Women's subsistence strategies predict fertility across cultures, but context matters.

While it is commonly assumed that farmers have higher, and foragers lower, fertility compared to populations practicing other forms of subsistence, robust supportive evidence is lacking. We tested whether subsistence activities-incorporating market integration-are associated with fertility in 10,250 women from 27 small-scale societies and found considerable variation in fertility. This variation did not align with group-level subsistence typologies. Societies labeled as "farmers" did not have higher fertility than others, while "foragers" did not have lower fertility. However, at the individual level, we found strong evidence that fertility was positively associated with farming and moderate evidence of a negative relationship between foraging and fertility. Markers of market integration were strongly negatively correlated with fertility. Despite strong cross-cultural evidence, these relationships were not consistent in all populations, highlighting the importance of the socioecological context, which likely influences the diverse mechanisms driving the relationship between fertility and subsistence.

A practical guide to cross-cultural and multi-sited data collection in the biological and behavioural sciences.

Researchers in the biological and behavioural sciences are increasingly conducting collaborative, multi-sited projects to address how phenomena vary across ecologies. These types of projects, however, pose additional workflow challenges beyond those typically encountered in single-sited projects. Through specific attention to cross-cultural research projects, we highlight four key aspects of multi-sited projects that must be considered during the design phase to ensure success: (1) project and team management; (2) protocol and instrument development; (3) data management and documentation; and (4) equitable and collaborative practices. Our recommendations are supported by examples from our experiences collaborating on the Evolutionary Demography of Religion project, a mixed-methods project collecting data across five countries in collaboration with research partners in each host country. To existing discourse, we contribute new recommendations around team and project management, introduce practical recommendations for exploring the validity of instruments through qualitative techniques during piloting, highlight the importance of good documentation at all steps of the project, and demonstrate how data management workflows can be strengthened through open science practices. While this project was rooted in cross-cultural human behavioural ecology and evolutionary anthropology, lessons learned from this project are applicable to multi-sited research across the biological and behavioural sciences.

Assessing acceptance and effects of child feeding counselling on nutritional status of children aged 6-23 months in a semi-urban community.

In Bangladesh, only 34 % of the children aged 18-23 months old are given minimum acceptable diets of complementary foods. Objective of the study was to find the effects of complementary feeding counselling on nutritional status among 6-23 months old children of poor families. This was a community-based randomised control trial. A total of 192 children in two groups were randomly selected. Nutrition education was given for a period of 4 months with post-intervention follow-up for 2 months. After 4 months of intervention, the difference in height for age Z score, weight for height Z score and weight for age Z score were significantly higher in the intervention group than in the control group (1·01 ± 0·31 v. 0·19 ± 0·01, P =< 0·001; 1·34 ± 0·15 v 0·72 ± 0·11, P =< 0·001; 1·5 ± 0·24 v. 0·62 ± 0·04, P =< 0·001). Mid-upper arm circumference Z score also improved in the intervention group than in the control group (0·95 ± 0·03 v. 0·57 ± 0·12, P =< 0·001). Morbidity of the children in the intervention group significantly reduced than in the control group (49 % v 80·20 %, P =< 0·001). Higher feeding frequency (3-4 times) (71·9 % v. 45·8 %) and energy intake increased in the intervention group than in the control group. Promotion of complementary feeding from the family foods can improve the nutritional status of 6-23 months old children of poor families within a short period.

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

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

Economic impacts and nutritional outcomes of the 2017 floods in Bangladeshi Shodagor fishing families.

OBJECTIVES: As climate change continues to increase the frequency and severity of flooding in Bangladesh and globally, it becomes increasingly critical to understand the pathways through which flooding influences health outcomes, particularly in lower-income and subsistence-based communities. We aim to assess economic pathways that link flooding to nutritional outcomes among Shodagor fishing families in Bangladesh. METHODS: We examine longitudinal economic data on kilograms of fish caught, the income earned from those fish, and household food expenditures (as a proxy for dietary intake) from before, during, and after severe flooding in August-September of 2017 to enumerate the impacts of flooding on Shodagor economics and nutrition. We also analyze seasonally collected anthropometric data to model the effects of flooding and household food expenditures on child growth rates and changes to adult body size. RESULTS: While Shodagor fishing income declined during the 2017 flooding, food expenditures simultaneously spiked with market inflation, and rice became the predominant expenditure only during and immediately following the flood. Our nutritional models show that children and adults lost more body mass in households that spent more money on rice during the flood. Shodagor children lost an average of 0.36 BMI-for-age z-scores and adults lost an average of 0.32 BMI units during the flooded 2017 rainy season, and these metrics continued to decline across subsequent seasons and did not recover by the end of the study period in 2019. CONCLUSIONS: These results show major flood-induced economic impacts that contributed to loss of child and adult body mass among Shodagor fishing families in Bangladesh. More frequent and severe flooding will exacerbate these nutritional insults, and more work is needed to effectively stabilize household nutrition throughout natural disasters and economic hardship.

Neonatal and child mortality data in retrospective population-based surveys compared with prospective demographic surveillance: EN-INDEPTH study.

BACKGROUND: Global mortality estimates remain heavily dependent on household surveys in low- and middle-income countries, where most under-five deaths occur. Few studies have assessed the accuracy of mortality data or determinants of capturing births in surveys. METHODS: The Every Newborn-INDEPTH study (EN-INDEPTH) included a large, multi-country survey of women aged 15-49 interviewed about livebirths and their survival status in five Health and Demographic Surveillance Systems (HDSSs). The HDSSs undertake regular household visits to register births and deaths for a given population. We analysed EN-INDEPTH survey data to assess background factors associated with not recalling a complete date-of-birth. We calculated Kaplan-Meier survival estimates for both survey and HDSS data and describe age-at-death distributions during the past 5 years for children born to the same women. We assessed the proportion of HDSS-births that could be matched on month-of-birth to survey-births and used regression models to identify factors associated with matching. RESULTS: 69,176 women interviewed in the survey reported 109,817 births and 3064 deaths in children under 5 years in the 5 years prior to the survey. In the HDSS data, the same women had 83,768 registered births and 2335 under-five deaths in the same period. A complete date-of-birth was not reported for 1-7% of survey-births. Birthdates were less likely to be complete for dead children and children born to women of higher parity or with little/no education. Distributions of reported age-at-death indicated heaping at full weeks (neonatal period) and at 12 months. Heaping was more pronounced in the survey data. Survey estimates of under-five mortality rates were similar to HDSS estimates of under-five mortality in two of five sites, higher in the survey in two sites (15%, 41%) and lower (24%) in one site. The proportion of HDSS-births matched to survey-births ranged from 51 to 89% across HDSSs and births of children who had died were less likely to be matched. CONCLUSIONS: Mortality estimates in the survey and HDSS were not markedly different for most sites. However, neither source is a "gold standard" and both sources miss some events. Research is required to improve capture and accuracy to better track newborn and child survival targets.

Electronic data collection in a multi-site population-based survey: EN-INDEPTH study.

BACKGROUND: Electronic data collection is increasingly used for household surveys, but factors influencing design and implementation have not been widely studied. The Every Newborn-INDEPTH (EN-INDEPTH) study was a multi-site survey using electronic data collection in five INDEPTH health and demographic surveillance system sites. METHODS: We described experiences and learning involved in the design and implementation of the EN-INDEPTH survey, and undertook six focus group discussions with field and research team to explore their experiences. Thematic analyses were conducted in NVivo12 using an iterative process guided by a priori themes. RESULTS: Five steps of the process of selecting, adapting and implementing electronic data collection in the EN-INDEPTH study are described. Firstly, we reviewed possible electronic data collection platforms, and selected the World Bank's Survey Solutions® as the most suited for the EN-INDEPTH study. Secondly, the survey questionnaire was coded and translated into local languages, and further context-specific adaptations were made. Thirdly, data collectors were selected and trained using standardised manual. Training varied between 4.5 and 10 days. Fourthly, instruments were piloted in the field and the questionnaires finalised. During data collection, data collectors appreciated the built-in skip patterns and error messages. Internet connection unreliability was a challenge, especially for data synchronisation. For the fifth and final step, data management and analyses, it was considered that data quality was higher and less time was spent on data cleaning. The possibility to use paradata to analyse survey timing and corrections was valued. Synchronisation and data transfer should be given special consideration. CONCLUSION: We synthesised experiences using electronic data collection in a multi-site household survey, including perceived advantages and challenges. Our recommendations for others considering electronic data collection include ensuring adaptations of tools to local context, piloting/refining the questionnaire in one site first, buying power banks to mitigate against power interruption and paying attention to issues such as GPS tracking and synchronisation, particularly in settings with poor internet connectivity.

Gestational age data completeness, quality and validity in population-based surveys: EN-INDEPTH study.

BACKGROUND: Preterm birth (gestational age (GA) <37 weeks) is the leading cause of child mortality worldwide. However, GA is rarely assessed in population-based surveys, the major data source in low/middle-income countries. We examined the performance of new questions to measure GA in household surveys, a subset of which had linked early pregnancy ultrasound GA data. METHODS: The EN-INDEPTH population-based survey of 69,176 women was undertaken (2017-2018) in five Health and Demographic Surveillance System sites in Bangladesh, Ethiopia, Ghana, Guinea-Bissau and Uganda. We included questions regarding GA in months (GAm) for all women and GA in weeks (GAw) for a subset; we also asked if the baby was 'born before expected' to estimate preterm birth rates. Survey data were linked to surveillance data in two sites, and to ultrasound pregnancy dating at <24 weeks in one site. We assessed completeness and quality of reported GA. We examined the validity of estimated preterm birth rates by sensitivity and specificity, over/under-reporting of GAw in survey compared to ultrasound by multinomial logistic regression, and explored perceptions about GA and barriers and enablers to its reporting using focus group discussions (n = 29). RESULTS: GAm questions were almost universally answered, but heaping on 9 months resulted in underestimation of preterm birth rates. Preference for reporting GAw in even numbers was evident, resulting in heaping at 36 weeks; hence, over-estimating preterm birth rates, except in Matlab where the peak was at 38 weeks. Questions regarding 'born before expected' were answered but gave implausibly low preterm birth rates in most sites. Applying ultrasound as the gold standard in Matlab site, sensitivity of survey-GAw for detecting preterm birth (GAw <37) was 60% and specificity was 93%. Focus group findings suggest that women perceive GA to be important, but usually counted in months. Antenatal care attendance, women's education and health cards may improve reporting. CONCLUSIONS: This is the first published study assessing GA reporting in surveys, compared with the gold standard of ultrasound. Reporting GAw within 5 years' recall is feasible with high completeness, but accuracy is affected by heaping. Compared to ultrasound-GAw, results are reasonably specific, but sensitivity needs to be improved. We propose revised questions based on the study findings for further testing and validation in settings where pregnancy ultrasound data and/or last menstrual period dates/GA recorded in pregnancy are available. Specific training of interviewers is recommended.

Labor migration is associated with lower rates of underweight and higher rates of obesity among left-behind wives in rural Bangladesh: a cross-sectional study.

BACKGROUND: Among Bangladeshi men, international labor migration has increased ten-fold since 1990 and rural to urban labor migration rates have steadily increased. Labor migration of husbands has increased household wealth and redefined women's roles, which have both positively and negatively impacted the health of wives "left behind". We examined the direct and indirect effects of husband labor migration on chronic disease indicators and outcomes among wives of labor migrants. METHODS: We collected survey, anthropometric, and biomarker data from a random sample of women in Matlab, Bangladesh, in 2018. We assessed associations between husband's migration and indicators of adiposity and chronic disease. We used structural equation modeling to assess the direct effect of labor migration on chronic disease, undernutrition, and adiposity, and the mediating roles of income, food security, and proportion of food purchased from the bazaar. Qualitative interviews and participant observation were used to help provide context for the associations we found in our quantitative results. FINDINGS: Among study participants, 9.0% were underweight, 50.9% were iron deficient, 48.3% were anemic, 39.6% were obese, 27.3% had a waist circumference over 35 in., 33.1% had a high whole-body fat percentage, 32.8% were diabetic, and 32.9% had hypertension. Slightly more women in the sample (55.3%) had a husband who never migrated than had a husband who had ever migrated (44.9%). Of those whose husband had ever migrated, 25.8% had a husband who was a current international migrant. Wives of migrants were less likely to be underweight, and more likely to have indicators of excess adiposity, than wives of non-migrants. Protection against undernutrition was attributable primarily to increased food security among wives of migrants, while increased adiposity was attributable primarily to purchasing a higher proportion of food from the bazaar; however, there was a separate path through income, which qualitative findings suggest may be related to reduced physical activity. CONCLUSIONS: Labor migration, and particularly international labor migration, intensifies the nutrition transition in Bangladesh through increasing wealth, changing how foods are purchased, and reducing physical activity, which both decreases risk for undernutrition and increases risk for excess adiposity.

On the estimation of population cause-specific mortality fractions from in-hospital deaths.

BACKGROUND: Almost all countries without complete vital registration systems have data on deaths collected by hospitals. However, these data have not been widely used to estimate cause of death (COD) patterns in populations because only a non-representative fraction of people in these countries die in health facilities. Methods that can exploit hospital mortality statistics to reliably estimate community COD patterns are required to strengthen the evidence base for disease and injury control programs. We propose a method that weights hospital-certified causes by the probability of death to estimate population cause-specific mortality fractions (CSMFs). METHODS: We used an established verbal autopsy instrument (VAI) to collect data from hospital catchment areas in Chandpur and Comilla Districts, Bangladesh, and Bohol province, the Philippines, between 2011 and 2014, along with demographic covariates for each death. Hospital medical certificates of cause of death (death certificates) were collected and mapped to the corresponding cause categories of the VAI. Tariff 2.0 was used to assign a COD for community deaths. Logistic regression models were created for broad causes in each country to calculate the probability of in-hospital death, given a set of covariate values. The reweighted CSMFs for deaths in the hospital catchment population, represented by each hospital death, were calculated from the corresponding regression models. RESULTS: We collected data on 4228 adult deaths in the Philippines and 3725 deaths in Bangladesh. Short time to hospital and education were consistently associated with in-hospital death in the Philippines and absence of a disability was consistently associated with in-hospital death in Bangladesh. Non-communicable diseases (excluding stroke) and stroke were the leading causes of death in both the Philippines (33.9%, 19.1%) and Bangladesh (46.1%, 21.1%) according to the reweighted method. The reweighted method generally estimated CSMFs that fell between those derived from hospitals and those diagnosed by Tariff 2.0. CONCLUSIONS: Statistical methods can be used to derive estimates of cause-specific probability of death in-hospital for Bangladesh and the Philippines to generate population CSMFs. In regions where hospital death certification is of reasonable quality and routine verbal autopsy is not applied, these estimates could be applied to generate cost-effective and robust CSMFs for the population.

Robustness of the Tariff method for diagnosing verbal autopsies: impact of additional site data on the relationship between symptom and cause.

BACKGROUND: Verbal autopsy (VA) is increasingly being considered as a cost-effective method to improve cause of death information in countries with low quality vital registration. VA algorithms that use empirical data have an advantage over expert derived algorithms in that they use responses to the VA instrument as a reference instead of physician opinion. It is unclear how stable these data driven algorithms, such as the Tariff 2.0 method, are to cultural and epidemiological variations in populations where they might be employed. METHODS: VAs were conducted in three sites as part of the Improving Methods to Measure Comparable Mortality by Cause (IMMCMC) study: Bohol, Philippines; Chandpur and Comila Districts, Bangladesh; and Central and Eastern Highlands Provinces, Papua New Guinea. Similar diagnostic criteria and cause lists as the Population Health Metrics Research Consortium (PHMRC) study were used to identify gold standard (GS) deaths. We assessed changes in Tariffs by examining the proportion of Tariffs that changed significantly after the addition of the IMMCMC dataset to the PHMRC dataset. RESULTS: The IMMCMC study added 3512 deaths to the GS VA database (2491 adults, 320 children, and 701 neonates). Chance-corrected cause specific mortality fractions for Tariff improved with the addition of the IMMCMC dataset for adults (+ 5.0%), children (+ 5.8%), and neonates (+ 1.5%). 97.2% of Tariffs did not change significantly after the addition of the IMMCMC dataset. CONCLUSIONS: Tariffs generally remained consistent after adding the IMMCMC dataset. Population level performance of the Tariff method for diagnosing VAs improved marginally for all age groups in the combined dataset. These findings suggest that cause-symptom relationships of Tariff 2.0 might well be robust across different population settings in developing countries. Increasing the total number of GS deaths improves the validity of Tariff and provides a foundation for the validation of other empirical algorithms.

Comparing tariff and medical assistant assigned causes of death from verbal autopsy interviews in Matlab, Bangladesh: implications for a health and demographic surveillance system.

BACKGROUND: Deaths in developing countries often occur outside health facilities, making it extremely difficult to gather reliable cause of death (COD) information. Automated COD assignment using a verbal autopsy instrument (VAI) has been proposed as a reliable and cost-effective alternative to traditional physician-certified verbal autopsy, but its performance is still being evaluated. The purpose of this study was to compare the similarity of diagnosis by Medical Assistants (MA) in the Matlab Health and Demographic Surveillance System (HDSS) with the SmartVA Analyze 1.2 (Tariff 2.0) diagnosis. METHODS: This study took place between January 2011 and April 2014 in Matlab, Bangladesh. MA with 3 years of medical training assigned COD to Matlab residents by reviewing the information collected using the Population Health Metrics Research Consortium (PHMRC) long-form VAI. Smart VA Analyze 1.2 automatically assigned COD using the same questionnaire. COD agreement and cause-specific mortality fractions (CSMFs) were compared for MA and Tariff. RESULTS: Of the 4969 verbal autopsy cases reviewed, 4328 were adults, 296 were children, and 345 were neonates. Cohen's kappa was 0.38 (0.36, 0.40) for adults, 0.43 (0.38, 0.49) for children, and 0.27 (0.22, 0.33) for neonates. For adults, the top two COD for MA were stroke (29.6%) and ischemic heart diseases (IHD) (14.2%) and for Tariff these were stroke (32.0%) and IHD (14.0%). For children, the top two COD for MA were drowning (33.5%) and pneumonia (13.2%) and for Tariff these were also drowning (36.8%) and pneumonia (12.4%). For neonates, the top two COD for MA were birth asphyxia (41.2%) and meningitis/sepsis (22.3%) and for Tariff these were birth asphyxia (37.0%) and preterm delivery (30.9%). CONCLUSION: The CSMFs for Tariff and MA showed very close agreement across all age categories but some differences were observed for neonate preterm delivery and meningitis/sepsis. Given the known advantages of automated methods over physician certified verbal autopsy, the SmartVA software, incorporating the shortened VAI questionnaire and Tariff 2.0, could serve as a cost-effective alternative to Matlab MA to routinely collect and analyze verbal autopsy data in a HDSS to generate essential population level COD data for planning.

Collecting verbal autopsies: improving and streamlining data collection processes using electronic tablets.

BACKGROUND: There is increasing interest in using verbal autopsy to produce nationally representative population-level estimates of causes of death. However, the burden of processing a large quantity of surveys collected with paper and pencil has been a barrier to scaling up verbal autopsy surveillance. Direct electronic data capture has been used in other large-scale surveys and can be used in verbal autopsy as well, to reduce time and cost of going from collected data to actionable information. METHODS: We collected verbal autopsy interviews using paper and pencil and using electronic tablets at two sites, and measured the cost and time required to process the surveys for analysis. From these cost and time data, we extrapolated costs associated with conducting large-scale surveillance with verbal autopsy. RESULTS: We found that the median time between data collection and data entry for surveys collected on paper and pencil was approximately 3 months. For surveys collected on electronic tablets, this was less than 2 days. For small-scale surveys, we found that the upfront costs of purchasing electronic tablets was the primary cost and resulted in a higher total cost. For large-scale surveys, the costs associated with data entry exceeded the cost of the tablets, so electronic data capture provides both a quicker and cheaper method of data collection. CONCLUSIONS: As countries increase verbal autopsy surveillance, it is important to consider the best way to design sustainable systems for data collection. Electronic data capture has the potential to greatly reduce the time and costs associated with data collection. For long-term, large-scale surveillance required by national vital statistical systems, electronic data capture reduces costs and allows data to be available sooner.

General service and child immunization-specific readiness assessment of healthcare facilities in two selected divisions in Bangladesh.

BACKGROUND: Service readiness of health facilities is an integral part of providing comprehensive quality healthcare to the community. Comprehensive assessment of general and service-specific (i.e. child immunization) readiness will help to identify the bottlenecks in healthcare service delivery and gaps in equitable service provision. Assessing healthcare facilities readiness also helps in optimal policymaking and resource allocation. METHODS: A health facility survey was conducted between March 2015 and December 2015 in two purposively selected divisions in Bangladesh; i.e. Rajshahi division (high performing) and Sylhet division (low performing). A total of 123 health facilities were randomly selected from different levels of service, both public and private, with variation in sizes and patient loads from the list of facilities. Data on various aspects of healthcare facility were collected by interviewing key personnel. General service and child immunization specific service readiness were assessed using the Service Availability and Readiness Assessment (SARA) manual developed by World Health Organization (WHO). The analyses were stratified by division and level of healthcare facilities. RESULTS: The general service readiness index for pharmacies, community clinics, primary care facilities and higher care facilities were 40.6%, 60.5%, 59.8% and 69.5%, respectively in Rajshahi division and 44.3%, 57.8%, 57.5% and 73.4%, respectively in Sylhet division. Facilities at all levels had the highest scores for basic equipment (ranged between 51.7% and 93.7%) and the lowest scores for diagnostic capacity (ranged between 0.0% and 53.7%). Though facilities with vaccine storage capacity had very high levels of service readiness for child immunization, facilities without vaccine storage capacity lacked availability of many tracer items. Regarding readiness for newly introduced pneumococcal conjugate vaccine (PCV) and inactivated polio vaccine (IPV), most of the surveyed facilities reported lack of sufficient funding and resources (antigen) for training programs. CONCLUSIONS: Our study suggested that health facilities suffered from lack of readiness in various aspects, most notably in diagnostic capacity. Conversely, with very few challenges, nearly all the health facilities designated to provide immunization services were ready to deliver routine childhood immunization services as well as newly introduced PCV and IPV.

Vitamin A deficiency and determinants of vitamin A status in Bangladeshi children and women: findings of a national survey.

OBJECTIVE: Using data from the national micronutrients survey 2011-2012, the present study explored the status of subclinical vitamin A nutrition and the underlying determinants in the Bangladeshi population. DESIGN: A nationwide cross-sectional study. Settings The survey covered 150 clusters; fifty in each of rural, urban and slum strata. SUBJECTS: Three population groups: (i) pre-school age children (6-59 months; PSAC); (ii) school age children (6-14 years; SAC); and (iii) non-pregnant non-lactating women (15-49 years; NPNLW). RESULTS: National prevalence of subclinical vitamin A deficiency was 20·5, 20·8 and 5·3 % in PSAC, SAC and NPNLW, respectively. Slum populations had higher prevalence compared with urban (PSAC: 38·1 v. 21·2 %, P0·05 for differences in ß between <3 months v. 3-6 months, 6-9 months and 9-12 months). CONCLUSIONS: Prevalence of subclinical vitamin A deficiency was high in children in Bangladesh. Intakes of animal-source foods and leafy vegetables were associated with higher and lower retinol status, respectively. Increased food diversity through animal-source foods is required.

The quality of medical death certification of cause of death in hospitals in rural Bangladesh: impact of introducing the International Form of Medical Certificate of Cause of Death.

BACKGROUND: Accurate and timely data on cause of death are critically important for guiding health programs and policies. Deaths certified by doctors are implicitly considered to be reliable and accurate, yet the quality of information provided in the international Medical Certificate of Cause of Death (MCCD) usually varies according to the personnel involved in certification, the diagnostic capacity of the hospital, and the category of hospitals. There are no published studies that have analysed how certifying doctors in Bangladesh adhere to international rules when completing the MCCD or have assessed the quality of clinical record keeping. METHODS: The study took place between January 2011 and April 2014 in the Chandpur and Comilla districts of Bangladesh. We introduced the international MCCD to all study hospitals. Trained project physicians assigned an underlying cause of death, assessed the quality of the death certificate, and reported the degree of certainty of the medical records provided for a given cause. We examined the frequency of common errors in completing the MCCD, the leading causes of in-hospital deaths, and the degree of certainty in the cause of death data. RESULTS: The study included 4914 death certificates. 72.9% of medical records were of too poor quality to assign a cause of death, with little difference by age, hospital, and cause of death. 95.6% of death certificates did not indicate the time interval between onset and death, 31.6% required a change in sequence, 13.9% required to include a new diagnosis, 50.7% used abbreviations, 41.5% used multiple causes per line, and 33.2% used an ill-defined condition as the underlying cause of death. 99.1% of death certificates had at least one error. The leading cause of death among adults was stroke (15.8%), among children was pneumonia (31.7%), and among neonates was birth asphyxia (52.8%). CONCLUSION: Physicians in Bangladeshi hospitals had difficulties in completing the MCCD correctly. Physicians routinely made errors in death certification practices and medical record quality was poor. There is an urgent need to improve death certification practices and the quality of hospital data in Bangladesh if these data are to be useful for policy.

Impact of mobile phone-based technology to improve health, population and nutrition services in Rural Bangladesh: a study protocol.

BACKGROUND: Mobile phone-based technology has been used in improving the delivery of healthcare services in many countries. However, data on the effects of this technology on improving primary healthcare services in resource-poor settings are limited. The aim of this study is to develop and test a mobile phone-based system to improve health, population and nutrition services in rural Bangladesh and evaluate its impact on service delivery. METHODS: The study will use a quasi-experimental pre-post design, with intervention and comparison areas. Outcome indicators will include: antenatal care (ANC), delivery care, postnatal care (PNC), neonatal care, expanded programme on immunization (EPI) coverage, and contraceptive prevalence rate (CPR). The study will be conducted over a period of 30 months, using the existing health systems of Bangladesh. The intervention will be implemented through the existing service-delivery personnel at various primary-care levels, such as community clinic, union health and family welfare centre, and upazila health complex. These healthcare providers will be given mobile phones equipped with Apps for sending text and voice messages, along with the use of Internet and device for data-capturing. Training on handling of the Smartphones, data-capturing and monitoring will be given to selected service providers. They will also be trained on inputs, editing, verifying, and monitoring the outcome variables. DISCUSSION: Mobile phone-based technology has the potential to improve primary healthcare services in low-income countries, like Bangladesh. It is expected that our study will contribute to testing and developing a mobile phone-based intervention to improve the coverage and quality of services. The learning can be used in other similar settings in the low-and middle-income countries.

Evaluation of impact of measles rubella campaign on vaccination coverage and routine immunization services in Bangladesh.

BACKGROUND: Like other countries in Asia, measles-rubella (MR) vaccine coverage in Bangladesh is suboptimal whereas 90-95 % coverage is needed for elimination of these diseases. The Ministry of Health and Family Welfare (MOHFW) of the Government of Bangladesh implemented MR campaign in January-February 2014 to increase MR vaccination coverage. Strategically, the MOHFW used both routine immunization centres and educational institutions for providing vaccine to the children aged 9 months to <15 years. The evaluation was carried out to assess the impact of the campaign on MR vaccination and routine immunization services. METHODS: Both quantitative and qualitative evaluations were done before and after implementation of the campaign. Quantitative data were presented with mean (standard deviation, SD) for continuous variables and with proportion for categorical variables. The overall and age- and sex-specific coverage rates were calculated for each region and then combined. Categorical variables were compared by chi-square statistics. Multiple logistic regression analysis were performed to estimate odds ratios (OR) and 95 % confidence intervals (CI) of coverage associated with covariates, with adjustment for other covariates. Qualitative data were analyzed using content analysis. RESULTS: The evaluations found MR coverage was very low (<13 %) before the campaign and it rose to 90 % after the campaign. The pre-post campaign difference in MR coverage in each stratum was highly significant (p < 0.001). The campaign achieved high coverage despite relatively low level (23 %) of interpersonal communication with caregivers through registration process. Child registration was associated with higher MR coverage (OR 2.91, 95 % CI 1.91-4.44). Children who attended school were more likely to be vaccinated (OR 8.97, 95 % CI 6.17-13.04) compared to those who did not attend school. Children of caregivers with primary or secondary or higher education had higher coverage compared to children of caregivers with no formal education. Most caregivers mentioned contribution of the campaign in vaccination for the children not previously vaccinated. CONCLUSIONS: The results of the evaluation indicated that the campaign was successful in terms of improving MR coverage and routine immunization services. The evaluation provided an important guideline for future evaluation of similar efforts in Bangladesh and elsewhere.

Determinants of iron status and Hb in the Bangladesh population: the role of groundwater iron.

OBJECTIVE: Using data from the national micronutrients survey 2011-2012, the present study explored the determinants of Fe status and Hb levels in Bangladesh with a particular focus on groundwater Fe. DESIGN: Cross-sectional study conducted at the nationwide scale. Settings The survey was conducted in 150 clusters, fifty in each of the three strata of rural, urban and slum. SUBJECTS: Three population groups: pre-school age children (6-59 months; PSAC), school age children (6-14 years; SAC) and non-pregnant non-lactating women (15-49 years; NPNLW). RESULTS: National prevalence of Fe deficiency was 10·7 %, 7·1 % and 3·9-9·5 % in PSAC, NPNLW and SAC, respectively. Prevalence of anaemia was 33·1 % (PSAC), 26·0 % (NPNLW) and 17·1-19·1 % (SAC). Multivariate regression analyses showed that the area with 'predominantly high groundwater Fe' was a determinant of higher serum ferritin levels in NPNLW (standardized ß=0·19; P=0·03), SAC (standardized ß=0·22; P=0·01) and PSAC (standardized ß=0·20; P=0·03). This area also determined higher levels of Hb in PSAC (standardized ß=0·14; P=0·01). CONCLUSIONS: National prevalence of Fe deficiency in Bangladesh is low, contrary to the widely held assumption. High Fe level in groundwater is associated with higher Fe status (all populations) and higher Hb level (PSAC).

A model comparison approach shows stronger support for economic models of fertility decline.

The demographic transition is an ongoing global phenomenon in which high fertility and mortality rates are replaced by low fertility and mortality. Despite intense interest in the causes of the transition, especially with respect to decreasing fertility rates, the underlying mechanisms motivating it are still subject to much debate. The literature is crowded with competing theories, including causal models that emphasize (i) mortality and extrinsic risk, (ii) the economic costs and benefits of investing in self and children, and (iii) the cultural transmission of low-fertility social norms. Distinguishing between models, however, requires more comprehensive, better-controlled studies than have been published to date. We use detailed demographic data from recent fieldwork to determine which models produce the most robust explanation of the rapid, recent demographic transition in rural Bangladesh. To rigorously compare models, we use an evidence-based statistical approach using model selection techniques derived from likelihood theory. This approach allows us to quantify the relative evidence the data give to alternative models, even when model predictions are not mutually exclusive. Results indicate that fertility, measured as either total fertility or surviving children, is best explained by models emphasizing economic factors and related motivations for parental investment. Our results also suggest important synergies between models, implicating multiple causal pathways in the rapidity and degree of recent demographic transitions.