Diurnal variability of fine-particulate pollution concentrations: data from 14 low- and middle-income countries.

BACKGROUND: Scientific understanding of indoor air pollution is predominately based on research carried out in cities in high-income countries (HICs). Less is known about how pollutant concentrations change over the course of a typical day in cities in low- and middle-income countries (LMICs).OBJECTIVE: To understand how concentrations of fine particulate matter smaller than 2.5 microns in diameter (PM2.5) change over the course of the day outdoors (across a range of countries) and indoors (using measurements from Dhaka, Bangladesh).DESIGN: Data on PM2.5 concentrations were gathered from 779 households in Dhaka as part of the MCLASS II (Muslim Communities Learning About Second-hand Smoke in Bangladesh) project, and compared to outdoor PM2.5 concentrations to determine the temporal variation in exposure to air pollution. Hourly PM2.5 data from 23 cities in 14 LMICs, as well as London (UK), Paris (France) and New York (NY, USA), were extracted from publicly available sources for comparison.RESULTS: PM2.5 in homes in Dhaka demonstrated a similar temporal pattern to outdoor measurements, with greater concentrations at night than in the afternoon. This pattern was also evident in 19 of 23 LMIC cities.CONCLUSION: PM2.5 concentrations are greater at night than during the afternoon in homes in Dhaka. Diurnal variations in PM2.5 in LMICs is substantial and greater than in London, Paris or New York. This has implications for public health community approaches to health effects of air pollution in LMICs.

Understanding demand for, and feasibility of, centre-based child-care for poor urban households: a mixed methods study in Dhaka, Bangladesh.

BACKGROUND: Centre-based child-care has potential to provide multiple health and development benefits to children, families and societies. With rapid urbanisation, increasing numbers of low-income women work with reduced support from extended family, leaving a child-care vacuum in many low- and middle-income countries. We aimed to understand perceptions of, and demand for, centre-based child-care in Dhaka, Bangladesh among poor, urban households, and test the feasibility of delivering sustainable centre-based child-care. METHODS: We used sequential mixed methods including a household survey (n = 222) and qualitative interviews with care-givers (n = 16), community leaders (n = 5) and policy-makers (n = 5). We co-produced and piloted a centre-based child-care model over ten-months, documenting implementation. A co-design focus group with mothers, parents' meetings, and qualitative interviews with child-care centre users (n = 5), non-users (n = 3), ex-users (n = 3) and staff (2) were used to refine the model and identify implementation issues. RESULTS: We found 24% (95% CI: 16,37%) of care-givers reported turning-down paid work due to lack of child-care and 84% (95% CI:74, 91%) reported wishing to use centre-based child-care and were willing to pay up to 283 Takka (~$3.30) per month. Adjusted odds of reported need for child-care among slum households were 3.8 times those of non-slum households (95% CI: 1.4, 10). Implementation highlighted that poor households needed free child-care with food provided, presenting feasibility challenges. Meta-inference across quantitative and qualitative findings identified the impact of the urban environment on child-care through long working hours, low social capital and fears for child safety. These influences interacted with religious and social norms resulting in caution in using centre-based child-care despite evident need. CONCLUSION: Sustainable provision of centre-based care that focuses on early childhood development requires subsidy and careful design sensitive to the working lives of poor families, particularly women and must respond to the dynamics of the urban environment and community values. We recommend increased research and policy focus on the evaluation and scale-up of quality centre-based child-care, emphasising early-childhood development, to support low-income working families in urban areas.

"Death is a better option than being treated like this": a prevalence survey and qualitative study of depression among multi-drug resistant tuberculosis in-patients.

BACKGROUND: Understanding of the relationship between multi-drug resistant tuberculosis and mental health is limited. With growing prevalence of multi-drug resistant tuberculosis, addressing mental ill-health has potential to improve treatment outcomes and well-being. In several low and middle-income contexts hospitalisation during treatment is common. Understanding of the impact on mental ill-health are required to inform interventions for patients with multi-drug resistant tuberculosis. Our aim was to identify the prevalence of comorbid depression among in-patients being treated for multi-drug resistant tuberculosis and to explore their experiences of comorbid disease and the care they received in a large specialist chest hospital in Dhaka, Bangladesh. METHODS: We conducted a quantitative cross-sectional survey among 150 multi-drug resistant tuberculosis in-patients (new cases = 34%, previously treated = 66%) in 2018. A psychiatrist assessed depression was assessed with the Structured Clinical Interview for Depression (SCID DSM-IV). We used multi-level modelling to identify associations with depression. Experience Bangladeshi researchers conducted qualitative interviews with 8 patients, 4 carers, 4 health professionals and reflective notes recorded. Qualitative data was analysed thematically. RESULTS: We found 33.8% (95% CI 26.7%; 41.7%) of patients were depressed. While more women were depressed 39.3% (95% CI 27.6%; 52.4%) than men 30.4% (95% CI 22%; 40.5%) this was not significant. After controlling for key variables only having one or more co-morbidity (adjusted odds ratio [AOR] = 2.88 [95% CI 1.13; 7.33]) and being a new rather than previously treated case (AOR = 2.33 [95% CI 1.06; 5.14]) were associated (positively) with depression. Qualitative data highlighted the isolation and despair felt by patients who described a service predominantly focused on providing medicines. Individual, familial, societal and health-care factors influenced resilience, nuanced by gender, socio-economic status and home location. CONCLUSIONS: Patients with multi-drug resistant tuberculosis are at high risk of depression, particularly those with co- and multi-morbidities. Screening for depression and psycho-social support should be integrated within routine TB services and provided throughout treatment.

Community engagement interventions for communicable disease control in low- and lower- middle-income countries: evidence from a review of systematic reviews.

BACKGROUND: Community engagement (CE) interventions include a range of approaches to involve communities in the improvement of their health and wellbeing. Working with communities defined by location or some other shared interest, these interventions may be important in assisting equity and reach of communicable disease control (CDC) in low and lower-middle income countries (LLMIC). We conducted an umbrella review to identify approaches to CE in communicable disease control, effectiveness of these approaches, mechanisms and factors influencing success. METHODS: We included systematic reviews that: i) focussed on CE interventions; ii) involved adult community members; iii) included outcomes relevant to communicable diseases in LLMIC; iv) were written in English. Quantitative results were extracted and synthesised narratively. A qualitative synthesis process enabled identification of mechanisms of effect and influencing factors. We followed guidance from the Joanna Briggs Institute, assessed quality with the DARE tool and reported according to standard systematic review methodology. RESULTS: Thirteen systematic reviews of medium-to-high quality were identified between June and July 2017. Reviews covered the following outcomes: HIV and STIs (6); malaria (2); TB (1); child and maternal health (3) and mixed (1). Approaches included: CE through peer education and community health workers, community empowerment interventions and more general community participation or mobilisation. Techniques included sensitisation with the community and involvement in the identification of resources, intervention development and delivery. Evidence of effectiveness of CE on health outcomes was mixed and quality of primary studies variable. We found: i) significantly reduced neonatal mortality following women's participatory learning and action groups; ii) significant reductions in HIV and other STIs with empowerment and mobilisation interventions with marginalised groups; iii) significant reductions in malaria incidence or prevalence in a small number of primary studies; iv) significant reductions in infant diarrhoea following community health worker interventions. Mechanisms of impact commonly occurred through social and behavioural processes, particularly: changing social norms, increasing social cohesion and social capacity. Factors influencing effectiveness of CE interventions included extent of population coverage, shared leadership and community control over outcomes. CONCLUSION: Community engagement interventions may be effective in supporting CDC in LLMIC. Careful design of CE interventions appropriate to context, disease and community is vital.

Integrating a diabetes and hypertension case management package within primary health care: a mixed methods feasibility study in Bangladesh.

BACKGROUND: Almost three quarters of non-communicable disease (NCD) deaths, and 82% of premature NCD deaths, occur in low- and middle-income countries. Bangladesh has an estimated 7 million hypertensives and 10 million diabetics, and primary care is struggling to respond. Our aim was to develop and support implementation of a diabetes and hypertension case management package, and assess its appropriateness, feasibility and acceptability in two NCD clinics within two primary-care centres in Bangladesh. METHODS: We used a convergent mixed methods design. We first assessed the level of appropriate hypertension and cardiovascular disease patient management, based on a composite outcome indicator using data from patients' treatment cards. Appropriate management was primarily informed by International Diabetes Federation (IDF) and World Health Organisation (WHO) guidelines. We then performed qualitative in-depth interviews with doctors and patients to explain these quantitative findings and to understand the challenges to achieving appropriate patient management in the NCD clinics. RESULTS: Eighty-one newly diagnosed patients were recruited. Over 3 months, 53.1% (95% CI 42.3% to 63.6%) of patients were appropriately managed. We found incomplete diagnosis (especially missing hypertension diagnosis alongside diabetes) and non-provision of follow-up appointments were the main causes of the relatively low level of appropriate management. We conducted interviews with 11 patients and 8 health professionals and found a shortage of human resources, reporting materials, available drugs and diagnostic equipment. This undermined patients' willingness to attend clinics and doctors' willingness to offer follow-ups. Hands-on skill-building training was valuable in increasing doctors' competence for appropriate management, but was seen as a novel training method and faced constraints to implementation. CONCLUSIONS: A clinical guide, skill-based training and recording package can be implemented in routine primary care and can lead to appropriate management of around half of diabetic and hypertensive patients in a low-income country. However, considerable health systems challenges must be addressed before more patients can be managed appropriately.

Multidrug-resistant tuberculosis treatment programmes insufficiently consider comorbid mental disorders.

The successful treatment of multidrug-resistant tuberculosis (MDR-TB) is a global health priority and a key pillar of the World Health Organization's (WHO's) End TB strategy. There has been significant global investment in diagnostic capabilities in recent years. However, we argue that the mental distress of those with MDR-TB and their families continues to be overlooked by TB programmes. Priorities in the End TB Strategy of 'patient-centred care' and 'patient support' are still to be delivered in practice in many low-income settings, and in particular consideration of mental distress. Our experience of undertaking MDR-TB operational research in China, Pakistan, Bangladesh, Nepal and Swaziland has given us detailed insight into the challenges facing patients, their families, health professionals and wider health systems. We are increasingly concerned that psychosocial support, and particularly support focused on mental health, is being insufficiently addressed in national MDR-TB programmes. We suggest that the presence of comorbid mental disorders reduces treatment adherence. We recommend the trialling within TB programmes of brief screening tools for common mental disorders and the incorporation of principles from the WHO Mental Health Gap Action Programme programme into TB programme treatment guidance. Our work in Nepal also suggests that brief psychological counselling delivered by non-specialist counsellors may be feasible.

Improving the quality of care of children in community clinics: an intervention and evaluation in Bangladesh.

SETTING: Community health care providers (CHCPs) in 40 rural community clinics of Comilla district, Bangladesh, were trained using a newly developed case-management job aid based on the World Health Organization Integrated Management of Childhood Illness and a communication guide. OBJECTIVES: To assess 1) the change in knowledge of the CHCPs after training; 2) the absolute quality of care provided by the CHCPs (determined as the proportion of children aged <5 years [under-fives] correctly diagnosed, treated and referred); and 3) the consultation behaviour of the CHCPs. DESIGN: Change in knowledge was assessed by tests pre-and post-training. The quality of care was determined by reassessments at the clinic exit by a medical officer, without a baseline comparison. Consultation behaviour was assessed through direct observation. The study was performed during 2014-2015. RESULTS: The mean standard knowledge score of the CH-CPs increased from 19 to 25 (P < 0.001). Of 1490 under-fives examined, 91% were correctly diagnosed, 86% were correctly treated and 99.5% received a correct referral decision. The CHCPs performed well on most of the measures of good communication, although one third did not explain the diagnosis and treatment to patients. CONCLUSION: The training was effective in changing knowledge. The CHCPs applied the knowledge gained and provided good quality care. Following these results, the Bangladesh Ministry of Health and Family Welfare has scaled up the training nationwide. The lessons learnt should be useful for other countries.

Contexte : Les prestataires des soins de santé communautaires (CHCP) de 40 communautés rurales du district de Comilla, au Bangladesh, ont été formés grâce à une aide au travail de prise en charge des cas, récemment élaborée, basée sur la « prise en charge intégrée des maladies de l'enfant ¼ de l'Organisation Mondiale de la Santé et sur un guide de communication.Objectifs : Evaluer l'amélioration des connaissances des CHCP après la formation ; la qualité absolue des soins prodigués par les CHCP (déterminée comme la proportion d'enfants âgés de <5 ans ayant eu un diagnostic, un traitement et une référence corrects) ; et le comportement des CHCP pendant la consultation.Schéma : L'amélioration des connaissances a été évaluée à l'aide de tests pré- et post-formation. La qualité des soins a été déterminée par des réévaluations lors de la sortie du centre par un officier médical, sans comparaison avec le statut de départ. Le comportement lors des consultations a été évalué par observation directe. L'étude a été réalisée en 2014­2015.Résultats : Le score moyen de connaissance des CHCP a augmenté de 19 à 25 (P < 0.001). Sur 1490 enfants âgés de <5 ans examinés, 91% ont eu un diagnostic correct, 86% un traitement correct et 99,5% ont bénéficié d'une décision de référence correcte. Les CHCP se sont bien comportés en ce qui concerne la plupart des mesures de bonne communication ; cependant, un tiers d'entre eux n'a pas expliqué le diagnostic et le traitement aux patients.Conclusion : La formation a été efficace en termes d'amélioration des connaissances. Les CHCP ont mis en application les connaissances acquises et ont fourni des soins de bonne qualité. Au vu de ces résultats, le Ministère de la Santé et du Bien-être Familial du Bangladesh a étendu la formation à tout le pays. Les leçons apprises devraient être utiles à d'autres pays.

Marco de referencia: Los agentes comunitarios de salud de 40 consultorios rurales del distrito de Comilla, en Bangladesh, recibieron capacitación con una ayuda de trabajo desarrollada recientemente sobre el manejo de los casos basado en el enfoque de 'la atención integrada de las enfermedades prevalentes de la infancia' de la Organización Mundial de la Salud y también una guía en materia de comunicación.Objetivos: Evaluar las modificaciones en los conocimientos de los agentes comunitarios de salud después de la capacitación; la calidad absoluta de la atención que prestaban (medida según la proporción de niños en edad <5 años que recibieron un diagnóstico, tratamiento y remisión correctos); y su comportamiento durante las consultas.Método: Las modificaciones en los conocimientos se analizaron mediante pruebas realizadas antes y después de la capacitación. Un médico de planta evaluó la calidad de la atención a la salida de la consulta, sin un punto de comparación. El comportamiento durante la consulta se evaluó mediante la observación directa. El estudio se llevó a cabo en el 2014 y el 2015.Resultados: La puntuación promedio de los agentes comunitarios de salud en la escala de conocimientos corrientes mejoró de 19 a 25 (P < 0,001). De los 1490 niños en edad <5 años examinados, el diagnóstico fue acertado en el 91%, el tratamiento fue apropiado en el 86% y 99,5% de los niños obtuvieron una remisión correcta. El desempeño de los agentes comunitarios en la mayoría de las medidas de comunicación fue adecuado, aunque un tercio de ellos no explicó el diagnóstico y el tratamiento a los pacientes.Conclusión: La capacitación modificó eficazmente los conocimientos de los agentes comunitarios de salud. Los agentes aplicaron los conocimientos adquiridos y prestaron una atención de buena calidad. Con base en estos resultados, el Ministerio de Salud y Bienestar Familiar de Bangladesh ha ampliado la escala de la capacitación a todo el país. Las enseñanzas extraídas en esta experiencia serán muy útiles en otros países.

Tuberculosis in the workplace: developing partnerships with the garment industries in Bangladesh.

OBJECTIVES: To implement and evaluate a public-private partnership model involving garment factories to reduce the tuberculosis (TB) burden in this workforce. DESIGN: We used operational research to develop and evaluate a mechanism for effective and sustainable TB control in workplaces in three areas of Dhaka, Bangladesh. Strategies, protocols, guides and tools were developed with stakeholders. We assessed the impact of the project using quantitative and qualitative measures: changes in TB outcomes were calculated using standard indicators based on factory and DOTS centre records; changes in TB care-seeking behaviour were assessed using qualitative in-depth interviews with factory managers and medical personnel, and focus group discussions with factory workers, including TB patients. FINDINGS: The project brought positive changes in knowledge, attitudes and practices of managers, workers and health care providers on TB care and control. During 2008-2010, a total of 3372 workers from a workforce of 69,000 were referred for sputum microscopy and 598 were diagnosed with smear-positive TB, 145 of whom received care at their workplace. The overall treatment success rate was 100%. CONCLUSION: It is feasible to engage factories in TB control activities in Bangladesh, and thereby increase case notifications and improve treatment outcomes.