Designing for Impact and Institutionalization: Applying Systems Thinking to Sustainable Postpartum Family Planning Approaches for First-Time Mothers in Bangladesh.

Integrated service delivery approaches have shown promise to increase use of services including postpartum family planning (PPFP) by young, first-time mothers (FTMs) but have proven challenging to scale and institutionalize. Integration adds complexity, requiring careful assessment of effects on a range of key system functions from demand creation and service delivery to oversight and governance. Through an innovative design process, we selected approaches to increase FTMs' PPFP use through existing health systems. We generated programmatic options and then sought to select approaches based on (1) potential impact on FTMs' PPFP uptake and (2) potential to institutionalize in the health system. The latter represented an innovation in addressing management systems' drivers of scalability and sustainability; to accomplish it, we developed a participatory design process to assess the potential of an approach to be institutionalized in a specific context.We adapted a management systems theory, the Viable System Model (VSM), which presents 5 essential organizational functions and the relations required between them to improve the viability (performance and institutionalization) of organizational systems. Drawing from the VSM, we developed a process for reviewing the effects of proposed approaches on provider workload, client flow, infrastructure, revisions to guidelines and job descriptions, coordination and management, and information systems. The VSM provided a structure to identify potential displacement of capacity in the health system and mitigate often neglected organizational challenges that compromise institutionalization. The process informed the elimination of approaches with potential for impact but that had deal-breakers to institutionalization, such as increased workload or shifted job descriptions, in the Bangladeshi context. For the selected approaches, consideration of systems elements fostered discussion of expected risks to institutionalization, highlighting needed mitigation efforts and monitoring during implementation.

Household Transmission of Carbapenemase-producing Enterobacterales in Ontario, Canada.

BACKGROUND: Data on household transmission of carbapenemase-producing Enterobacterales (CPE) remain limited. We studied risk of CPE household co-colonization and transmission in Ontario, Canada. METHODS: We enrolled CPE index cases (identified via population-based surveillance from January 2015 to October 2018) and their household contacts. At months 0, 3, 6, 9, and 12, participants provided rectal and groin swabs. Swabs were cultured for CPE until September 2017, when direct polymerase chain reaction (PCR; with culture of specimens if a carbapenemase gene was detected) replaced culture. CPE risk factor data were collected by interview and combined with isolate whole-genome sequencing to determine likelihood of household transmission. Risk factors for household contact colonization were explored using a multivariable logistic regression model with generalized estimating equations. RESULTS: Ninety-five households with 177 household contacts participated. Sixteen (9%) household contacts in 16 (17%) households were CPE-colonized. Household transmission was confirmed in 3/177 (2%) cases, probable in 2/177 (1%), possible in 9/177 (5%), and unlikely in 2/177 (1%). Household contacts were more likely to be colonized if they were the index case's spouse (odds ratio [OR], 6.17; 95% confidence interval [CI], 1.05-36.35), if their index case remained CPE-colonized at household enrollment (OR, 7.00; 95% CI, 1.92-25.49), or if they had at least 1 set of specimens processed after direct PCR was introduced (OR, 6.46; 95% CI, 1.52-27.40). CONCLUSIONS: Nine percent of household contacts were CPE-colonized; 3% were a result of household transmission. Hospitals may consider admission screening for patients known to have CPE-colonized household contacts.

Emergence of Carbapenemase-Producing Enterobacteriaceae, South-Central Ontario, Canada1.

We analyzed population-based surveillance data from the Toronto Invasive Bacterial Diseases Network to describe carbapenemase-producing Enterobacteriaceae (CPE) infections during 2007-2015 in south-central Ontario, Canada. We reviewed patients' medical records and travel histories, analyzed microbiologic and clinical characteristics of CPE infections, and calculated incidence. Among 291 cases identified, New Delhi metallo-ß-lactamase was the predominant carbapenemase (51%). The proportion of CPE-positive patients with prior admission to a hospital in Canada who had not received healthcare abroad or traveled to high-risk areas was 13% for patients with oxacillinase-48, 24% for patients with New Delhi metallo-ß-lactamase, 55% for patients with Klebsiella pneumoniae carbapenemase, and 67% for patients with Verona integron-encoded metallo-ß-lactamase. Incidence of CPE infection increased, reaching 0.33 cases/100,000 population in 2015. For a substantial proportion of patients, no healthcare abroad or high-risk travel could be established, suggesting CPE acquisition in Canada. Policy and practice changes are needed to mitigate nosocomial CPE transmission in hospitals in Canada.

Socioeconomic inequality in child injury in Bangladesh - implication for developing countries.

BACKGROUND: Child injury is an emerging public health issue in both developed and developing countries. It is the main cause of deaths and disabilities of children after infancy. The aim of this study was to investigate the socioeconomic inequality in injury related morbidity and mortality among 1-4 years children. MATERIALS AND METHODS: Data used for this study derived from Bangladesh Health and Injury Survey. A multistage cluster sampling technique was conducted for this survey. In this study quintiles of socioeconomic status were calculated on the basis of assets and wealth score by using principle component analysis. The numerical measures of inequality in mortality and morbidity were assessed by the concentration index. RESULTS: The poorest-richest quintile ratio of mortality due to injury was 6.0 whereas this ratio was 5.6 and 5.5 for the infectious diseases and non-communicable diseases. The values of mortality concentration indices for child mortality due to infection, non-communicable diseases and injury causes were -0.40, -0.32 and -0.26 respectively. Among the morbidity concentration indices, injury showed significantly greater inequality. All the concentration indices revealed that there were significant inequalities among the groups. The logistic regression analysis indicated that poor children were 2.8 times more likelihood to suffer from injury mortality than rich children, taking into account all the other factors. CONCLUSION: Despite concentration indices used in this study, the analysis reflected the family's socioeconomic position in a Bangladesh context, showing a very strong statistical association with child mortality. Due to the existing socioeconomic situation in Bangladesh, the poor children were more vulnerable to injury occurrence.

Community perception of childhood drowning and its prevention measures in rural Bangladesh: a qualitative study.

OBJECTIVES: To gain an in-depth understanding of people's perception of causes and their concepts of prevention of childhood drowning in rural Bangladesh. DESIGN: A qualitative study and focus group discussion (FGD) was adopted. SETTING: A rural community in Bangladesh. PARTICIPANTS: FGDs were conducted with mothers of children aged under 5 years, adolescent male and female students, fathers and local leaders. One FGD was conducted for each group. Out of 53 participants 25 were women. RESULTS: The respondents considered that children of 5-10 years are at risk of drowning. Ponds, ditches and canals were frequently mentioned locations of drowning. Most of the drownings were reported to occur around noon. For prevention of childhood drowning the participants suggested that the children should be constantly supervised, unwanted ditches should be filled in, ponds should be fenced and drowning prevention awareness in the community be increased by community leaders. They suggested that government should organise campaigns for preventing childhood drowning, promoting swimming instruction activities for children and motivating communities to fence ponds. CONCLUSIONS: People interviewed in general know the causes of childhood drowning and its preventive measures, but they do not put their knowledge into preventative actions as they fail to recognise this as a major child survival issue and they are never reached with definite actions points to change the behaviours.

The magnitude of child injuries in Bangladesh: a major child health problem.

In recent times, many developing countries including Bangladesh not only have to cope with infectious diseases and malnutrition but also with new health problems, such as asthma, cancer and accidents. The emergence of chronic diseases and injuries has not been seen as an important health issue to date. The work presented here has the objectives of conceptualizing the dynamic changes in child mortality within the framework of the health transition, to provide a basis for projection of future mortality and disability in children in Bangladesh. This paper reviews a number of reports and published articles related to the causes of child deaths in Bangladesh. These include: 1) Year books of Bangladesh Bureau of Statistics; 2) UNICEF reports; 3) Reports of International Centre for Diarrhoeal Disease and Research, Bangladesh; and 4) Reports of Institute of Child and Mother Health. Bangladesh clearly has been progressing along its epidemiological transition. At the current stage, chronic diseases and injuries have overtaken infectious diseases as leading causes of child death. Injury has been identified as a major cause of child death in Bangladesh, and is emerging as the leading cause of child mortality, similar to what is occurring in other developing countries. For these countries, in the advancing stages of their health transition, more research aimed at understanding the dynamic change of child health priorities is urgently needed for appropriate policy and planning.