A quantitative assessment of natural and anthropogenic effects on the occurrence of high air pollution loading in Dhaka and neighboring cities and health consequences.

Although existing studies mainly focused on the air quality status in Bangladesh, quantifying the natural and manmade effects, the frequency of high pollution levels, and the associated health risks remained beyond detailed investigation. Air quality and meteorological data from the Department of Environment for 2012-2019 were analyzed, attempting to answer those questions. Cluster analysis of PM2.5, PM10, and gaseous pollutants implied that Dhaka and neighboring cities, Narayangonj and Gazipur, are from similar sources compared to the other major cities in the country. Apart from the transboundary sources, land use types and climate parameters unevenly affected local pollution loadings across city domains. The particulate concentrations persistently remained above the national standard for almost half the year, with the peaks during the dry months. Even though nitrogen oxides remained high in all three cities, other gaseous pollutants, such as CO and O3, except SO2, showed elevated concentrations solely in Dhaka city. Concentrations of gaseous pollutants in Dhaka vary spatially, but no statistical differences could be discerned between the working days and holidays. Frequency analysis results and hazard quotients revealed the likelihood of adverse health outcomes in Narayangonj ensuing from particulate exposures surpasses the other cities for different age, gender, and occupation groups. Nonetheless, school-aged children and construction workers were most at risk from chronic exposure to gaseous pollutants mostly in Dhaka. One limitation of this study was that the routine air quality monitoring happens just from five sites, making the evidence-based study concerning health outcomes quite challenging.

Dhaka city water logging hazards: area identification and vulnerability assessment through GIS-remote sensing techniques.

Water logging is one of the most detrimental phenomena continuing to burden Dhaka dwellers. This study aims to spatio-temporarily identify the water logging hazard zones within Dhaka Metropolitan area and assess the extent of their water logging susceptibility based on informal settlements, built-up areas, and demographical characteristics. The study utilizes integrated geographic information system (GIS)-remote sensing (RS) methods, using the Normalized Difference Vegetation Water and Moisture Index, distance buffer zone from drainage streams, and built-up distributions to identify waterlogged zones with a temporal extent, incorporating social and infrastructural attributes to evaluate water logging effects. These indicators were integrated into an overlay GIS method to measure the vulnerability level across Dhaka city areas. The findings reveal that south and south-western parts of Dhaka were more susceptible to water logging hazards. Almost 35% of Dhaka belongs to the high/very highly vulnerable zone. Greater number of slum households were found within high to very high water logging vulnerable zones and approximately 70% of them are poorly structured. The built-up areas were observed to be increased toward the northern part of Dhaka and were exposed to severe water logging issues. The overall findings reveal the spatio-temporal distribution of the water logging vulnerabilities across the city as well as its impact on the social indicators. An integrated approach is necessary for future development plans to mitigate the risk of water logging.

The effects of social determinants on children's health outcomes in Bangladesh slums through an intersectionality lens: An application of multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA).

Empirical evidence suggests that the health outcomes of children living in slums are poorer than those living in non-slums and other urban areas. Improving health especially among children under five years old (U5y) living in slums, requires a better understanding of the social determinants of health (SDoH) that drive their health outcomes. Therefore, we aim to investigate how SDoH collectively affects health outcomes of U5y living in Bangladesh slums through an intersectionality lens. We used data from the most recent national Urban Health Survey (UHS) 2013 covering urban populations in Dhaka, Chittagong, Khulna, Rajshahi, Barisal, Sylhet, and Rangpur divisions. We applied multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) to estimate the Discriminatory Accuracy (DA) of the intersectional effects estimates using Variance Partition Coefficient (VPC) and the Area Under the Receiver Operating Characteristic Curve (AUC-ROC). We also assessed the Proportional Change in Variance (PCV) to calculate intersectional effects. We considered three health outcomes: cough, fever, and acute respiratory infections (ARI) in U5y.We found a low DA for cough (VPC = 0.77%, AUC-ROC = 61.90%), fever (VPC = 0.87%, AUC-ROC = 61.89%) and ARI (VPC = 1.32%, AUC-ROC = 66.36%) of intersectional strata suggesting that SDoH considered do not collectively differentiate U5y with a health outcome from those with and without a health outcome. The PCV for cough (85.90%), fever (78.42%) and ARI (69.77%) indicates the existence of moderate intersectional effects. We also found that SDoH factors such as slum location, mother's employment, age of household head, and household's garbage disposal system are associated with U5y health outcomes. The variables used in this analysis have low ability to distinguish between those with and without health outcomes. However, the existence of moderate intersectional effect estimates indicates that U5y in some social groups have worse health outcomes compared to others. Therefore, policymakers need to consider different social groups when designing intervention policies aimed to improve U5y health outcomes in Bangladesh slums.

The economics of healthcare access: a scoping review on the economic impact of healthcare access for vulnerable urban populations in low- and middle-income countries.

BACKGROUND: The growing urban population imposes additional challenges for health systems in low- and middle-income countries (LMICs). We explored the economic burden and inequities in healthcare utilisation across slum, non-slum and levels of wealth among urban residents in LMICs. METHODS: This scoping review presents a narrative synthesis and descriptive analysis of studies conducted in urban areas of LMICs. We categorised studies as conducted only in slums, city-wide studies with measures of wealth and conducted in both slums and non-slums settlements. We estimated the mean costs of accessing healthcare, the incidence of catastrophic health expenditures (CHE) and the progressiveness and equity of health expenditures. The definitions of slums used in the studies were mapped against the 2018 UN-Habitat definition. We developed an evidence map to identify research gaps on the economics of healthcare access in LMICs. RESULTS: We identified 64 studies for inclusion, the majority of which were from South-East Asia (59%) and classified as city-wide (58%). We found severe economic burden across health conditions, wealth quintiles and study types. Compared with city-wide studies, slum studies reported higher direct costs of accessing health care for acute conditions and lower costs for chronic and unspecified health conditions. Healthcare expenditures for chronic conditions were highest amongst the richest wealth quintiles for slum studies and more equally distributed across all wealth quintiles for city-wide studies. The incidence of CHE was similar across all wealth quintiles in slum studies and concentrated among the poorest residents in city-wide studies. None of the definitions of slums used covered all characteristics proposed by UN-Habitat. The evidence map showed that city-wide studies, studies conducted in India and studies on unspecified health conditions dominated the current evidence on the economics of healthcare access. Most of the evidence was classified as poor quality. CONCLUSIONS: Our findings indicated that city-wide and slums residents have different expenditure patterns when accessing healthcare. Financial protection schemes must consider the complexity of healthcare provision in the urban context. Further research is needed to understand the causes of inequities in healthcare expenditure in rapidly expanding and evolving cities in LMICs.

Occupational Health Sufferings of Child Waste Workers in South Asia: A Scoping Review.

BACKGROUND: Child labor remains a health hazard, affecting the mental, physical, and emotional well-being of children. Children engage in waste management through various channels while constantly working to create a healthier and cleaner environment and exposing themselves to numerous health risks. Thus, this scoping review aims to explore the occupational injuries, health hazards, and sufferings of child waste workers in South Asia. METHODS: Following the PRISMA guidelines, a scoping review of available relevant scientific literature was completed to comprehensively analyze the extent of child waste workers' health suffering. Online databases PubMed, SCOPUS, and Google Scholar were searched for predefined criteria. Collected references were screened with Rayyan web tools and Endnote. Based on study inclusion criteria, a thematic synthesis was performed on the findings of 12 articles. RESULTS: This study's findings provided deep insights into the most prevalent occupational health sufferings among child waste workers, as depicted in the available literature. Prevalence of injuries like cuts and wounds was found predominant. These injuries are caused by the collection, transportation, dumping, and recycling of waste. Respiratory, musculoskeletal, and skin diseases are more prevalent among child waste worker children than in control groups of the same socioeconomic backgrounds. A higher chance of genetic or neuro-degenerative disorder and DNA mutation indicates a long-term effect on the children working in the waste management sector. Psychological sufferings were the least explored, although very common among child laborers. MPD (Minor Psychiatric Disorder) was very high among waste workers. Regarding healthcare-seeking behavior, traditional methods are preferable rather than formal health facilities. More research is required in this area due to a lack of evidence on the health problems of child waste workers. CONCLUSIONS: Occupational hazards were myriad among child waste workers. Though many children are involved in waste management, they are typically excluded from mainstream child protection and support systems, making them more exposed to occupational harassment and injury. Policymakers should design specific programs for these vulnerable groups considering the issues below, i.e., provide protective equipment such as facemasks, gloves, footwear, and rag sorting tools to safeguard them from physical damage and illness, ensure access to health care, to school, and provide basic nutrients to them. Furthermore, the authorities should think of alternative income generating programs for these groups of children.

The Role of the Private Sector in the COVID-19 Pandemic: Experiences From Four Health Systems.

As societies urbanize, their populations have become increasingly dependent on the private sector for essential services. The way the private sector responds to health emergencies such as the COVID-19 pandemic can determine the health and economic wellbeing of urban populations, an effect amplified for poorer communities. Here we present a qualitative document analysis of media reports and policy documents in four low resource settings-Bangladesh, Ghana, Nepal, Nigeria-between January and September 2020. The review focuses on two questions: (i) Who are the private sector actors who have engaged in the COVID-19 first wave response and what was their role?; and (ii) How have national and sub-national governments engaged in, and with, the private sector response and what have been the effects of these engagements? Three main roles of the private sector were identified in the review. (1) Providing resources to support the public health response. (2) Mitigating the financial impact of the pandemic on individuals and businesses. (3) Adjustment of services delivered by the private sector, within and beyond the health sector, to respond to pandemic-related business challenges and opportunities. The findings suggest that a combination of public-private partnerships, contracting, and regulation have been used by governments to influence private sector involvement. Government strategies to engage the private sector developed quickly, reflecting the importance of private services to populations. However, implementation of regulatory responses, especially in the health sector, has often been weak reflecting the difficulty governments have in ensuring affordable, quality private services. Lessons for future pandemics and other health emergencies include the need to ensure that essential non-pandemic health services in the government and non-government sector can continue despite elevated risks, surge capacity to minimize shortages of vital public health supplies is available, and plans are in place to ensure private workplaces remain safe and livelihoods protected.

Effects of social determinants on children's health in informal settlements in Bangladesh and Kenya through an intersectionality lens: a study protocol.

INTRODUCTION: Several studies have shown that residents of urban informal settlements/slums are usually excluded and marginalised from formal social systems and structures of power leading to disproportionally worse health outcomes compared to other urban dwellers. To promote health equity for slum dwellers, requires an understanding of how their lived realities shape inequities especially for young children 0-4 years old (ie, under-fives) who tend to have a higher mortality compared with non-slum children. In these proposed studies, we aim to examine how key Social Determinants of Health (SDoH) factors at child and household levels combine to affect under-five health conditions, who live in slums in Bangladesh and Kenya through an intersectionality lens. METHODS AND ANALYSIS: The protocol describes how we will analyse data from the Nairobi Cross-sectional Slum Survey (NCSS 2012) for Kenya and the Urban Health Survey (UHS 2013) for Bangladesh to explore how SDoH influence under-five health outcomes in slums within an intersectionality framework. The NCSS 2012 and UHS 2013 samples will consist of 2199 and 3173 under-fives, respectively. We will apply Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy approach. Some of SDoH characteristics to be considered will include those of children, head of household, mothers and social structure characteristics of household. The primary outcomes will be whether a child had diarrhoea, cough, fever and acute respiratory infection (ARI) 2 weeks preceding surveys. ETHICS AND DISSEMINATION: The results will be disseminated in international peer-reviewed journals and presented in events organised by the Accountability and Responsiveness in Informal Settlements for Equity consortium and international conferences. Ethical approval was not required for these studies. Access to the NCSS 2012 has been given by Africa Population and Health Center and UHS 2013 is freely available.

An overview of progress towards implementation of solid waste management policies in Dhaka, Bangladesh.

OBJECTIVES: Considering the increased solid waste generation and its management, this paper aims at reviewing and identifying the gaps and challenges in implementing the existing solid waste management relevant policies, strategies and action plans in Bangladesh for providing further strategic recommendations to establish a sustainable waste management system. METHODS: This study adopted a multi-method approach by reviewing 24 policy/strategy documents; implementation gap analysis with extensive desk review and data obtained from the qualitative approach and co-production workshop. It allowed this study to capture the multidimensional and comprehensive scenario of waste management in Dhaka city. RESULTS: Bangladesh has undergone reforms in solid waste management since 1983 with the adoption of the Dhaka City Corporation Ordinance and the enactment of the National 3R Strategy in 2010. With few exceptions, the overall waste management system cannot be defined as an effective comprehensive waste reduction, recycling and disposal mechanism based on global standards. Study found that several action plans have been introduced yet not all of those have proper implementation like adhering the waste segregation and recycling practices from households to landfill level. Lack of monitoring and coordination among the existing policy implementing agencies have emerged as significant concerns in Bangladesh. CONCLUSION: Challenges in the implementation of pragmatic and improved policies and strategies should be addressed.

Synthesizing the links between secure housing tenure and health for more equitable cities.

Millions of households in rich and poor countries alike are at risk of being unwilfully displaced from their homes or the land on which they live (i.e., lack secure tenure), and the urban poor are most vulnerable. Improving housing tenure security may be an intervention to improve housing and environmental conditions and reduce urban health inequalities. Building on stakeholder workshops and a narrative review of the literature, we developed a conceptual model that infers the mechanisms through which more secure housing tenure can improve housing, environmental quality, and health. Empirical studies show that more secure urban housing tenure can boost economic mobility, improve housing and environmental conditions including reduced exposure to pollution, create safer and more resourced communities, and improve physical and mental health. These links are shared across tenure renters and owners and different economic settings. Broader support is needed for context-appropriate policies and actions to improve tenure security as a catalyst for cultivating healthier homes and neighbourhoods and reducing urban health inequalities in cities.

Dhaka landfill waste practices: addressing urban pollution and health hazards.

Two Dhaka, Bangladesh, landfills are explored to understand how management practices impact environmental quality and public health in the surrounding areas. A combination of research methods is used, such as geospatial buffer zone analysis, semi-structured observation checklist and qualitative interviews, to gain an understanding of the waste transportation, leachate percolation, and adverse health and environmental effects. A multi-ring buffer zone and ground truth method were applied through ArcMap for the spatial distribution of landfill-adjacent environmental features. Qualitative interviews were conducted with landfill officials and nearby residents. Findings reveal that landfills are situated very close to residential areas, water bodies and agricultural lands, exposing them to various health and environmental hazards. Improper solid waste management practices of the landfills cause adverse environmental effects by leachate percolation, waste incineration and vector breeding. Adjacent dwellers suffer from bronchial diseases, pneumonia, diarrhoea, itching problems, headache and appetite loss. The existing solid waste management system requires managerial and technical modifications to reduce the associated environmental pollution and health hazards.

Economics of healthcare access in low-income and middle-income countries: a protocol for a scoping review of the economic impacts of seeking healthcare on slum-dwellers compared with other city residents.

INTRODUCTION: People living in slums face several challenges to access healthcare. Scarce and low-quality public health facilities are common problems in these communities. Costs and prevalence of catastrophic health expenditures (CHE) have also been reported as high in studies conducted in slums in developing countries and those suffering from chronic conditions and the poorest households seem to be more vulnerable to financial hardship. The COVID-19 pandemic may be aggravating the economic impact on the extremely vulnerable population living in slums due to the long-term consequences of the disease. The objective of this review is to report the economic impact of seeking healthcare on slum-dwellers in terms of costs and CHE. We will compare the economic impact on slum-dwellers with other city residents. METHODS AND ANALYSIS: This scoping review adopts the framework suggested by Arksey and O'Malley. The review is part of the accountability and responsiveness of slum-dwellers (ARISE) research consortium, which aims to enhance accountability to improve the health and well-being of marginalised populations living in slums in India, Bangladesh, Sierra Leone and Kenya. Costs of accessing healthcare will be updated to 2020 prices using the inflation rates reported by the International Monetary Fund. Costs will be presented in International Dollars by using purchase power parity. The prevalence of CHE will also be reported. ETHICS AND DISSEMINATION: Ethical approval is not required for scoping reviews. We will disseminate our results alongside the events organised by the ARISE consortium and international conferences. The final manuscript will be submitted to an open-access international journal. Registration number at the Research Registry: reviewregistry947.

Loops and Building Blocks: a Knowledge co-Production Framework for Equitable Urban Health.

This paper sets out a structured process for the co-production of knowledge between researchers and societal partners and illustrates its application in an urban health equity project in Accra, Ghana. The main insight of this approach is that research and knowledge co-production is always partial, both in the sense of being incomplete, as well as being circumscribed by the interests of participating researchers and societal partners. A second insight is that project-bound societal engagement takes place in a broader context of public and policy debate. The approach to co-production described here is formed of three recursive processes: co-designing, co-analysing, and co-creating knowledge. These 'co-production loops' are themselves iterative, each representing a stage of knowledge production. Each loop is operationalized through a series of research and engagement practices, which we call building blocks. Building blocks are activities and interaction-based methods aimed at bringing together a range of participants involved in joint knowledge production. In practice, recursive iterations within loops may be limited due of constraints on time, resources, or attention. We suggest that co-production loops and building blocks are deployed flexibly.

Challenges and strategies in conducting sexual and reproductive health research among Rohingya refugees in Cox's Bazar, Bangladesh.

BACKGROUND: Rohingya diaspora or Forcibly Displaced Myanmar Nationals (FDMNs), took shelter in the refugee camps of Cox's Bazar, Bangladesh due to armed conflict in the Rakhine state of Myanmar. In such humanitarian crises, delivering sexual and reproductive health (SRH) services is critical for better health outcomes of this most-at-risk population where more than half are adolescent girls and women. This is a reflective paper on challenges and related mitigation strategies to conduct SRH research among FDMNs. The research on which this paper is based employed a concurrent mixed-method design combining a cross-sectional survey and qualitative interviews and group discussions with FDMNs to understand their SRH needs and demand-side barriers. Assessment of health facilities and qualitative interviews with healthcare providers and key stakeholders were carried out to assess facility readiness and supply-side barriers. CHALLENGES AND STRATEGIES: The researchers faced different challenges while conducting this study due to the unique characteristics of the FDMN population and the location of the refugee camps. The three key challenges researchers encountered include: sensitivity regarding SRH in the FDMNs, identifying appropriate sampling strategies, and community trust issues. The key approaches to overcome these challenges involved: actively engaging community members and gatekeepers in the data collection process to access respondents, identifying sensitive SRH issues through survey and exploring in-depth during qualitative interviews; and contextually modifying the sampling strategy. CONCLUSION: Contextual adaptation of research methods and involving community and local key stakeholders in data collection are the key lessons learnt from this study. Another important lesson was researchers' identity and positionality as a member of the host country may create distrust and suspicion among the refugees. The multi-level complexities of humanitarian settings may introduce unforeseen challenges and interrupt research plans at different stages of research which require timely and contextual adaptations.

Developing core economic parameter sets for asthma studies: a realist review and an analytical framework.

OBJECTIVE: To develop a standardised set of economic parameters (core economic parameter set) for economic evaluations in asthma studies. DESIGN: A systematic literature review and an analytical framework. OUTCOME MEASURES: Economic parameters used to evaluate costs and cost-effectiveness of healthcare interventions for people with asthma. DATA SOURCES: PubMed, the Cochrane Database of Systematic Reviews, the National Health Service Economic Evaluation Database, the Database of Abstracts of Reviews of Effects and the Health Technology Aaaessment Library starting from 1990. REVIEW METHODS: Research methods were based on the realist review methodology and included a number of non-sequential, iterative and overlapping components, such as developing an analytical framework for the realist review; systematic literature review of economic parameters; identifying and categorising economic parameters; producing preliminary list of core economic parameters. RESULTS: Database searches found 2531 publications of which 224 were included in the systematic review. We identified 65 economic parameters that were categorised into 11 groups to enable the realist synthesis. Parameters related to secondary care, primary care, medication use, emergency care and work productivity comprised 84% of all economic parameters. An analytical framework was used to investigate the rationale behind the choices of economic parameters in these studies. The main framework domains included type of intervention, research population, study design, study setting and a stakeholder's perspective. CONCLUSION: Past research thus suggests that in asthma study parameters depicting the use of secondary care, primary care, medication, emergency care and work productivity can be considered as core economic parameters, since they apply to different types of studies. Parameters including diagnostics, healthcare delivery, school activity, informal care, medical devices and health utility apply to a particular type of study (or research question), and thus can be recommended as supplemental parameters. PROSPERO REGISTRATION NUMBER: CRD42017067867.

Economic evaluation of culprit lesion only PCI vs. immediate multivessel PCI in acute myocardial infarction complicated by cardiogenic shock: the CULPRIT-SHOCK trial.

BACKGROUND: The CULPRIT-SHOCK trial compared two treatment strategies for patients with acute myocardial infarction and multivessel coronary artery disease complicated by cardiogenic shock: (a) culprit vessel only percutaneous coronary intervention (CO-PCI), with additional staged revascularisation if indicated, and (b) immediate multivessel PCI (MV-PCI). METHODS: A German societal and national health service perspective was considered for three different analyses. The cost utility analysis (CUA) estimated costs and quality adjusted life years (QALYs) based on a pre-trial decision analytic model taking a lifelong time horizon. In addition, a within trial CUA estimated QALYs and costs for 1 year. Finally, the cost effectiveness analysis (CEA) used the composite primary outcome, mortality and renal failure at 30-day follow-up, and the within trial costs. Econometric and survival analysis on the trial data was used for the estimation of the model parameters. Subgroup analysis was performed following an economic protocol. RESULTS: The lifelong CUA showed an incremental cost effectiveness ratio (ICER), CO-PCI vs. MV-PCI, of €7010 per QALY and a probability of CO-PCI being the most cost-effective strategy > 64% at a €30,000 threshold. The ICER for the within trial CUA was €14,600 and the incremental cost per case of death/renal failure avoided at 30-day follow-up was €9010. Cost-effectiveness improved with patient age and for those without diabetes. CONCLUSIONS: The estimates of cost-effectiveness for CO-PCI vs. MV-PCI have been shown to change depending on the time horizon and type of economic evaluation performed. The results favoured a long-term horizon analysis for avoiding underestimation of QALY gains from the CO-PCI arm.

Estimated societal costs of stroke in the UK based on a discrete event simulation.

BACKGROUND: there are around 100,000 new stroke cases and over a million people living with its consequences annually in the UK. This has large impacts on health and social care, unpaid carers and lost productivity. We aimed to estimate associated costs. METHODS: we estimated 2014/2015 annual mean cost per person and aggregate UK cost of stroke for individuals aged ≥40 from a societal perspective. Health and social care costs in the first and subsequent years after stroke were estimated from discrete event simulation modelling, with probability of progression and length of receipt of different health and social care services obtained from routine registry and audit data. Unpaid care hours and lost productivity were obtained from trial data. UK unit costs were applied to estimate mean costs. Epidemiological estimates of stroke incidence and prevalence were then applied to estimate aggregate costs for the UK. RESULTS: mean cost of new-onset stroke is £45,409 (95% CI 42,054-48,763) in the first year after stroke and £24,778 (20,234-29,322) in subsequent years. Aggregate societal cost of stroke is £26 billion per year, including £8.6 billion for NHS and social care. The largest component of total cost was unpaid care (61%) and, given high survival, £20.6 billion related to ongoing care. CONCLUSION: the estimated aggregate cost of stroke substantially exceeds previous UK estimates. Since most of the cost is attributed to unpaid care, interventions aimed at rehabilitation and reducing new and recurrent stroke are likely to yield substantial benefits to carers and cost savings to society.

Situation analysis for delivering integrated comprehensive sexual and reproductive health services in humanitarian crisis condition for Rohingya refugees in Cox's Bazar, Bangladesh: protocol for a mixed-method study.

INTRODUCTION: Rohingya diaspora are one of the most vulnerable groups seeking refuge in camps of Cox's Bazar, Bangladesh, arising an acute humanitarian crisis. More than half of the Rohingya refugees are women and adolescent girls requiring quality sexual and reproductive health (SRH) services. Minimum initial service package of SRH are being rendered in the refugee camps; however, WHO is aiming to provide integrated comprehensive SRH services to meet the unmet needs of this most vulnerable group. For sustainable and successful implementation of such comprehensive SRH service packages, a critical first step is to undertake a situation analysis and understand the current dimensions and capture the lessons learnt on their SRH-specific needs and implementation challenges. This situation analysis is pertinent in current humanitarian condition and will provide an overview of the needs, availability and delivery of SRH services for adolescent girls and women, barriers in accessing and providing those services in Rohingya refugee camps in Cox's Bazar, Bangladesh, and similar humanitarian contexts. METHODS AND ANALYSIS: A concurrent mixed-methods design will be used in this study. A community-based household survey coupled with facility assessments as well as qualitative in-depth interviews, key informant interviews and focus group discussions will be conducted with community people of Rohingya refugee camps and relevant stakeholders providing SRH services to Rohingya population in Cox's Bazar, Bangladesh. Survey data will be analysed using univariate, bivariate and multivariable regression statistics. Descriptive analysis will be done for facility assessment and thematic analysis will be conducted with qualitative data. ETHICS AND DISSEMINATION: Ethical approval from Institutional Review Board of BRAC James P Grant School of Public Health (2018-017-IR) has been obtained. Findings from this research will be disseminated through presentations in local, national and international conferences, workshops, peer-reviewed publications, policy briefs and interactive project report.

Children's toothache is becoming everybody's business: where do parents go when their children have oral pain in London, England? A cross-sectional analysis.

OBJECTIVES: To assess the number of parents who visited community pharmacies in London seeking pain medications for their children's pain and specifically for oral pain, to identify which health services parents contacted before their pharmacy visit and to estimate the cost to the National Health Service (NHS) when children with oral pain who visit pharmacies also see health professionals outside dentistry. DESIGN: A cross-sectional study. SETTING: 1862 pharmacies in London in November 2016-January 2017. PARTICIPANTS: Parents, carers and adolescents purchasing over-the-counter pain medications or collecting pain prescriptions for children (0-19 years). BRIEF INTERVENTION: A survey administered by pharmacy staff to participants and a guidance pack. MAIN OUTCOME MEASURES: The number of parents who visited pharmacies seeking pain medications for their children's pain and oral pain and the number of parents who contacted health professionals outside dentistry before their pharmacy visit. Estimated costs of visits by children with oral pain to health professionals outside dentistry. RESULTS: One in two (951) pharmacies participated collecting information from 6915 parents seeking pain medications for their children. The majority (65%) of parents sought pain medications to relieve their children's oral pain. Only 30% of children with oral pain had seen a dentist before the pharmacy visit, while 28% of children had seen between one and four different health professionals. The cost to the NHS of children contacting health professionals outside dentistry was £36 573, extrapolated to an annual cost of £373 288. Replicating these findings across all pharmacies in England could mean that the NHS spends an estimated £2.3 million annually when children with oral pain inappropriately use multiple health services. CONCLUSION: Most parents who visited pharmacies for children's pain medications in London sought pain medications for children's oral pain. Children's inappropriate contact with multiple health services when they have oral pain adds significant costs to the NHS.

Protocol for an economic evaluation of the randomised controlled trial of culprit lesion only PCI versus immediate multivessel PCI in acute myocardial infarction complicated by cardiogenic shock: CULPRIT-SHOCK trial.

INTRODUCTION: Emergency percutaneous coronary intervention (PCI) of the culprit lesion for patients with acute myocardial infarctions is an accepted practice. A majority of patients present with multivessel disease with additional relevant stenoses apart from the culprit lesion. In haemodynamically stable patients, there is increasing evidence from randomised trials to support the practice of immediate complete revascularisation. However, in the presence of cardiogenic shock, the optimal management strategy for additional non-culprit lesions is unknown. A multicentre randomised controlled trial, CULPRIT-SHOCK, is examining whether culprit vessel only PCI with potentially subsequent staged revascularisation is more effective than immediate multivessel PCI. This paper describes the intended economic evaluation of the trial. METHODS AND ANALYSIS: The economic evaluation will be conducted using a pre-trial decision model and within-trial analysis. The modelling-based analysis will provide expected costs and health outcomes, and incremental cost-effectiveness ratio over the lifetime for the cohort of patients included in the trial. The within-trial analysis will provide estimates of cost per life saved at 30 days and in 1 year, and estimates of health-related quality of life. Bootstrapping and cost-effectiveness acceptability curves will be used to address any uncertainty around these estimates. Different types of regression models within a generalised estimating equation framework will be used to examine how the total cost and quality-adjusted life years are explained by patients' characteristics, revascularisation strategy, country and centre. The cost-effectiveness analysis will be from the perspective of each country's national health services, where costs will be expressed in euros adjusted for purchasing power parity. ETHICS AND DISSEMINATION: Ethical approval for the study was granted by the local Ethics Committee at each recruiting centre. The economic evaluation analyses will be published in peer-reviewed journals of the concerned literature and communicated through the profiles of the authors at www.twitter.com and www.researchgate.net. TRIAL REGISTRATION NUMBER: NCT01927549; Pre-results.