A Rapid Ethnographic Assessment of Cultural and Social Perceptions and Practices About COVID-19 in Bangladesh: What the Policy Makers and Program Planners Should Know.

Anthropological literature on health beliefs and practices related to COVID-19 is scarce, particularly in low and middle-income countries. We conducted a qualitative research on perceptions of COVID-19 among slum residents of Dhaka, Bangladesh from November 2020 through January, 2021. Methods included in-depth interviews and photo elicitation with community residents. Interviews were transcribed and analyzed thematically. Results show scientific explanations of COVID-19 conflicted with interviewees' cultural and spiritual beliefs such as: coronavirus is a disease of rich, sinful people; the virus is a curse from Allah to punish sinners. Interviewees rejected going to hospitals in favor of home remedies, and eschewed measures such as mask-wearing or social distancing instead preferring to follow local beliefs. We have highlighted a gap between community beliefs about the pandemic and science-led interventions proposed by health professionals. For public health policy to be more effective it requires a deeper understanding of and response to community perceptions.

The state of diet-related NCD policies in Afghanistan, Bangladesh, Nepal, Pakistan, Tunisia and Vietnam: a comparative assessment that introduces a 'policy cube' approach.

We assessed the technical content of sugar, salt and trans-fats policies in six countries in relation to the World Health Organization 'Best Buys' guidelines for the prevention and control of non-communicable diseases (NCDs). National research teams identified policies and strategies related to promoting healthy diets and restricting unhealthy consumption, including national legislation, development plans and strategies and health sector-related policies and plans. We identified relevant text in relation to the issuing agency, overarching aims, goals, targets and timeframes, specific policy measures and actions, accountability systems, budgets, responsiveness to inequitable vulnerabilities across population groups (including gender) and human rights. We captured findings in a 'policy cube' incorporating three dimensions: policy comprehensiveness, political salience and effectiveness of means of implementation, and equity/rights. We compared diet-related NCD policies to human immunodeficiency virus policies in relation to rights, gender and health equity. All six countries have made high-level commitments to address NCDs, but dietary NCDs policies vary and tend to be underdeveloped in terms of the specificity of targets and means of achieving them. There is patchwork reference to internationally recognized, evidence-informed technical interventions and a tendency to focus on interventions that will encounter least resistance, e.g. behaviour change communication in contrast to addressing food reformulation, taxation, subsidies and promotion/marketing. Policies are frequently at the lower end of the authoritativeness spectrum and have few identified budgetary commitments or clear accountability mechanisms. Of concern is the limited recognition of equity and rights-based approaches. Healthy diet policies in these countries do not match the severity of the NCDs burden nor are they designed in such a way that government action will focus on the most critical dietary drivers and population groups at risk. We propose a series of recommendations to expand policy cubes in each of the countries by re-orienting diet-related policies so as to ensure healthy diets for all.

Exploratory qualitative study to understand the underlying motivations and strategies of the private for-profit healthcare sector in urban Bangladesh.

OBJECTIVES: This paper explores the underlying motivations and strategies of formal small and medium-sized formal private for-profit sector hospitals and clinics in urban Bangladesh and their implications for quality and access. METHODS: This exploratory qualitative study was conducted in Dhaka, Sylhet and Khulna City Corporations. Data collection methods included key informant interviews (20) with government and private sector leaders, in-depth interviews (30) with clinic owners, managers and providers and exit interviews (30) with healthcare clients. RESULTS: Profit generation is a driving force behind entry into the private healthcare business and the provision of services. However, non-financial motivations are also emphasised such as aspirations to serve the disadvantaged, personal ambition, desire for greater social status, obligations to continue family business and adverse family events.The discussion of private sector motivations and strategies is framed using the Business Policy Model. This model is comprised of three components: products and services, and efforts to make these attractive including patient-friendly discounts and service-packages, and building 'good' doctor-patient relationships; the market environment, cultivated using medical brokers and referral fees to bring in fresh clientele, and receipt of pharmaceutical incentives; and finally, organisational capabilities, in this case overcoming human resource shortages by relying on medical staff from the public sector, consultant specialists, on-call and less experienced doctors in training, unqualified nursing staff and referring complicated cases to public facilities. CONCLUSIONS: In the context of low public sector capacity and growing healthcare demands in urban Bangladesh, private for-profit engagement is critical to achieving universal health coverage (UHC). Given the informality of the sector, the nascent state of healthcare financing, and a weak regulatory framework, the process of engagement must be gradual. Further research is needed to explore how engagement in UHC can be enabled while maintaining profitability. Incentives that support private sector efforts to improve quality, affordability and accountability are a first step in building this relationship.

Exploring the system capacity to meet occupational health and safety needs: the case of the ready-made garment industry in Bangladesh.

BACKGROUND: Since the 2013 Rana Plaza incident in Bangladesh, the government of Bangladesh has been under pressure to improve health and safety conditions for workers in the ready-made garment industry. Its efforts have focused heavily on structural safety of the buildings but have largely ignored broader occupational health system issues. This qualitative study explores contextual factors and system challenges that create barriers for ensuring a healthy and safe workplace in the ready-made garment industry in Bangladesh. METHODS: Data were collected through key informant interviews (n = 14) with government officials from the Department of Inspection for Factories and Establishments (DIFE), factory employers, factory doctors and representatives from the Bangladesh Garment Manufacturers and Exporters Association (BGMEA). A thematic analysis was conducted using Atlas-ti v 5.2. RESULTS: A thematic analysis suggests that the capacity of the DIFE to provide adequate occupational health services remains a problem. There is a shortage of both appropriately trained staff and equipment to monitor occupational health and safety in factories and to gather useful data for evidence-based decision-making. Another barrier to effective occupational health and safety of workers is the lack of cooperation by employers in recording data on workers' health and safety problems. Finally, government officials have limited resources and power to enforce compliance with regulations. Such deficiencies threaten the health and safety of this important, largely female, working population. CONCLUSION: This case example focused on the valuable ready-made garment industry sector of Bangladesh's economy. It identifies the critical need for occupational health system strengthening. Specifically system capacity needs to be improved by both increasing human resources for in-factory hazards and health monitoring, regulatory inspection, enforcement, and improved training of government officials around monitoring and reporting.

Sewing shirts with injured fingers and tears: exploring the experience of female garment workers health problems in Bangladesh.

BACKGROUND: The ready-made garment industry in Bangladesh not only contributes to the nation's economic development, but has created income opportunities for women, benefiting their whole family. However, these benefits come at considerable cost to the women. This research examines how the work environment and gendered family role in this conservative society affect the health of the female industrial workers. METHODS: A qualitative study employed in-depth interviews (n-20) and focus group discussions with female garment workers (n-4) in two cities of Dhaka district. Further, key informant interviews (n = 4) with factory doctors, along with eight workplace observations were conducted to explore the lived experience of female workers' health issues. Interview transcripts were coded in Atlas-ti, 5.2. The data were analysed using thematic analysis approach. The themes are illustrated with case narratives. RESULTS: The female workers reported that their work has led to back and joint pain, continuous headache, eye pain and difficulty in breathing associated with inhaling fabric dust. Inadequate lighting, constantly sitting in one position without back rest and continuous noise from hundreds of machines makes them feel permanently tired. Further, the female workers reported that working in the factory and meeting the expectations of the families at home has doubled their workload. The doctors indicated that the physical work environment, their low job status and the nature of the job affect the health of female workers. CONCLUSION: This study found that female workers in the ready-made garment industry face a high risk of health problems. Both government and non-government organizations need to be better involved in designing interventions targeting these women, to protect them from such health risks. In addition, recognition by the whole society of the important role the women play in the economy is needed, so that support by both family and society can be improved.

What makes pregnant workers sick: why, when, where and how? An exploratory study in the ready-made garment industry in Bangladesh.

BACKGROUND: Bangladesh has made significant progress in reducing maternal mortality. Many factors have contributed to this; one is the socio-economic development of the country. The ready-made garment industry is at the forefront of this development creating employment for many women. However, the work environment has the potential to create health problems, particularly for vulnerable groups such as pregnant women. This paper explores perceptions of health problems during pregnancy of factory workers, in this important industry in Bangladesh. METHODS: This study was conducted in four factories using qualitative research methods to provide a view of pregnant workers' health risks beyond a bio-medical approach. Data was collected through in-depth interviews of pregnant workers and observations of their homes and workplaces. Further, key informant interviews with factory health care providers, government officials and employers revealed different perspectives and experiences. Data was collected in the local language (Bengali), then transcribed and analysed using a framework analysis approach. RESULTS: Female workers reported that participation in paid work created an opportunity for them to earn money but pregnancy and the nature of the job, including being pressured to meet the production quota, pressure to leave the job because of their pregnancy and withholding of maternity benefits, cause stress, anxiety and may contribute to hypertensive disorders of pregnancy. This was confirmed by factory doctors who suggested that developing hypertensive disorders during pregnancy was influenced by the nature of work and stress. The employers seemed focused on profit and meeting quotas and the health of pregnant workers appeared to be a lower priority. This study found that the government lacks the resources to understand the extent of the problem or the level of compliance with maternity related regulations. CONCLUSIONS: These results indicate the vulnerability of female workers to physical and mental stress at work and associations with their health problems during pregnancy. It identifies the deficiencies of family, workplace and health service support for these pregnant workers, highlighting the urgent need for government and non-government organisations to work with this important export industry to improve health surveillance and monitoring and the enforcement of existing laws to protect the rights and conditions of pregnant women.

Work, gender roles, and health: neglected mental health issues among female workers in the ready-made garment industry in Bangladesh.

BACKGROUND: Traditionally, women in Bangladesh stayed at home in their role as daughter, wife, or mother. In the 1980s, economic reforms created a job market for poor, uneducated rural women in the ready-made garment industry, mostly located in urban areas. This increased participation in paid work has changed the gender roles of these women. Women's earnings support their family, but they are also separated from their children, with impacts on their mental health and well-being. This study explores the lived experience of women in Bangladesh working in the ready-made garment industry as they strive to be mothers and family providers, often in high-stress conditions. METHODS: The study was conducted in two industrial areas of Dhaka over 8 months. Data collection included a literature review, 20 in-depth interviews with married female garment workers, and 14 key-informant interviews with officials from the Ministry of Labour and Employment, health-service providers within the garment factories, factory managers, and representatives of the Bangladesh Garment Manufacturers and Exporters Association. The data collected were analyzed thematically. RESULTS: Poverty was a key motivating factor for female migrant workers to move from rural areas. Their children stay in their village with their grandparents, because of their mothers' work conditions and the lack of childcare. The women reported stress, anxiety, restlessness, and thoughts of suicide, due to the double burden of work and separation from their children and family support. Further, they cannot easily access government hospital services due to their long work hours, and the limited medical services provided in the workplace do not meet their needs. CONCLUSION: In order to improve the health and well-being of female garment workers, steps should be taken to develop health interventions to meet the needs of this important group of workers who are contributing significantly to the economic development of the country.

Assessing the capacity of ministries of health to use research in decision-making: conceptual framework and tool.

BACKGROUND: The capacity to demand and use research is critical for governments if they are to develop policies that are informed by evidence. Existing tools designed to assess how government officials use evidence in decision-making have significant limitations for low- and middle-income countries (LMICs); they are rarely tested in LMICs and focus only on individual capacity. This paper introduces an instrument that was developed to assess Ministry of Health (MoH) capacity to demand and use research evidence for decision-making, which was tested for reliability and validity in eight LMICs (Bangladesh, Fiji, India, Lebanon, Moldova, Pakistan, South Africa, Zambia). METHODS: Instrument development was based on a new conceptual framework that addresses individual, organisational and systems capacities, and items were drawn from existing instruments and a literature review. After initial item development and pre-testing to address face validity and item phrasing, the instrument was reduced to 54 items for further validation and item reduction. In-country study teams interviewed a systematic sample of 203 MoH officials. Exploratory factor analysis was used in addition to standard reliability and validity measures to further assess the items. RESULTS: Thirty items divided between two factors representing organisational and individual capacity constructs were identified. South Africa and Zambia demonstrated the highest level of organisational capacity to use research, whereas Pakistan and Bangladesh were the lowest two. In contrast, individual capacity was highest in Pakistan, followed by South Africa, whereas Bangladesh and Lebanon were the lowest. CONCLUSION: The framework and related instrument represent a new opportunity for MoHs to identify ways to understand and improve capacities to incorporate research evidence in decision-making, as well as to provide a basis for tracking change.

A cluster-randomized evaluation of a responsive stimulation and feeding intervention in bangladesh.

OBJECTIVES: The goal of this study was to determine if a responsive stimulation and feeding intervention improved developmental and nutritional outcomes compared with a regular information-based parenting program. The hypothesis was that mothers in the intervention would exhibit better parenting skills and children would exhibit better developmental and nutritional outcomes than controls. METHODS: A cluster-randomized field trial was conducted with 302 children aged 8 to 20 months and their mothers in rural Bangladesh who were randomly assigned according to village to 1 of 3 groups. The control mothers received 12 informational sessions on health and nutrition. The intervention groups received an additional 6 sessions delivered by peer educators who included modeling and coached practice in self-feeding and verbal responsiveness with the child during play. A second intervention group received, along with the sessions, 6 months of a food powder fortified with minerals and vitamins. Developmental outcomes included the Home Observation for Measurement of the Environment (HOME) Inventory, mother-child responsive talk, and language development. Nutritional outcomes included weight, height, self-feeding, and mouthfuls eaten. We used analysis of covariance to compare the 3 groups at the posttest and at follow-up, covarying the pretest levels and confounders. RESULTS: At follow-up, responsive stimulation-feeding groups had better HOME inventory scores, responsive talking, language, mouthfuls eaten, and hand-washing. Micronutrient fortification resulted in more weight gain. CONCLUSIONS: A brief behavior-change program that focused on modeling and practice in stimulation and feeding was found to benefit children's nutrition and language development. Micronutrients benefited children's weight but not length.