Unmasking the truth: Experimental evidence of facemask compliance in Bangladesh, Kenya, and Nigeria during the COVID-19 pandemic.

High levels of compliance with public health measures are critical to ensure a successful response to the COVID-19 pandemic and other public health emergencies. However, most data on compliance are self-reported and the tendency to overreport due to social desirability could yield biased estimates of actual compliance. A list experiment is a widely used method to estimate social desirability bias in self-reported estimates of sensitive behaviours. We estimate rates of compliance with facemask mandates in Kenya, Nigeria, and Bangladesh using data from phone surveys conducted in March-April 2021. Data on compliance were collected from two different survey modules: a self-reported compliance module (stated) and a list experiment (elicited). We find large gaps between stated and elicited rates of facemask wearing for different groups depending on specific country contexts and high levels of overreporting of facemask compliance in self-reported surveys: there was an almost 40 percentage point gap in Kenya, 30 percentage points in Nigeria, and 20 percentage points in Bangladesh. We also observe differences in rates of self-reported facemask wearing among key groups but not using the elicited responses from the list experiment, which suggest that social desirability bias may vary by demographics. Data collected from self-reported surveys may not be reliable to monitor ongoing compliance with public health measures. Moreover, elicited compliance rates indicate levels of mask wearing are likely much lower than those estimated using self-reported data.

Consent Requirements for Testing Health Policies: An Intercontinental Comparison of Expert Opinions.

Individual informed consent is a central requirement for clinical research on human subjects, yet whether and how consent requirements should apply to health policy experiments (HPEs) remains unclear. HPEs test and evaluate public health policies prior to implementation. We interviewed 58 health experts in Tanzania, Bangladesh and Germany on informed consent requirements for HPEs. Health experts across all countries favored a strong evidence base, prior information to the affected populations, and individual consent for 'risky' HPEs. Differences pertained to individual risk perception, how and when consent by group representatives should be obtained and whether HPEs could be treated as health policies. The study adds to representative consent options for HPEs, yet shows that more research is needed in this field - particularly in the present Covid-19 pandemic which has highlighted the need for HPEs nationally and globally.

Food insecurity and COVID-19 risk in low- and middle-income countries.

The COVID-19 pandemic prompted social distancing, workplace closures, and restrictions on mobility and trade that had cascading effects on economic activity, food prices, and employment in low- and middle-income countries. Using longitudinal data from Bangladesh, Kenya, and Nigeria covering a period from October 2020 to April 2021, the paper assesses whether knowledge of a person infected with COVID-19 is associated with food insecurity, job loss and business closures, and coping strategies to smooth consumption. The likelihood of households to experience food insecurity at the extensive and intensive margins increased among those who knew an infected person in Bangladesh and Kenya.

Mandatory employer-sponsored health financing scheme for semiformal workers in Bangladesh: An experimental assessment.

In this study, we present findings from an experimental evaluation of a mandatory employer-sponsored health insurance scheme in Bangladesh. We randomly introduced the scheme to female artisans to understand the impacts on healthcare utilisation, expenditure and subjective well-being using both survey and administrative data. Our findings suggest that the scheme broke even; however, it covered only six percent of the overall health expenditure and 16 percent of the hospitalisation costs. We find higher inpatient care utilisation, particularly among women, and in favour of empanelled hospitals causally associated with the intervention, consistent with the design of the scheme. We do not find significant healthcare savings or improvement in subjective well-being, consistent with low coverage. The findings suggest the scheme to be financially sustainable and it changes the healthcare seeking behaviours as the scheme incentivises. However, meaningful savings and protection against catastrophic health expenditures will require a higher level of coverage.

Effective Demand for In-Line Chlorination Bundled with Rental Housing in Dhaka, Bangladesh.

Delivering safe water in cities of lower- and middle-income countries remains elusive even where there is a piped supply. Passive, in-line chlorination upstream of the point of water collection reduces child diarrhea without the behavior change required for point-of-use water treatment products or manual chlorine dispensers. We conducted a price experiment to measure effective demand (willingness and ability to pay) for an in-line chlorination service using tablet chlorinators among 196 landlords of rental housing properties in Dhaka, Bangladesh. We offered a 12-month subscription using Becker-DeGroot-Marschak auctions with real money payments. The service consistently delivered chlorinated water and satisfied tenants. Landlords' effective demand for in-line chlorination was similar to or greater than that for point-of-use treatment products and manual chlorine dispensers previously documented among Dhaka households. Over the service period, landlords renting to low-income households had lower effective demand than those renting to middle-income households despite similar initial rates of payment across both groups. Making in-line chlorination financially viable for the lowest-income consumers would likely require service cost reductions, subsidies, or both. Our findings suggest that even revealed preference experiments may overestimate the effective demand needed to sustain water supply improvements, especially in low-income populations, if they only measure demand once.

A distress-continuum, disorder-threshold model of depression: a mixed-methods, latent class analysis study of slum-dwelling young men in Bangladesh.

BACKGROUND: Binary categorical approaches to diagnosing depression have been widely criticized due to clinical limitations and potential negative consequences. In place of such categorical models of depression, a 'staged model' has recently been proposed to classify populations into four tiers according to severity of symptoms: 'Wellness;' 'Distress;' 'Disorder;' and 'Refractory.' However, empirical approaches to deriving this model are limited, especially with populations in low- and middle-income countries. METHODS: A mixed-methods study using latent class analysis (LCA) was conducted to empirically test non-binary models to determine the application of LCA to derive the 'staged model' of depression. The study population was 18 to 29-year-old men (n = 824) from an urban slum of Bangladesh, a low resource country in South Asia. Subsequently, qualitative interviews (n = 60) were conducted with members of each latent class to understand experiential differences among class members. RESULTS: The LCA derived 3 latent classes: (1) Severely distressed (n = 211), (2) Distressed (n = 329), and (3) Wellness (n = 284). Across the classes, some symptoms followed a continuum of severity: 'levels of strain', 'difficulty making decisions', and 'inability to overcome difficulties.' However, more severe symptoms such as 'anhedonia', 'concentration issues', and 'inability to face problems' only emerged in the severely distressed class. Qualitatively, groups were distinguished by severity of tension, a local idiom of distress. CONCLUSIONS: The results indicate that LCA can be a useful empirical tool to inform the 'staged model' of depression. In the findings, a subset of distress symptoms was continuously distributed, but other acute symptoms were only present in the class with the highest distress severity. This suggests a distress-continuum, disorder-threshold model of depression, wherein a constellation of impairing symptoms emerge together after exceeding a high level of distress, i.e., a tipping point of tension heralds a host of depression symptoms.

Health shock and preference instability: assessing health-state dependency of willingness-to-pay for corrective eyeglasses.

BACKGROUND: Differences in contingent valuation (CV) estimates for identical healthcare goods can cast considerable doubt on the true economic measures of consumer preferences. Hypothetical nature of CV methods can potentially depend on the salience, context and perceived relevance of the good or service under consideration. Thus, the high demand elasticity for healthcare goods warrants careful selection of study population as the contexts of valuation significantly changes after experiencing health shock. METHODS: In this study, using triple-bounded dichotomous choice (TBDC) experiments, we test how negative health shock (namely, being diagnosed with refractive errors), can alter preference over a common health good (namely, corrective eyeglasses). We compared elicited WTP of diagnosed patients with a synthetically constructed comparable cohort without the same health shock, controlling for the possible self-selection using a number of matching techniques based on the observable socio-demographic characteristics. RESULTS: The consumers diagnosed with vision problems exhibit a rightward shift in their demand curve compared to observationally identical consumers without such problems resulting in about 17% higher consumer surplus. The consumers without the health shock are willing to pay about BDT 762.4 [95% CI: BDT 709.9 - BDT 814.9] for corrective eyeglasses, which gets 15-30% higher for the matched with-health-shock consumers. Multivariable analyses suggest more educated and wealthier individuals are willing to pay respectively BDT 208 and BDT 119 more for corrective eyeglasses. We have tested the models for different matching protocols. Our results are fairly robust to alternate specifications and various matching techniques. CONCLUSION: The preferences for healthcare goods, such as eyeglasses, can significantly depend upon the respondent being diagnosed with refractive errors. Our findings have implications for general cost-benefit analyses often relying on WTP, which can vary depending on the contexts. There are also increasing interests in cost recovery models, which require understanding the demand for healthcare goods and services. We find eliciting the demand needs to consider the health status of the population from which the respondents are sampled.

Willingness to Pay for Cataract Surgeries Among Patients Visiting Eye Care Facilities in Dhaka, Bangladesh.

BACKGROUND: Cataract is the leading cause of avoidable blindness globally. It is estimated that 89% of people with visual impairment live in low- and middle-income countries where the cost of cataract surgery represents a major barrier for accessing these services. Developing self-sustaining healthcare programs to cater the unmet demands warrants a better understanding of patients' willingness to pay (WTP) for their services. OBJECTIVES: Using a sample of patients visiting eye care facilities in Dhaka, Bangladesh, we estimate WTP for two different cataract extraction techniques, namely small incision cataract surgery (SICS) and phacoemulsification. METHODS: We used contingent valuation (CV) approach and elicited WTP through double-bounded dichotomous choice experiments. We interviewed 556 randomly selected patients (283 for SICS and 273 for phacoemulsification) from five different eye care hospitals of Dhaka. In this paper, we estimated the mean and marginal WTP using interval regression models. We also compared the estimated WTP and stated demand for cataract surgeries against the prevailing market prices of SICS and phacoemulsification. RESULTS: We found the mean WTP of BDT 7579 (US$93) for SICS and BDT 10,208 (US$126) for phacoemulsification are equivalent to 12 and 16 days of household income, respectively. Household income and assets appeared as the major determinants of WTP for cataract surgeries. However, we did not find any significant association with gender, occupation, and household size among other socioeconomic characteristics. Comparisons between market prices and average WTP suggest it is possible to have a viable market for SICS, but a subsidy-based model for phacoemulsification will be financially challenging because of low WTP and high costs. CONCLUSION: Our findings suggest lower-cost SICS can potentially provide patients access to surgeries to treat cataract conditions. Moreover, price discrimination and cross-subsidization could be a viable strategy to increase the service-uptake as well as ensure financial sustainability.

Social network analysis of psychological morbidity in an urban slum of Bangladesh: a cross-sectional study based on a community census.

OBJECTIVES: To test whether social ties play any roles in mitigating depression and anxiety, as well as in fostering mental health among young men living in a poor urban community. SETTING: A cohort of all young men living in an urban slum in Dhaka, the capital of Bangladesh. PARTICIPANTS: All men aged 18-29 years (n=824) living in a low-income urban community at the time of the survey. PRIMARY AND SECONDARY OUTCOME MEASURES: Unspecified psychological morbidity measured using the General Health Questionnaire, 12-item (GHQ-12), where lower scores suggest better mental status. RESULTS: The GHQ scores (mean=9.2, SD=4.9) suggest a significant psychological morbidity among the respondents. However, each additional friend is associated with a 0.063 SD lower GHQ score (95% CI -0.106 to -0.021). Between centrality measuring the relative importance of the respondent within his social network is also associated with a 0.103 SD lower GHQ score (95% CI -0.155 to -0.051), as are other measures of social network ties. Among other factors, married respondents and recent migrants also report a better mental health status. CONCLUSIONS: Our results underscore the importance of social connection in providing a buffer against stress and anxiety through psychosocial support from one's peers in a resource-constraint urban setting. Our findings also suggest incorporating a social network and community ties in designing mental health policies and interventions.

Trends and determinants of inequities in childhood stunting in Bangladesh from 1996/7 to 2014.

BACKGROUND: We explore long-term trends and determinants of socioeconomic inequities in chronic childhood undernutrition measured by stunting among under-five children in Bangladesh. Given that one in three children remain stunted in Bangladesh, the socioeconomic mapping of stunting prevalence may be critical in designing public policies and interventions to eradicate childhood undernutrition. METHODS: Six rounds of Bangladesh Demographic and Health Survey data are utilized, spanning the period 1996/97 to 2014. Using recognized measures of absolute and relative inequality (namely, absolute and relative difference, concentration curve and index), we quantify trends, and decompose changes in the concentration index to identify factors that best explain observed dynamics. RESULTS: Despite remarkable improvements in average nutritional status over the last two decades, socio-economic inequalities have persisted, and according to some measures, even worsened. For example, expressed as rate-ratios, the relative inequality in under-five stunting increased by 56% and the concentration index more than doubled between 1996/97 and 2014. Decomposition analyses find that wealth and maternal factors such as mothers' schooling and short stature are major contributors to observed socio-economic inequalities in child undernutrition and their changes over time. CONCLUSIONS: Reflecting on recent success around socioeconomic and gender equity in child mortality, and the weak legacy of nutrition policy in Bangladesh, we suggest that nutrition programming energies be focused specifically on the most disadvantaged and applied at scale to close socioeconomic gaps in stunting prevalence.

On identifying the causal links between local political Leadership and Sanitation

In this project, we want to understand whether community led information and education campaign can lead to better environmental hygiene practices and reduction in exposure to pathogens that may be associated with unsafe sanitation and hygiene behavior. Additionally this project will also aim to identify some of the pathways by which these interventions may have impacts on adopting better hygienic practices. Since the interventions are implemented following an RCT protocol, we can interpret the differences in different outcomes (such as bacteriological count from hand swabs) between control and treatment unions (the lowest administrative tier in Bangladesh) as causal relationships. The project will primarily use microbiological analysis of sanitation related environmental outcomes (e.g. E. coli contamination). Moreover, we want to test whether the capacity building activities improve the ability (e.g. as measured by their knowledge on sanitation and hygiene issues) of the female local government members and the ward sanitation sub-committees as well as the perception toward the local government leaders and institutions. We believe the results will have important implications for public policy, as capable institutions are increasingly believed to ensure the households invest in sanitation, which in turn has implications for preservation of local environmental and natural resources such as water bodies.

Explaining equity gains in child survival in Bangladesh: scale, speed, and selectivity in health and development.

By disaggregating gains in child health in Bangladesh over the past several decades, significant improvements in gender and socioeconomic inequities have been revealed. With the use of a social determinants of health approach, key features of the country's development experience can be identified that help explain its unexpected health trajectory. The systematic equity orientation of health and socioeconomic development in Bangladesh, and the implementation attributes of scale, speed, and selectivity, have been important drivers of health improvement. Despite this impressive pro-equity trajectory, there remain significant residual inequities in survival of girls and lower wealth quintiles as well as a host of new health and development challenges such as urbanisation, chronic disease, and climate change. Further progress in sustaining and enhancing equity-oriented achievements in health hinges on stronger governance and longer-term systems thinking regarding how to effectively promote inclusive and equitable development within and beyond the health system.

Changes in glitazone use among office-based physicians in the U.S., 2003-2009.

OBJECTIVE: Little is known regarding recent changes in glitazone use. RESEARCH DESIGN AND METHODS: Interrupted time series analyses of nationally representative office-visit data using IMS Health's National Disease and Therapeutic Index. RESULTS: From 2003 through 2005, glitazone use increased steadily. From February 2005 to January 2007, rosiglitazone use decreased by 16% (95% CI -20 to -11) annually; pioglitazone use increased at an annual rate of 14% (9-18). During a period of Food and Drug Administration (FDA) advisories, rosiglitazone use declined sharply from 0.42 million monthly treatment visits (February 2007) to 0.13 million monthly visits (May 2008). Pioglitazone use remained stable, accounting for approximately 5.8 million physician visits (77% of all glitazone use) where a treatment was used during the final 12 months of observation. CONCLUSIONS: The combined effect of scientific publications, advisories, and media exposure was associated with a substantial decrease in rosiglitazone use. Despite a class-level FDA advisory, pioglitazone use was not similarly affected.

Impact of FDA black box advisory on antipsychotic medication use.

BACKGROUND: In April 2005, the US Food and Drug Administration (FDA) issued an advisory and subsequent black box warning regarding the risks of atypical anti psychotic use among elderly patients with dementia. The impact of these warnings on atypical drug use is unknown. METHODS: We used quasi-experimental, interrupted time-series analyses to examine nationally representative data from IMS Health's National Disease and Therapeutic Index from January 2003 through December 2008. The primary measurement from this audit of office-based physicians was the use of an atypical antipsychotic agent. We quantified the impact of the advisory on atypical antipsychotic use among all individuals and those 65 years or older with dementia. RESULTS: From January 2003 to March 2005, mentions of total atypical antipsychotic drugs increased at an annual rate of 34%, and among patients with dementia, 16%. In the year prior to the FDA advisory, there were approximately 13.6 million atypical drug mentions, including 0.8 million among those with dementia. In the year following the advisory, atypical drug mentions fell 2% overall and 19% among those with dementia. In 2004, 19% (0.8 of 4.1 million) of drug mentions for dementia were for an atypical agent. By 2008, this proportion decreased to 9% (0.4 of 4.3 million). Atypical drug use slowed for both FDA-approved and off-label indications and declined through 2008 for all populations examined. CONCLUSION: The FDA advisory was associated with decreases in the use of atypical antipsychotics, especially among elderly patients with dementia.

Cost savings associated with filling a 3-month supply of prescription medicines.

BACKGROUND: Many patients are burdened by prescription costs, and patients, providers and policy makers may attempt to reduce these costs by substituting 3-month for 1-month supplies of medicines. OBJECTIVES: To measure the difference in out-of-pocket and total costs among patients receiving different quantities of the same prescription drug used to treat a chronic condition, and to examine patient and health system characteristics associated with the use of a 3-month supply. METHODS: Data were pooled from the 2000-5 Medical Expenditure Panel Survey, a nationally representative survey of the US non-institutionalized civilian population, to compare prescription drug expenditures for medicines dispensed as both 3-month and 1-month supplies. Logistic regression was used to model correlates associated with 3-month use. The main outcome measures were the mean monthly out-of-pocket and total costs expressed in year 2005 values. RESULTS: Forty-four percent of prescriptions examined were dispensed as 3-month supplies. The average (95% CI) monthly total and out-of-pocket costs for a 1-month supply were $US42.72 (42.01, 43.42) and $US20.44 (19.99, 20.89), respectively, while the corresponding monthly costs for a 3-month supply were $US37.95 (37.26, 38.64) and $US15.10 (14.68, 15.53). After adjustment for potential confounders, this represented a 29% decrease in out-of-pocket costs and an 18% decrease in total prescription costs through the use of a 3-month rather than a 1-month supply. Eighty percent of patients achieved some cost savings from a 3-month supply and there was considerable variation in the amount saved. There were no marked differences in the characteristics of individuals using 3-month versus 1-month supplies. CONCLUSIONS: Although such opportunities are not universally available, these findings quantify the cost savings that patients in the US can achieve through filling larger quantities of a prescription for a chronic condition.

Impact of family structure on stimulant use among children with attention-deficit/hyperactivity disorder.

OBJECTIVE: To examine the impact of family structure on pharmacologic stimulant use among children with attention-deficit/hyperactivity disorder (ADHD). DATA SOURCE: Nationally representative, population-based sample of the National Health Interview Survey from 1997 to 2003 linked with drug event files from the Medical Expenditure Panel Survey from 1998 to 2005. STUDY DESIGN: Stepwise multivariate logistic regression was used to examine the likelihood of stimulant use for each individual during 2 years of observation after adjustment for sociodemographic, health, and family characteristics. Stratified analyses were also conducted to examine whether family characteristics had different impacts within single-mother and dual-parent households. PRINCIPAL FINDINGS: Stimulant use varied based on children's sociodemographic and health characteristics. In multivariate analyses, associations between children's household structure, parental education, and stimulant use appeared to be mediated by children's access to care and health status. However, in full multivariate models, there remained a robust positive association between family size and stimulant use. CONCLUSIONS: These findings highlight the influence that nonclinical factors such as family size may have in mediating the use of pharmacologic therapies for children.

The association between family structure, reports of illness and health care demand for children: evidence from rural Bangladesh.

Access to health care in lesser-developed countries is often quite limited, especially in rural areas. However, less is known about how different factors, such as household structure, parental income and parental education, modify such access to care. This study uses individual-level data from rural Bangladesh during and following a period of major flooding to examine factors associated with reports of illness and demand for doctors in households with children less than 10 years of age. Using information about the number of children who were reported sick and also those who were taken to a doctor, a model was estimated for such reports and decisions to visit a doctor. Overall, 74% of households reported an illness in a child during the study period. The likelihood of reports was significantly greater for boys (36%) than girls (31%). In most analyses, there was no association between parental education and reports of child illness after adjusting for village- and household-level heterogeneity. However, in analyses limited to female children, greater education of the household head was associated with lower odds of such a report (odds ratio [OR] 0.95, 95% confidence interval [CI] 0.91-1.00). Parental education and income were also related to household decisions to seek medical care, though results once again differed based on the sex of the child. There was a particularly strong effect between maternal education level and demand for medical care for boys (OR 1.13; CI 1.01-1.27), though not for girls (OR 0.96; CI 0.84-1.09). Overall, the likelihood of a doctor's visit for a sick child was positively related to household income and at the highest levels of income was a virtual certainty.

Out-of-pocket and total costs of fixed-dose combination antihypertensives and their components.

BACKGROUND: Many patients are burdened by prescription costs, yet it is not clear whether brand-named fixed-dose combination medicines are less expensive than the sum of the cost of their generic components. METHODS: We used the Medical Expenditure Panel Survey, a rigorously conducted, nationally representative, population-based survey, to examine the out-of-pocket and third party costs associated with the most commonly prescribed, brand-named fixed-dose combination antihypertensive drugs. We compared the out-of-pocket and third party cost for a 30-day supply of each of these combination drugs with the sum of these costs for their individual generic components. RESULTS: Twenty-seven combination antihypertensive medicines were examined. Overall, combination products had higher out-of-pocket costs and lower total costs than did the sum of the costs of their components. For example, the out-of-pocket costs were greater for 24 of 27 combination drugs examined, and the mean increase in monthly out-of-pocket costs associated with combination therapy was $13.38 (95% confidence interval, $12.27-14.50). In contrast, the total cost was lower for 23 of the 27 combination drugs examined, and the mean decrease in monthly total costs was $20.89 (95% confidence interval, $20.10-21.68). CONCLUSIONS: Given patient burden and nonadherence from out-of-pocket prescription costs, the clinical benefits of brand-named fixed-dose combination antihypertensive therapy should be balanced with their greater out-of-pocket costs.

The effect of the Medicare Part D prescription benefit on drug utilization and expenditures.

BACKGROUND: Information about the effect of the Medicare Part D Prescription Drug Benefit on drug utilization and expenditures is limited. OBJECTIVE: To estimate changes in prescription utilization and out-of-pocket expenditures attributable to Part D among a sample of persons eligible for the benefit. DESIGN: Generalized estimating equations were used to estimate changes in expenditures and utilization among beneficiaries. A control group was included to control for secular trends unrelated to the Part D benefit. SETTING: National pharmacy chain representing approximately 15% of all U.S. retail pharmacy sales. PARTICIPANTS: Persons age 66 to 79 years (those eligible for Part D) and a control group of persons age 60 to 63 years (those ineligible for Part D). The final sample represented approximately 5.1 million unique beneficiaries and 1.8 million unique control individuals. MEASUREMENTS: Prescription utilization (measured in pill-days) and out-of-pocket expenditures, as determined from pharmacy claims from September 2004 to April 2007. RESULTS: During the penalty-free Part D enrollment period (January 2006 to May 2006), average monthly drug utilization increased by 1.1% (95% CI, 0.5% to 1.7%; P < 0.001) and out-of-pocket expenditures decreased by 8.8% (CI, 6.6% to 11.0%; P < 0.001). After enrollment stabilized (June 2006 to April 2007), average monthly drug utilization increased by 5.9% (CI, 5.1% to 6.7%; P < 0.001) and out-of-pocket expenditures decreased by 13.1% (CI, 9.6% to 16.6%; P = 0.003). Compared with eligible nonenrollees, enrollees had higher out-of-pocket expenditures and utilization at baseline but experienced significantly larger decreases in expenditures and increases in utilization after enrollment. LIMITATIONS: Analyses were limited to claims within 1 pharmacy chain. The effect of the "doughnut hole" and the effect of changes on clinical outcomes were not evaluated. CONCLUSION: The Medicare Part D prescription benefit resulted in modest increases in average drug utilization and decreases in average out-of-pocket expenditures among Part D beneficiaries. Further research is needed to examine patterns among other beneficiaries and to evaluate the effect of these changes on health outcomes.