Who is absent and why? Factors affecting doctor absenteeism in Bangladesh.

Absenteeism by doctors in public healthcare facilities in rural Bangladesh is a form of chronic rule-breaking and is recognised as a critical problem by the government. We explored the factors underlying this phenomenon from doctors' perspectives. We conducted a facility-based cross-sectional survey in four government hospitals in Dhaka, Bangladesh. Junior doctors with experience in rural postings were interviewed to collect data on socio-demographic characteristics, work and living experience at the rural facilities, and associations with professional and social networks. Multiple logistic regression was used to determine the factors associated with rural retention. Of 308 respondents, 74% reported having served each term of their rural postings without interruptions. The main reasons for absenteeism reported by those who interrupted rural postings were formal training opportunities (65%), family commitments (41%), and a miscellaneous group of others (17%). Almost half of the respondents reported unmanageable workloads. Most (96%) faced challenges in their last rural posting, such as physically unsafe environments (70%), verbally abusive behaviour by patients/caregivers (67%) and absenteeism by colleagues that impacted them (48%). Respondents who did not serve their entire rural posting were less likely to report an unmanageable workload than respondents who did (AOR 0.39, 95% CI 0.22-0.70). Respondents with connections to influential people in the local community had a 2.4 times higher chance of serving in rural facilities without interruption than others (AOR 2.40, 95% CI 1.26-4.57). Our findings demonstrate that absenteeism is not universal and depends upon doctors' socio-political networks. Policy interventions rarely target unsupportive or threatening behaviour by caregivers and community members, a pivotal disincentive to doctors' willingness to work in underserved rural areas. Policy responses must promote opportunities for doctors with weak networks who are willing to attend work with appropriate support.

A qualitative exploration of the facility-based trauma care for Road Traffic Crash patients in Bangladesh: When only numbers do not tell the whole story.

OBJECTIVE: Bangladesh is currently undergoing an epidemic of road traffic crashes (RTCs). In addition to morbidity and mortality, the economic loss from RTC as per cent of gross domestic product is comparatively higher than in countries with similar socioeconomic conditions. However, trauma care remained poorly developed as a specialty and service delivery mechanism. This study aimed to examine the current situation of in-hospital trauma care after RTCs to inform the design of a comprehensive service for Bangladesh. DESIGN, SETTING AND PARTICIPANTS: This qualitative study attempted to elicit stakeholders' perceptions and experiences of managing RTCs through in-depth interviews and focus group discussions. Three districts and Dhaka city were selected based on the frequency of occurrence of RTCs. Fifteen in-depth interviews and 5 focus group discussions were conducted with 38 RTC patients, their relatives and community members in the catchment areas of 11 facilities managing trauma patients. Key informant interviews were conducted with 21 service providers and 17 key stakeholders/policy-makers. RESULTS: Hospital-based trauma care was generally poor in primary and secondary-level facilities. There was no triage area or triage protocol in the emergency rooms, no trained staff for trauma care, no dedicated RTC patient register and scarce life-saving equipment. Only in Dhaka-based tertiary hospitals was trauma care prioritised. These hospitals follow Advanced Trauma Life Support guidelines and maintain an RTC logbook. Emergency diagnostic services were not always available in the hospitals. Most RTC patients were males; the female participants were additionally vulnerable to physical and mental trauma. Affected people avoided taking legal action considering it a lengthy, complicated and ultimately ineffective process. CONCLUSION: The trauma care services currently available in the studied health facilities are very rudimentary and without the necessary human and financial resources. This needs urgent attention from policymakers, programmers and practitioners to reduce morbidity and mortality from the current epidemic of RTCs in Bangladesh.

Trauma Care Scenarios Following Road Traffic Crashes in Bangladesh: A Scoping Review.

INTRODUCTION: We conducted a scoping review of the trauma care situation following road traffic crashes (RTCs) in Bangladesh to inform the design of a comprehensive program for mitigating associated morbidity and mortality. METHODS: We used the Preferred Reporting Items for Systematic Reviews and Meta-Analysis approach to select relevant articles, documents, and reports following a set of inclusion and exclusion criteria. In total, 52 articles and 8 reports and program documents were included in the analysis. We adopted a mixed studies review method for synthesizing evidence and organized information by key themes using a data extraction matrix. RESULTS: Findings revealed RTC mortality to be 15.3 per 100,000 population in 2019. Pedestrians, cyclists, and motorcyclists were the most vulnerable groups succumbing to moderate to grave injuries. We found that 81% of motorcycle victims did not use any safety device, an estimated 1,844 people per day suffered different degrees of injury, and 29 people per day became permanently disabled. The ambulance-based prehospital care operated in a disjointed and disorganized manner without standard operating procedures and dispatch structure. This disorganization and a lack of a universal communication system led to treatment delay, resulting in chronic disability for the victims. Injury-related patients occupied about 33% of hospital beds, 19% of which were RTC victims. The cost of care for these victims involved substantial out-of-pocket spending, which sometimes reached catastrophic levels. Since 2009, the management of RTCs has deteriorated with a concomitant increase in morbidity and mortality, resulting in a drain on people's lives and livelihoods. CONCLUSION: The current situation regarding post-crash care in the country, especially when RTCs are on the rise, is not compatible with reaching the SDG targets 3.6 and 11.2 or the government's stated goal of achieving universal health coverage by 2030.

The Implementation of National Action Plan (NAP) on Antimicrobial Resistance (AMR) in Bangladesh: Challenges and Lessons Learned from a Cross-Sectional Qualitative Study.

This study explored the current situation of the National Action Plan (NAP) on Antimicrobial Resistance (AMR) implementation in Bangladesh and examined how different sectors (human, animal, and environment) addressed the AMR problem in policy and practice, as well as associated challenges and barriers to identifying policy lessons and practices. Informed by a rapid review of the available literature and following the World Health Organization (WHO) AMR situation analysis framework, a guideline was developed to conduct in-depth interviews with selected stakeholders from January to December 2021. Data were analysed using an adapted version of Anderson's governance framework. Findings reveal the absence of required inter-sectoral coordination essential to a multisectoral approach. There was substantial coordination between the human health and livestock/fisheries sectors, but the environment sector was conspicuously absent. The government initiated some hospital-based awareness programs and surveillance activities, yet no national Monitoring and Evaluation (M&E) framework was established for NAP activities. Progress of implementation was slow, constrained by the shortage of a trained health workforce and financial resources, as well as the COVID-19 pandemic. To summarise, five years into the development of the NAP in Bangladesh, its implementation is not up to the level that the urgency of the situation requires. The policy and practice need to be cognisant of this fact and do the needful things to avoid a catastrophe.

Exploring the knowledge, attitudes, practices and lived experiences of frontline health workers in the times of COVID-19 : a qualitative study from Bangladesh.

OBJECTIVE: This study explored Frontline Health Workers' (FLWs) knowledge, attitude and practice (KAP) on COVID-19 and their lived experiences, in both their personal and work lives, at the early stage of the pandemic in Bangladesh. DESIGN, SETTING AND PARTICIPANTS: This was a qualitative study conducted through telephone interviews in May 2020. A total of 41 FLWs including physicians, nurses, paramedics, community healthcare workers and hospital support staff from 34 public and private facilities of both urban and rural parts of Bangladesh participated in the interview. A purposive sampling technique supplemented by a snowball sampling method was followed to select the participants. The in-depth interviews followed a semi-structured interview guide, and we applied the thematic analysis method for the qualitative data analysis. FINDINGS: Except physicians, the FLWs did not receive any institutional training on COVID-19, including its prevention and management, in most instances. Also, they had no training in the use of personal protective equipment (PPE). Their common source of knowledge was the different websites or social media platforms. The FLWs were at risk while delivering services because patients were found to hide histories and not maintaining safety rules, including physical distancing. Moreover, inadequate supply of PPE, fear of getting infected, risk to family members and ostracisation by the neighbours were mentioned to be quite common by them. This situation eventually led to the development of mental stress and anxiety; however, they tried to cope up with this dire situation and attend to the call of humanity. CONCLUSION: The uncertain work environment during the COVID-19 pandemic simultaneously affected FLWs' physical and emotional health in Bangladesh. However, they showed professional devotion in overcoming such obstacles and continued to deliver essential services. This could be further facilitated by a quick and targeted training package on COVID-19, and the provision of supplies for delivering services with appropriate safety precautions.

Do social accountability approaches work? A review of the literature from selected low- and middle-income countries in the WHO South-East Asia region.

Governance failures undermine efforts to achieve universal health coverage and improve health in low- and middle-income countries by decreasing efficiency and equity. Punitive measures to improve governance are largely ineffective. Social accountability strategies are perceived to enhance transparency and accountability through bottom-up approaches, but their effectiveness has not been explored comprehensively in the health systems of low- and middle-income countries in south and Southeast Asia where these strategies have been promoted. We conducted a narrative literature review to explore innovative social accountability approaches in Bangladesh, Bhutan, India, Indonesia, the Maldives, Myanmar and Nepal spanning the period 2007-August 2017, searching PubMed, Scopus and Google Scholar. To augment this, we also performed additional PubMed and Google Scholar searches (September 2017-December 2019) to identify recent papers, resulting in 38 documents (24 peer-reviewed articles and 14 grey sources), which we reviewed. Findings were analysed using framework analysis and categorized into three major themes: transparency/governance (eight), accountability (11) and community participation (five) papers. The majority of the reviewed approaches were implemented in Bangladesh, India and Nepal. The interventions differed on context (geographical to social), range (boarder reform to specific approaches), actors (public to private) and levels (community-specific to system level). The initiatives were associated with a variety of positive outcomes (e.g. improved monitoring, resource mobilization, service provision plus as a bridge between the engaged community and the health system), yet the evidence is inconclusive as to the extent that these influence health outcomes and access to health care. The review shows that there is no common blueprint which makes accountability mechanisms viable and effective; the effectiveness of these initiatives depended largely on context, capacity, information, spectrum of actor involvement, independence from power agendas and leadership. Major challenges that undermined effective implementation include lack of capacity, poor commitment and design and insufficient community participation.

Tackling antimicrobial resistance in Bangladesh: A scoping review of policy and practice in human, animal and environment sectors.

BACKGROUND: Antimicrobial resistance (AMR) has become an emerging issue in the developing countries as well as in Bangladesh. AMR is aggravated by irrational use of antimicrobials in a largely unregulated pluralistic health system. This review presents a 'snap shot' of the current situation including existing policies and practices to address AMR, and the challenges and barriers associated with their implementation. METHODS: A systematic approach was adopted for identifying, screening, and selecting relevant literature on AMR situation in Bangladesh. We used Google Scholar, Pubmed, and Biomed Central databases for searching peer-reviewed literature in human, animal and environment sectors during January 2010-August 2019, and Google for grey materials from the institutional and journal websites. Two members of the study team independently reviewed these documents for inclusion in the analysis. We used a 'mixed studies review' method for synthesizing evidences from different studies. RESULT: Of the final 47 articles, 35 were primary research, nine laboratory-based research, two review papers and one situation analysis report. Nineteen articles on human health dealt with prescribing and/or use of antimicrobials, five on self-medication, two on non-compliance of dosage, and 10 on the sensitivity and resistance patterns of antibiotics. Four papers focused on the use of antimicrobials in food animals and seven on environmental contamination. Findings reveal widespread availability of antimicrobials without prescription in the country including rise in its irrational use across sectors and consequent contamination of environment and spread of resistance. The development and transmission of AMR is deep-rooted in various supply and demand side factors. Implementation of existing policies and strategies remains a challenge due to poor awareness, inadequate resources and absence of national surveillance. CONCLUSION: AMR is a multi-dimensional problem involving different sectors, disciplines and stakeholders requiring a One Health comprehensive approach for containment.

Increased Fecal Lactobacillus Is Associated With a Positive Glucose Hydrogen Breath Test in Bangladeshi Children.

BACKGROUND: Glucose hydrogen breath testing is a noninvasive test for small intestine bacterial overgrowth (SIBO). A positive glucose hydrogen breath test is common in children from low-income countries and has been found to be associated with malnutrition as measured by stunted growth. The microbiome associated with positive breath testing is relatively unstudied. METHODS: We performed 16 S V4 rDNA microbiome analysis on the stool of 90 Bangladeshi children aged 2 years from an impoverished neighborhood who were tested at the same time for SIBO by glucose hydrogen breath testing. Data were analyzed by linear discriminant analysis effect size with SIBO as the outcome. Any selected genera were tested individually by Wilcoxon's rank-sum test to ensure that linear discriminant analysis effect size results were not outlier-skewed. RESULTS: Linear discriminant analysis effect size analysis identified Lactobacillus (linear discriminate analysis score, 4.59; P = .03) as over-represented in 15 out of the 90 children who were SIBO positive. CONCLUSIONS: These results suggest that glucose hydrogen breath test positivity in children from low-income settings may be due to an upper intestinal Lactobacillus bloom, potentially explaining the association of SIBO with the gut damage and inflammation that leads to malnutrition.

Assessing informed consent practices during normal vaginal delivery and immediate postpartum care in tertiary-level hospitals of Bangladesh.

INTRODUCTION: This study was conducted to assess the informed consent practices during normal vaginal delivery (NVD) process and immediate postpartum care in the tertiary-level hospitals of Bangladesh. METHODS: A cross-sectional study was conducted at Dhaka Medical College Hospital (DMCH) and Sir Salimullah Medical College & Mitford Hospital (SSMCH) in November 2015. The study population and respondents were mothers who gave normal vaginal childbirth within the past 24 hours and received postpartum care in the study sites (N=190). The interview of every alternate mother from the patient register was conducted by researchers using a structured questionnaire. Descriptive analysis of findings was carried out using MS Excel 2013. RESULTS: The study findings revealed the complete absence of informed consent practices during NVD and postpartum care in the tertiary-level hospitals in Bangladesh. Consent (not informed consent) was taken from 95% of the mothers before proceeding with the NVD process, 50-72% of examinations (except breast examination, 0%) and 8-72% of procedures during postpartum care. Choice and preferences of mothers for taking an alternative process/examination/procedure were absent in all cases. CONCLUSIONS: The Respectful Maternity Care (RMC) Charter endorsed informed consent as one of the basic rights of child-bearing women. Absence of informed consent practices in the study sites indicates disrespect to maternity care and violation of this right. The Standard Clinical Management Protocols of Bangladesh also lacks clarification of this right. Improvement of the existing protocol, increased awareness and practices are essential to address protection of this right.

Small Intestine Bacterial Overgrowth and Environmental Enteropathy in Bangladeshi Children.

UNLABELLED: Recent studies suggest small intestine bacterial overgrowth (SIBO) is common among developing world children. SIBO's pathogenesis and effect in the developing world are unclear. Our objective was to determine the prevalence of SIBO in Bangladeshi children and its association with malnutrition. Secondary objectives included determination of SIBO's association with sanitation, diarrheal disease, and environmental enteropathy. We performed a cross-sectional analysis of 90 Bangladeshi 2-year-olds monitored since birth from an impoverished neighborhood. SIBO was diagnosed via glucose hydrogen breath testing, with a cutoff of a 12-ppm increase over baseline used for SIBO positivity. Multivariable logistic regression was performed to investigate SIBO predictors. Differences in concomitant inflammation and permeability between SIBO-positive and -negative children were compared with multiple comparison adjustment. A total of 16.7% (15/90) of the children had SIBO. The strongest predictors of SIBO were decreased length-for-age Z score since birth (odds ratio [OR], 0.13; 95% confidence interval [CI], 0.03 to 0.60) and an open sewer outside the home (OR, 4.78; 95% CI, 1.06 to 21.62). Recent or frequent diarrheal disease did not predict SIBO. The markers of intestinal inflammation fecal Reg 1ß (116.8 versus 65.6 µg/ml; P = 0.02) and fecal calprotectin (1,834.6 versus 766.7 µg/g; P = 0.004) were elevated in SIBO-positive children. Measures of intestinal permeability and systemic inflammation did not differ between the groups. These findings suggest linear growth faltering and poor sanitation are associated with SIBO independently of recent or frequent diarrheal disease. SIBO is associated with intestinal inflammation but not increased permeability or systemic inflammation. IMPORTANCE: A total of 165 million children worldwide are considered stunted, which is associated with increased risk of death prior to age 5 years and cognitive disability. Stunting has, in part, been attributed to the presence of environmental enteropathy. Environmental enteropathy is a poorly understood condition leading to chronic intestinal inflammation. It has been postulated that small intestine bacterial overgrowth contributes to the pathogenesis of environmental enteropathy as overgrowth has been associated with intestinal inflammation and micronutrient malabsorption when it develops in other clinical contexts. This study confirms the finding that overgrowth occurs at high rates in the developing world. This is the first study to show that overgrowth is associated with intestinal inflammation and linear growth delay in this setting and is the first to examine why children with no known gastrointestinal dysfunction develop overgrowth from the developing world environment.