Opportunities and challenges in delivering maternal and child nutrition services through public primary health care facilities in urban Bangladesh: a qualitative inquiry.

BACKGROUND: Public primary health facilities are an important source of nutrition services for the urban areas in Bangladesh. We aimed to understand the challenges and facilitators of delivering maternal and child nutrition services through public sector from the perspectives of the users and service providers. METHOD: The study was conducted in selected public primary health care facilities and their catchment area in Dhaka city from April-July 2019. We carried out 15 free listing exercises and 43 semi-structured interviews (SSI) with pregnant women and mothers of 0-24 months old children; 6 key informant interviews (KII) with facility managers and healthcare providers; and observed service delivery in 8 health facilities. RESULTS: Findings reveal that public primary health facilities address some economic and cultural barriers to access such as cost and provision of female service providers for maternal and child health services but challenges such as distance, waiting time, and cleanliness remained. In terms of service provision, there were gaps in provision of anthropometric measurement and counseling, and healthcare providers had inadequate training and therefore, knowledge of nutrition. The low priority given to nutrition services during program design hampered the delivery of nutrition services provided through urban public sector health facilities. CONCLUSIONS: There were important gaps in terms of service provision and capacity of healthcare providers, and therefore, the quality of nutrition service provided through public primary health care facilities. To maximize the coverage of quality nutrition services in the urban areas, it is important to think through the design of nutrition service delivery and allocate adequate resources to fill the material and capacity gaps.

Qualitative exploration of the impact of COVID-19 on the food environment of urban informal settlements of Dhaka, Bangladesh.

OBJECTIVE: Our study explored the impact of the COVID-19 pandemic on the food environment from the perspective of the urban poor and food vendors. DESIGN: This was a qualitative study conducted during September 2020 and February 2021. SETTING: The study was carried out in two purposively selected informal settlements of Dhaka City, Bangladesh. PARTICIPANTS: We conducted 21 in-depth interviews with residents of informal settlements and 10 key informant interviews with food vendors and food aid workers. RESULT: The availability of staple foods was not disrupted during the pandemic but some perishables foods became more expensive due to supply chain disruptions and increased transportation costs. Limited market hours affected market access and mobility restrictions adversely affected local vendors. Cart vendors selling perishables incurred business losses they could ill afford. Demand for food reduced as employment disruption lead to reduced purchasing power and, therefore, reduction of quantity, quality and desirability of foods purchased. Respondents reported skipping meals and going hungry. The aid received was considered inadequate to meet needs. CONCLUSION: The food environment of the urban poor was disrupted from both supply and demand sides and the organisational response (both government and non-government) was severely inadequate. The social safety net needs to be extended and redesigned to ensure food security and health for the urban working poor in the future.

Knowledge, attitude, and practice of Bangladeshi urban slum dwellers towards COVID-19 transmission-prevention: A cross-sectional study.

The first COVID-19 case in Bangladesh was detected on March 8, 2020. Since then, efforts are being made across the country to raise awareness among the population for preventing the spread of this virus. We aimed to examine the urban slum dwellers' knowledge, attitude, and practice (KAP) towards COVID-19 transmission-prevention. A phone-based cross-sectional survey was conducted in five slums of Dhaka City. Total 476 adult slum dwellers were interviewed between October 31 to December 1, 2020 using a pre-tested questionnaire. During an interview, information was collected on participants' demographic characteristics and KAP items towards COVID-19. We used quartiles for categorization of knowledge and practice score where the first quartile represents poor, the second and third quartiles represent average while the fourth quartile represents good. Attitude score was standardized using z-score and identified as positive and negative attitude. Multiple linear regression models were used separately to identify the socioeconomic predictors of the KAP scores. The results showed that 25% of the respondents had good knowledge and 25% had poor knowledge, 48% had a positive attitude and 52% had a negative attitude, and 21% maintained good practice and 33% maintained poor practice towards COVID-19 transmission-prevention. About 75% respondents relied on television for COVID-19 related information. Regression results showed that knowledge and attitude scores were significantly higher if respondents had primary or secondary and above level of education compared to the uneducated group. Female respondents maintained significantly good practice compared to their male counterparts (ß = 6.841; p<0.01). This study has found that one third of the studied slum dwellers maintained poor practice and one fourth had poor knowledge towards COVID-19 transmission-prevention. As KAP domains are significantly correlated, efforts are needed to raise awareness of COVID-19 particularly targeting individuals with average and lower knowledge to improve attitude and practice for the prevention of COVID-19.

Promoting healthy foods among urban school children in Bangladesh: a qualitative inquiry of the challenges and opportunities.

BACKGROUND: In Bangladesh overweight and obesity among urban school children are on the rise. Urban school children tend to consume foods dense in calories and few fruits and vegetables which is associated with overweight and obesity. The current study explored the barriers and opportunities for promoting healthy diets among school children from the perspective of teachers and parents in Dhaka, Bangladesh. METHODS: We conducted 14 key informant interviews with teachers and principals, six focus group discussions with 31 mothers of school children (5 to 15 year old) and 14 structured observations of the school food environment. Inductive thematic analysis was performed manually. RESULTS: Schools were important for development of food preferences of children, however, most school cafeterias provided foods based on profit rather than health considerations. A shift in food culture resulted in making eating out acquire many meanings beyond convenience. Mothers, especially those who were employed, struggled to prepare healthy foods due to time pressure. Mothers were generally concerned about chemicals added to raw foods in markets which led to limited fruit and vegetable consumption. CONCLUSIONS: There were many challenges to promoting healthy foods to school children within and outside the school. It is important to formulate policies and guidance to create a supportive environment for healthy foods in and in the proximity of schools. It is also important to educate consumers about identifying and choosing healthy foods. Laws related to food safety should be adequately implemented to boost the population's confidence in safety of available healthy foods in the food system.

Do community scorecards improve utilisation of health services in community clinics: experience from a rural area of Bangladesh.

BACKGROUND: The government of Bangladesh initiated community clinics (CC) to extend the reach of public health services and these facilities were planned to be run through community participation. However, utilisation of CC services is still very low. Evidence indicates community score card is an effective tool to increase utilisation of services from health facility through regular interface meeting between service providers and beneficiary. We investigated whether community scorecards (CSC) improve utilisation of health services provided by CCs in rural area of Bangladesh. METHODS: This study was conducted from December 2017 to November 2018. Three intervention and three control CCs were selected from Chakaria, a rural sub-district of Bangladesh. CSC was introduced with the Community Groups and Community Support Groups in intervention CCs between January to October 2018. Data were collected through observation of CCs during operational hours, key informant interviews, focus group discussions, and from DHIS2. Utilisation of CC services was compared between intervention and control areas, pre and post CSC intervention. RESULTS: Post CSC intervention, community awareness about CC services, utilisation of clinic operational hours, and accountability of healthcare providers have increased in the intervention CCs. Utilisation of primary healthcare services including family planning services, antenatal care, postnatal care and basic health services have significantly improved in intervention CCs. CONCLUSION: CSC is an effective tool to increase the service utilization provided by CCs by ensuring community awareness and participation, and service providers' accountability. Policy makers and concerned authorities may take necessary steps to integrate community scorecard in the health system by incorporating it in CCs.

Feasibility, acceptability and initial outcome of implementing community scorecard to monitor community level public health facilities: experience from rural Bangladesh.

BACKGROUND: Engaging communities in health facility management and monitoring is an effective strategy to increase health system responsiveness. Many developing countries have used community scorecard (CSC) to encourage community participation in health. However, the use of CSC in health in Bangladesh has been limited. In 2017, icddr,b initiated a CSC process to improve health service delivery at the community clinics (CC) providing primary healthcare in rural Bangladesh. The current study presents learnings around feasibility, acceptability, initial outcome and challenges of implementing CSC at community clinics. METHODS: A pilot study conducted between January'2018-December'2018 explored feasibility and acceptability of CSC using a thematic framework. The tool was implemented in purposively selected three CCs in Chakaria and one CC in Teknaf sub-district of Bangladesh. Qualitative data from 20 Key-Informant Interviews and four Focus Group Discussions with service users, healthcare providers, and government personnel, document reviews and meeting observations were used in analysis. RESULTS: The study showed that participants were enthusiastic and willing to take part in the CSC intervention. They perceived CSC to be useful in raising awareness about health in the community and facilitating structured monitoring of CC services. The process facilitated building stronger community ownership, enhancing accountability and stakeholder engagement. The participants identified issues around service provision, set SMART (specific, measurable, attainable, relevant and time-bound) targets and indicators on supplies, operations, logistics, environment, and patient satisfaction through CSC. However, some systematic and operational challenges of implementation were identified including time and resource constraint, understanding and facilitation of CSC, provider-user conflict, political influence, and lack of central level monitoring. CONCLUSION: The findings suggest that CSC is a feasible and acceptable tool to engage community and healthcare providers in monitoring and managing health facilities. For countries with health systems faced with challenges around accountability, quality and coverage, CSC has the potential to improve community level health-service delivery. The findings are intended to inform program implementers, donors and other stakeholders about context, mechanisms, outcomes and challenges of CSC implementation in Bangladesh and other developing countries. However, proper contextualization, institutional capacity building and policy integration will be critical in establishing effectiveness of CSC at scale.

Work and breast milk feeding: a qualitative exploration of the experience of lactating mothers working in ready made garments factories in urban Bangladesh.

BACKGROUND: In Bangladesh 65% of children under 6 months of age were exclusively breastfed with maternal employment being a risk factor that has jeopardized exclusive breastfeeding. As Ready Made Garment (RMG) factories have been the largest employer of low income women in Bangladesh, the objective of our study was to explore the barriers and facilitators of breastfeeding and perceptions about use of expressed breast milk among mothers who worked in the RMG sector. METHODS: This formative research was conducted during July-September 2015 in two slums of Dhaka among RMG workers who were mothers and the caregivers of 0-12 month old infants. Qualitative data was obtained from purposively selected participants of 8 in-depth interviews and 4 focus group discussions (mothers and caregivers), and 2 key informant (RMG factory official) interviews. Mothers were from multiple RMG factories while factory officials were from a single factory. Thematic analysis was conducted. RESULTS: The main themes of qualitative exploration were knowledge and experience of breastfeeding; structural barriers (home and workplace); consequences of inadequate breastfeeding; and perception and experience of using expressed breast milk. Despite knowledge both of the benefits of breast milk and of the importance of breastfeeding for 6 months, most mothers introduced formula as early as 2 months to prepare for their return to work. Barriers such as excessive workload, inadequate crèche facilities at work, and lack of adequate caregivers at home impeded exclusive breastfeeding. Mothers and caregivers had very little knowledge about the use of expressed breast milk and were concerned about contamination. CONCLUSION: As RMG factories are the largest employer of low-income women in Bangladesh, facilitating RMG factory working mothers' ability to use breast milk could help to promote infant health and help women remain in the workforce.

Challenges of promoting physical activity among school children in urban Bangladesh: A qualitative inquiry.

INTRODUCTION: Physical activity (PA) confers a multitude of health benefits. Unfortunately, Bangladeshi school children get little PA. The current study assessed the barriers to promoting PA from the perspectives of school authorities and parents in urban Bangladesh. MATERIALS AND METHODS: This study was conducted between January-June 2018 in Dhaka city. Fourteen schools were sampled to represent different school types. We used qualitative methods: 14 key Informant interviews (teachers), six focus group discussions (parents), and 14 observations of school environments. Thematic analysis was performed. RESULTS: PA was not prioritized at most schools for two primary reasons: 1) there was a general lack of understanding of the importance of PA; and 2) physical education classes did not contribute to grades. Little time and resources were allotted for physical education classes because little priority was given to PA by school authorities. Outside school, lack of adequate safe open spaces undermined access to PA. Further, there were social barriers to PA including lack of parental support due to concerns about tiredness and injury and the perception that PA was detrimental to academic achievement. Many parents chose screen-based activities for children over PA. CONCLUSION: Despite policies that mandate PA, PA lost out to school and parental priorities for academic achievement. Parental concerns about tiredness, injury and safe spaces impeded children's access to PA outside of school. Steps should be taken to enforce existing policies that mandate effective PA for school children, and parents and teachers should be educated about the need for and benefits of PA.