A multinational Delphi consensus to end the COVID-19 public health threat.

Despite notable scientific and medical advances, broader political, socioeconomic and behavioural factors continue to undercut the response to the COVID-19 pandemic1,2. Here we convened, as part of this Delphi study, a diverse, multidisciplinary panel of 386 academic, health, non-governmental organization, government and other experts in COVID-19 response from 112 countries and territories to recommend specific actions to end this persistent global threat to public health. The panel developed a set of 41 consensus statements and 57 recommendations to governments, health systems, industry and other key stakeholders across six domains: communication; health systems; vaccination; prevention; treatment and care; and inequities. In the wake of nearly three years of fragmented global and national responses, it is instructive to note that three of the highest-ranked recommendations call for the adoption of whole-of-society and whole-of-government approaches1, while maintaining proven prevention measures using a vaccines-plus approach2 that employs a range of public health and financial support measures to complement vaccination. Other recommendations with at least 99% combined agreement advise governments and other stakeholders to improve communication, rebuild public trust and engage communities3 in the management of pandemic responses. The findings of the study, which have been further endorsed by 184 organizations globally, include points of unanimous agreement, as well as six recommendations with >5% disagreement, that provide health and social policy actions to address inadequacies in the pandemic response and help to bring this public health threat to an end.

Reproductive health service access and utilisation among migrant women in Dhaka's urban slums: a qualitative study.

This study explores the impact of migration on the access and utilisation of sexual and reproductive health services by women living in an informal settlement in Dhaka, Bangladesh. A total of 16 in-depth interviews were conducted in March and April of 2019 with women (18-49 years old) who had migrated from rural areas to Dhaka. They reported continued economic insecurity while receiving minimal support from the state. All women reported financial and infrastructural barriers to accessing formal sexual and reproductive health services and tended to seek resources and support through social networks within the slum and from informal health services. Compared with more recent migrants, women who had migrated and resided in the slums for longer found it easier to utilise social networks and resources for sexual and reproductive health. Women had more agency in experimenting with contraceptives but had less power in making decisions during pregnancy and when seeking health care. Menstrual health was a neglected aspect of public health. The study indicates that public health policy targeting the urban poor needs to address the unique challenges faced by migrant women in informal settlements to rectify inequities in health services that leave significant portions of the urban poor population behind.

Livelihood challenges of single female household heads in the Rohingya and host communities in Cox's Bazar, Bangladesh during the COVID-19 pandemic.

BACKGROUND: Following the mass influx of Rohingya refugees into Cox's Bazaar, Bangladesh in 2017, makeshift settlement camps in Ukhiya and Teknaf have been overburdened, leading to livelihood challenges for both Rohingya and host communities. The humanitarian crisis has had adverse effects on vulnerable populations, which include older people, persons with disabilities, adolescents, and single female household heads. Using a subset of a larger dataset on households with most vulnerable groups in both communities, we analysed the effect of the pandemic and lockdown on the livelihood of single female household (HH) heads. METHODS: A cross-sectional household roster survey was designed to collect data from households with most vulnerable groups (MVGs) of host and Rohingya communities from December 2020 to March 2021; 11 host community villages and 10 Rohingya camps purposively selected as per the affiliated intervention of the project. The paper analysed quantitative and qualitative data from the sub-group of single female household heads without any income/low income. Participants were surveyed for their socio-demographic characteristics, COVID-19 experiences and knowledge, food security situation, social experiences and mental health using PHQ-2 test for depression. RESULTS: We surveyed 432 single female HH heads. Support during the pandemic was reported to be low, with less than 50% of HHs reporting relief meeting their needs; only 36% and 15% of these HHs received rations in camps and host communities respectively. Loan facilities were mostly unavailable and there were reported insufficiencies in food consumption. Over 50% of respondents tested positive on the PHQ-2, a scale used to screen for depression. Further analyses indicates that having a chronic health issue (OR 2.2, 95% CI 1.33-3.66) was positively associated with the PHQ-2 score for Rohingya single females. For host single females, having an ill member in the HH (OR 1.46, 95% CI 1.02-2.08) and the inability to save before the pandemic (OR 1.57 95% CI 1.11-2.23) increased the odds of screening positive for depression. CONCLUSION: Our study findings revealed insufficiencies with economic opportunities and food security for single female-headed households, as well as a high rate of positive screening for depression amongst this population. These findings call for a more in-depth understanding of the needs of this group.

Designing transformative public health education for the developing world: how one course re-imagined a more indigenous MPH.

This manuscript proposes a novel version of an academic program for community outreach in Native populations of Bangladesh. The curricular content was designed to gather and comprehensively understand community health experiences, and the design methodology proposed structured student learning around integrative factors that determined community health realities. The authors refer to the need to curricularly assign a basic human health need, such as water, nutrition, housing, sanitation, or work, so as to undertake an in-depth exploration of that topic and understand the practical conceptual foundation and interdependencies among the social determinants of health that produce community health outcomes. This document showcases student projects, their own practical solutions to real health problems, and how they and their community of teachers successfully learned and carried out simple solutions that can be applied to disadvantaged communities.

Housing as a Social Determinant of Health: Evidence from Singapore, the UK, and Kenya: the 3-D Commission.

Housing is a paradigmatic example of a social determinant of health, as it influences and is influenced by structural determinants, such as social, macroeconomic, and public policies, politics, education, income, and ethnicity/race, all intersecting to shaping the health and well-being of populations. It can therefore be argued that housing policy is critically linked to health policy. However, the extent to which this linkage is understood and addressed in public policies is limited and highly diverse across and within countries. This analysis seeks to describe the linkages between housing policies and health and well-being using examples from three countries at different levels of the wealth spectrum: Singapore, the UK, and Kenya.We conducted a comparative policy analysis across three country contexts (Singapore, the UK, and Kenya) to document the extent to which housing policies address health and well-being, highlighting commonalities and differences among them. To guide our analysis, we used the United Nations (UN) definition of adequate housing as it offers a broad framework to analyze the impact of housing on health and well-being.The anatomy of housing policies has a strong correlation to the provision of adequate housing across Singapore, the UK, and Kenya, especially for vulnerable groups. The paper demonstrates that contextual factors including population composition (i.e., aging versus youthful), political ideologies, legal frameworks (i.e., welfare versus market-based provision of housing), and presence (or absence) of adequate, quality, timely, reliable, robust data systems for decision-making, which are taken up by stakeholders/state, have strong implications of the type of housing policies developed and implemented, in turn directly and indirectly impacting the overall health and well-being of populations.This analysis demonstrates the value of viewing housing policies as public health policies that could significantly impact the health and well-being of populations, especially vulnerable groups. Moreover, the findings highlight the importance of the Health in All Policies approach to facilitate integrated policy responses to address social determinants of health such as housing. This is more critical than ever, given the context of the global pandemic that has led to worsening overall health and well-being.

'Most at risk' for COVID19? The imperative to expand the definition from biological to social factors for equity.

First recognized in December 2019, the Coronavirus Disease 2019 (COVID19) was declared a global pandemic by the World Health Organization on March 11, 2020. To date, the most utilized definition of 'most at risk' for COVID19 morbidity and mortality has focused on biological susceptibility to the virus. This paper argues that this dominant biomedical definition has neglected the 'fundamental social causes' of disease, constraining the effectiveness of prevention and mitigation measures; and exacerbating COVID19 morbidity and mortality for population groups living in marginalizing circumstances. It is clear - even at this early stage of the pandemic - that inequitable social conditions lead to both more infections and worse outcomes. Expanding the definition of 'most at risk' to include social factors is critical to implementing equitable interventions and saving lives. Prioritizing populations with social conditions is necessary for more effective control of the epidemic in its next phase; and should become standard in the planning for, and prevention and mitigation of all health conditions. Reversing disparities and health inequities is only possible through an expansion of our 'most-at-risk' definition to also include social factors.

Slum Health: Arresting COVID-19 and Improving Well-Being in Urban Informal Settlements.

The informal settlements of the Global South are the least prepared for the pandemic of COVID-19 since basic needs such as water, toilets, sewers, drainage, waste collection, and secure and adequate housing are already in short supply or non-existent. Further, space constraints, violence, and overcrowding in slums make physical distancing and self-quarantine impractical, and the rapid spread of an infection highly likely. Residents of informal settlements are also economically vulnerable during any COVID-19 responses. Any responses to COVID-19 that do not recognize these realities will further jeopardize the survival of large segments of the urban population globally. Most top-down strategies to arrest an infectious disease will likely ignore the often-robust social groups and knowledge that already exist in many slums. Here, we offer a set of practice and policy suggestions that aim to (1) dampen the spread of COVID-19 based on the latest available science, (2) improve the likelihood of medical care for the urban poor whether or not they get infected, and (3) provide economic, social, and physical improvements and protections to the urban poor, including migrants, slum communities, and their residents, that can improve their long-term well-being. Immediate measures to protect residents of urban informal settlements, the homeless, those living in precarious settlements, and the entire population from COVID-19 include the following: (1) institute informal settlements/slum emergency planning committees in every urban informal settlement; (2) apply an immediate moratorium on evictions; (3) provide an immediate guarantee of payments to the poor; (4) immediately train and deploy community health workers; (5) immediately meet Sphere Humanitarian standards for water, sanitation, and hygiene; (6) provide immediate food assistance; (7) develop and implement a solid waste collection strategy; and (8) implement immediately a plan for mobility and health care. Lessons have been learned from earlier pandemics such as HIV and epidemics such as Ebola. They can be applied here. At the same time, the opportunity exists for public health, public administration, international aid, NGOs, and community groups to innovate beyond disaster response and move toward long-term plans.

Salaried and voluntary community health workers: exploring how incentives and expectation gaps influence motivation.

BACKGROUND: The recent publication of the WHO guideline on support to optimise community health worker (CHW) programmes illustrates the renewed attention for the need to strengthen the performance of CHWs. Performance partly depends on motivation, which in turn is influenced by incentives. This paper aims to critically analyse the use of incentives and their link with improving CHW motivation. METHODS: We undertook a comparative analysis on the linkages between incentives and motivation based on existing datasets of qualitative studies in six countries. These studies had used a conceptual framework on factors influencing CHW performance, where motivational factors were defined as financial, material, non-material and intrinsic and had undertaken semi-structured interviews and focus group discussions with CHWs, supervisors, health managers and selected community members. RESULTS: We found that (a mix of) incentives influence motivation in a similar and sometimes different way across contexts. The mode of CHW engagement (employed vs. volunteering) influenced how various forms of incentives affect each other as well as motivation. Motivation was negatively influenced by incentive-related "expectation gaps", including lower than expected financial incentives, later than expected payments, fewer than expected material incentives and job enablers, and unequally distributed incentives across groups of CHWs. Furthermore, we found that incentives could cause friction for the interface role of CHWs between communities and the health sector. CONCLUSIONS: Whether CHWs are employed or engaged as volunteers has implications for the way incentives influence motivation. Intrinsic motivational factors are important to and experienced by both types of CHWs, yet for many salaried CHWs, they do not compensate for the demotivation derived from the perceived low level of financial reward. Overall, introducing and/or sustaining a form of financial incentive seems key towards strengthening CHW motivation. Adequate expectation management regarding financial and material incentives is essential to prevent frustration about expectation gaps or "broken promises", which negatively affect motivation. Consistently receiving the type and amount of incentives promised appears as important to sustain motivation as raising the absolute level of incentives.

Changing global policy to deliver safe, equitable, and affordable care for women's cancers.

Breast and cervical cancer are major threats to the health of women globally, particularly in low-income and middle-income countries. Radical progress to close the global cancer divide for women requires not only evidence-based policy making, but also broad multisectoral collaboration that capitalises on recent progress in the associated domains of women's health and innovative public health approaches to cancer care and control. Such multisectoral collaboration can serve to build health systems for cancer, and more broadly for primary care, surgery, and pathology. This Series paper explores the global health and public policy landscapes that intersect with women's health and global cancer control, with new approaches to bringing policy to action. Cancer is a major global social and political priority, and women's cancers are not only a tractable socioeconomic policy target in themselves, but also an important Trojan horse to drive improved cancer control and care.

Utilization of mobile phones for accessing menstrual regulation services among low-income women in Bangladesh: a qualitative analysis.

BACKGROUND: As many as one-third of all pregnancies in Bangladesh are unplanned, with nearly one-half of these pregnancies ending in either menstrual regulation (MR) or illegal clandestine abortion. Although MR is provided free of charge, or at a nominal cost, through the public sector and various non-profits organizations, many women face barriers in accessing safe, affordable MR and post-MR care. Mobile health (mHealth) services present a promising platform for increasing access to MR among low-income women at risk for clandestine abortion. We sought to investigate the knowledge, attitudes and practices regarding mHealth of both MR clients and formal and informal sexual and reproductive healthcare providers in urban and rural low-income settlements in Bangladesh. METHODS: A total of 58 interviews were conducted with MR clients, formal MR providers, and informal MR providers in four low-income settlements in the Dhaka and Sylhet districts of Bangladesh. Interview data was coded and qualitatively analysed for themes using standard qualitative research practices. RESULTS: Our findings suggest that low-income MR clients in Bangladesh have an inadequate understanding of how to use their mobile phones to obtain health service information or counselling related to MR, and correspondingly low levels of formal or informal mHealth service utilization. Few were aware of any formal mHealth services in place in their communities, despite the fact that providers stated that hotlines were available. Overall, MR clients expressed positive opinions of mHealth services as a means of improving women's access to affordable and timely MR. Formal and informal MR providers believed that mobile phones had benefits with respect to information dissemination and making appointments, but emphasized the necessity of in-person consultations for effective sexual and reproductive healthcare. CONCLUSIONS: We report low utilization yet high acceptability of mHealth services among low-income MR clients in Bangladesh. Expanding formal and informal mHealth services targeted towards MR - and increasing publicity of these services in low-income communities - may help increase timely access to accurate MR information and formal providers among women at risk for clandestine abortion. While expanding formal and informal mHealth services for SRHR in Bangladesh may be useful in disseminating information about MR and connecting women with formal providers, in-person visits remain necessary for adequate treatment.

From knowing our needs to enacting change: findings from community consultations with indigenous communities in Bangladesh.

INTRODUCTION: Indigenous peoples are among the most marginalized peoples in the world due to issues relating to well-being, political representation, and economic production. The research consortium Goals and Governance for Global Health (Go4Health) conducted a community consultation process among marginalized groups across the global South aimed at including their voices in the global discourse around health in the post-2015 development agenda. This paper presents findings from the consultations carried out among indigenous communities in Bangladesh. METHODS: For this qualitative study, our research team consulted the Tripura and Mro communities in Bandarban district living in the isolated Chittagong Hill Tracts region. Community members, leaders, and key informants working in health service delivery were interviewed. Data was analyzed using thematic analysis. FINDINGS: Our findings show that remoteness shapes the daily lives of the communities, and their lack of access to natural resources and basic services prevents them from following health promotion messages. The communities feel that their needs are impossible to secure in a politically indifferent and sometimes hostile environment. CONCLUSION: Communities are keen to participate and work with duty bearers in creating the conditions that will lead to their improved quality of life. Clear policies that recognize the status of indigenous peoples are necessary in the Bangladeshi context to allow for the development of services and infrastructure.

Exploring the context in which different close-to-community sexual and reproductive health service providers operate in Bangladesh: a qualitative study.

BACKGROUND: A range of formal and informal close-to-community (CTC) health service providers operate in an increasingly urbanized Bangladesh. Informal CTC health service providers play a key role in Bangladesh's pluralistic health system, yet the reasons for their popularity and their interactions with formal providers and the community are poorly understood. This paper aims to understand the factors shaping poor urban and rural women's choice of service provider for their sexual and reproductive health (SRH)-related problems and the interrelationships between these providers and communities. Building this evidence base is important, as the number and range of CTC providers continue to expand in both urban slums and rural communities in Bangladesh. This has implications for policy and future programme interventions addressing the poor women's SRH needs. METHODS: Data was generated through 24 in-depth interviews with menstrual regulation clients, 12 focus group discussions with married men and women in communities and 24 semi-structured interviews with formal and informal CTC SRH service providers. Data was collected between July and September 2013 from three urban slums and one rural site in Dhaka and Sylhet, Bangladesh. Atlas.ti software was used to manage data analysis and coding, and a thematic analysis was undertaken. RESULTS: Poor women living in urban slums and rural areas visit a diverse range of CTC providers for SRH-related problems. Key factors influencing their choice of provider include the following: availability, accessibility, expenses and perceived quality of care, the latter being shaped by notions of trust, respect and familiarity. Informal providers are usually the first point of contact even for those clients who subsequently access SRH services from formal providers. Despite existing informal interactions between both types of providers and a shared understanding that this can be beneficial for clients, there is no effective link or partnership between these providers for referral, coordination and communication regarding SRH services. CONCLUSION: Training informal CTC providers and developing strategies to enable better links and coordination between this community-embedded cadre and the formal health sector has the potential to reduce service cost and improve availability of quality SRH (and other) care at the community level.

Qualitative insights into promotion of pharmaceutical products in Bangladesh: how ethical are the practices?

BACKGROUND: The pharmaceutical market in Bangladesh is highly concentrated (top ten control around 70 % of the market). Due to high competition aggressive marketing strategies are adopted for greater market share, which sometimes cross limit. There is lack of data on this aspect in Bangladesh. This exploratory study aimed to fill this gap by investigating current promotional practices of the pharmaceutical companies including the role of their medical representatives (MR). METHODS: This qualitative study was conducted as part of a larger study to explore the status of governance in health sector in 2009. Data were collected from Dhaka, Chittagong and Bogra districts through in-depth interview (healthcare providers and MRs), observation (physician-MR interaction), and round table discussion (chief executives and top management of the pharmaceutical companies). RESULTS: Findings reveal a highly structured system geared to generate prescriptions and ensure market share instituted by the pharmaceuticals. A comprehensive training curriculum for the MRs prepares the newly recruited science graduates for generating enough prescriptions by catering to the identified needs and demands of the physicians expressed or otherwise, and thus grab higher market-share for the companies they represent. Approaches such as inducements, persuasion, emotional blackmail, serving family members, etc. are used. The type, quantity and quality of inducements offered to the physicians depend upon his/her capacity to produce prescriptions. The popular physicians are cultivated meticulously by the MRs to establish brand loyalty and fulfill individual and company targets. The physicians, willingly or unwillingly, become part of the system with few exceptions. Neither the regulatory authority nor the professional or consumer rights bodies has any role to control or ractify the process. CONCLUSIONS: The aggressive marketing of the pharmaceutical companies compel their MRs, programmed to maximize market share, to adopt unethical means if and when necessary. When medicines are prescribed and dispensed more for financial interests than for needs of the patients, it reflects system's failed ability to hold individuals and entities accountable for adhering to basic professional ethics, code of conduct, and statutory laws.

Explaining equity gains in child survival in Bangladesh: scale, speed, and selectivity in health and development.

By disaggregating gains in child health in Bangladesh over the past several decades, significant improvements in gender and socioeconomic inequities have been revealed. With the use of a social determinants of health approach, key features of the country's development experience can be identified that help explain its unexpected health trajectory. The systematic equity orientation of health and socioeconomic development in Bangladesh, and the implementation attributes of scale, speed, and selectivity, have been important drivers of health improvement. Despite this impressive pro-equity trajectory, there remain significant residual inequities in survival of girls and lower wealth quintiles as well as a host of new health and development challenges such as urbanisation, chronic disease, and climate change. Further progress in sustaining and enhancing equity-oriented achievements in health hinges on stronger governance and longer-term systems thinking regarding how to effectively promote inclusive and equitable development within and beyond the health system.

The impact of humanitarian emergencies on adolescent boys: Findings from the Rohingya refugee crisis.

Adolescent boys (age 9-19) are impacted differently by humanitarian emergencies. However, academic research on adolescent health and child protection has tended to focus on the direct impacts of an emergency rather than indirect impacts that may arise after a crisis. We sought to identify child protection concerns affecting adolescent boys in emergency settings and boys who are more vulnerable to harm through a case study of the humanitarian response to the 2017 Rohingya refugee crisis. We collected data in the Rohingya refugee crisis in Cox's Bazar, Bangladesh between 2018-2019. This included six months of participant observation, 23 semi-structured interviews and 12 informal ethnographic interviews with humanitarian staff working in the crisis, and 10 focus group discussions with a total of 52 child protection caseworkers from four child protection organisations. Our results showed that adolescent Rohingya boys were exposed to numerous protection concerns, including child labour, drug trafficking, substance abuse, family violence, and neglect. We classified these into three main typologies: community-related violence, income-related violence, and life-stage vulnerabilities. We found that adolescent boys who were unaccompanied or separated from their caregivers, adolescent boys who were members of vulnerable households, and adolescent boys with a disability were at more risk of harm. Our findings indicate that adolescent boys are exposed to an array of impactful child protection concerns in humanitarian emergencies and that this has implications for the delivery of public health and child protection interventions. We believe that humanitarian actors should improve recognition of the complexity of adolescent boys' lives and their exposure to gender and age-based harm as a critical matter for addressing adolescent health equity.

Understanding the impacts of COVID-19 pandemic on mental health and well-being among university students in Dhaka, Bangladesh: A nested mixed-methods study.

Background: University students are more at risk of mental illness compared with the general population. Declaration of a global COVID-19 pandemic led the Bangladesh government in March 2020 to implement a national lockdown, home quarantining, social distancing measures, and closure of educational institutions. We aimed to explore the impact of lockdown on the mental health and well-being of university students in Bangladesh. Methods: A nested mixed-methods survey design was undertaken using a semi structured questionnaire and in-depth interviews conducted by telephone of 73 university students (mean age of 22 years, range 18 to 26-years-old) attending public and private academic institutions in Dhaka. A questionnaire was developed de-novo and pre-tested. Qualitative, open-ended questions were used to understand experiences regarding students' mental health and well-being, their perceptions of COVID-19, and coping strategies. Results: Fifty nine percent of students reported that lockdown had a significant impact on their mental health and well-being. They described difficulties with social isolation and loneliness, motivation, and interpersonal conflict within families. Students' knowledge of COVID-19 were high with television, newspapers, online, and social media were main sources of information; few relied on government reports. Most pressing concerns were timely graduation and employment (83%), not being able to socialize (46%), being stuck at home (37%), and financial difficulties regarding university fees (29%). Additional underlying stressors included financial insecurity of respondents' households and parental health. Coping strategies included watching television or films, online meetings with friends, social media, as well interactions with family. Conclusion: As a result of Bangladesh's first national lockdown, university students experienced negative effects on their mental health and well-being. There is an urgent need for greater proactive measures within educational settings, such as mental health literacy programmes and diagnosis management that could mitigate and prevent adverse impacts of future lockdowns.

Protocol for the Adolescent Menstrual Experiences and Health Cohort (AMEHC) Study in Khulna, Bangladesh: A Prospective cohort to quantify the influence of menstrual health on adolescent girls' health and education outcomes.

BACKGROUND: Menstrual health is essential for gender equity and the well-being of women and girls. Qualitative research has described the burden of poor menstrual health on health and education; however, these impacts have not been quantified, curtailing investment. The Adolescent Menstrual Experiences and Health Cohort (AMEHC) Study aims to describe menstrual health and its trajectories across adolescence, and quantify the relationships between menstrual health and girls' health and education in Khulna, Bangladesh. METHODS AND ANALYSIS: AMEHC is a prospective longitudinal cohort of 2016 adolescent girls recruited at the commencement of class 6 (secondary school, mean age=12) across 101 schools selected through a proportional random sampling approach. Each year, the cohort will be asked to complete a survey capturing (1) girls' menstrual health and experiences, (2) support for menstrual health, and (3) health and education outcomes. Survey questions were refined through qualitative research, cognitive interviews and pilot survey in the year preceding the cohort. Girls' guardians will be surveyed at baseline and wave 2 to capture their perspectives and household demographics. Annual assessments will capture schools' water, sanitation and hygiene, and support for menstruation and collect data on participants' education, including school attendance and performance (in maths, literacy). Cohort enrolment and baseline survey commenced in February 2023. Follow-up waves are scheduled for 2024, 2025 and 2026, with plans for extension. A nested subcohort will follow 406 post-menarche girls at 2-month intervals throughout 2023 (May, August, October) to describe changes across menstrual periods. This protocol outlines a priori hypotheses regarding the impacts of menstrual health to be tested through the cohort. ETHICS AND DISSEMINATION: AMEHC has ethical approval from the Alfred Hospital Ethics Committee (369/22) and BRAC James P Grant School of Public Health Institutional Review Board (IRB-06 July 22-024). Study materials and outputs will be available open access through peer-reviewed publication and study web pages.