Does maternal health voucher scheme have association with distance inequality in maternal and newborn care utilization? Evidence from rural Bangladesh.

BACKGROUND: Bangladesh has made substantial progress in maternal health. However, persistent inequities in service use undermine the achievements at the national level. In 2007, the government introduced a Maternal Health Voucher Scheme (MHVS) to reduce barriers to service utilization. The current study explores the impact of MHVS on reducing distance inequality in utilization across the maternal and newborn continuum of care (MNCoC). METHODS: A cross-sectional survey was conducted from October'2017 to April'2018 in four selected MHVS sub-districts of Chattogram and Sylhet Divisions of Bangladesh. 2,400 women with at-least one child aged below two years were randomly selected. Both bivariate and multivariate analyses were carried out to explore the absolute and relative influence of the voucher scheme and chi-square test was used for hypothesis testing. RESULTS: Nineteen percent of the women were MHVS beneficiaries and 23% of them lived within 5 km of the health facility. Among the beneficiaries no significant differences were observed in the utilization of at-least 4 antenatal visits, skilled-assistance at delivery, postnatal care, and MNCoC between those living closer to the health facility and those living far away. However, a higher facility delivery rate was observed among beneficiary women living closer. By contrast, for non-beneficiaries, a significant difference was found in service use between women living closer to health facilities compared to those living further away. CONCLUSION: The study found the use of MNCoC to be similar for all MHVS beneficiaries irrespective of their distance to health facilities whereas non-beneficiary women living further away had lower utilization rates. MHVS could have potentially reduced distance-related inequality for its beneficiaries. However, despite the provision of transport incentives under MHVS the reduction in inequality in facility delivery was limited. We propose a revision of the transportation incentive adjusting for distance, geographical remoteness, road condition, and transport cost to enhance the impact of MHVS.

Phytocompounds Targeting Metabolic Reprogramming in Cancer: An Assessment of Role, Mechanisms, Pathways, and Therapeutic Relevance.

The metabolism of cancer is remarkably different from that of normal cells and confers a variety of benefits, including the promotion of other cancer hallmarks. As the rewired metabolism is a near-universal property of cancer cells, efforts are underway to exploit metabolic vulnerabilities for therapeutic benefits. In the continued search for safer and effective ways of cancer treatment, structurally diverse plant-based compounds have gained substantial attention. Here, we present an extensive assessment of the role of phytocompounds in modulating cancer metabolism and attempt to make a case for the use of plant-based compounds in targeting metabolic vulnerabilities of cancer. We discuss the pharmacological interactions of phytocompounds with major metabolic pathways and evaluate the role of phytocompounds in the regulation of growth signaling and transcriptional programs involved in the metabolic transformation of cancer. Lastly, we examine the potential of these compounds in the clinical management of cancer along with limitations and challenges.

Arsenic and lead in the indoor residential settings of different socio-economic status; assessment of human health risk via dust exposure.

In the present study, occurrence of arsenic (As) and lead (Pb) is reported in rural and urban household dust (floor and AC filter dust) of the Kingdom of Saudi Arabia (KSA). Several studies have found concerning concentrations of these toxic metals in indoor dust from different countries, but data from this region is missing. The association between studied toxic metals and different socioeconomic parameters was investigated. Furthermore, health risk associated with these toxic metals via dust exposure was evaluated for the Saudi population. Mean concentration of Pb was several times higher than As in both types of dust samples. AC filter dust was more contaminated with these metals than floor dust. Levels of Pb were up to 775 ppm in AC filter dust from urban areas, while 167 ppm in rural AC filter dust. Different socioeconomic parameters did not influence much on the presence of studied metals in both AC and floor dust. To estimate health risk from contaminated dust hazardous index (HI), hazardous quotient (HQ), and incremental lifetime cancer risk (ILCR) via dust ingestion, inhalation, and dermal contact was calculate using USEPA equations. The ILCR range for both toxic metals was within the tolerable range of reference values of USEPA (1 × 10-5 to 5 × 10-7). Nonetheless, HI was close to 1 for Pb via dust exposure for young urban children, which signifies the risk of non-carcinogenic health problems in studied area. Graphical abstract.

Macroeconomic impacts of cigarette consumption in Pakistan.

BACKGROUND: Pakistan has a large population of tobacco users, with about 24 million adults consuming tobacco products in one form or another. There is a dearth of research on the impact of a reduction in tobacco use on Pakistan's economy which can inform policy-makers on the extent that tobacco control measures would affect macroeconomic indicators such as output and employment. OBJECTIVES: The objective of this study is to quantify the changes in output, income and employment resulting from changes in cigarette consumption and to quantify the impact of such changes on the overall economy. METHODOLOGY: The study uses the input-output table for the fiscal year 2010-2011 for Pakistan's economy, to estimate the output, income and employment multipliers. The Leontief input-output model is used to estimate the sectorwise multiplier effects. It estimates direct, indirect and consumption-induced effects of changes in tobacco use on the economy. RESULTS: The cigarette industry's share in large-scale manufacturing and industrial employment is 1.1% and 0.3%, respectively. The estimates of gross output, income and employment multipliers for the cigarette industry have relatively small magnitudes indicating minimal impact on the economy. A simulation analysis based on the latest estimates of price elasticity of cigarette and input-output multipliers, shows that a 10% increase in price will lead to an 11% reduction in cigarette consumption, which translates into annual savings of Pakistani Rupees (Rs) 16 billion by households. Reduction in cigarette consumption will allow individuals to spend their savings on other commodities. For example, spending this amount on food items will lead to a net increase of Rs 40 billion annual output of the economy. CONCLUSION: Reduction in tobacco consumption will lead to initial losses to the economy but there will be considerable gains in output, employment and income due to redistribution of tobacco expenditures.

Digital Health and Inequalities in Access to Health Services in Bangladesh: Mixed Methods Study.

BACKGROUND: Globally, the rapid growth of technology and its use as a development solution has generated much interest in digital health. In line with global trends, Bangladesh is also integrating technology into its health system to address disparities. Strong political endorsement and uptake of digital platforms by the government has influenced the rapid proliferation of such initiatives in the country. This paper aims to examine the implications of digital health on access to health care in Bangladesh, considering who uses electronic devices to access health information and services and why. OBJECTIVE: This study aims to understand how access to health care and related information through electronic means (digital health) is affected by sociodemographic determinants (ie, age, gender, education, socioeconomic status, and personal and household ownership of mobile phones) in a semiurban community in Bangladesh. METHODS: A cross-sectional survey of 854 households (between October 2013 and February 2014) and 20 focus group discussions (between February 2017 and March 2017) were conducted to understand (1) who owns electronic devices; (2) who, among the owners, uses these to access health information and services and why; (3) the awareness of electronic sources of health information; and (4) the role of intermediaries (family members or peers who helped to look for health information using electronic devices). RESULTS: A total of 90.3% (771/854) of households (471/854, 55.2% of respondents) owned electronic devices, mostly mobile phones. Among these, 7.2% (34/471) used them to access health information or services. Middle-aged (35-54 years), female, less (or not) educated, and poorer people used these devices the least (α=.05, α is the level of significance). The lack of awareness, discomfort, differences with regular care-seeking habits, lack of understanding and skills, and proximity to a health facility were the main reasons for not using devices to access digital health. CONCLUSIONS: Although influenced by sociodemographic traits, access to digital health is not merely related to device ownership and technical skill. Rather, it is a combination of general health literacy, phone ownership, material resources, and technical skill as well as social recognition of health needs and inequity. This study's findings should serve as a basis for better integrating technology within the health system and ensuring equitable access to health care.

Trace metals in different socioeconomic indoor residential settings, implications for human health via dust exposure.

In this study a number of heavy metals namely chromium (Cr), cadmium (Cd), zinc (Zn), barium (Ba), copper (Cu), manganese (Mn), cobalt (Co), rubidium (Rb), selenium (Se) are studied in the floor and air condition (AC) filter dust collected from urban and rural households of Saudi Arabia. To the best of our knowledge, many of these heavy metals are reported for the very first time in the indoor dust of Saudi Arabia. Studied metals were higher in urban dust than rural except Mn and Rb which were significantly higher (P < 0.05) in rural dust. All metals, except Cd, Zn, and Ba in urban settings, were detected at higher (P < 0.05) levels in AC filter dust than household floor dust from both rural and urban residential settings. Levels of the two dominant metals i.e., Zn and Mn were up to 1600 and 700 µg/g, respectively in studied dust samples. Also associations between heavy metals and a number of different socio-economic parameters were studied which was significant for some trace metals. In literature exposure to many of trace metals are associated with various health problems, therefore health risk assessment for the Saudi population was calculated by incremental lifetime cancer risk (ILCR) and hazardous index (HI) via dust ingestion, inhalation, and dermal contact. The ILCR for all metals was within the tolerable range of reference values of USEPA (1 × 10- 11 to 1 × 10- 4). However, calculated HI for Mn, Cu, Ni, and Zn was more than 1 via dust exposure, which signifies the non-carcinogenic risk. The study highlights the occurrence of toxic metals in the indoor environments of Saudi Arabia and provides baseline data for future studies on these toxic metals in the region.

Does healthcare voucher provision improve utilisation in the continuum of maternal care for poor pregnant women? Experience from Bangladesh.

Background: Improving maternal health is a major development goal, with ambitious targets set for high-mortality countries like Bangladesh. Following a steep decline in the maternal mortality ratio over the past decade in Bangladesh, progress has plateaued at 196/100,000 live births. A voucher scheme was initiated in 2007 to reduce financial, geographical and institutional barriers to access for the poorest.Objective: The current paper reports the effect of vouchers on the use of continuum of maternal care.Methods: Cross-sectional surveys were carried out in the Chattogram and Sylhet divisions of Bangladesh in 2017 among 2400 women with children aged 0-23 months. Using Cluster analysis utilisation groups for antenatal care, facility delivery and postnatal care were formed. Clusters were regressed on voucher receipt to identify the underlying relationship between voucher receipt and utilisation of care while controlling for possible confounders.Results: Four clusters with varying levels of utilisation were identified. A significantly higher proportion of voucher-recipients belonged to the high-utilisation cluster compared to non-voucher recipients (43.5% vs. 15.4%). For the poor voucher recipients, the probability of belonging to the high-utilisation cluster was higher compared to poor non-voucher recipients (33.3% vs. 6.8%) and the probability of being in the low-utilisation cluster was lower than poor non-voucher recipients (13.3% vs. 55.4%).Conclusion: The voucher programme enhanced uptake of the complete continuum of maternal care and the benefits extended to the most vulnerable women. However, a lack of continued transition through the continuum of maternal care was identified. This insight can assist in designing effective interventions to prevent intermittent or interrupted care-seeking. Programmes that improve access to quality healthcare in pregnancy, childbirth and the postnatal period can have wide-ranging benefits. A coherent continuum-based approach to understanding maternal care-seeking behaviour is thus expected to have a greater impact on maternal, newborn and child health outcomes.

Who enrols in voluntary micro health insurance schemes in low-resource settings? Experience from a rural area in Bangladesh.

BACKGROUND: Micro health insurance (MHI) has proved to be a potential health-financing tool for many developing countries. Bangladesh also included MHI in its current health-financing strategy which aims to achieve universal health coverage. However, low uptake, low renewal and high dropouts have historically challenged financial sustainability of these schemes. OBJECTIVE: This study aims to identify factors influencing people from low-resource settings, particularly those from Bangladesh, to enrol in MHI schemes. METHODS: The study analyses the 'Amader Shasthya' MHI scheme operating in Chakaria, a sub-district under Cox's Bazar district, Bangladesh. A household survey was carried out during May-June 2016 among 2,000 households from the scheme coverage area. The Outreville's insurance-demand framework was used to identify enrolment influencing factors. Multivariate logistic regression analysis was carried out to identify significant influencing factors of enrolment. RESULTS: Enrolment influencing factors were identified in four dimensions: economic, socio-cultural, demographic and structural. Households with the main income earner having 10+ years of schooling (odds 1.9 [CI 1.2-2.9] compared to illiterate), having financial literacy (odds 1.5 [CI 1.2-1.8] compared to financially illiterate) and being a public/private service holder (odds 1.6 [CI 1.1-2.4] compared to menial labour) were more likely to enrol. Membership in development programmes of NGOs also influenced enrolment decision significantly (odds 1.3 [CI 1.0-1.5]). The presence of chronic illness in household encouraged enrolment (odds 1.5 [CI 1.2-1.8]). Households living closer to health centres were more likely to enrol (odds 2.1 [CI 1.6-2.7]) compared to those living further away. CONCLUSION: The findings are expected to have significant implications in terms of designing similar health insurance schemes, particularly in terms of designing demand-driven and context adapted schemes that have greater potential to attract a larger client pool, ensure effective risk pooling and eventually expedite the achievement of universal health coverage in low-resource settings.

Policy content and stakeholder network analysis for infant and young child feeding in Bangladesh.

BACKGROUND: Appropriate infant and young child feeding (IYCF) practices are essential for nutrition of infants and young children. Bangladesh has one of the highest levels of malnutrition globally along with sub-optimal IYCF practices. A supportive policy environment is essential to ensure that effective IYCF interventions are scaled up. The objectives of our study were to assess the support for IYCF in the national policy environment through policy analysis and stakeholder analysis and in so doing identify opportunities to strengthen the policy environment. METHODS: We used a matrix developed by SAIFRN (the South Asian Infant Feeding Research Network) to systematically identify supportive national policies, plans and guidelines for IYCF. We adapted narrative synthesis and descriptive approaches to analyze policy content, based on four themes with a focus on support for mothers. We conducted three Net-Map interviews to identify stakeholders who influenced the policies and programs related to IYCF. RESULTS: We identified 19 national policy documents relevant to IYCF. Overall, there was good level of support for IYCF practices at policy level - particularly regarding general support for IYCF and provision of information to mothers - but these were not consistently supported at implementation level, particularly regarding specificity and population coverage. We identified gaps regarding the training of health workers, capacity building, the monitoring and targeting of vulnerable mothers and providing an enabling environment to mothers, specifically with respect to maternity leave for working women. Urban populations and providers outside the public sector remained uncovered by policy. Our stakeholder analysis identified government entities such as the National Nutrition Service, as the most influential in terms of both technical and funding support as they had the mandate for formulation and implementation of policies and national programs. Stakeholders from different sectors played important roles, demonstrating the salience of IYCF. CONCLUSIONS: Although there is strong supportive policy environment for IYCF, it is important that policies cover all populations. Our analysis indicated that opportunities to strengthen the policy environment include: expanding population coverage, increasing inter-sector coordination, improving translation of policy objectives to implementation-level documents, and the engagement of non-public sectors. In addition, we recommend explicit strategies to engage diverse stakeholders in the formulation and implementation of IYCF policies.

Techno-economic feasibility of waste biorefinery: Using slaughtering waste streams as starting material for biopolyester production.

The utilization of industrial waste streams as input materials for bio-mediated production processes constitutes a current R&D objective not only to reduce process costs at the input side but in parallel, to minimize hazardous environmental emissions. In this context, the EU-funded project ANIMPOL elaborated a process for the production of polyhydroxyalkanoate (PHA) biopolymers starting from diverse waste streams of the animal processing industry. This article provides a detailed economic analysis of PHA production from this waste biorefinery concept, encompassing the utilization of low-quality biodiesel, offal material and meat and bone meal (MBM). Techno-economic analysis reveals that PHA production cost varies from 1.41 €/kg to 1.64 €/kg when considering offal on the one hand as waste, or, on the other hand, accounting its market price, while calculating with fixed costs for the co-products biodiesel (0.97 €/L) and MBM (350 €/t), respectively. The effect of fluctuating market prices for offal materials, biodiesel, and MBM on the final PHA production cost as well as the investment payback time have been evaluated. Depending on the current market situation, the calculated investment payback time varies from 3.25 to 4.5years.

Socioeconomic and programmatic determinants of renewal of membership in a voluntary micro health insurance scheme: evidence from Chakaria, Bangladesh.

BACKGROUND: Out-of-pocket (OOP) healthcare expenditure is a major obstacle for achieving universal health coverage in low-income countries including Bangladesh. Sixty-three percent of the USD 27 annual per-capita healthcare expenditure in Bangladesh comes from individuals' pockets. Although health insurance is a financial tool for reducing OOP, use of such tools in Bangladesh has been limited to some small-scale voluntary micro health insurance (MHI) schemes run by non-governmental organizations (NGO). The MHI, however, can orient people on health insurance concept and provide learning for product development, implementation, barriers to enrolment, membership renewal, and other operational challenges and solutions. Keeping this in mind, icddr,b in 2012 initiated a pilot MHI, Amader Shasthya, in Chakaria, Bangladesh. This paper explores the determinants of membership renewal in this scheme, which is a perpetual challenge for MHI. OBJECTIVE: Identify socioeconomic and programmatic determinants and their effects on membership renewal in a voluntary MHI scheme. METHODS: Data came from the online management information system of the scheme and Health and Demographic Surveillance System of Chakaria, covering the period February 2012-May 2015. Association between renewal and independent variables was examined using cross-tabular and logistic regression analyses. RESULTS: Nearly 20% of households in the catchment area ever enroled in the scheme, and 38% renewed membership over the initial 3 years of operation. Frequency of consultation with healthcare providers, benefits received, proximity of member's residence to health facility, socioeconomic status, educational level, and age of the household head showed significant positive association with renewal of membership. CONCLUSIONS: Villagers' enrolment in the scheme indicated that even in poor economic and literacy conditions people can be motivated to enrol in insurance schemes. Degree of service utilization and benefits received can greatly enhance the probability of membership renewal, which can be ensured with good quality of services and ease of access.

What do they do? Interactions between village doctors and medical representatives in Chakaria, Bangladesh.

BACKGROUND: Informally trained village doctors supply the majority of healthcare services to the rural poor in many developing countries. This study describes the demographic and socio-economic differences between medical representatives (MRs) and village doctors in rural Bangladesh, and explores the nature of their interactions. METHODS: This study was conducted in Chakaria, a rural sub-district of Bangladesh. Focus group discussions and in-depth interviews were conducted, along with a quantitative survey to understand practice perceptions. Data analysis was performed using grounded theory and bivariate statistical tests. RESULTS: We surveyed 43 MRs and 83 village doctors through 22 focus group discussions and 33 in-depth interviews. MRs have a higher average per capita monthly expenditure compared to village doctors. MRs are better educated with 98% having bachelor's degrees whereas 84% of village doctors have twelfth grade education or less (p<0.001). MRs are the principal information source about new medications for the village doctors. Furthermore, incentives offered by MRs and credit availability influence the prescription practices of village doctors. CONCLUSIONS: MRs being the key player in providing information about drugs to village doctors might influence their prescription practices. Improvements in the quality of healthcare delivered to the rural poor in informal provider-based health markets require stricter regulations and educational initiatives for providers and MRs.

Prospects of mHealth services in Bangladesh: recent evidence from Chakaria.

INTRODUCTION: Bangladesh has a serious shortage of qualified health workforce. The limited numbers of trained service providers are based in urban areas, which limits access to quality healthcare for the rural population. mHealth provides a new opportunity to ensure access to quality services to the population. A recent review suggested that there are 19 mHealth initiatives in the country. This paper reports findings on people's knowledge, perception, use, cost and compliance with advice received from mHealth services from a study carried out during 2012-13 in Chakaria, a rural sub-district in Bangladesh. METHODS: A total of 4,915 randomly-chosen respondents aged 18 years and above were interviewed. RESULTS: Household ownership of mobile phones in the study area has increased from 2% in 2004 to 81% in 2012; 45% of the respondents reported that they had mobile phones. Thirty-one percent of the respondents were aware of the use of mobile phones for healthcare. Very few people were aware of the available mHealth services. Males, younger age group, better educated, and those from richer households were more knowledgeable about the existing mHealth services. Among the respondents who sought healthcare in the preceding two weeks of the survey, only 2% used mobile phones for healthcare. Adherence to the advice from the healthcare providers in terms of purchasing and taking the drugs was somewhat similar between the patients who used mobile phone for consultation versus making a physical visit. CONCLUSIONS: The high penetration of mobile phones into the society provides a unique opportunity to use the mHealth technology for consulting healthcare providers. Although knowledge of the existence of mHealth services was low, it was encouraging that the compliance with the prescriptions was almost similar for advice received through mobile phone and physical visits. The study revealed clear indications that society is looking forward to embracing the mHealth technology.

eHealth and mHealth initiatives in Bangladesh: a scoping study.

BACKGROUND: The health system of Bangladesh is haunted by challenges of accessibility and affordability. Despite impressive gains in many health indicators, recent evidence has raised concerns regarding the utilization, quality and equity of healthcare. In the context of new and unfamiliar public health challenges including high population density and rapid urbanization, eHealth and mHealth are being promoted as a route to cost-effective, equitable and quality healthcare in Bangladesh. The aim of this paper is to highlight such initiatives and understand their true potential. METHODS: This scoping study applies a combination of research tools to explore 26 eHealth and mHealth initiatives in Bangladesh. A screening matrix was developed by modifying the framework of Arksey & O'Malley, further complemented by case study and SWOT analysis to identify common traits among the selected interventions. The WHO health system building blocks approach was then used for thematic analysis of these traits. RESULTS: Findings suggest that most eHealth and mHealth initiatives have proliferated within the private sector, using mobile phones. The most common initiatives include tele-consultation, prescription and referral. While a minority of projects have a monitoring and evaluation framework, less than a quarter have undertaken evaluation. Most of the initiatives use a health management information system (HMIS) to monitor implementation. However, these do not provide for effective sharing of information and interconnectedness among the various actors. There are extremely few individuals with eHealth training in Bangladesh and there is a strong demand for capacity building and experience sharing, especially for implementation and policy making. There is also a lack of research evidence on how to design interventions to meet the needs of the population and on potential benefits. CONCLUSION: This study concludes that Bangladesh needs considerable preparation and planning to sustain eHealth and mHealth initiatives successfully. Additional formative and operational research is essential to explore the true potential of the technology. Frameworks for regulation in regards to eHealth governance should be the aim of future research on the integration of eHealth and mHealth into the Bangladesh health system.

An assessment of the liquid-gas partitioning behavior of major wastewater odorants using two comparative experimental approaches: liquid sample-based vaporization vs. impinger-based dynamic headspace extraction into sorbent tubes.

The gas-liquid partitioning behavior of major odorants (acetic acid, propionic acid, isobutyric acid, n-butyric acid, i-valeric acid, n-valeric acid, hexanoic acid, phenol, p-cresol, indole, skatole, and toluene (as a reference)) commonly found in microbially digested wastewaters was investigated by two experimental approaches. Firstly, a simple vaporization method was applied to measure the target odorants dissolved in liquid samples with the aid of sorbent tube/thermal desorption/gas chromatography/mass spectrometry. As an alternative method, an impinger-based dynamic headspace sampling method was also explored to measure the partitioning of target odorants between the gas and liquid phases with the same detection system. The relative extraction efficiency (in percent) of the odorants by dynamic headspace sampling was estimated against the calibration results derived by the vaporization method. Finally, the concentrations of the major odorants in real digested wastewater samples were also analyzed using both analytical approaches. Through a parallel application of the two experimental methods, we intended to develop an experimental approach to be able to assess the liquid-to-gas phase partitioning behavior of major odorants in a complex wastewater system. The relative sensitivity of the two methods expressed in terms of response factor ratios (RFvap/RFimp) of liquid standard calibration between vaporization and impinger-based calibrations varied widely from 981 (skatole) to 6,022 (acetic acid). Comparison of this relative sensitivity thus highlights the rather low extraction efficiency of the highly soluble and more acidic odorants from wastewater samples in dynamic headspace sampling.

Severe hypoglycaemia requiring emergency medical assistance by ambulance services in the East Midlands: a retrospective study.

AIMS: To report the characteristics and treatment of individuals requiring emergency ambulance services for severe hypoglycaemia and estimate associated provider costs. METHODS: Retrospective analysis of routinely collected data collected by the East Midlands Ambulance Trust, UK, of episodes of severe hypoglycaemia attended by emergency ambulance services during a four-month period. Standard clinical measures, response time, on-site treatment and transportation were recorded and ambulance services costs calculated. RESULTS: 90,435 emergency calls were recorded, 523 (0.6%) for severe hypoglycaemia, equating to an incidence of to 2.76 per 100 patient years; 74% of individuals were insulin-treated, 28% of events occurred nocturnally (00:00-07:59), and 32% were transported to hospital. Higher respiratory rate was a positive predictor (p=0.03), whereas higher post treatment blood glucose (p=0.05) and insulin treatment (p<0.01) were negative predictors of transport to hospital. Median treatment costs for individuals transported and not transported to hospital were £92 and £176 respectively. CONCLUSIONS: Most cases of severe hypoglycaemia requiring assistance from emergency ambulance services are successfully treated at the scene. Individuals not responding to treatment or were non insulin-treated were more likely to be transported to hospital. Further studies are needed to evaluate the effect of prehospital ambulance care by treatment and diabetes type on subsequent outcomes.

Profile: the Chakaria Health and Demographic Surveillance System.

Chakaria Health and Demographic Surveillance System (CHDSS), located on the south-eastern coast of the Bay of Bengal, was established in 1999 and is one of the field sites of International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDRB). The surveillance covers 118 315 residents living in 19 847 households. Data on socio-demographic and health indicators including birth, death, migration, marriage, maternal health, education and employment are recorded through quarterly household visits. The primary objective of CHDSS is to monitor the changes in socio-demographic indicators, inequalities in health and impact of public health interventions. A demographic change was accompanied by a shift from traditional to modern society during the past decade, but inequality in health still persists. The findings from the surveillance are shared regularly among the local and global communities. Data are also available upon request to ICDDRB and INDEPTH for use by researchers and policy makers.