A quantitative assessment of natural and anthropogenic effects on the occurrence of high air pollution loading in Dhaka and neighboring cities and health consequences

Although existing studies mainly focused on the air quality status in Bangladesh, quantifying the natural and manmade effects, the frequency of high pollution levels, and the associated health risks remained beyond detailed investigation. Air quality and meteorological data from the Department of Environment for 2012-2019 were analyzed, attempting to answer those questions. Cluster analysis of PM2.5, PM10, and gaseous pollutants implied that Dhaka and neighboring cities, Narayangonj and Gazipur, are from similar sources compared to the other major cities in the country. Apart from the transboundary sources, land use types and climate parameters unevenly affected local pollution loadings across city domains. The particulate concentrations persistently remained above the national standard for almost half the year, with the peaks during the dry months. Even though nitrogen oxides remained high in all three cities, other gaseous pollutants, such as CO and O3, except SO2, showed elevated concentrations solely in Dhaka city. Concentrations of gaseous pollutants in Dhaka vary spatially, but no statistical differences could be discerned between the working days and holidays. Frequency analysis results and hazard quotients revealed the likelihood of adverse health outcomes in Narayangonj ensuing from particulate exposures surpasses the other cities for different age, gender, and occupation groups. Nonetheless, school-aged children and construction workers were most at risk from chronic exposure to gaseous pollutants mostly in Dhaka. One limitation of this study was that the routine air quality monitoring happens just from five sites, making the evidence-based study concerning health outcomes quite challenging.

Dhaka city water logging hazards: area identification and vulnerability assessment through GIS-remote sensing techniques

Water logging is one of the most detrimental phenomena continuing to burden Dhaka dwellers. This study aims to spatio-temporarily identify the water logging hazard zones within Dhaka Metropolitan area and assess the extent of their water logging susceptibility based on informal settlements, built-up areas, and demographical characteristics. The study utilizes integrated geographic information system (GIS)-remote sensing (RS) methods, using the Normalized Difference Vegetation Water and Moisture Index, distance buffer zone from drainage streams, and built-up distributions to identify waterlogged zones with a temporal extent, incorporating social and infrastructural attributes to evaluate water logging effects. These indicators were integrated into an overlay GIS method to measure the vulnerability level across Dhaka city areas. The findings reveal that south and south-western parts of Dhaka were more susceptible to water logging hazards. Almost 35% of Dhaka belongs to the high/very highly vulnerable zone. Greater number of slum households were found within high to very high water logging vulnerable zones and approximately 70% of them are poorly structured. The built-up areas were observed to be increased toward the northern part of Dhaka and were exposed to severe water logging issues. The overall findings reveal the spatio-temporal distribution of the water logging vulnerabilities across the city as well as its impact on the social indicators. An integrated approach is necessary for future development plans to mitigate the risk of water logging.

Synthesizing the links between secure housing tenure and health for more equitable cities

Millions of households in rich and poor countries alike are at risk of being unwilfully displaced from their homes or the land on which they live (i.e., lack secure tenure), and the urban poor are most vulnerable. Improving housing tenure security may be an intervention to improve housing and environmental conditions and reduce urban health inequalities. Building on stakeholder workshops and a narrative review of the literature, we developed a conceptual model that infers the mechanisms through which more secure housing tenure can improve housing, environmental quality, and health. Empirical studies show that more secure urban housing tenure can boost economic mobility, improve housing and environmental conditions including reduced exposure to pollution, create safer and more resourced communities, and improve physical and mental health. These links are shared across tenure renters and owners and different economic settings. Broader support is needed for context-appropriate policies and actions to improve tenure security as a catalyst for cultivating healthier homes and neighbourhoods and reducing urban health inequalities in cities.

The effects of social determinants on children's health outcomes in Bangladesh slums through an intersectionality lens: An application of multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA)

Empirical evidence suggests that the health outcomes of children living in slums are poorer than those living in non-slums and other urban areas. Improving health especially among children under five years old (U5y) living in slums, requires a better understanding of the social determinants of health (SDoH) that drive their health outcomes. Therefore, we aim to investigate how SDoH collectively affects health outcomes of U5y living in Bangladesh slums through an intersectionality lens. We used data from the most recent national Urban Health Survey (UHS) 2013 covering urban populations in Dhaka, Chittagong, Khulna, Rajshahi, Barisal, Sylhet, and Rangpur divisions. We applied multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) to estimate the Discriminatory Accuracy (DA) of the intersectional effects estimates using Variance Partition Coefficient (VPC) and the Area Under the Receiver Operating Characteristic Curve (AUC-ROC). We also assessed the Proportional Change in Variance (PCV) to calculate intersectional effects. We considered three health outcomes: cough, fever, and acute respiratory infections (ARI) in U5y.We found a low DA for cough (VPC = 0.77%, AUC-ROC = 61.90%), fever (VPC = 0.87%, AUC-ROC = 61.89%) and ARI (VPC = 1.32%, AUC-ROC = 66.36%) of intersectional strata suggesting that SDoH considered do not collectively differentiate U5y with a health outcome from those with and without a health outcome. The PCV for cough (85.90%), fever (78.42%) and ARI (69.77%) indicates the existence of moderate intersectional effects. We also found that SDoH factors such as slum location, mother's employment, age of household head, and household's garbage disposal system are associated with U5y health outcomes. The variables used in this analysis have low ability to distinguish between those with and without health outcomes. However, the existence of moderate intersectional effect estimates indicates that U5y in some social groups have worse health outcomes compared to others. Therefore, policymakers need to consider different social groups when designing intervention policies aimed to improve U5y health outcomes in Bangladesh slums.

The economics of healthcare access: a scoping review on the economic impact of healthcare access for vulnerable urban populations in low- and middle-income countries

BACKGROUND

The growing urban population imposes additional challenges for health systems in low- and middle-income countries (LMICs). We explored the economic burden and inequities in healthcare utilisation across slum, non-slum and levels of wealth among urban residents in LMICs.

METHODS

This scoping review presents a narrative synthesis and descriptive analysis of studies conducted in urban areas of LMICs. We categorised studies as conducted only in slums, city-wide studies with measures of wealth and conducted in both slums and non-slums settlements. We estimated the mean costs of accessing healthcare, the incidence of catastrophic health expenditures (CHE) and the progressiveness and equity of health expenditures. The definitions of slums used in the studies were mapped against the 2018 UN-Habitat definition. We developed an evidence map to identify research gaps on the economics of healthcare access in LMICs.

RESULTS

We identified 64 studies for inclusion, the majority of which were from South-East Asia (59%) and classified as city-wide (58%). We found severe economic burden across health conditions, wealth quintiles and study types. Compared with city-wide studies, slum studies reported higher direct costs of accessing health care for acute conditions and lower costs for chronic and unspecified health conditions. Healthcare expenditures for chronic conditions were highest amongst the richest wealth quintiles for slum studies and more equally distributed across all wealth quintiles for city-wide studies. The incidence of CHE was similar across all wealth quintiles in slum studies and concentrated among the poorest residents in city-wide studies. None of the definitions of slums used covered all characteristics proposed by UN-Habitat. The evidence map showed that city-wide studies, studies conducted in India and studies on unspecified health conditions dominated the current evidence on the economics of healthcare access. Most of the evidence was classified as poor quality.

CONCLUSIONS

Our findings indicated that city-wide and slums residents have different expenditure patterns when accessing healthcare. Financial protection schemes must consider the complexity of healthcare provision in the urban context. Further research is needed to understand the causes of inequities in healthcare expenditure in rapidly expanding and evolving cities in LMICs.

The Role of the Private Sector in the COVID-19 Pandemic: Experiences From Four Health Systems

As societies urbanize, their populations have become increasingly dependent on the private sector for essential services. The way the private sector responds to health emergencies such as the COVID-19 pandemic can determine the health and economic wellbeing of urban populations, an effect amplified for poorer communities. Here we present a qualitative document analysis of media reports and policy documents in four low resource settings-Bangladesh, Ghana, Nepal, Nigeria-between January and September 2020. The review focuses on two questions: (i) Who are the private sector actors who have engaged in the COVID-19 first wave response and what was their role?; and (ii) How have national and sub-national governments engaged in, and with, the private sector response and what have been the effects of these engagements? Three main roles of the private sector were identified in the review. (1) Providing resources to support the public health response. (2) Mitigating the financial impact of the pandemic on individuals and businesses. (3) Adjustment of services delivered by the private sector, within and beyond the health sector, to respond to pandemic-related business challenges and opportunities. The findings suggest that a combination of public-private partnerships, contracting, and regulation have been used by governments to influence private sector involvement. Government strategies to engage the private sector developed quickly, reflecting the importance of private services to populations. However, implementation of regulatory responses, especially in the health sector, has often been weak reflecting the difficulty governments have in ensuring affordable, quality private services. Lessons for future pandemics and other health emergencies include the need to ensure that essential non-pandemic health services in the government and non-government sector can continue despite elevated risks, surge capacity to minimize shortages of vital public health supplies is available, and plans are in place to ensure private workplaces remain safe and livelihoods protected.

Effects of social determinants on children's health in informal settlements in Bangladesh and Kenya through an intersectionality lens: a study protocol

INTRODUCTION

Several studies have shown that residents of urban informal settlements/slums are usually excluded and marginalised from formal social systems and structures of power leading to disproportionally worse health outcomes compared to other urban dwellers. To promote health equity for slum dwellers, requires an understanding of how their lived realities shape inequities especially for young children 0-4 years old (ie, under-fives) who tend to have a higher mortality compared with non-slum children. In these proposed studies, we aim to examine how key Social Determinants of Health (SDoH) factors at child and household levels combine to affect under-five health conditions, who live in slums in Bangladesh and Kenya through an intersectionality lens.

METHODS AND ANALYSIS

The protocol describes how we will analyse data from the Nairobi Cross-sectional Slum Survey (NCSS 2012) for Kenya and the Urban Health Survey (UHS 2013) for Bangladesh to explore how SDoH influence under-five health outcomes in slums within an intersectionality framework. The NCSS 2012 and UHS 2013 samples will consist of 2199 and 3173 under-fives, respectively. We will apply Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy approach. Some of SDoH characteristics to be considered will include those of children, head of household, mothers and social structure characteristics of household. The primary outcomes will be whether a child had diarrhoea, cough, fever and acute respiratory infection (ARI) 2 weeks preceding surveys.

ETHICS AND DISSEMINATION

The results will be disseminated in international peer-reviewed journals and presented in events organised by the Accountability and Responsiveness in Informal Settlements for Equity consortium and international conferences. Ethical approval was not required for these studies. Access to the NCSS 2012 has been given by Africa Population and Health Center and UHS 2013 is freely available.

An overview of progress towards implementation of solid waste management policies in Dhaka, Bangladesh

OBJECTIVES

Considering the increased solid waste generation and its management, this paper aims at reviewing and identifying the gaps and challenges in implementing the existing solid waste management relevant policies, strategies and action plans in Bangladesh for providing further strategic recommendations to establish a sustainable waste management system.

METHODS

This study adopted a multi-method approach by reviewing 24 policy/strategy documents; implementation gap analysis with extensive desk review and data obtained from the qualitative approach and co-production workshop. It allowed this study to capture the multidimensional and comprehensive scenario of waste management in Dhaka city.

RESULTS

Bangladesh has undergone reforms in solid waste management since 1983 with the adoption of the Dhaka City Corporation Ordinance and the enactment of the National 3R Strategy in 2010. With few exceptions, the overall waste management system cannot be defined as an effective comprehensive waste reduction, recycling and disposal mechanism based on global standards. Study found that several action plans have been introduced yet not all of those have proper implementation like adhering the waste segregation and recycling practices from households to landfill level. Lack of monitoring and coordination among the existing policy implementing agencies have emerged as significant concerns in Bangladesh.

CONCLUSION

Challenges in the implementation of pragmatic and improved policies and strategies should be addressed.

Synthesizing the links between secure housing tenure and health for more equitable cities

Millions of households in rich and poor countries alike are at risk of being unwilfully displaced from their homes or the land on which they live (i.e., lack secure tenure), and the urban poor are most vulnerable. Improving housing tenure security may be an intervention to improve housing and environmental conditions and reduce urban health inequalities. Building on stakeholder workshops and a narrative review of the literature, we developed a conceptual model that infers the mechanisms through which more secure housing tenure can improve housing, environmental quality, and health. Empirical studies show that more secure urban housing tenure can boost economic mobility, improve housing and environmental conditions including reduced exposure to pollution, create safer and more resourced communities, and improve physical and mental health. These links are shared across tenure renters and owners and different economic settings. Broader support is needed for context-appropriate policies and actions to improve tenure security as a catalyst for cultivating healthier homes and neighbourhoods and reducing urban health inequalities in cities.

Dhaka landfill waste practices: addressing urban pollution and health hazards

Two Dhaka, Bangladesh, landfills are explored to understand how management practices impact environmental quality and public health in the surrounding areas. A combination of research methods is used, such as geospatial buffer zone analysis, semi-structured observation checklist and qualitative interviews, to gain an understanding of the waste transportation, leachate percolation, and adverse health and environmental effects. A multi-ring buffer zone and ground truth method were applied through ArcMap for the spatial distribution of landfill-adjacent environmental features. Qualitative interviews were conducted with landfill officials and nearby residents. Findings reveal that landfills are situated very close to residential areas, water bodies and agricultural lands, exposing them to various health and environmental hazards. Improper solid waste management practices of the landfills cause adverse environmental effects by leachate percolation, waste incineration and vector breeding. Adjacent dwellers suffer from bronchial diseases, pneumonia, diarrhoea, itching problems, headache and appetite loss. The existing solid waste management system requires managerial and technical modifications to reduce the associated environmental pollution and health hazards.

Economics of healthcare access in low-income and middle-income countries: a protocol for a scoping review of the economic impacts of seeking healthcare on slum-dwellers compared with other city residents

INTRODUCTION

People living in slums face several challenges to access healthcare. Scarce and low-quality public health facilities are common problems in these communities. Costs and prevalence of catastrophic health expenditures (CHE) have also been reported as high in studies conducted in slums in developing countries and those suffering from chronic conditions and the poorest households seem to be more vulnerable to financial hardship. The COVID-19 pandemic may be aggravating the economic impact on the extremely vulnerable population living in slums due to the long-term consequences of the disease. The objective of this review is to report the economic impact of seeking healthcare on slum-dwellers in terms of costs and CHE. We will compare the economic impact on slum-dwellers with other city residents.

METHODS AND ANALYSIS

This scoping review adopts the framework suggested by Arksey and O'Malley. The review is part of the accountability and responsiveness of slum-dwellers (ARISE) research consortium, which aims to enhance accountability to improve the health and well-being of marginalised populations living in slums in India, Bangladesh, Sierra Leone and Kenya. Costs of accessing healthcare will be updated to 2020 prices using the inflation rates reported by the International Monetary Fund. Costs will be presented in International Dollars by using purchase power parity. The prevalence of CHE will also be reported.

ETHICS AND DISSEMINATION

Ethical approval is not required for scoping reviews. We will disseminate our results alongside the events organised by the ARISE consortium and international conferences. The final manuscript will be submitted to an open-access international journal. Registration number at the Research Registry: reviewregistry947.

Loops and Building Blocks: a Knowledge co-Production Framework for Equitable Urban Health

This paper sets out a structured process for the co-production of knowledge between researchers and societal partners and illustrates its application in an urban health equity project in Accra, Ghana. The main insight of this approach is that research and knowledge co-production is always partial, both in the sense of being incomplete, as well as being circumscribed by the interests of participating researchers and societal partners. A second insight is that project-bound societal engagement takes place in a broader context of public and policy debate. The approach to co-production described here is formed of three recursive processes: co-designing, co-analysing, and co-creating knowledge. These 'co-production loops' are themselves iterative, each representing a stage of knowledge production. Each loop is operationalized through a series of research and engagement practices, which we call building blocks. Building blocks are activities and interaction-based methods aimed at bringing together a range of participants involved in joint knowledge production. In practice, recursive iterations within loops may be limited due of constraints on time, resources, or attention. We suggest that co-production loops and building blocks are deployed flexibly.

Challenges and strategies in conducting sexual and reproductive health research among Rohingya refugees in Cox's Bazar, Bangladesh

Background

Rohingya diaspora or Forcibly Displaced Myanmar Nationals (FDMNs), took shelter in the refugee camps of Cox’s Bazar, Bangladesh due to armed conflict in the Rakhine state of Myanmar. In such humanitarian crises, delivering sexual and reproductive health (SRH) services is critical for better health outcomes of this most-at-risk population where more than half are adolescent girls and women. This is a reflective paper on challenges and related mitigation strategies to conduct SRH research among FDMNs. The research on which this paper is based employed a concurrent mixed-method design combining a cross-sectional survey and qualitative interviews and group discussions with FDMNs to understand their SRH needs and demand-side barriers. Assessment of health facilities and qualitative interviews with healthcare providers and key stakeholders were carried out to assess facility readiness and supply-side barriers.

Challenges and strategies

The researchers faced different challenges while conducting this study due to the unique characteristics of the FDMN population and the location of the refugee camps. The three key challenges researchers encountered include: sensitivity regarding SRH in the FDMNs, identifying appropriate sampling strategies, and community trust issues. The key approaches to overcome these challenges involved: actively engaging community members and gatekeepers in the data collection process to access respondents, identifying sensitive SRH issues through survey and exploring in-depth during qualitative interviews; and contextually modifying the sampling strategy.

Conclusion

Contextual adaptation of research methods and involving community and local key stakeholders in data collection are the key lessons learnt from this study. Another important lesson was researchers’ identity and positionality as a member of the host country may create distrust and suspicion among the refugees. The multi-level complexities of humanitarian settings may introduce unforeseen challenges and interrupt research plans at different stages of research which require timely and contextual adaptations.

Economic evaluation of culprit lesion only PCI vs. immediate multivessel PCI in acute myocardial infarction complicated by cardiogenic shock: the CULPRIT-SHOCK trial

BACKGROUND

The CULPRIT-SHOCK trial compared two treatment strategies for patients with acute myocardial infarction and multivessel coronary artery disease complicated by cardiogenic shock: (a) culprit vessel only percutaneous coronary intervention (CO-PCI), with additional staged revascularisation if indicated, and (b) immediate multivessel PCI (MV-PCI).

METHODS

A German societal and national health service perspective was considered for three different analyses. The cost utility analysis (CUA) estimated costs and quality adjusted life years (QALYs) based on a pre-trial decision analytic model taking a lifelong time horizon. In addition, a within trial CUA estimated QALYs and costs for 1 year. Finally, the cost effectiveness analysis (CEA) used the composite primary outcome, mortality and renal failure at 30-day follow-up, and the within trial costs. Econometric and survival analysis on the trial data was used for the estimation of the model parameters. Subgroup analysis was performed following an economic protocol.

RESULTS

The lifelong CUA showed an incremental cost effectiveness ratio (ICER), CO-PCI vs. MV-PCI, of €7010 per QALY and a probability of CO-PCI being the most cost-effective strategy > 64% at a €30,000 threshold. The ICER for the within trial CUA was €14,600 and the incremental cost per case of death/renal failure avoided at 30-day follow-up was €9010. Cost-effectiveness improved with patient age and for those without diabetes.

CONCLUSIONS

The estimates of cost-effectiveness for CO-PCI vs. MV-PCI have been shown to change depending on the time horizon and type of economic evaluation performed. The results favoured a long-term horizon analysis for avoiding underestimation of QALY gains from the CO-PCI arm.

Developing core economic parameter sets for asthma studies: a realist review and an analytical framework

OBJECTIVE

To develop a standardised set of economic parameters (core economic parameter set) for economic evaluations in asthma studies.

DESIGN

A systematic literature review and an analytical framework.

OUTCOME MEASURES

Economic parameters used to evaluate costs and cost-effectiveness of healthcare interventions for people with asthma.

DATA SOURCES

PubMed, the Cochrane Database of Systematic Reviews, the National Health Service Economic Evaluation Database, the Database of Abstracts of Reviews of Effects and the Health Technology Aaaessment Library starting from 1990.

REVIEW METHODS

Research methods were based on the realist review methodology and included a number of non-sequential, iterative and overlapping components, such as developing an analytical framework for the realist review; systematic literature review of economic parameters; identifying and categorising economic parameters; producing preliminary list of core economic parameters.

RESULTS

Database searches found 2531 publications of which 224 were included in the systematic review. We identified 65 economic parameters that were categorised into 11 groups to enable the realist synthesis. Parameters related to secondary care, primary care, medication use, emergency care and work productivity comprised 84% of all economic parameters. An analytical framework was used to investigate the rationale behind the choices of economic parameters in these studies. The main framework domains included type of intervention, research population, study design, study setting and a stakeholder's perspective.

CONCLUSION

Past research thus suggests that in asthma study parameters depicting the use of secondary care, primary care, medication, emergency care and work productivity can be considered as core economic parameters, since they apply to different types of studies. Parameters including diagnostics, healthcare delivery, school activity, informal care, medical devices and health utility apply to a particular type of study (or research question), and thus can be recommended as supplemental parameters.

PROSPERO REGISTRATION NUMBER

CRD42017067867.

Exploring health risk of people living near the Secondary Transfer Stations and Landfills in Dhaka

Background

Proper management of increasing solid waste is a major challenge for Dhaka city. Hence, the consequences on health are numerous and depend on the nature of the waste, individuals exposed, duration of exposure and availability of interventions for those exposed. This study seeks to identify the potential health risk associated with contamination from STSs and landfills in Dhaka city.

Methods

This study has adopted a multi-method approach that includes qualitative data collection and analysis of secondary spatial data. Thematic analysis was performed for analysing the qualitative data and. Spatial data were collected from the Survey of Bangladesh and analysed to show the spatial distribution of 68 STSs out of 81 STSs in Dhaka City.

Results

Qualitative study suggests that the leachate migration from the landfill and STSs make the surrounding environment worse and causes health sufferings to the people living near the STS or landfill along with the people directly working. Furthermore, findings from the spatial data reveal that, 12 STSs within 50-100 meters and 54 STSs within 100 meters radius of an education institute and round 75 STSs are also located within 100 meters radius of the health facilities. Numerous settlements and natural features are also located within 500 meters of buffer zone from the both landfills. Flies and mosquitoes are breeding at a greater pace in and around the landfills where high quantities of solid waste are being dumped. Again, waterlogging is very common due to the dumping of waste which in turn is causing the spread of dengue and other water borne diseases in the surrounding area.

Conclusions

Poor management and incautious allocation of the STSs and landfills have adverse effects on the people's health residing nearby. Managing waste in the landfill and STS with a proper manner, and engaging more manpower with adequate safety equipment could be a great help to reduce the health sufferings of the people living nearby.

Key messages

Improper solid waste management practice effects on the health of people residing near the STSs and landfills. To manage the waste of the STSs and landfills in an efficient way and not cause daily nuisance to the nearby residents.

Rethinking policies and possibilities of sustainable solid waste management system of Dhaka City

Issues

Solid waste management is one of the biggest concerns in Bangladesh, particularly in Dhaka city at present. This paper aims to find the gaps and challenges in solid waste management policies and implementations and thus, gives an insight towards sustainable solid waste management system in the country.

Description of the Problem

Improper solid waste management is adversely impacting environmental protection, public health and the control of carbon emissions in Bangladesh. As a result solid waste has become a major area of public policy with growing concern.

Lessons

Bangladesh has been experiencing changes in solid waste management since 1983 with the introduction of Dhaka City Corporation Ordinance and later the promulgation of National 3R Policy in 2010. With few exceptions, the overall waste management system cannot be termed as an efficient sequential process of waste minimization, recycling, and disposal based on global standards. Many initiatives are being implemented as part of independent projects by the non-governmental organizations (NGOs) and not always supported by policies. Though the establishment of several secondary transfer stations (STSs) has improved the environmental conditions and cleanliness of the cities, the waste segregation and recycling practices in the pathways from households to landfill do not adhere to the 3R Policy. Both the recyclable and non-recyclable waste are collected and dumped all together at different levels of waste management, i.e. collection from households, dumping at STSs, and later in the landfill without any formal procedures of sorting and recycling. Lack of coordination between implementing agencies is another problem.

Conclusions

Absence of sustainable solid waste management policy and proper execution agency are the main obstacles towards a proper waste management system. This problem is huge and should be addressed immediately to protect the environment and ensure better health of the city population.

Key messages

Even though the formation of STSs is one of the significant changes in the system nowadays, it is not evaluated or monitored under any specific policy or ordinance. In order to implement the existing policies, adequate funding and monitoring bodies should be introduced to the waste management sector.

Estimated societal costs of stroke in the UK based on a discrete event simulation

BACKGROUND

there are around 100,000 new stroke cases and over a million people living with its consequences annually in the UK. This has large impacts on health and social care, unpaid carers and lost productivity. We aimed to estimate associated costs.

METHODS

we estimated 2014/2015 annual mean cost per person and aggregate UK cost of stroke for individuals aged ≥40 from a societal perspective. Health and social care costs in the first and subsequent years after stroke were estimated from discrete event simulation modelling, with probability of progression and length of receipt of different health and social care services obtained from routine registry and audit data. Unpaid care hours and lost productivity were obtained from trial data. UK unit costs were applied to estimate mean costs. Epidemiological estimates of stroke incidence and prevalence were then applied to estimate aggregate costs for the UK.

RESULTS

mean cost of new-onset stroke is £45,409 (95% CI 42,054-48,763) in the first year after stroke and £24,778 (20,234-29,322) in subsequent years. Aggregate societal cost of stroke is £26 billion per year, including £8.6 billion for NHS and social care. The largest component of total cost was unpaid care (61%) and, given high survival, £20.6 billion related to ongoing care.

CONCLUSION

the estimated aggregate cost of stroke substantially exceeds previous UK estimates. Since most of the cost is attributed to unpaid care, interventions aimed at rehabilitation and reducing new and recurrent stroke are likely to yield substantial benefits to carers and cost savings to society.

Situation analysis for delivering integrated comprehensive sexual and reproductive health services in humanitarian crisis condition for Rohingya refugees in Cox's Bazar, Bangladesh: protocol for a mixed-method study

INTRODUCTION

Rohingya diaspora are one of the most vulnerable groups seeking refuge in camps of Cox's Bazar, Bangladesh, arising an acute humanitarian crisis. More than half of the Rohingya refugees are women and adolescent girls requiring quality sexual and reproductive health (SRH) services. Minimum initial service package of SRH are being rendered in the refugee camps; however, WHO is aiming to provide integrated comprehensive SRH services to meet the unmet needs of this most vulnerable group. For sustainable and successful implementation of such comprehensive SRH service packages, a critical first step is to undertake a situation analysis and understand the current dimensions and capture the lessons learnt on their SRH-specific needs and implementation challenges. This situation analysis is pertinent in current humanitarian condition and will provide an overview of the needs, availability and delivery of SRH services for adolescent girls and women, barriers in accessing and providing those services in Rohingya refugee camps in Cox's Bazar, Bangladesh, and similar humanitarian contexts.

METHODS AND ANALYSIS

A concurrent mixed-methods design will be used in this study. A community-based household survey coupled with facility assessments as well as qualitative in-depth interviews, key informant interviews and focus group discussions will be conducted with community people of Rohingya refugee camps and relevant stakeholders providing SRH services to Rohingya population in Cox's Bazar, Bangladesh. Survey data will be analysed using univariate, bivariate and multivariable regression statistics. Descriptive analysis will be done for facility assessment and thematic analysis will be conducted with qualitative data.

ETHICS AND DISSEMINATION

Ethical approval from Institutional Review Board of BRAC James P Grant School of Public Health (2018-017-IR) has been obtained. Findings from this research will be disseminated through presentations in local, national and international conferences, workshops, peer-reviewed publications, policy briefs and interactive project report.

Children's toothache is becoming everybody's business: where do parents go when their children have oral pain in London, England? A cross-sectional analysis

OBJECTIVES

To assess the number of parents who visited community pharmacies in London seeking pain medications for their children's pain and specifically for oral pain, to identify which health services parents contacted before their pharmacy visit and to estimate the cost to the National Health Service (NHS) when children with oral pain who visit pharmacies also see health professionals outside dentistry.

DESIGN

A cross-sectional study.

SETTING

1862 pharmacies in London in November 2016-January 2017.

PARTICIPANTS

Parents, carers and adolescents purchasing over-the-counter pain medications or collecting pain prescriptions for children (0-19 years).

BRIEF INTERVENTION

A survey administered by pharmacy staff to participants and a guidance pack.

MAIN OUTCOME MEASURES

The number of parents who visited pharmacies seeking pain medications for their children's pain and oral pain and the number of parents who contacted health professionals outside dentistry before their pharmacy visit. Estimated costs of visits by children with oral pain to health professionals outside dentistry.

RESULTS

One in two (951) pharmacies participated collecting information from 6915 parents seeking pain medications for their children. The majority (65%) of parents sought pain medications to relieve their children's oral pain. Only 30% of children with oral pain had seen a dentist before the pharmacy visit, while 28% of children had seen between one and four different health professionals. The cost to the NHS of children contacting health professionals outside dentistry was £36 573, extrapolated to an annual cost of £373 288. Replicating these findings across all pharmacies in England could mean that the NHS spends an estimated £2.3 million annually when children with oral pain inappropriately use multiple health services.

CONCLUSION

Most parents who visited pharmacies for children's pain medications in London sought pain medications for children's oral pain. Children's inappropriate contact with multiple health services when they have oral pain adds significant costs to the NHS.

Protocol for an economic evaluation of the randomised controlled trial of culprit lesion only PCI versus immediate multivessel PCI in acute myocardial infarction complicated by cardiogenic shock: CULPRIT-SHOCK trial

INTRODUCTION

Emergency percutaneous coronary intervention (PCI) of the culprit lesion for patients with acute myocardial infarctions is an accepted practice. A majority of patients present with multivessel disease with additional relevant stenoses apart from the culprit lesion. In haemodynamically stable patients, there is increasing evidence from randomised trials to support the practice of immediate complete revascularisation. However, in the presence of cardiogenic shock, the optimal management strategy for additional non-culprit lesions is unknown. A multicentre randomised controlled trial, CULPRIT-SHOCK, is examining whether culprit vessel only PCI with potentially subsequent staged revascularisation is more effective than immediate multivessel PCI. This paper describes the intended economic evaluation of the trial.

METHODS AND ANALYSIS

The economic evaluation will be conducted using a pre-trial decision model and within-trial analysis. The modelling-based analysis will provide expected costs and health outcomes, and incremental cost-effectiveness ratio over the lifetime for the cohort of patients included in the trial. The within-trial analysis will provide estimates of cost per life saved at 30 days and in 1 year, and estimates of health-related quality of life. Bootstrapping and cost-effectiveness acceptability curves will be used to address any uncertainty around these estimates. Different types of regression models within a generalised estimating equation framework will be used to examine how the total cost and quality-adjusted life years are explained by patients' characteristics, revascularisation strategy, country and centre. The cost-effectiveness analysis will be from the perspective of each country's national health services, where costs will be expressed in euros adjusted for purchasing power parity.

ETHICS AND DISSEMINATION

Ethical approval for the study was granted by the local Ethics Committee at each recruiting centre. The economic evaluation analyses will be published in peer-reviewed journals of the concerned literature and communicated through the profiles of the authors at www.twitter.com and www.researchgate.net.

TRIAL REGISTRATION NUMBER

NCT01927549; Pre-results.

"Can community level interventions have an impact on equity and utilization of maternal health care" - evidence from rural Bangladesh

Background

Evidence from low and middle income countries (LMICs) suggests that maternal mortality is more prevalent among the poor whereas access to maternal health services is concentrated among the rich. In Bangladesh substantial inequities exist both in the use of facility-based basic obstetric care and for home births attended by skilled birth attendant. BRAC initiated an intervention on Improving Maternal, Neonatal, and Child Survival (IMNCS) in the rural areas of Bangladesh in 2008. One of the objectives of the intervention is to improve the utilization of maternal and child health care services among the poor. This study aimed to look at the impact of the intervention on utilization and also on equity of access to maternal health services.

Methods

A quasi-experimental pre-post comparison study was conducted in rural areas of five districts comprising three intervention (Gaibandha, Rangpur and Mymensingh) and two comparison districts (Netrokona and Naogaon). Data on health seeking behaviour for maternal health were collected from a repeated cross sectional household survey conducted in 2008 and 2010.

Results

Results show that the intervention appears to cause an increase in the utilization of antenatal care. The concentration index (CI) shows that this has become pro-poor over time (from CI: 0.30 to CI: 0.04) in the intervention areas. In contrast the use of ANC from medically trained providers has become pro-rich (from, CI: 0.18 to CI: 0.22). There was a significant increase in the utilisation of trained attendants for home delivery in the intervention areas compared to the comparison areas and the change was found to be pro-poor. Use of postnatal care cervices was also found to be pro-poor (from CI: 0.37 to CI: 0.14). Utilization of ANC services provided by medically trained provider did not improve in the intervention area. However, where the intervention had a positive effect on utilization it also seemed to have had a positive effect on equity.

Conclusions

To sustain equity in health care utilization, the IMNCS programme needs to continue providing free home based services. In addition to this, the programme should also continue to provide funding to bear the cost to those mothers who are not able to have the comprehensive ANC from medically trained providers.

Has laparoscopic colorectal surgery become more cost-effective over time?

BACKGROUND

Several studies have confirmed that laparoscopic colorectal surgery (LCS) has superior short-term outcomes when compared to open colorectal surgery. However, the evidence for cost-effectiveness of LCS is less clear.

AIM

The aim of this study is to explore the cost-effectiveness of LCS over time since it was first developed in 1991.

METHODS

Systematic review of the literature was conducted. Electronic databases (PubMed, ScienceDirect and Google Scholar) were searched for studies from 1991 to 2010 using the keywords "laparoscopic, colorectal surgery cost, economic evaluation".

RESULTS

Fifteen economic evaluations met the inclusion criteria. The percentage cost difference between open and laparoscopic surgery varied widely between different studies. The general trend when observing all the included economic evaluations is that there is a moderate negative correlation between progression of time and the size of the cost gap between laparoscopic and open surgery (R-value=-0.44). This correlation is even stronger (R-value=-0.64, P=0.046) if the studies are subdivided by the country where the surgery was carried out in. Western healthcare systems, even though they had a heterogeneous set of results (SD=27%), showed a decline in costs of laparoscopic surgery with time.

CONCLUSION

From the current trends, it is projected that the results of future economic evaluations will unequivocally show that laparoscopic surgery is cheaper than open surgery. The initial higher costs of laparoscopic surgery training may be worth the savings made in the long term if it is practised in settings where postoperative care is expensive.

Clinical effectiveness and cost-effectiveness of imatinib dose escalation for the treatment of unresectable and/or metastatic gastrointestinal stromal tumours that have progressed on treatment at a dose of 400 mg/day: a systematic review and economic evaluation

BACKGROUND

Imatinib dose escalation is advocated for gastrointestinal stromal tumour (GIST) treatment, but its effectiveness compared with sunitinib and best supportive care (BSC) after failure at the 400 mg/day dose is unknown.

OBJECTIVES

To assess the effectiveness and cost-effectiveness of imatinib at escalated doses of 600 or 800 mg/day for patients with unresectable and/or metastatic GISTs whose disease had progressed on 400 mg/day.

DATA SOURCES

Electronic databases, including MEDLlNE, MEDLINE In-Process, EMBASE, BIOSIS, Science Citation Index, Health Management Information Consortium and the Cochrane Controlled Trials Register, were searched until September 2009.

REVIEW METHODS

A systematic review of the literature was carried out according to standard methods. An economic model was constructed to assess the cost-effectiveness of seven alternative pathways for treating patients with unresectable and/or metastatic GISTs.

RESULTS

Five primary studies involving 669 people were included for clinical effectiveness; four reported imatinib and one reported sunitinib. The data were essentially observational as none of the studies was designed to specifically assess treatment of patients whose disease had progressed on 400 mg/day imatinib. For 600 mg/day imatinib, between 26% and 42% of patients showed either a partial response (PR) or stable disease (SD). Median time to progression was 1.7 months (range 0.7-24.9 months). For 800 mg/day imatinib, between 29% and 33% of patients showed either a PR or SD. Median overall survival (OS) was 19 months [95% confidence interval (CI) 13 to 23 months]. Progression-free survival ranged from 81 days to 5 months (95% CI 2 to 10 months). Median duration of response was 153 days (range 37-574 days). Treatment progression led to 88% discontinuations but between 16% and 31% of patients required a dose reduction, and 23% required a dose delay. There was a statistically significant increase in the severity of fatigue (p < 0.001) and anaemia (p = 0.015) following dose escalation. For sunitinib, median OS was 90 weeks (95% CI 73 to 106 weeks). For the cost-effectiveness review, only one full-text study and one abstract were identified, comparing imatinib at an escalated dose, sunitinib and BSC, although neither was based on a UK context. The definition of BSC was not consistent across the studies, and the pattern of resources (including drugs for treatment) and measures of effectiveness also varied. Within the model, BSC (assumed to include continuing medication to prevent tumour flare) was the least costly and least effective. It would be the care pathway most likely to be cost-effective when the cost per quality-adjusted life-year threshold was < £25,000. Imatinib at 600 mg/day was most likely to be cost-effective at a threshold between £25,000 and £45,000. Imatinib at 600 mg/day followed by further escalation followed by sunitinib was most likely to be cost-effective at a threshold > £45,000.

LIMITATIONS

The evidence base was sparse, data were non-randomised and potentially biased. The economic model results are surrounded by a considerable degree of uncertainty and open to biases of unknown magnitude and direction.

CONCLUSIONS

Around one-third of patients with unresectable and/or metastatic GIST, who fail on 400 mg/day of imatinib, may show response or SD with escalated doses. Between a threshold of £25,000 and £45,000, provision of an escalated dose of imatinib would be most likely to be cost-effective. However, these results should be interpreted with caution owing to the limited evidence available on outcomes following imatinib dose escalation or sunitinib for this group of patients.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

The effectiveness of early lens extraction with intraocular lens implantation for the treatment of primary angle-closure glaucoma (EAGLE): study protocol for a randomized controlled trial

Background

Glaucoma is the leading cause of irreversible blindness. Although primary open-angle glaucoma is more common, primary angle-closure glaucoma (PACG) is more likely to result in irreversible blindness. By 2020, 5·3 million people worldwide will be blind because of PACG. The current standard care for PACG is a stepped approach of a combination of laser iridotomy surgery (to open the drainage angle) and medical treatment (to reduce intraocular pressure). If these treatments fail, glaucoma surgery (eg, trabeculectomy) is indicated. It has been proposed that, because the lens of the eye plays a major role in the mechanisms leading to PACG, early clear lens extraction will improve glaucoma control by opening the drainage angle. This procedure might reduce the need for drugs and glaucoma surgery, maintain good visual acuity, and improve quality of life compared with standard care.

EAGLE aims to evaluate whether early lens extraction improves patient-reported, clinical outcomes, and cost-effectiveness, compared with standard care.

Methods/Design

EAGLE is a multicentre pragmatic randomized trial. All people presenting to the recruitment centres in the UK and east Asia with newly diagnosed PACG and who are at least 50 years old are eligible.

The primary outcomes are EQ-5D, intraocular pressure, and incremental cost per quality adjusted life year (QALY) gained. Other outcomes are: vision and glaucoma-specific patient-reported outcomes, visual acuity, visual field, angle closure, number of medications, additional surgery (e.g., trabeculectomy), costs to the health services and patients, and adverse events.

A single main analysis will be done at the end of the trial, after three years of follow-up. The analysis will be based on all participants as randomized (intention to treat). 400 participants (200 in each group) will be recruited, to have 90% power at 5% significance level to detect a difference in EQ-5D score between the two groups of 0·05, and a mean difference in intraocular pressure of 1·75 mm Hg. The study will have 80% power to detect a difference of 15% in the glaucoma surgery rate. Trial Registration: ISRCTN44464607.

Systematic review of the clinical effectiveness and cost-effectiveness of rapid point-of-care tests for the detection of genital chlamydia infection in women and men

OBJECTIVE

To assess whether or not the Chlamydia Rapid Test (CRT) could improve detection of genital chlamydia, and whether it is more effective than current practice using nucleic acid amplification tests (NAATs), in terms of the number of cases of chlamydia that are detected and treated and the proportion of partners identified and treated.

DATA SOURCES

Eleven electronic bibliographic databases (including MEDLINE and EMBASE) were searched until November 2008, as well as relevant websites.

REVIEW METHODS

Studies of sexually active adolescent and adult women and men suspected of having or being tested for genital chlamydia infection were considered. The tests considered were the CRT and other comparator point-of-care tests identified, using a NAAT as a reference standard. Summary sensitivity, specificity, positive and negative likelihood ratios, and diagnostic odds ratios for each model were reported as a median and a 95% confidence interval (CI). Effectiveness was measured in terms of the absolute numbers of true-positives, false-positives, false-negatives (and other positive cases missed) and true-negatives detected. Costs were considered from the health service's perspective. Incremental cost-effectiveness ratios were used to examine the relative cost-effectiveness, and values of the major parameters of the models were varied in a sensitivity analysis.

RESULTS

Thirteen studies enrolling 8817 participants were included in the analysis. In the pooled estimates for the CRT, sensitivity (95% CI) was 80% (73% to 85%) for vaginal swab specimens and 77% (59% to 89%) for first void urine (FVU) specimens. Specificity was 99% (99% to 100%) for vaginal swab specimens and 99% (98% to 99%) for FVU specimens. In the pooled estimates for a comparator point-of-care test (Clearview Chlamydia), sensitivity (95% CI) was 52% (39% to 65%) for vaginal, cervical and urethral swab specimens combined, and 64% (47% to 77%) for cervical specimens alone. Specificity was 97% (94% to 100%) for vaginal, cervical and urethral swab specimens combined, and 97% (88% to 99%) for cervical specimens alone. The results of the economic evaluation showed that for a hypothetical cohort of 1000 people, using the current practice of polymerase chain reaction testing would result in 12.63 people who were offered testing being correctly treated and having their sexual partners contacted, at a cost of 7070 pounds (for the whole cohort). For the CRT, the number being correctly treated would be 10.98, at a cost of 7180 pounds. For the Clearview Chlamydia test, the number correctly treated would be 7.14, at a cost of 7170 pounds. Both point-of-care tests were therefore more costly and less effective than current practice.

CONCLUSIONS

The limited evidence available suggests that NAATs are still the most accurate and cost-effective method for diagnosing chlamydia infection. There may be circumstances in which point-of-care tests could be provided in addition to existing NAAT services, but there is currently little evidence on point-of-care methods in such settings. Robust evidence of the diagnostic accuracy of point-of-care tests for different types of samples is also still required, as are studies evaluating clinical effectiveness outcomes for these tests in comparison with NAATs.

The clinical effectiveness of glucosamine and chondroitin supplements in slowing or arresting progression of osteoarthritis of the knee: a systematic review and economic evaluation

OBJECTIVE

To assess the clinical effectiveness and cost-effectiveness of glucosamine sulphate/hydrochloride and chondroitin sulphate in modifying the progression of osteoarthritis (OA) of the knee.

DATA SOURCES

Electronic databases were searched from 1950 to 2008 and included: MEDLINE and PubMed; EMBASE; Cochrane Library (including Cochrane Systematic Reviews Database, CENTRAL, DARE, NHS EED and HTA databases); Allied and Complementary Medicine (AMED); National Research Register (NRR); Web of Science Proceedings; Current Controlled Trials; and Clinical Trials.gov. Other sources included bibliographies of retrieved papers, registered but unpublished trials, internet searches and the Food Standards Agency website.

REVIEW METHODS

A search was conducted for systematic reviews of randomised controlled trials (RCTs), which were used to identify RCTs of at least 12 months' duration and updated with searches for primary studies. A cost-effectiveness model was constructed using cohort simulation and drawing on available evidence. Sensitivity analysis was undertaken and value of information analysis conducted. A review of studies of mechanism of action was carried out to explore the biological plausibility of the preparations.

RESULTS

Five systematic reviews and one clinical guideline met the inclusion criteria. They reported inconsistent conclusions with only modest effects on reported pain and function. A reduction in joint space narrowing was more consistently observed, but the effect size was small and the clinical significance uncertain. A separate review of eight primary trials of > 12 months' duration showed evidence of statistically significant improvements in joint space loss, pain and function for glucosamine sulphate, but the clinical importance of these differences was not clear. In two studies of glucosamine sulphate, the need for knee arthroplasty was reduced from 14.5% to 6.3% at 8 years' follow-up. For other preparations of glucosamine, chondroitin and combination therapy, there was less evidence to support a clinical effect. Cost-effectiveness modelling was restricted to glucosamine sulphate. Over a lifetime horizon the incremental cost per quality-adjusted life-year (QALY) gain for adding glucosamine sulphate to current care was estimated to be 21,335 pounds. Deterministic sensitivity analysis suggested that the cost-effectiveness of glucosamine sulphate therapy was particularly dependent on the magnitude of the quality of life (QoL) gain, the change in knee arthroplasty probability with therapy and the discount rate. At a cost per QALY gained threshold of 20,000 pounds, the likelihood that glucosamine sulphate is more cost-effective than current care is 0.43, while at a threshold of 30,000 pounds, the probability rises to 0.73. Probabilistic sensitivity analysis showed that estimates were imprecise and subject to a degree of decision uncertainty. Value of information analysis demonstrated the need for further research. Several biologically plausible mechanisms of action for glucosamine sulphate and chondroitin were proposed.

CONCLUSIONS

There was evidence that glucosamine sulphate shows some clinical effectiveness in the treatment of OA of the knee. No trial data came from the UK and caution should be exercised in generalising the findings to the UK health-care setting. Cost-effectiveness was not conclusively demonstrated. There was evidence to support the potential clinical impact of glucosamine sulphate. The value of information analysis identified three research priorities: QoL, structural outcomes and knee arthroplasty. The biological mechanism of glucosamine sulphate and chondroitin remains uncertain and, in particular, the proposal that the active substance may be sulphate should be explored further.

The cost-effectiveness of consistent and early intervention of harm reduction for injecting drug users in Bangladesh

AIMS

To assess the cost-effectiveness of the CARE-SHAKTI harm reduction intervention for injecting drug users (IDUs) over a 3-year period, the impact on the cost-effectiveness of stopping after 3 years and how the cost-effectiveness might vary with baseline human immunodeficiency virus (HIV) prevalence.

DESIGN

Economic cost data were collected from the study site and combined with impact estimates derived from a dynamic mathematical model.

SETTING

Dhaka, Bangladesh, where the HIV prevalence has remained low despite high-risk sexual and injecting behaviours, and growing HIV epidemics in neighbouring countries.

FINDINGS

The cost per HIV infection prevented over the first 3 years was USD 110.4 (33.1-182.3). The incremental cost-effectiveness of continuing the intervention for a further year, relative to stopping at the end of year 3, is USD 97 if behaviour returns to pre-intervention patterns. When baseline IDU HIV prevalence is increased to 40%, the number of HIV infections averted is halved for the 3-year period and the cost per HIV infection prevented doubles to USD 228.

CONCLUSIONS

The analysis confirms that harm reduction activities are cost-effective. Early intervention is more cost-effective than delaying activities, although this should not preclude later intervention. Starting harm reduction activities when IDU HIV prevalence reaches as high as 40% is still cost-effective. Continuing harm reduction activities once a project has matured is vital to sustaining its impact and cost-effectiveness.

Economic Burden of Intracranial Vascular Malformations in Adults

Background and Purpose— Although intracranial vascular malformations (IVMs) are the leading cause of intracerebral hemorrhage (ICH) in young adults, there has not been a cost-of-illness study on an unselected cohort.

Methods— We measured the direct healthcare costs (inpatient, outpatient, intervention, and brain imaging) incurred by every adult within 3 years after their first presentation with a brain arteriovenous malformation (AVM) or cavernous malformation (CM) in a prospective, population-based study. We estimated the indirect cost of lost productivity for the whole cohort over the same period by projecting questionnaire responses from living consenting adults.

Results— 369 adults (AVM=229 [62%], CM=140 [38%]) incurred healthcare costs of £5.96 million over 3 years, of which AVMs accounted for 90%, inpatient care accounted for 75%, and the first year of care accounted for 69%. Median 3-year healthcare costs were statistically significantly higher for adults presenting with ICH, aged <65 years, receiving interventional treatment, and adults with AVMs rather than CMs (£15 784 versus £1385, P <0.0005). Healthcare costs diminished with increasing AVM nidus size ( P =0.005). Mean 3-year costs of lost productivity per questionnaire respondent (n=145) were £17 111 for AVMs and £6752 for CMs ( P =0.1), and the projected 3-year cost of lost productivity for all 369 adults was £8.7 million.

Conclusions— The costs of healthcare and lost productivity attributable to IVMs are considerable, and highest in those aged <65 years, presenting with ICH, receiving interventional treatment, and harboring AVMs rather than CMs. Long-term studies of the cost-effectiveness of interventional treatment are needed.

The demand for child curative care in two rural thanas of Bangladesh: effect of income and women's employment

This paper seeks to investigate the determinants of child health care seeking behaviours in rural Bangladesh. In particular, the effects of income, women's access to income, and the prices of obtaining child health care are examined. Data on the use of child curative care were collected in two rural areas of Bangladesh--Abhoynagar Thana of Jessore District and Mirsarai Thana of Chittagong District--in March 1997. In estimating the use of child curative care, the nested multinomial logit specification was used. The results of the analysis indicate that a woman's involvement in a credit union or income generation affected the likelihood that curative child care was used. Household wealth decreased the likelihood that the child had an illness episode and affected the likelihood that curative child care was sought. Among facility characteristics, travel time was statistically significant and was negatively associated with the use of a provider.

Impact of national immunization days on polio-related knowledge and practice of urban women in Bangladesh

Bangladesh began to hold National Immunization Days (NIDs) from 1995 as part of the country's goal to eradicate poliomyelitis by the turn of the century. The NIDs brought together government agencies, the media, voluntary organisations and individual volunteers in social mobilization and service delivery activities. This paper assesses the impact of the first two polio NIDs in terms of the immunization coverage and change in knowledge about the disease among women living in Dhaka city, the capital of the country. Data were collected through pre- and post-NID cross-sectional surveys in a sample of one area of Dhaka city which included slum and non-slum households. Knowledge data were collected from 525 women with at least one child aged less than five years. The oral polio vaccine (OPV) coverage during NIDs was obtained from 720 children. Knowledge of polio as a vaccine preventable disease increased after NIDs among both slum and non-slum women. The knowledge gap between the two groups was significantly reduced. Field workers, who regularly visit women at their homes to promote health and family planning services, were the main source of information for the slum women while television was cited as the most important source of information by non-slum women. The study revealed that 88% of children under five years received at least one dose of oral polio vaccine (OPV) during NIDs, and 67% received two stipulated doses with no significant differences between slum (65%) and non-slum (69%) groups. In addition, 68% of the children contacted during the NIDs were given vitamin A supplementation. The study suggests that strategies like NID can be effectively used to tap into community resources and to generate political commitments for health programmes.