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.

A scoping review on integrated health campaigns for immunization in low- and middle-income countries.

Health campaign integration is a key implementation strategy outlined by the World Health Organization to achieve universal health coverage. This scoping review synthesizes the evidence on Integrated Health Campaigns (IHC) in the field of immunization in low- and middle-income countries (LMICs) regarding the most common strategies, facilitators and barriers. Four reviewers followed a systematic approach to identify, screen and analyse relevant articles. The team used three search engines (PubMed, Scopus and Google Scholar) to identify peer-reviewed journal articles as well as select institutional websites for grey literature publications. Full-text articles using any study design and across any time frame were included. Data were extracted following a predefined matrix, analysed deductively and presented in a narrative synthesis. Thirty articles (20 academic and 10 grey) were included in the final review. All studies included identified IHCs as effective when planning or implementation is integrated. The common strategies were: using resources efficiently in remote locations; using national immunization days to maximize impact; targeting specific age groups by selecting intervention sites that are frequented by that age group; building community ownership over the integrated program; and integrating programs that already share common elements. The key facilitators were: closing the gap between services and communities; planning, coordination and resource management both before and during integration; cost-effectiveness; and utilization of pre-existing infrastructure. The common barriers included seemingly optimized initial cost to appear feasible only in the short term and additional responsibilities on the field staff. This review finds IHCs a common practice in immunization and identifies gaps in evidence on evaluation; indicating the need for additional research. Strong evidence accounts IHCs to increase coverage, improve community acceptance of health services and strengthen the community models of health service delivery.

Digitalized to reach and track: a retrospective comparison between traditional and conditional estimate of vaccination coverage and dropout rates using e-Tracker data below one-year children in Bangladesh during-COVID and pre-COVID period.

Background: With an impressive track record in expanding childhood immunization and an inclination to adopt digitalization in healthcare service delivery, Expanded Program on Immunization (EPI) Bangladesh piloted the e-Tracker intervention in Moulvibazar district and Dhaka South City Corporation (Zone-5) from 2019 till the end of 2021. Methods: We retrieved and analyzed the digitalized e-Tracker data of 114,194 infants born between January 1, 2019 and December 31, 2020, with help from Health Management Information System (HMIS) and UNICEF Bangladesh. Childhood vaccination coverage and dropout rates were determined using a 'Traditional approach' traditionally used by WHO and a 'Conditional technique' with a modified denominator. Using a multiple logistic regression model, we examined the effects of COVID-19, birth-cohorts, mother education, and location on vaccination rates (coverages & dropouts) to aid with informed decision-making by the policymakers. Findings: The conditional estimation method yielded a lower full vaccination coverage during pre-COVID period than the national and global reported coverage derived using the 'traditional method' (73.4% vs. 89.0% & 81.0%). As expected, while the coverage has decreased, the dropout rate increased "during-COVID" compared to the "pre-COVID" period. However, dropouts were estimated lower in the 'conditional method.' The average age (in months) for getting BCG was higher in Moulvibazar (∼2.5 months) than that in Dhaka (∼1.4 months). All birth-cohorts from 'the during-COVID period had about 30% lower odds of getting fully vaccinated than those from the 'pre-COVID' period. Interpretations: Age-cohort-specific analysis showed a decline in coverage rates before and during COVID, but e-Tracker didn't have enough data to draw additional conclusions. The server only stored the child's gender, the caregiver's monthly salary, and the mother's education. It didn't track any other factors related to dropout rates. The e-Tracker is an excellent tool for measuring real coverage and should be scaled nationwide. Funding: UNICEF, Bangladesh.

Effectiveness of a community health worker-led low-sodium salt intervention to reduce blood pressure in rural Bangladesh: protocol for a cluster randomized controlled trial.

BACKGROUND: High blood pressure is a major public health problem in low- and middle-income countries. Low-sodium salt substitute (LSSS) is a promising population-level blood pressure-lowering intervention requiring minimal behavioral change. The optimal method of delivering LSSS to individuals, however, is currently unknown. Community health workers (CHWs) have successfully been used to implement health interventions in Bangladesh and may provide a venue for the dissemination of LSSS. METHODS: We aim to conduct a cluster-randomized controlled trial involving 309 households in rural Bangladesh previously identified and characterized by the BRAC James P Grant School of Public Health, BRAC University (BRAC JPGSPH). These households will be randomly assigned to three arms: (1) control, i.e., no intervention; (2) information only, i.e., community health workers will provide basic information on high blood pressure, the health consequences of excessive salt consumption, and feedback to the participant on the likely quantity of salt s/he consumes (estimated using a questionnaire); (3) free LSSS arm: the same information as in arm 2 will be provided, but participants will receive 6 months of free low-sodium salt along with education on the benefits of LSSS. One male and one female adult (age ≥ 18 years) in each household will be invited to participate, the exclusion criteria being households with members known to have high serum potassium levels, are taking medications known to elevate potassium levels (e.g., ACE inhibitors, ARBs, potassium-sparing diuretics), are already taking potassium supplements, or those who have known kidney disease or abnormal serum creatinine at baseline. The primary endpoint will be blood pressure at 6 months post-intervention. DISCUSSION: Recent large clinical trials of LSSS in China and India have shown not only blood pressure improvements, but also stroke, major cardiac event, and all-cause mortality reductions. Nevertheless, how to best translate this intervention to population-level effectiveness remains unclear. Our study would test whether a community health worker-based program could be effectively used to disseminate LSSS and achieve measurable blood pressure benefits. TRIAL REGISTRATION: ClinicalTrials.gov NCT05425030. Registered on June 21, 2022.

Increasing Effectiveness and Equity in Strengthening Health Research Capacity Using Data and Metrics: Recent Advances of the ESSENCE Mechanism.

Background: The ESSENCE on Health Research initiative established a Working Group on Review of Investments in 2018 to improve coordination and collaboration among funders of health research capacity strengthening. The Working Group comprises more than a dozen ESSENCE members, including diverse representation by geography, country income level, the public sector, and philanthropy. Objective: The overall goal of the Working Group is increased research on national health priorities as well as improved pandemic preparedness, and, ultimately, fewer countries with very limited research capacity. Methods: We developed a basic set of metrics for national health research capacity, assessed different models of coordination and collaboration, took a deeper dive into eight countries to characterize their national research capacity, and began to identify opportunities to better coordinate our investments. In this article, we summarize the presentations, discussions, and outcomes of our second annual (virtual) meeting, which had more than 100 participants representing funders, researchers, and other stakeholders from higher- and lower-income countries worldwide. Findings and conclusions: Presentations on the first day included the keynote speaker, Dr. Soumya Swaminathan, chief scientist of the World Health Organization (WHO), and updates on data and metrics for research capacity, which are critical to establish targets, road maps, and budgets. The second day focused on improving collaboration and coordination among funders and other stakeholders, the potential return on investment for health research, ongoing work to increase coordination at the country level, and examples of research capacity strengthening efforts in diverse health research areas from around the world. We concluded that an intentional data- and metric-driven approach to health research capacity strengthening, emphasizing coordination among funders, local leadership, and equitable partnerships and allocation of resources, will enhance the health systems of resource-poor countries as well as the world's pandemic preparedness.

Rapidly Rising Diabetes and Increasing Body Weight: A Counterfactual Analysis in Repeated Cross-sectional Nationally Representative Data from Bangladesh.

BACKGROUND: Diabetes is a growing concern in South Asia but few nationally representative studies identify factors behind this rising disease burden. We studied the nationwide change in diabetes prevalence in Bangladesh, subpopulations disproportionately affected, and the contribution of rising unhealthy weight to the change in diabetes prevalence. METHODS: Based on a sample of 13,959 adults aged 35 years and older with biomarker measurements from the 2011 and 2017/2018 Bangladesh Demographic and Health Surveys, we estimated how the prevalence of diabetes changed nationally and across socioeconomic/geographic groups. Using counterfactual decomposition, we assessed how much the prevalence of diabetes would have grown if body mass index (BMI) had not changed between 2011 and 2017. RESULTS: Diabetes prevalence increased from 12.1% (11.1, 13.1) to 14.4% (13.3, 15.5) between 2011 and 2017/2018. Diabetes grew disproportionately quickly among population groups with higher household wealth, and more education, and in three regions. Over this same period, mean BMI increased from 20.9 (20.8, 21.1) to 22.5 kg/m 2 (22.4, 22.7) and overweight from 25.8 (24.4, 27.3) to 42.1% (40.4, 43.7). Under the counterfactual scenario of constant BMI, diabetes would have risen by only 1.0 (-0.4, 2.4) instead of 2.3 percentage points (0.8, 3.7) nationally, corresponding to a contribution of 58% (-106.3, 221.7). Similarly, group-specific trends were largely attributable to increasing BMI. CONCLUSIONS: Diabetes prevalence in Bangladesh has increased rapidly between 2011 and 2017/2018. Decomposition analysis estimates have wide confidence intervals but are consistent with the hypothesis that this change was driven by the dramatic rise in body weights.

Early diagnostic indicators of dengue versus other febrile illnesses in Asia and Latin America (IDAMS study): a multicentre, prospective, observational study.

BACKGROUND: Improvements in the early diagnosis of dengue are urgently needed, especially in resource-limited settings where the distinction between dengue and other febrile illnesses is crucial for patient management. METHODS: In this prospective, observational study (IDAMS), we included patients aged 5 years and older with undifferentiated fever at presentation from 26 outpatient facilities in eight countries (Bangladesh, Brazil, Cambodia, El Salvador, Indonesia, Malaysia, Venezuela, and Viet Nam). We used multivariable logistic regression to investigate the association between clinical symptoms and laboratory tests with dengue versus other febrile illnesses between day 2 and day 5 after onset of fever (ie, illness days). We built a set of candidate regression models including clinical and laboratory variables to reflect the need of a comprehensive versus parsimonious approach. We assessed performance of these models via standard measures of diagnostic values. FINDINGS: Between Oct 18, 2011, and Aug 4, 2016, we recruited 7428 patients, of whom 2694 (36%) were diagnosed with laboratory-confirmed dengue and 2495 (34%) with (non-dengue) other febrile illnesses and met inclusion criteria, and were included in the analysis. 2703 (52%) of 5189 included patients were younger than 15 years, 2486 (48%) were aged 15 years or older, 2179 (42%) were female and 3010 (58%) were male. Platelet count, white blood cell count, and the change in these variables from the previous day of illness had a strong association with dengue. Cough and rhinitis had strong associations with other febrile illnesses, whereas bleeding, anorexia, and skin flush were generally associated with dengue. Model performance increased between day 2 and 5 of illness. The comprehensive model (18 clinical and laboratory predictors) had sensitivities of 0·80 to 0·87 and specificities of 0·80 to 0·91, whereas the parsimonious model (eight clinical and laboratory predictors) had sensitivities of 0·80 to 0·88 and specificities of 0·81 to 0·89. A model that includes laboratory markers that are easy to measure (eg, platelet count or white blood cell count) outperformed the models based on clinical variables only. INTERPRETATION: Our results confirm the important role of platelet and white blood cell counts in diagnosing dengue, and the importance of serial measurements over subsequent days. We successfully quantified the performance of clinical and laboratory markers covering the early period of dengue. Resulting algorithms performed better than published schemes for distinction of dengue from other febrile illnesses, and take into account the dynamic changes over time. Our results provide crucial information needed for the update of guidelines, including the Integrated Management of Childhood Illness handbook. FUNDING: EU's Seventh Framework Programme. TRANSLATIONS: For the Bangla, Bahasa Indonesia, Portuguese, Khmer, Spanish and Vietnamese translations of the abstract see Supplementary Materials section.

Factors affecting motivation of close-to-community sexual and reproductive health workers in low-income urban settlements in Bangladesh: A qualitative study.

Close-to-community (CTC) health workers play a vital role in providing sexual and reproductive health services in low-income urban settlements in Bangladesh. Retention of CTC health workers is a challenge, and work motivation plays a vital role in this regard. Here, we explored the factors which affect their work motivation. We conducted 22 in-depth interviews in two phases with purposively selected CTC health workers operating in low-income urban settlements in Dhaka, Bangladesh. We analyzed our data using the framework technique which involved identifying, abstracting, charting, and matching themes across the interviews following the two-factor theory on work motivation suggested by Herzberg and colleagues. Our results suggest that factors affecting CTC sexual and reproductive health workers' work motivation include both extrinsic and intrinsic factors. Extrinsic or hygiene factors include financial incentives, job security, community attitude, relationship with the stakeholders, supportive and regular supervision, monitoring, and physical safety and security. While, the intrinsic factors or motivators are the perceived quality of the services provided, witnessing the positive impact of the work in the community, the opportunity to serve vulnerable clients, professional development opportunities, recognition, and clients' compliance. In the context of a high unemployment rate, people might take a CTC health worker's job temporarily to earn a living or to use it as a pathway move to more secure employment. To maintain and improve the work motivation of the CTC sexual and reproductive health workers serving in low-income urban settlements, organizations should provide adequate financial incentives, job security, and professional development opportunities in addition to supportive and regular supervision.

Prevalence and correlates of knowledge and practices regarding infection prevention and control, and triage in primary healthcare settings: A cross-sectional study in Bangladesh.

Background: Despite the high prevalence of healthcare-acquired infection in resource-limited settings, healthcare workers' (HCWs') knowledge and practices of infection prevention and control (IPC) and triage are not well-researched. We examined thisin Bangladesh's primary healthcare facilities (HCFs) during the COVID-19 pandemic. Methods: We surveyed 312 HCWs in 94 community clinics (CCs) and 90 family welfare centres (FWCs) in six districts from February to April 2021. We assessed HCWs' self-reported knowledge and observed practices in four domains: personal hygiene, medical instrument processing, waste management, and triage. We constructed a weighted composite knowledge score and estimated the association between knowledge and background characteristics using a generalised linear mixed effects model. Practices were described through univariate analysis. Findings: On a scale of 100, the mean composite knowledge score was 38.3 (SD: 13.3) overall and 44.0 (SD: 13.1) and 33.8 (SD: 11.6) for FWCs and CCs, respectively. The HCWs of FWCs were more aged, experienced, and educated than those of CCs. Knowledge score was the highest in personal hygiene and the lowest in medical waste segregation. Knowledge was significantly associated with HCWs' designation and education. Concerning practices, not more than one-third of the HCWs or HCFs, on average, followed the recommended protocols, except for wearing face masks while on duty (87.1%) and referring potential COVID-19 patients to higher-level facilities (68.3%). Conclusions: HCWs' capacity in instrument processing, waste management, and triage needs to be improved through formal education and training initiatives. Our study can contribute to the under-researched IPC and triage domains in resource-limited settings.

Implementation barriers and facilitators to a COVID-19 intervention in Bangladesh: The benefits of engaging the community for the delivery of the programme.

BACKGROUND: BRAC (Bangladesh Rural Advancement Committee), the largest NGO globally, implemented a community-based comprehensive social behavior communication intervention to increase community resilience through prevention, protection, and care for COVID-19. We conducted implementation research to assess fidelity and explore the barriers and facilitators of this intervention implementation. METHODS: We adopted a concurrent mixed-method triangulation design. We interviewed 666 members of 60 Community Corona Protection Committees (CCPCs) and 80 members of 60 Community Support Teams (CSTs) through multi-stage cluster sampling using a structured questionnaire. The qualitative components relied on 54 key informant interviews with BRAC implementers and government providers. RESULTS: The knowledge about wearing mask, keeping social distance, washing hands and COVID-19 symptoms were high (on average more than 70%) among CCPC and CST members. While 422 (63.4%) CCPC members reported they 'always' wear a mask while going out, 69 (86.3%) CST members reported the same practice. Only 247 (37.1%) CCPC members distributed masks, and 229 (34.4%) donated soap to the underprivileged population during the last two weeks preceding the survey. The key facilitators included influential community members in the CCPC, greater acceptability of the front-line health workers, free-of-cost materials, and telemedicine services. The important barriers identified were insufficient training, irregular participation of the CCPC members, favouritism of CCPC members in distributing essential COVID-19 preventive materials, disruption in supply and shortage of the COVID-19 preventative materials, improper use of handwashing station, the non-compliant attitude of the community people, challenges to ensure home quarantine, challenges regarding telemedicine with network interruptions, lack of coordination among stakeholders, the short duration of the project. CONCLUSIONS: Engaging the community in combination with health services through a Government-NGO partnership is a sustainable strategy for implementing the COVID-19 prevention program. Engaging the community should be promoted as an integral component of any public health intervention for sustainability. Engagement structures should incorporate a systems perspective to facilitate the relationships, ensure the quality of the delivery program, and be mindful of the heterogeneity of different community members concerning capacity building. Finally, reaching out to the underprivileged through community engagement is also an effective mechanism to progress through universal health coverage.

Midwifery centers as enabled environments for midwifery: A quasi experimental design assessing women's birth experiences in three models of care in Bangladesh, before and during covid.

BACKGROUND: The midwifery model of care is a human rights-based approach (HRBA) that is unique and appropriate for the majority of healthy pregnant women, yet full expression may be limited within the medical model. Midwifery centers are facilities designed specifically to enable the practice of midwifery. In high resource countries, they have been shown to be cost effective, evidence-based, avoid over medicalization, and provide safe, efficient and satisfying care. METHODS: A quasi-experimental design was used to assess the impact of three models of care on women's experiences of respect, and trust in maternity care provision, both before and during the pandemic in Bangladesh, as well as their fear and knowledge around COVID-19, during the pandemic. The models were: "fully enabled midwifery" ("FEM") in freestanding midwifery centers; "midwifery and medicine" ("MAM") in medical facilities with midwives working alongside nurses and doctors; and "no midwifery" ("NoM") in medical facilities without midwives. Phone survey data were collected and analyzed from all women (n = 1,191) who delivered from Jan 2020-June 2020 at seven health care facilities in Bangladesh. Comparison of means, ANOVA, post hoc Tukey, and effect size were used to explore the differences in outcomes across time periods. FINDINGS: Pre-pandemic, women served by the FEM model reported significantly higher rates of trust and respect (p<0·001) compared to the NoM model, and significantly higher rates of trust (p<0·001) compared to MAM. During the pandemic, in the FEM model, the experiences of respect and trust did not change significantly from the pre-pandemic rates, and were significantly higher than both the MAM and NoM models (p < 0·001). Additionally, during the pandemic, women served by the FEM model had the lowest experience of COVID fear (p<0·001). INTERPRETATION: Fully enabled midwifery in midwifery centers had a significantly positive effect on woman's experience of respect and trust in care compared to the other models, even in the context of a pandemic.

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.

Facilitators and Barriers to Implementation of a Childhood Tuberculosis Control Program in Bangladesh: A Mixed-Methods Study from BRAC Urban DOTS Centres in Dhaka.

The case detection rate of childhood tuberculosis in Bangladesh is 4%, far below the World Health Organization predicted rate of 10-15% for a country with a high burden of tuberculosis. A concurrent triangulation mixed-methods study was carried out in eight urban DOTS (Directly Observed Treatment, Short-course) centres to investigate the factors contributing to the diagnosis and treatment of childhood tuberculosis. Front-line health care workers (Shasthya Shebika) (n = 111) were surveyed to understand knowledge, attitude, and practice (KAP) of the diagnosis and treatment of childhood tuberculosis. In-depth interviews were conducted with field workers (n = 32) and mothers of TB cases (n = 4). Stakeholders involved in implementing the tuberculosis program (n = 9) participated in the key informant interviews. Knowledge of Shasthya Shebika was associated with the components addressed during refresher training (p = 0.02). Government stewardship, presence of specific guidelines, knowledge and capacity building of front-line health workers were identified as the key facilitators. Frequent turnover of key managerial positions in the government, stigma, delays in seeking care, lack of diagnostic facilities, and poor engagement of private practitioners were identified as major constraints. It was identified that the government should focus on improving diagnostic capacities, conduct research on childhood tuberculosis, and produce awareness materials.