Equity assessment of maternal and child healthcare benefits utilization and distribution in public healthcare facilities in Bangladesh: a benefit incidence analysis.

BACKGROUND: The distribution of healthcare services should be based on the needs of the population, regardless of their ability to pay. Achieving universal health coverage implies first ensuring that people of all income levels have access to quality healthcare, and then allocating resources reasonably considering individual need. Hence, this study aims to understand how public benefits in Bangladesh are currently distributed among wealth quintiles considering different layers of healthcare facilities and to assess the distributional impact of public benefits. METHODS: To conduct this study, data were extracted from the recent Bangladesh Demographic and Health Survey 2017-18. We performed benefit incidence analysis to determine the distribution of maternal and child healthcare utilization in relation to wealth quintiles. Disaggregated and national-level public benefit incidence analysis was conducted by the types of healthcare services, levels of healthcare facilities, and overall utilization. Concentration curves and concentration indices were estimated to measure the equity in benefits distribution. RESULTS: An unequal utilization of public benefits observed among the wealth quintiles for maternal and child healthcare services across the different levels of healthcare facilities in Bangladesh. Overall, upper two quintiles (richest 19.8% and richer 21.7%) utilized more benefits from public facilities compared to the lower two quintiles (poorest 18.9% and poorer 20.1%). Benefits utilization from secondary level of health facilities was highly pro-rich, while benefit utilization found pro-poor at primary levels. The public benefits in Bangladesh were also not distributed according to the needs of the population; nevertheless, poorest 20% household cannot access 20% share of public benefits in most of the maternal and child healthcare services even if we ignore their needs. CONCLUSIONS: Benefit incidence analysis in public health spending demonstrates the efficacy with which the government allocates constrained health resources to satisfy the needs of the poor. Public health spending in Bangladesh on maternal and child healthcare services were not equally distributed among wealth quintiles. Overall health benefits were more utilized by the rich relative to the poor. Hence, policymakers should prioritize redistribution of resources by targeting the socioeconomically vulnerable segments of the population to increase their access to health services to meet their health needs.

Increasing rates of cesarean birth in Bangladesh: A household-level pooled analysis.

BACKGROUND: Cesarean birth (CB) rates have been increasing rapidly globally, including in Bangladesh. This study aimed to assess national trends in CB rates and to investigate associated factors in Bangladesh. METHODS: We analyzed data from the five most recent Bangladesh Demographic and Health Surveys (BDHS) between 2003 and 2018. A total of 27,328 ever-married women aged 15-49 who had a live birth in the 2 years preceding the survey were included in this study. We estimated the prevalence of CB from 2003 to 2018, as well as changes in the prevalence. Logistic regression analysis was used to measure the association between dependent and independent variables. RESULTS: The overall prevalence of CB among Bangladeshi mothers was 3.99% in 2003-04; this rate increased to 33.22% in 2017-18. The annual percentage change in CB rate was 16.34% from 2004 to 2017-18, which is alarming relative to the World Health Organization's cesarean birth recommended threshold. Several factors, such as maternal age, maternal and paternal education, working status of the mother, maternal BMI, age at first pregnancy, antenatal care (ANC) use, administrative division, and wealth status, had a significant influence on the rising rate of CB in Bangladesh. CONCLUSIONS: This study documents the alarming rate of CB increase in Bangladesh since 2003. It is critical that authorities implement more effective national monitoring measures to identify the causes of this dramatic increase and work to mitigate the rate of unnecessary CB in Bangladesh.

Economic evaluations of immunization programs as an indispensable tool for policymakers.

Introducing new vaccines within national immunization programs requires careful consideration of disease- and vaccine-related issues as well as of the strength of the program and the affected health system. Economic evaluations play an essential role in this process. In this editorial, we set the context and invite contributions for a BMC Health Services Research Collection of articles titled 'Economic Evaluations of Vaccine Programs'.

Disease-specific distress healthcare financing and catastrophic out-of-pocket expenditure for hospitalization in Bangladesh.

BACKGROUND: Financial risk protection and equity are two fundamental components of the global commitment to achieve Universal Health Coverage (UHC), which mandates health system reform based on population needs, disease incidence, and economic burden to ensure that everyone has access to health services without any financial hardship. We estimated disease-specific incidences of catastrophic out-of-pocket health expenditure and distress financing to investigate progress toward UHC financial risk indicators and investigated inequalities in financial risk protection indicators by wealth quintiles. In addition, we explored the determinants of financial hardship indicators as a result of hospitalization costs. METHODS: In order to conduct this research, data were extracted from the latest Bangladesh Household Income and Expenditure Survey (HIES), conducted by the Bangladesh Bureau of Statistics in 2016-2017. Financial hardship indicators in UHC were measured by catastrophic health expenditure and distress financing (sale/mortgage, borrowing, and family support). Concentration curves (CC) and indices (CI) were estimated to measure the pattern and severity of inequalities across socio-economic classes. Binary logistic regression models were used to assess the determinants of catastrophic health expenditure and distress financing. RESULTS: We found that about 26% of households incurred catastrophic health expenditure (CHE) and 58% faced distress financing on hospitalization in Bangladesh. The highest incidence of CHE was for cancer (50%), followed by liver diseases (49.2%), and paralysis (43.6%). The financial hardship indicators in terms of CHE (CI = -0.109) and distress financing (CI = -0.087) were more concentrated among low-income households. Hospital admission to private health facilities, non-communicable diseases, and the presence of chronic patients in households significantly increases the likelihood of higher UHC financial hardship indicators. CONCLUSIONS: The study findings strongly suggest the need for national-level social health security schemes with a particular focus on low-income households, since we identified greater inequalities between low- and high-income households in UHC financial hardship indicators. Regulating the private sector and implementing subsidized healthcare programmes for diseases with high treatment costs, such as cancer, heart disease, liver disease, and kidney disease are also expected to be effective to protect households from financial hardship. Finally, in order to reduce reliance on OOPE, the government should consider increasing its allocations to the health sector.

Drivers and distribution of the household-level double burden of malnutrition in Bangladesh: analysis of mother-child dyads from a national household survey.

OBJECTIVE: The double burden of malnutrition (DBM) has become an emerging public health issue in many low- and middle-income countries. This study aims to provide important evidence for the prevalence of different types of DBM at the national and subnational levels in Bangladesh. DESIGN: The study utilised data from the latest Bangladesh Demographic and Health Survey (BDHS) 2017-2018. Multivariable logistic regression was performed to identify the sociodemographic factors associated with DBM. SETTING: Nationally representative cross-sectional survey. PARTICIPANTS: 8697 mothers aged 15 to 49 years with <5 children. RESULTS: The overall prevalence of the DBM was approximately 21 %, where the prevalence of overweight mother (OWM) & stunted child/wasted child/underweight child (SC/WC/UWC) and underweight mother (UWM) & overweight child (OWC) was 13·35 % and 7·69 %, respectively, with a higher prevalence among urban households (OWM & SC/WC/UWC = 14·22 %; UWM & OWC = 10·58 %) in Bangladesh. High inequality was observed among UWM & OWC dyads, concentration index (CI) = -0·2998, while low level of inequality of DBM were observed for OWM & SC (CI = 0·0153), OWM & WC (CI = 0·1165) and OWM & UWC (CI = 0·0135) dyads. We observed that the age and educational status of the mother, number of children, fathers' occupation, size and wealth index of the household, and administrative division were significantly associated with all types of DBM. CONCLUSIONS: Health policymakers, concerned authorities and various stakeholders should stress the prevalence of DBM issues and take necessary actions aimed at identifying and addressing the DBM in Bangladesh.

Antimicrobial Resistance: Is Health Technology Assessment Part of the Solution or Part of the Problem?

Antimicrobial resistance is a serious challenge to the success and sustainability of our healthcare systems. There has been increasing policy attention given to antimicrobial resistance in the last few years, and increased amounts of funding have been channeled into funding for research and development of antimicrobial agents. Nevertheless, manufacturers doubt whether there will be a market for new antimicrobial technologies sufficient to enable them to recoup their investment. Health technology assessment (HTA) has a critical role in creating confidence that if valuable technologies can be developed they will be reimbursed at a level that captures their true value. We identify 3 deficiencies of current HTA processes for appraising antimicrobial agents: a methods-centric approach rather than problem-centric approach for dealing with new challenges, a lack of tools for thinking about changing patterns of infection, and the absence of an approach to epidemiological risks. We argue that, to play their role more effectively, HTA agencies need to broaden their methodological tool kit, design and communicate their analysis to a wider set of users, and incorporate long-term policy goals, such as containing resistance, as part of their evaluation criteria alongside immediate health gains.

Households' out-of-pocket expenditure for healthcare in Bangladesh: A health financing incidence analysis.

BACKGROUND: Despite improvements in many health indicators, providing access to affordable healthcare remains a considerable challenge in Bangladesh. Financing incidence analysis will enable an evaluation of how well the healthcare system performs to achieve equity in health financing. The objective of this study is to assess the burden of out-of-pocket (OOP) cost on different socio-economic groups by assessing the health financing incidence because OOP cost dominates household expenditure on health in Bangladesh. METHODS: The study was conducted using latest Household Income and Expenditure Survey (HIES) 2016. We focused mainly on four specific indicators: level of monthly household OOP cost on in-patient care, urban-rural differences in OOP cost, socio-economic status differences in different payment mechanisms and the Kakwani index. Descriptive statistics were employed to analyse and summarise the selected variables based on the SES and location of residence (e.g., rural and urban). RESULTS: The study showed the overall OOP healthcare expenditure was 7.7% of the household monthly income while the poorer income group suffered more and spent up to 35% of their household income on healthcare. The Kakwani index indicated that the poorest quintile spends a greater share of their income on healthcare services than the richest quintile. CONCLUSIONS: This study observed that OOP cost in Bangladesh is regressive, that is, poorer members of society contribute a greater share of their income. Therefore, policymakers should initiate health reforms for developing and implementing risk-pooling financing mechanisms such as social health insurance to achieve the Universal Health Coverage in Bangladesh.

Inequality of childhood undernutrition in Bangladesh: A decomposition approach.

BACKGROUND: Undernutrition is one of the major public health concerns in Bangladesh. This study examined the trends and patterns of childhood undernutrition, inequality, and its socioeconomic contributors in Bangladesh. METHODS: Data were extracted from the last four rounds of the Bangladesh Demographic Health Survey (BDHS). A regression-based decomposition method was applied to assess the socioeconomic contributors of inequality. RESULTS: Although the prevalence of childhood undernutrition has declined during the period 2004 to 2014, the rate of undernutrition is higher among the children of mothers who had lower education, live in rural areas, and are from the poorest wealth quintile. Socioeconomic status accounted for almost half of the total inequality in the prevalence of both stunting and underweight among children, whereas maternal education was ranked second among the contributors. CONCLUSIONS: Findings of the study indicate that undernutrition inequalities in terms of socioeconomic aspects appear to have widened over time. Improving economic activity and maternal education will improve the nutritional status of children and as a consequence reduce inequality. Therefore, investments in education, creation of working opportunities, and empowerment of vulnerable and disadvantaged people along with nutrition-specific interventions will be important measures to eliminate this inequality at the population level.

Measuring perinatal and postpartum quality of life of women and associated factors in semi-urban Bangladesh.

PURPOSE: The objective of this study was to measure the health-related quality of life (HRQoL) among pregnant women in the perinatal and postpartum periods and determine influencing factors that predict their HRQoL. METHODS: The study was conducted among pregnant women who live in a semi-urban area of Chandpur, Bangladesh. A total of 465 women were recruited. The EuroQoL 5-Dimension 3-Level (EQ-5D-3L) and EuroQoL visual analog scale (EQ-VAS) instruments were used to measure the HRQoL of participants. Two-sample mean test (t test) was performed to examine the changes in HRQoL between the perinatal and postnatal periods of the same individuals. Multivariate linear regression was employed to identify the factors influencing HRQoL during the two periods. RESULTS: Overall, the HRQoL scores improved significantly from the perinatal (0.49) to postpartum (0.86) period. Approximately 58% of women experienced moderate or extreme levels of health problems during the perinatal period regardless of their health status. However, most women had significantly improved health status in the postpartum period. Gestational weight gain and recommended postnatal care were significantly associated with improved HRQoL. Factors that negatively influenced changes in HRQoL included adolescent motherhood, caesarean delivery, inadequate antenatal care consultations and living in a poor household, during both the perinatal and postpartum periods. CONCLUSIONS: Overall health status is found to be poor among women during the perinatal period compared with the postpartum period. The study indicates that interventions to address the influencing factors are needed to ensure better quality of life for women both pre- and post-birth. Community-based initiatives, such as awareness building, might address negative factors and subsequently improve health status and reduce adverse health outcomes related to pregnancy and postnatal care.

Coverage and Determinants of Full Immunization: Vaccination Coverage among Senegalese Children.

Background and Objectives: In line with the global success of immunization, Senegal achieved impressive progress in childhood immunization program. However, immunization coverage is often below the national and international targets and even not equally distributed across the country. The objective of this study is to estimate the full immunization coverage across the geographic regions and identify the potential factors of full immunization coverage among the Senegalese children. Materials and Methods: Nationally representative dataset extracted from the latest Continuous Senegal Demographic and Health Survey 2017 was used for this analysis. Descriptive statistics such as the frequency with percentage and multivariable logistic regression models were constructed and results were presented in terms of adjusted odds ratio (AOR) with a 95% confidence interval (CI). Results: Overall, 70.96% of Senegalese children aged between 12 to 36 months were fully immunized and the coverage was higher in urban areas (76.51%), west ecological zone (80.0%), and among serer ethnic groups (77.24%). Full immunization coverage rate was almost the same between male and female children, and slightly higher among the children who were born at any health care facility (74.01%). Children who lived in the western zone of Senegal were 1.66 times (CI: 1.25-2.21; p = 0.001) and the children of Serer ethnic groups were 1.43 times (CI: 1.09-1.88; p = 0.011) more likely to be fully immunized than the children living in the southern zone and from the Poular ethnic group. In addition, children who were born at health facilities were more likely to be fully immunized than those who were born at home (AOR = 1.47; CI: 1.20-1.80; p < 0.001), and mothers with recommended antenatal care (ANC) (4 and more) visits during pregnancy were more likely to have their children fully immunized than those mother with no ANC visits (AOR: 2.06 CI: 1.19-3.57; p = 0.010). Conclusions: Immunization coverage was found suboptimal by type of vaccines and across ethnic groups and regions of Senegal. Immunization program should be designed targeting low performing areas and emphasize on promoting equal access to education, decision-making, encouraging institutional deliveries, and scaling up the use of antenatal and postnatal care which may significantly improve the rate full immunization coverage in Senegal.

Cost comparison and determinants of out-of-pocket payments on child delivery care in Bangladesh.

OBJECTIVES: The objective of this study is to capture the relevant out-of-pocket (OOP) costs, coping mechanisms, and associated factors that are related to child delivery in Bangladesh through the use of nationwide household level data. DATA AND METHODS: The study was conducted using a secondary data source of the latest Bangladesh Demographic and Health Survey 2014. A cross-sectional survey was performed for 6 months, from June to November 2014, where closed-ended questions regarding child delivery-related expenditure were included. Log linear regression and descriptive analysis methods were used to analyze these data. RESULTS: Analysis indicated that the average self-reported OOP payment per child delivery was US$ 79.23 (SD ±128.05). The highest OOP was observed for C-section (US$ 249.89, SD ±153.54), followed by institutional normal delivery (US$ 61.62, SD ±75.28). The average cost per normal home delivery was US$ 15.89 (SD ±25.84). The richest quintile spent significantly more than the poorest quintile regarding C-section (US$ 281 vs US$ 204), normal delivery at an institution (US$ 80 vs US$ 65), and even normal delivery at home (US$ 22 vs US$ 13). CONCLUSIONS: The study showed that there was a huge variation of OOP, which was dependent on the facility and socioeconomic demographic status of the households. As such, policy efforts need to focus on lowest wealth quintiles to avoid economic burdens during child delivery-related activities, and therefore, financial risk protection should be provided. Social health insurance might be an option for financing during child delivery, which is in line with the core objective of the Healthcare Financing Strategy of Bangladesh, which is to achieve universal health coverage.

The effectiveness of introducing Group Prenatal Care (GPC) in selected health facilities in a district of Bangladesh: study protocol.

BACKGROUND: Despite high rates of antenatal care and relatively good access to health facilities, maternal and neonatal mortality remain high in Bangladesh. There is an immediate need for implementation of evidence-based, cost-effective interventions to improve maternal and neonatal health outcomes. The aim of the study is to assess the effect of the intervention namely Group Prenatal Care (GPC) on utilization of standard number of antenatal care, post natal care including skilled birth attendance and institutional deliveries instead of usual care. METHODS: The study is quasi-experimental in design. We aim to recruit 576 pregnant women (288 interventions and 288 comparisons) less than 20 weeks of gestational age. The intervention will be delivered over around 6 months. The outcome measure is the difference in maternal service coverage including ANC and PNC coverage, skilled birth attendance and institutional deliveries between the intervention and comparison group. DISCUSSION: Findings from the research will contribute to improve maternal and newborn outcome in our existing health system. Findings of the research can be used for planning a new strategy and improving the health outcome for Bangladeshi women. Finally addressing the maternal health goal, this study is able to contribute to strengthening health system.

Cost of illness for cholera in a high risk urban area in Bangladesh: an analysis from household perspective.

BACKGROUND: Cholera poses a substantial health burden to developing countries such as Bangladesh. In this study, the objective is to estimate the economic burden of cholera treatments incurred by households. The study was carried out in the context of a large vaccine trial in an urban area of Bangladesh. METHODS: The study used a combination of prospective and retrospective incidence-based cost analyses of cholera illness per episode per household. A total of 394 confirmed cholera hospitalized cases were identified and treated in the study area during June-October 2011. Households with cholera patients were interviewed within 15 days after discharge from hospitals or clinics. To estimate the total cost of cholera illness a structured questionnaire was used, which included questions on direct medical costs, non-medical costs, and the indirect costs of patients and caregivers. RESULTS: The average total household cost of treatment for an episode of cholera was US$30.40. Total direct and indirect costs constituted 24.6% (US$7.40) and 75.4% (US$23.00) of the average total cost, respectively. The cost for children under 5 years of age (US$21.50) was higher than that of children aged 5-14 years (US$17.50). The direct cost of treatment was similar for male and female patients, but the indirect cost was higher for males. CONCLUSION: Our study suggests that by preventing one cholera episode (3 days on an average), we can avert a total cost of 2,278.50 BDT (US$30.40) per household. Among medical components, medicines are the largest cost driver. No clear socioeconomic gradient emerged from our study, but limited demographic patterns were observed in the cost of illness. By preventing cholera cases, large production losses can be reduced.

Economic assessment of childhood rotavirus vaccination in Bangladesh.

Rotavirus is one of the most highly prevalent communicable diseases in Bangladesh. The objective of this study is to evaluate the benefit-cost ratio of childhood rotavirus vaccination program in Bangladesh. A spreadsheet-based model was used to estimate the benefit and cost of a nationwide universal rotavirus vaccination program against rotavirus infections among under-five children in Bangladesh. A benefit-cost analysis was performed to evaluate a universal vaccination program compared with a status quo. Data from various published vaccination-related studies and public reports were used. The introduction of a childhood rotavirus vaccination program in Bangladesh for 14.78 million under-five children is projected to prevent approximately 1.54 million rotavirus cases during the first 2 years including 0.7 million severe rotavirus infections. This study shows that among the WHO-prequalified rotavirus vaccines, the net societal benefit is the highest if the vaccination program adopts ROTAVAC® rather than Rotarix® or ROTASIIL®. For every dollar invested in the outreach-based ROTAVAC® vaccination program, society would gain $2.03 in return, while in a facility-based vaccination program, society would gain up to about $2.2. The findings of this study demonstrate that a universal childhood rotavirus vaccination program is a cost-beneficial investment of public money. Thus, the government should consider the introduction of rotavirus vaccination in their Expanded Program on Immunization since the rotavirus immunization policy in Bangladesh will be economically justifiable.

Healthcare-seeking experiences of older citizens in Bangladesh: A qualitative study.

Despite improvements in many health indicators in the last few decades, providing access to affordable and quality healthcare for older citizen remains a considerable challenge in Bangladesh. This study aimed to understand individuals 'experiences regarding their healthcare-seeking, treatment cost, accessibility and coping mechanisms for the promotion of appropriate strategies to enhance the quality of life of the older citizens of Bangladesh.A qualitative descriptive approach was used in this study. A total of 27 In-Depth Interviews (IDIs) were conducted in a district in Bangladesh with older people between January and February 2020, where gender distribution was equal. Face-to-face interviews were conducted by trained and experienced interviewers regarding healthcare-seeking and accessibility, affordability, and healthcare coping strategy. Thematic analysis was conducted to analyse the data. It was found that the health condition of the older population is not satisfactory. Most of them had been suffering from several diseases such as benign tumor, chronic kidney disease, body aches, gastric ulcers for a longer period of time. The majority of the participants were suffering from multiple non-communicable diseases while diabetes and hypertension were the foremost of all diseases. This study provides insight into the challenges of managing healthcare services for older citizens in Bangladesh. Healthcare facilities were available, but high out-of-pocket payments, lack of caregivers, and time distance created a barrier to the service provision. The findings indicated that geriatric care policymakers and service providers should prioritize the older-friendly health infrastructures with affordable cost of treatment for the betterment of the health status of older citizens in Bangladesh.

Economic burden of dengue in urban Bangladesh: A societal perspective.

BACKGROUND: Dengue, a vector-borne disease, is a major public health problem in many tropical and subtropical countries including Bangladesh. The objective of this study is to estimate the societal cost of illness of dengue infections among the urban population in Dhaka, Bangladesh. METHODS: A cost-of-illness study was conducted using a prevalence-based approach from a societal perspective. Costs attributable to dengue were estimated from a bottom-up strategy using the guideline proposed by the World Health Organization for estimating the economic burden of infectious diseases. RESULTS: A total of 302 hospitalized confirmed dengue patients were enrolled in this study. The average cost to society for a person with a dengue episode was US$ 479.02. This amount was ranged between US$ 341.67 and US$ 567.12 for those patients who were treated at public and private hospitals, respectively. The households out-of-pocket cost contributed to a larger portion of the total costs of illness (66%) while the cost burden was significantly higher for the poorest households than the richest quintile. CONCLUSIONS: Dengue disease imposes a substantial financial burden on households and society. Therefore, decision-makers should consider the treatment cost of dengue infections, particularly among the poor in the population while balancing the benefits of introducing potentially effective dengue preventive programs in Bangladesh.

Correction: Changes in inequality of childhood morbidity in Bangladesh 1993-2014: A decomposition analysis.

[This corrects the article DOI: 10.1371/journal.pone.0218515.].

Socio-economic inequalities in diabetes and prediabetes among Bangladeshi adults.

Diabetes and prediabetes are overwhelming public health concerns in Bangladesh. However, there is a paucity of the literature examining and measuring socioeconomic inequalities in the prevalence of diabetes in Bangladesh. To provide reliable data and contribute to a nationwide scenario analysis, this study aims to estimate the inequality in prevalence of diabetes and prediabetes and to identify factors potentially contributing to socioeconomic inequalities in Bangladesh. This study used data from the latest Bangladesh Demographic and Health Survey (BDHS) 2017-18, a nationally representative survey. A regression-based decomposition method was applied to assess the socioeconomic contributors to inequality. The prevalence of diabetes and prediabetes were about 10 and 15% among Bangladeshi adults, respectively. Both diabetes and prediabetes were significantly associated with age, wealth status, suffering from overweight or obesity and administrative divisions of the respondents (p < 0.001). Respondents' household wealth status accounted for about 74 and 81% of the total inequality in diabetes and prediabetes in Bangladesh, respectively. Administrative region contributed 24.85% of the inequality in prediabetes and 12.26% of the inequality in diabetes. In addition, overweight or obesity status contributed 11.37% and exposure to television contributed 5.17% of the inequality in diabetes. Diabetes and prediabetes affect a substantial proportion of the Bangladeshi adult population. Therefore, these findings should be considered in the context of current and proposed policy decision making and for tracking its progression with economic development in Bangladesh.

Factors Associated with Post-Natal Care Utilization among the Women of Reproductive age Group: Evidence from Bangladesh Demographic and Health Survey 2017-18.

Introduction: Postnatal period is a crucial stage of illness for mothers and their newborn children. Lack of post-natal care (PNC) services during this period is lifethreatening for both the mother and the babies. This study aims at examining the associated factors of PNC utilization among the mothers to explore the opportunities to accelerate it. Methods: This study utilized the latest data from Bangladesh Demographic and Health Survey (BDHS) 2017-18, a nationally representative survey. A weighted sample of 5043 Bangladeshi women who gave birth three years prior to the survey was studied. Bivariate and multivariate analyses were performed to identify the underlying factors associated with the utilization of PNC. Results: Around 63% women sought PNC from any kind of provider within 24 h to 42 days of the delivery among whom more than 48% received it from medically trained providers. Together with several sociodemographic factors- administrative division, place of residence, educational level, employment status, wealth status, some maternal factors such as- antenatal care (ANC) visits, place and mode of delivery- played a significant role in utilizing PNC services from trained providers. Conclusion: To further improve utilization of post-natal care, national and local level action plans should be introduced to promote health facility delivery irrespective of their place of residence. In the meantime, PNC awareness campaigns, intervention and economic empowerment programs targeting mothers from the poorest quintile needs to be implemented, particularly those who are unable to attend at least four ANC visits, and have accessibility issues to education.

Validity and reliability of the Patient Health Questionnaire scale (PHQ-9) among university students of Bangladesh.

This study investigated the reliability and factorial validity of Patient Health Questionnaire-9 (PHQ-9) in the context of university students in Bangladesh. The research aimed to assess whether the original one-dimensional model or a model containing both somatic and cognitive-emotional factors is appropriate in the case of a sample of university students. A repeated cross-sectional survey design based on convenience sampling was used to collect data from 677 university students from both public and private universities. The factor structure of the PHQ-9 was assessed using confirmatory factor analysis (CFA). Measurement invariances were assessed across gender, type of university, level of education and victim of domestic violence. Its convergent validity was determined by investigating its correlations with Generalized Anxiety Disorder-7 (GAD-7) and Patient Health Questionnaire Anxiety-Depression Scale (PHQ-ADS). Results showed excellent reliability of PHQ-9 as measured by both Cronbach's α and McDonald's ω. CFA suggested that a modified one-factor model where the error variances between item-3 ('sleeping difficulties') and item-6 ('feeling as a failure'), item-6 and item-9 ('suicidal thoughts'), item-4 ('feeling tired') and item-9, item-3 and item-9 were allowed to covary is appropriate for the sample. This model provided high values of comparative fit index (CFI), goodness of fit index (GFI), and Tucker Lewis Index (TLI), low value of standardized root mean square residual (SRMR) and a non-significant root mean square error of approximation (RMSEA) as well as a high Factor Determinacy Score Coefficient. Correlation between PHQ-9 and GAD-7 was 0.751 and 0.934 between PHQ-9 and PHQ-ADS. Finally, the model is strictly invariant across gender and university type. Overall, the study provided support for modified unidimensional structure for PHQ-9 and showed high internal consistency along with good convergent validity.