A qualitative exploration of challenges in childhood TB patients identification and diagnosis in Bangladesh.

Background: As childhood tuberculosis is difficult to identify and diagnose, the experiences of the caregivers and healthcare providers of childhood tuberculosis patients remain a potential area of study. This study aims to illustrate the challenges caregivers and healthcare providers encounter in identifying and diagnosing childhood tuberculosis in two sub-districts of Bangladesh. Methods: We conducted semi-structured in-depth interviews with eight caregivers of childhood tuberculosis patients and key informant interviews with 36 healthcare providers from September 2020 to December 2020 from different levels of the tuberculosis control program in Keraniganj (with high childhood tuberculosis cases notification), Faridpur Sadar (with low childhood tuberculosis cases notification), and Dhaka city. Results: There is a dearth of understanding among caregivers about childhood tuberculosis. Passive case finding process and focus on cough during community mobilisation contribute to the delay in childhood tuberculosis identification. The stigmatisation that caregivers anticipate and experience has an impact on their mental health and implies that there are misunderstandings about tuberculosis in the community. Furthermore, diagnostic dilemma among healthcare providers accounts for diagnosis delays. Some, but not all, institutions in different geographical locations provide free diagnostic tests and have GeneXpert devices. Conclusions: Various factors, including caregivers' knowledge and experience, the process of case finding and community mobilization, healthcare providers' way of service provision and diagnosis, and the unavailability of required logistics at facilities challenge the identification and diagnosis of childhood tuberculosis that need to be minimized for childhood tuberculosis's early identification, diagnosis, treatment initiation, and successful completion of treatment. Awareness should also be raised in the community of childhood tuberculosis.

Community-based referral transportation system for accessing emergency obstetric services in the Rohingya refugee camp during the COVID-19 pandemic in Bangladesh: facilitators and barriers through beneficiaries' and providers' lens using a mixed-method design.

BACKGROUND: Delays in seeking timely maternity care from health care professionals are crucial to address among the Rohingya population where many preventable pregnancy-related deaths occur within the camps when care is not sought. To address the challenges related to the referral of emergency and routine Sexual and Reproductive Health and Rights (SRHR) cases, United Nations Population Fund, through its partners, implemented a community-based referral transportation project called Referral hub. This paper presents the barriers and facilitators to the implementation of this referral transportation system from the perspectives of the beneficiaries and providers. METHODS: The research adopted a sequential explanatory mixed-method design. The quantitative phase consisted of a survey among 100 women while the qualitative phase comprised of in-depth interviews with a total of 12 mothers who used the services and key informant interviews with 21 providers. RESULTS: The barriers identified for referral hub are discordant understanding of emergency, strict gender norms and practices, distrust in providers, poor roads and mobile phone networks. The facilitators are partnership with the community, within and other organizations. CONCLUSION: The study observed that the referral hub has a high potential to increase the utilization of SRHR services. Despite the barriers, the facilitating factors show a scope of improvement for these services.

Consent Requirements for Testing Health Policies: An Intercontinental Comparison of Expert Opinions.

Individual informed consent is a central requirement for clinical research on human subjects, yet whether and how consent requirements should apply to health policy experiments (HPEs) remains unclear. HPEs test and evaluate public health policies prior to implementation. We interviewed 58 health experts in Tanzania, Bangladesh and Germany on informed consent requirements for HPEs. Health experts across all countries favored a strong evidence base, prior information to the affected populations, and individual consent for 'risky' HPEs. Differences pertained to individual risk perception, how and when consent by group representatives should be obtained and whether HPEs could be treated as health policies. The study adds to representative consent options for HPEs, yet shows that more research is needed in this field - particularly in the present Covid-19 pandemic which has highlighted the need for HPEs nationally and globally.

Implementation of a community-based referral project to improve access to emergency obstetric and newborn care in Rohingya population during COVID-19 pandemic in Bangladesh.

Introduction: The delay in seeking emergency obstetric care leads to significant maternal morbidity and mortality and can worsen during pandemics, especially in humanitarian conflict settings with low uptake of obstetric services. To mitigate the challenges related to the second delay caused by lack of transport in the COVID-19 pandemic, the organisation United Nations Population Fund implements a community-based referral project called Referral Hub in the Rohingya refugee population in Bangladesh. The objective of the paper is to describe the implementation process of the Referral hub and present clients' utilisation and perception of the service. Methods: Findings from part of a larger mixed-method study, the analysis of the standard operating protocol of the intervention, secondary data of routine utilisation of the 12 referral hubs between January and August 2020, 21 key informant interviews and a community survey among 100 pregnant women are presented in this paper. Results: The findings show an increasing trend in the referral hub utilisation and a strong recommendation of the service. Conclusion: Due to a robust referral mechanism by collaborating with the community and engaging accessible and free of cost transport service, the intervention has high potential to improve access to facility care in low-resource and humanitarian contexts, especially during pandemics.

A critical look at synergies and fragmentations of universal health coverage, global health security, and health promotion in delivery of frontline health care services: A case study of Bangladesh.

Universal Health Coverage (UHC) and Global Health Security (GHS) activities encompass mitigation of risks to health and well-being rights posed by infectious disease outbreaks and facilitated by health promotion (HP) activities. This case study investigated Bangladesh's readiness and capacity to 'prevent, detect and respond' to such outbreaks of an epidemic/pandemic nature. A rapid review of relevant documents, key informant interviews with policymakers/practitioners, and a deliberative dialogue with a crisscross of stakeholders were used to identify challenges and opportunities for 'synergy' among these streams of activities. Findings reveal conceptual ambiguity among respondents about the scope of the three `agendas and their inter-linkages. They perceived the synergy between UHC and GHS superfluous and were obsessed with losing their respective constituencies and resources. Poor coordination among the focal agencies in field activities, lack of supporting infrastructure, and shortage of human and financial resources posed additional challenges for better pandemic/epidemic preparation in future. Funding: This study, "Researching the UHC-GHS-HP Triangle in Bangladesh," was funded by the Wellcome Trust, UK.

Disciplining sexual and reproductive behaviour of tuberculosis patients in Bangladesh: a mixed method study exploring divergent messages.

There is scant information on the instructions provided by health workers to patients diagnosed with tuberculosis and the implications these instructions have for sexual and reproductive health and rights and tuberculosis control in Bangladesh. This paper aims to draw attention to tuberculosis control guidelines and information dissemination practices that may need to be adapted to the living situations of those with tuberculosis. Data collection took place in the Monohardi and Narsingdi Sadar sub-districts in Narsingdi and the Mirpur slum in Dhaka, Bangladesh, between December 2015 and March 2016. We present findings from an analysis of four significant documents, 45 in-depth interviews (of current and former tuberculosis patients, their family members, and health workers), and two focus group discussions with health workers. The findings show that the official guidelines and policies hardly address sexual health or rights. During the treatment period, patients received mixed and inconsistent instructions from health workers on sexual intercourse, contraception, pregnancy, and living arrangements. The messages were interpreted differently based on who delivered and received them, and different instructions were provided to women and men. The instructions were not specific to the living situations of patients and therefore led to implementation challenges. Future interventions should ensure correct and consistent messaging, and policies should be adapted to the sexual needs of those infected with the disease.

Tuberculosis and the sexual and reproductive lives of women in Bangladesh.

When they do not meet norms related to sexuality and reproduction, Bangladeshi women often face abandonment and are thus deprived of an active sexual life, a marital relationship, and motherhood. Little is known about how a stigmatised disease such as tuberculosis (TB) may constrain the reproductive health and sexual lives of women. This article, derived from a larger study on the impact of TB on women's sexual and reproductive health and rights in Narsingdi district and Dhaka, Bangladesh, aims to fill this gap. Based on interviews with nine married women who have or had TB, four husbands, and two mothers-in-law, this article highlights that the ways in which TB impedes on the sexual and reproductive lives of women depends on the stigma within their family and community, their relationships with their husbands, motherhood, their living arrangements, their economic contribution to the family and/or their disclosure of their TB diagnosis. Women with children and supportive husbands retain a stronger position among their in-laws and are less likely to be isolated or rejected. The patients' narratives revealed that the instructions of health workers influenced their decisions about intercourse or abstinence. Future studies should examine the instructions patients receive from health workers regarding their living and sleeping arrangements, sexual intercourse, and pregnancy, as well as policy documents on TB treatment and prevention.

Double Trouble: Prevalence and Factors Associated with Tuberculosis and Diabetes Comorbidity in Bangladesh.

BACKGROUND: Diabetes among tuberculosis patients increases the risk of tuberculosis treatment failure, death, and development of multidrug-resistant tuberculosis. Yet, there is no data is available in Bangladesh on the prevalence of diabetes among tuberculosis patients. The objective of the current study was to estimate prevalence and identify factors associated with tuberculosis-diabetes co-morbidity among TB patients enrolled in the Directly Observed Treatment, Short course program. METHODS: A community based cross-sectional quantitative study was conducted among 1910 tuberculosis patients living in six urban and eleven rural areas among whom Oral Glucose Tolerance Test (those who fasted) and Random Blood Sugar test (those who did not fast) were performed. Besides glucose levels, data on socio-demographic information, family history of diabetes and anthropometric measurements (height and weight) were also collected. RESULT: Among the 1910 TB patients who participated in screening for diabetes, 245 (12.8%) were found to have diabetes and 296 (15.5%) to have pre-diabetes. Out of those who had diabetes, 34.7% were newly diagnosed through the current study and 65.3% already knew their status. Among those who were found to have prediabetes, 27 (9.1%) had impaired Fasting Blood Glucose (FBG), 230 (77.7%) had Impaired Glucose Tolerance (IGT), and 39 (13.2%) had both Impaired FBG and IGT. Older age, higher BMI, higher education (secondary level and above), being married, participation in less active work, and family history of diabetes are associated with higher prevalence of diabetes. CONCLUSION: We observed a higher prevalence of diabetes and pre-diabetes in TB patients than reported previously in Bangladesh among the general population which may challenge TB and diabetes control in Bangladesh. Diabetes diagnosis, treatment and care should be integrated in the National TB Program.

Knowledge and attitude of key community members towards tuberculosis: mixed method study from BRAC TB control areas in Bangladesh.

BACKGROUND: Bangladesh National Tuberculosis (TB) Control Programme adopted a number of strategies to facilitate TB diagnosis and treatment. 'Advocacy, Communication and Social Mobilization' (ACSM) was one of the key strategies implemented by BRAC (Bangladesh Rural Advancement Committee, a non-governmental development organization) TB control program. The purpose of this study is to assess the knowledge and attitudes of the key community members (KCMs) participated in ACSM in BRAC TB control areas. METHODS: This study combined quantitative and qualitative methods using a mixed method approach. KCMs in three districts with low TB case detection rates were targeted to assess the ACSM program. The quantitative survey using a multi-stage random-sampling strategy was conducted among 432 participants. The qualitative study included in-depth interviews (IDIs) of a sub sample of 48 respondents. For quantitative analysis, descriptive statistics were reported using frequencies, percentages, and Chi square tests, while thematic analysis was used for qualitative part. RESULTS: Most (99%) of the participants had heard about TB, and almost all knew that TB is a contagious yet curable disease. More than half (53%) of the KCMs had good knowledge regarding TB, but BRAC workers were found to be more knowledgeable compared to other KCMs. However, considerable knowledge gaps were observed among BRAC community health workers. Qualitative results revealed that the majority of the KCMs were aware about the signs, symptoms and transmission pathways of TB and believed that smoking and addiction were the prime causes of transmission of TB. The knowledge about child TB was poor even among BRAC health workers. Stigma associated with TB was not uncommon. Almost all respondents expressed that young girls diagnosed with TB. CONCLUSIONS: This study finding has revealed varying levels of knowledge and mixed attitudes about TB among the KCMs. It also provides insight on the poor knowledge regarding child TB and indicate that despite the significant success of the TB program stigma is yet prevalent in the community. Future ACSM activities should engage community members against stigma and promote child TB related information for further improvement of BRAC TB Control Programme.