR disproportionately impacts low- and middle-income countries (LMICs), where capacity for surveillance and management of resistant pathogens is least developed. Poorly regulated antibiotic consumption in the community is a major driver of AMR, especially in LMICs, yet community-based interventions are neglected in stewardship research, which is often undertaken in high-income settings and/or in hospitals. We reviewed the evidence available to researchers and policymakers testing or implementing community-based antimicrobial stewardship strategies in LMICs. We critically appraise that evidence, deliver recommendations and identify outstanding areas of research need. We find that multifaceted, education-focused interventions are likely most effective in our setting. We also confirm that the quality and quantity of community-based stewardship intervention research is limited, with research on microbiological, clinical and economic sustainability most urgently needed.
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Affiliation(s)
- Thanh Tuan Lam
- The Woolcock Institute of Medical Research, Kim Ma, Ha Noi, Vietnam
| | - Duc Anh Dang
- National Institute of Hygiene and Epidemiology, Hai Ba Trung, Hanoi, Vietnam
| | - Huy Hoang Tran
- National Institute of Hygiene and Epidemiology, Hai Ba Trung, Hanoi, Vietnam
| | - Dung Van Do
- The University of Medicine and Pharmacy, Hong Bang, Q5, Ho Chi Minh City, Vietnam
| | - Hien Le
- The Woolcock Institute of Medical Research, Kim Ma, Ha Noi, Vietnam
| | - Joel Negin
- The Sydney School of Public Health, University of Sydney, NSW 2006, Australia
| | - Stephen Jan
- The George Institute for Global Health, Sydney, NSW 2042, Australia
| | - Guy B Marks
- The University of New South Wales, Sydney, NSW 2052, Australia
| | - Thu Anh Nguyen
- The Woolcock Institute of Medical Research, Kim Ma, Ha Noi, Vietnam.,The Central Clinical School, The Faculty of Medicine and Health, The University of Sydney, NSW 2006, Australia
| | - Greg J Fox
- The Woolcock Institute of Medical Research, Kim Ma, Ha Noi, Vietnam.,The Central Clinical School, The Faculty of Medicine and Health, The University of Sydney, NSW 2006, Australia
| | - Justin Beardsley
- The Marie Bashir Institute, Westmead Institute for Medical Research, The University of Sydney, NSW 2145, Australia.,Oxford University Clinical Research Unit, Vo Van Kiet, Q5, Ho Chi Minh City, Vietnam
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Rahman AE, Mhajabin S, Dockrell D, Nair H, El Arifeen S, Campbell H. Managing pneumonia through facility-based integrated management of childhood management (IMCI) services: an analysis of the service availability and readiness among public health facilities in Bangladesh. BMC Health Serv Res 2021; 21:667. [PMID: 34229679 PMCID: PMC8260350 DOI: 10.1186/s12913-021-06659-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 06/02/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND With an estimated 24,000 deaths per year, pneumonia is the single largest cause of death among young children in Bangladesh, accounting for 18% of all under-5 deaths. The Government of Bangladesh adopted the WHO recommended Integrated Management of Childhood Illness (IMCI)-strategy in 1998 for outpatient management of pneumonia, which was scaled-up nationally by 2014. This paper reports the service availability and readiness related to IMCI-based pneumonia management in Bangladesh. We conducted a secondary analysis of the Bangladesh Health Facility Survey-2017, which was conducted with a nationally representative sample including all administrative divisions and types of health facilities. We limited our analysis to District Hospitals (DHs), Maternal and Child Welfare Centres (MCWCs), Upazila (sub-district) Health Complexes (UHCs), and Union Health and Family Welfare Centres (UH&FWCs), which are mandated to provide IMCI services. Readiness was reported based on 10 items identified by national experts as 'essential' for pneumonia management. RESULTS More than 90% of DHs and UHCs, and three-fourths of UH&FWCs and MCWCs provide IMCI-based pneumonia management services. Less than two-third of the staff had ever received IMCI-based pneumonia training. Only one-third of the facilities had a functional ARI timer or a watch able to record seconds on the day of the visit. Pulse oximetry was available in 27% of the district hospitals, 18% of the UHCs and none of the UH&FWCs. Although more than 80% of the facilities had amoxicillin syrup or dispersible tablets, only 16% had injectable gentamicin. IMCI service registers were not available in nearly one-third of the facilities and monthly reporting forms were not available in around 10% of the facilities. Only 18% of facilities had a high-readiness (score 8-10), whereas 20% had a low-readiness (score 0-4). The readiness was significantly poorer among rural and lower level facilities (p < 0.001). Seventy-two percent of the UHCs had availability of one of any of the four oxygen sources (oxygen concentrators, filled oxygen cylinder with flowmeter, filled oxygen cylinder without flowmeter, and oxygen distribution system) followed by DHs (66%) and MCWCs (59%). CONCLUSION There are substantial gaps in the readiness related to IMCI-based pneumonia management in public health facilities in Bangladesh. Since pneumonia remains a major cause of child death nationally, Bangladesh should make a substantial effort in programme planning, implementation and monitoring to address these critical gaps to ensure better provision of essential care for children suffering from pneumonia.
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Affiliation(s)
- Ahmed Ehsanur Rahman
- University of Edinburgh, Edinburgh, UK.
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh.
| | - Shema Mhajabin
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | | | | | - Shams El Arifeen
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
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8
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Ban B, Hodgins S, Thapa P, Thapa S, Joshi D, Dhungana A, Kc A, Guenther T, Adhikari S, Scudder E, Ram PK. A national survey of private-sector outpatient care of sick infants and young children in Nepal. BMC Health Serv Res 2020; 20:545. [PMID: 32546276 PMCID: PMC7298835 DOI: 10.1186/s12913-020-05393-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 06/03/2020] [Indexed: 12/28/2022] Open
Abstract
Background Previous research has documented that across South Asia, as well as in some countries in Sub-Saharan Africa, the private sector is the primary source of outpatient care for sick infants and children and, in many settings, informal providers play a bigger role than credentialed health professionals (particularly for the poorer segments of the population). This is the case in Nepal. This study sought to characterize medicine shop-based service providers in rural areas and small urban centers in Nepal, their role in the care and treatment of sick infants and children (with a particular focus on infants aged < 2 months), and the quality of the care provided. A secondary objective was to characterize availability and quality of such care provided by physicians in these settings. Methods A nationally representative sample of medicine shops was drawn, in rural settings and small urban centers in Nepal, from 25 of the 75 districts in Nepal, using multi-stage cluster methodology, with a final sample of 501 shops and 82 physician-run clinics. Face-to-face interviews were conducted. Results Most medicine shops outside urban areas were not registered with the Department of Drug Administration (DDA). Most functioned as de facto clinics, with credentialed paramedical workers (having 2–3 years of training) diagnosing patients and making treatment decisions. Such a role falls outside their formally sanctioned scope of practice. Quality of care problems were identified among medicine shop-based providers and physicians, including over-use of antibiotics for treating diarrhea, inaccurate weighing technique to determine antibiotic dose, and inappropriate use of injectable steroids for treating potentially severe infections in young infants. Conclusions Medicine shop-based practitioners in Nepal represent a particular type of informal provider; although most have recognized paramedical credentials, they offer services falling outside their formal scope of practice. Nevertheless, given the large proportion of the population served by these practitioners, engagement to strengthen quality of care by these providers and referral to the formal health sector is warranted.
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Affiliation(s)
- Bharat Ban
- Independent consultant, Kathmandu, Nepal.,Save the Children, Washington, D.C., USA
| | - Stephen Hodgins
- Save the Children, Washington, D.C., USA. .,School of Public Health, Univ. of Alberta, Edmonton, Canada.
| | | | | | - Deepak Joshi
- Save the Children, Washington, D.C., USA.,USAID's Maternal & Child Survival Program, Washington, D.C., USA
| | - Adhish Dhungana
- Save the Children, Washington, D.C., USA.,USAID's Maternal & Child Survival Program, Washington, D.C., USA
| | - Anjana Kc
- Save the Children, Washington, D.C., USA.,USAID's Maternal & Child Survival Program, Washington, D.C., USA
| | - Tanya Guenther
- Save the Children, Washington, D.C., USA.,, Dili, Timor-Leste
| | - Shilu Adhikari
- USAID, Kathmandu, Nepal.,UNFPA, Honiara, Solomon Islands
| | - Elaine Scudder
- Save the Children, Washington, D.C., USA.,USAID's Maternal & Child Survival Program, Washington, D.C., USA
| | - Pavani K Ram
- USAID, Washington, D.C., USA.,University at Buffalo, Buffalo, New York, USA
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Applegate JA, Ahmed S, Harrison M, Callaghan-Koru J, Mousumi M, Begum N, Moin MI, Joarder T, Ahmed S, George J, Mitra DK, Ahmed ASMNU, Shahidullah M, Baqui AH. Caregiver acceptability of the guidelines for managing young infants with possible serious bacterial infections (PSBI) in primary care facilities in rural Bangladesh. PLoS One 2020; 15:e0231490. [PMID: 32287286 PMCID: PMC7156040 DOI: 10.1371/journal.pone.0231490] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 03/24/2020] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Many infants with possible serious bacterial infections (PSBI) do not receive inpatient treatment because hospital care may not be affordable, accessible, or acceptable for families. In 2015, WHO issued guidelines for managing PSBI in young infants (0-59 days) with simpler antibiotic regimens when hospital care is not feasible. Bangladesh adopted WHO's guidelines for implementation in outpatient primary health centers. We report results of an implementation research study that assessed caregiver acceptability of the guidelines in three rural sub-districts of Bangladesh during early implementation (October 2015-August 2016). METHODS We included 19 outpatient primary health centers involved in the initial rollout of the infection management guidelines. We extracted data for all PSBI cases (N = 192) from facility registers to identify gaps in referral feasibility, simplified antibiotic treatment, and follow-up. Focus group discussions (FGD) and in-depth interviews (IDI) were conducted with both caregivers (6 FGDs; 23 IDIs) and providers (2 FGDs; 28 IDIs) to assess caregiver acceptability of the guidelines. RESULTS Referral to the hospital was not feasible for many families (83.3%; N = 160/192) and acceptance varied by infection severity. Barriers to referral feasibility included economic and household factors, and previous experiences with poor quality of care at the sub-district hospital. Conversely, providers and caregivers indicated high acceptability of simplified antibiotic treatment. 80% (N = 96/120) of infants with clinical severe infection for whom referral was not feasible returned to the facility for the second antibiotic injection. Some providers reported developing local solutions-including engaging informal providers in treatment of the infant-to address organizational barriers and promote treatment compliance. Follow-up of young infants receiving simplified treatment is critical, but only 67.4% (N = 87/129) of infants received fourth day follow-up. Some providers' reported deviations from the guidelines that shifted responsibility of follow-up to the caregiver, which may have contributed to lapses. CONCLUSION Caregivers' perception of trust and communication with providers were influential in caregiver acceptability of care. Few caregivers accepted referral to the sub-district hospital, suggesting low acceptability of this option. When referral was not feasible, many caregivers reported satisfaction with simplified antibiotic treatment. Local solutions described by providers require further examination in this context to assess the safety and potential value of these strategies in outpatient treatment. Our findings suggest strengthening providers' interpersonal skills could improve caregiver acceptability of the guidelines.
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Affiliation(s)
- Jennifer A. Applegate
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | | | - Meagan Harrison
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Jennifer Callaghan-Koru
- Department of Sociology, Anthropology, and Health Administration and Policy, University of Maryland, Baltimore County, Baltimore, Maryland, United States of America
| | | | - Nazma Begum
- Johns Hopkins University-Bangladesh, Dhaka, Bangladesh
| | | | - Taufique Joarder
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Sabbir Ahmed
- USAID’s MaMoni Health Systems Strengthening Project, Save the Children, Washington, DC, United States of America
| | - Joby George
- USAID’s MaMoni Health Systems Strengthening Project, Save the Children, Washington, DC, United States of America
| | - Dipak K. Mitra
- Department of Public Health, School of Health and Life Sciences, North South University, Dhaka, Bangladesh
| | | | - Mohammod Shahidullah
- Department of Neonatology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh
| | - Abdullah H. Baqui
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
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