Effectiveness of a hand hygiene training intervention in improving knowledge and compliance rate among healthcare workers in a respiratory disease hospital.

Background: Practicing hand hygiene (HH) is a crucial element of infection control, with healthcare workers (HCWs) playing a vital role in preventing the spread of infection. However, inadequate knowledge and non-compliance to HH protocols pose significant challenges in healthcare settings. This study aimed to evaluate the effectiveness of an HH training intervention in enhancing knowledge and staff compliance within a respiratory disease hospital. Method: A pre-and post-training study was conducted among the healthcare workers in a respiratory disease treatment facility. The intervention comprised a series of 3-hour training sessions conducted over five days, focusing on the World Health Organization's (WHO) recommended guideline "Your Five Moments For Hand Hygiene." These sessions covered proper HH techniques and underscored the repercussions of inadequate compliance. Educational materials related to HH were displayed in prominent locations throughout the facility. The knowledge levels and compliance rate were assessed before and after the intervention. Result: The intervention significantly improved HH knowledge levels and compliance rates among the participants. Marking a significant improvement, the compliance rate of HH protocols increased from 66.0% to 88.3% during the pre-to post-training period, with a concurrent increase in the mean knowledge score from 68.6% to 78.9%. Conclusion: This study underscores the potential of training and education in elevating HH compliance and knowledge among healthcare workers. The findings advocate that healthcare facilities routinely incorporate such interventions into their infection control programs, ultimately improving patient and healthcare worker safety.

Smoking and pre-existing co-morbidities as risk factors for developing severity of COVID-19 infection: Evidence from a field hospital in a rural area of Bangladesh.

Since August 2020; the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) in collaboration with UNICEF has been operating a COVID-19 field hospital at the Teknaf sub-district of Cox's Bazar in Bangladesh. This paper is focused on estimating the effects of a history of tobacco smoking and pre-existing co-morbidities on the severity of COVID-19 infection among adult patients admitted into the aforesaid hospital. We conducted a retrospective data analysis of COVID-19 adult patients hospitalized from August 27, 2020 to April 20, 2022. Based on inclusion criteria; a total of 788 admitted patients were included in the analysis. We conducted a Chi-squared test and Fisher's exact test for the categorical variables to see their associations. Multinomial logistic regression models were performed to explore the risk factors for the severity of COVID-19 infection. Among 788 patients, 18.4%, 18.8%, 13%, 7.1%, 3.4%, and 1.9% have had a history of smoking, hypertension, diabetes, chronic obstructive pulmonary disease (COPD), cardiovascular diseases (CVD), and asthma respectively. Overall, the mean age of the patients was 40.3 ± 16.4 years and 51% were female. In multivariate analysis, history of smoking and co-morbidities were identified as the risk factors for the severity of COVID-19 infection; the history of smoking was found linked with an increase in the risk of developing critical, severe, and moderate level of COVID-19 infection- notably 3.17 times (RRR = 3.17; 95% CI: 1.3-7.68), 2.98 times (RRR = 2.98; 95% CI: 1.87-4.76) and 1.96 times (RRR = 1.96; 95% CI: 1.25-3.08) respectively more than the patients who never smoked. It was evident that patients with at least one of the selected co-morbidities such as hypertension, diabetes, COPD, CVD, and asthma exhibited a significantly higher likelihood of experiencing severe illness of COVID-19 compared to patients without any co-morbidity. History of tobacco smoking and pre-existing co-morbidities were significantly associated with an increased severity of COVID-19 infection.

Plant Growth Regulators with a Balanced Supply of Nutrients Enhance the Phytoextraction Efficiency of Parthenium hysterophorus for Cadmium in Contaminated Soil.

Heavy metal contamination in soil, such as cadmium (Cd), poses a serious threat to global food security and human health. It must be managed using environmentally friendly and cost-effective technologies. Plants with high resistance to Cd stress and high biomass production could be potential candidates for the phytoremediation of Cd-contaminated soils to improve Cd phytoextraction. In this regard, the present study was carried out to determine the effect of gibberellic acid (GA3), indole acetic acid (IAA), and fertilizers (N, P, and K) on Parthenium hysterophorus growth and biomass production as well as Cd phytoextraction capabilities. A pot experiment was conducted with various combinations of PGRs and fertilizers, with treatments arranged in five replicates using a completely randomized design. After harvesting, each plant was divided into various parts such as stems, roots, and leaves, and different growth, physiological, and biochemical parameters were recorded. Results showed that under Cd stress, growth, physiological, and biochemical parameters were all significantly decreased. With the combined application of plant growth regulators (GA3 and IAA) and nutrients, Cd stress was alleviated and all parameters significantly improved. In comparison to the control treatment, the combined application of N + P + K + GA3 + IAA resulted in the highest fresh and dry biomass production of the root (12.31 and 5.11 g pot-1), shoot (19. 69 and 6.99 g pot-1), leaves (16.56 and 7.09 g pot-1), and entire plant (48.56 and 19.19 g pot-1). Similarly, the same treatment resulted in higher chlorophyll a and b and total chlorophyll contents under Cd stress, which were 2.19, 2.03, and 3.21 times higher than the control, which was Cd stress without any treatment. The combination of N + P + K + GA3 + IAA also resulted in the highest proline and phenolic contents. In the case of different enzyme activities, the combined application of N + P + K + GA3 + IAA under Cd stress led to a high increase in catalase (2.5 times), superoxide (3.5 times), and peroxidase (3.7 times) compared to the control. With the combined application of N+ P+ K + GA3 + IAA, the maximum values of BCF (8.25), BAC (2.6), and RF (5.14%) were measured for phytoextraction potential. On the basis of these findings, it is concluded that P. hysterophorus has a high potential to grow, produce the most biomass, and act as a Cd hyperaccumulator in Cd-contaminated soil.

Costs of services and funding gap of the Bangladesh National Tuberculosis Control Programme 2016-2022: An ingredient based approach.

BACKGROUND: Bangladesh National Tuberculosis (TB) Control Programme (NTP) has deployed improved diagnostic technologies which may drive up the programme costs. We aimed to estimate the supply-side costs associated with the delivery of the NTP and the funding gap between the cost of implementation and available funding for the Bangladesh NTP. METHODS: An ingredient-based costing approach was applied using WHO's OneHealth Tool software. We considered 2016, as the base year and projected cost estimates up to 2022 using information on NTP planned activities. Data were collected through consultative meetings with experts and officials/managers, review of documents and databases, and visits to five purposively selected TB healthcare facilities. The estimated costs were compared with the funds allocated to the NTP between 2018 and 2022 to estimate the funding gap. FINDINGS: The estimated total cost of NTP was US$ 49.22 million in 2016, which would increase to US$ 146.93 million in 2022. Human resources (41.1%) and medicines and investigations/ supplies (38.0%) were the major two cost components. Unit costs were highest for treating extensively drug-resistant TB at US$ 7,422.4 in 2016. Between 2018-2022, NTP would incur US$ 536.8 million, which is US$ 235.18 million higher than the current allocation for NTP. CONCLUSION: Our results indicated a funding gap associated with the NTP in each of the years between 2018-2022. Policy planners should advocate for additional funding to ensure smooth delivery of TB services in the upcoming years. The cost estimates of TB services can also be used for planning and budgeting for delivering TB services in similar country contexts.

Assessment of Pb and Ni and potential health risks associated with the consumption of vegetables grown on the roadside soils in District Swat, Khyber Pakhtunkhwa, Pakistan.

Vegetables cultivated near roads absorb toxic metals from polluted soil, which enter the human body through the food chain and cause serious health problems to humans. The present study investigated the concentration of lead (Pb) and nickel (Ni) in soils and vegetables grown along the roadside of District Swat, Pakistan, and the health risks associated with the consumption of the tested vegetables. In results, Pb concentration was higher in plants located at the distance between 0-10 m away from the roadside than the WHO permissible limit. In such plants, Pb concentration was higher than Ni. Rumex dentatus contained the highest concentration of Pb (75.63 mg kg-1 DW) among the tested vegetables while Ni concentration (27.57 mg kg-1 DW) was highest in Trachyspermum ammi as compared to other plants. Concentration and accumulation of both the metals decreased in soil and plants with increasing distance from the road. Similarly, target hazard quotient values noted for Pb (up to 3.37) were greater than unity, which shows that there is a potential risk associated with the consumption of tested vegetables near the road. Moreover, the values of target cancer risk (up to 0.8413) were greater than 0.0001, which shows that there is a risk of cancer with the consumption of tested vegetables. In conclusion, the consumption of tested vegetables was very dangerous as it may lead to higher risks of cancer. Strict regulatory control is recommended on the cultivation of these vegetables along the roadside to avoid any contamination due to roadside exhaust.

Factors affecting the healthcare utilization from Shasthyo Suroksha Karmasuchi scheme among the below-poverty-line population in one subdistrict in Bangladesh: a cross sectional study.

BACKGROUND: Financing healthcare through out-of-pocket (OOP) payment is a major barrier in accessing healthcare for the poor people. The Health Economics Unit (HEU) of the Ministry of Health and Family Welfare of the government of Bangladesh has developed Shasthyo Suroksha Karmasuchi (SSK), a health protection scheme, with the aim of reducing OOP expenditure and improving access of the below-poverty-line (BPL) population to healthcare. The scheme started piloting in 2016 at Kalihati sub-district of Tangail District. Our objective was to assess healthcare utilization by the enrolled BPL population and to identify the factors those influencing their utilization of the scheme. METHOD: A cross-sectional household survey was conducted from July to September 2018 in the piloting sub-district. A total of 806 households were surveyed using a semi-structured questionnaire. Information on illness and sources of healthcare service were captured for the last 90 days before the survey. Multiple logistic regression models were applied to determine the factors related to utilization of healthcare from the SSK scheme and other medically trained providers (MTPs) by the SSK members for both inpatient and outpatient care. RESULT: A total of 781 (24.6%) people reported of suffering from illness of which 639 (81.8%) sought healthcare from any sources. About 8.0% (51 out of 639) of them sought healthcare from SSK scheme and 28.2% from other MTPs within 90 days preceding the survey. Households with knowledge about SSK scheme were more likely to utilize healthcare from the scheme and less likely to utilize healthcare from other MTPs. Non-BPL status and suffering from an accident/injury were significantly positively associated with utilization of healthcare from SSK scheme. CONCLUSION: Among the BPL population, healthcare utilization from the SSK scheme was very low compared to that of other MTPs. Effective strategies should be in place for improving knowledge of BPL population on SSK scheme and the benefits package of the scheme should be updated as per the need of the target population. Such initiative can be instrumental in increasing utilization of the scheme and ultimately will reduce the barriers of OOP payment among BPL population for accessing healthcare.

Perception and Validity of Online Formative Oral Assessment in Surgical Trainees: A Cross-Sectional Study.

BACKGROUND: Online oral assessments have been poorly studied in medical education. This study aims to assess the perception of the online oral assessment strategy for formative purposes. OBJECTIVE: To explore the perception of trainees and examiners on their experience of online oral assessment. METHODS: Online oral assessments were conducted using the Zoom platform (Zoom Video Communications, Inc., San Jose, California, United States) over a period of six days. Each candidate was examined by two examiners and formative feedback was provided at the same time. At the end of the course, participants were asked to fill out an online questionnaire regarding their perception of this online platform for oral assessment.  Results: A total of 192 participants were included in this study as examiners (n=48), candidates (n=53), and observers (n=91). The overall impression of the organization and accessibility of the model was found favorable with a generally lower degree of perceived anxiety in this format. Major limitations faced by participants included technical difficulties (n=84), linguistic issues (n=37), and failure to observe body language (n=38). Using the Joughin matrix, this model of online oral assessment was found as a fair and valid assessment tool with relatively low reliability. CONCLUSIONS: The online oral assessment model has been found to be a reliable and valid method of formative assessment. Further work could be done on this model to assess its potential for summative purposes.

Assessing the incidence of catastrophic health expenditure and impoverishment from out-of-pocket payments and their determinants in Bangladesh: evidence from the nationwide Household Income and Expenditure Survey 2016.

BACKGROUND: Out-of-pocket (OOP) payments for healthcare have been increasing steadily in Bangladesh, which deteriorates the financial risk protection of many households. METHODS: We aimed to investigate the incidence of catastrophic health expenditure (CHE) and impoverishment from OOP payments and their determinants. We employed nationally representative Household Income and Expenditure Survey 2016 data with a sample of 46 076 households. A household that made OOP payments of >10% of its total or 40% of its non-food expenditure was considered to be facing CHE. We estimated the impoverishment using both national and international poverty lines. Multiple logistic models were employed to identify the determinants of CHE and impoverishment. RESULTS: The incidence of CHE was estimated as 24.6% and 10.9% using 10% of the total and 40% of non-food expenditure as thresholds, respectively, and these were concentrated among the poor. About 4.5% of the population (8.61 million) fell into poverty during 2016. Utilization of private facilities, the presence of older people, chronic illness and geographical location were the main determinants of both CHE and impoverishment. CONCLUSION: The financial hardship due to OOP payments was high and it should be reduced by regulating the private health sector and covering the care of older people and chronic illness by prepayment-financing mechanisms.

Effectiveness of health voucher scheme and micro-health insurance scheme to support the poor and extreme poor in selected urban areas of Bangladesh: An assessment using a mixed-method approach.

BACKGROUND: National healthcare financing strategy recommends tax-based equity funds and insurance schemes for the poor and extreme poor living in urban slums and pavements as the majority of these population utilise informal providers resulting in adverse health effects and financial hardship. We assessed the effect of a health voucher scheme (HVS) and micro-health insurance (MHI) scheme on healthcare utilisation and out-of-pocket (OOP) payments and the cost of implementing such schemes. METHODS: HVS and MHI schemes were implemented by Concern Worldwide through selected NGO health centres, referral hospitals, and private healthcare facilities in three City Corporations of Bangladesh from December 2016 to March 2020. A household survey with 1,294 enrolees, key-informant interviews, focus group discussions, consultative meetings, and document reviews were conducted for extracting data on healthcare utilisation, OOP payments, views of enrolees, and suggestions of implementers, and costs of services at the point of care. RESULTS: Healthcare utilisation including maternal, neonatal and child health (MNCH) services, particularly from medically trained providers, was higher and OOP payments were lower among the scheme enrolees compared to corresponding population groups in general. The beneficiaries were happy with their access to healthcare, especially for MNCH services, and their perceived quality of care was fair enough. They, however, suggested expanding the benefits package, supported by an additional workforce. The cost per beneficiary household for providing services per year was €32 in HVS and €15 in MHI scheme. CONCLUSION: HVS and MHI schemes enabled higher healthcare utilisation at lower OOP payments among the enrolees, who were happy with their access to healthcare, particularly for MNCH services. However, they suggested a larger benefits package in future. The provider's costs of the schemes were reasonable; however, there are potentials of cost containment by purchasing the health services for their beneficiaries in a competitive basis from the market. Scaling up such schemes addressing the drawback would contribute to achieving universal health coverage.

Impact of varying housing systems on egg quality characteristics, fatty acid profile, and cholesterol content of Rhode Island Red × Fyoumi laying hens.

The present study was designed to study the effects of conventional and free range systems on egg quality attributes, fatty acid profile, and cholesterol contents of laying hen. Two hundred and forty R1 cross of Rhode Island Red (RIR) × Fyoumi (F) layers during the peak production were divided into two groups and reared in two different housing systems (free range vs. conventional systems). The statistical analysis of the results revealed that the housing system (modification of diet) significantly (p < 0.05) affected egg quality, fatty acid profile, and cholesterol contents. The highest (p < 0.05) whole egg and albumen weights were recorded for eggs produced in a conventional system and higher yolk weight and shell thickness were recorded in free range hens. Significantly (p < 0.05) lower concentration of saturated and higher concentration of mono- and polyunsaturated fatty acids were observed in eggs produced under a free range system. In addition, higher level of total omega-3 fatty acids and higher ratio of omega-6 to omega-3 fatty acids were observed in free range eggs as compared to those in the conventional system. From the results of the present study, we concluded that eggs produced from Rhode Island Red × Fyoumi laying hens in a free range system are qualitatively superior compared to those in the conventional system.

Characterization of Rheumatoid Arthritis Risk-Associated SNPs and Identification of Novel Therapeutic Sites Using an In-Silico Approach.

Single-nucleotide polymorphisms (SNPs) are reported to be associated with many diseases, including autoimmune diseases. In rheumatoid arthritis (RA), about 152 SNPs are reported to account for ~15% of its heritability. These SNPs may result in the alteration of gene expression and may also affect the stability of mRNA, resulting in diseased protein. Therefore, in order to predict the underlying mechanism of these SNPs and identify novel therapeutic sites for the treatment of RA, several bioinformatics tools were used. The damaging effect of 23 non-synonymous SNPs on proteins using different tools suggested four SNPs, including rs2476601 in PTPN22, rs5029941 and rs2230926 in TNFAIP3, and rs34536443 in TYK2, to be the most damaging. In total, 42 of 76 RA-associated intronic SNPs were predicted to create or abolish potential splice sites. Moreover, the analysis of 11 RA-associated UTR SNPs indicated that only one SNP, rs1128334, located in 3'UTR of ETS1, caused functional pattern changes in BRD-BOX. For the identification of novel therapeutics sites to treat RA, extensive gene-gene interaction network interactive pathways were established, with the identification of 13 potential target sites for the development of RA drugs, including three novel target genes. The anticipated effect of these findings on RA pathogenesis may be further validated in both in vivo and in vitro studies.

Association of AFF3 Gene Polymorphism rs10865035 with Rheumatoid Arthritis: A Population-Based Case-Control Study on a Pakistani Cohort.

Rheumatoid arthritis (RA) is one of the complex diseases with the involvement of the genetic as well as environmental factors in its onset and severity. Different genome-wide association and candidate gene studies have shown the role of several genetic variants in multiple loci/genes with ethnical and geographical variations. This study was designed to detect the association of a single-nucleotide polymorphism (SNP) rs10865035 in the AFF3 gene with the genetic background of rheumatoid arthritis (RA) in the Pakistani cohort. A total of 703 individuals, including 409 RA patients and 294 healthy controls, were genotyped using TaqMan assay and Tri primer ARMS-PCR (amplification-refractory mutation system-polymerase chain reaction) methods. The association of rs10865035 with the RA was statistically determined using different models. Interestingly, besides the homozygous recessive model (G/G vs. A/G + A/A) (OR = 1.693(1.06-2.648); P = 0.025), all other models, which included the codominant (χ 2 = 5.169; P = 0.075), homozygous dominant (A/A vs. G/G + A/G) (OR = 0.867 (0.636-1.187); P = 0.41), heterozygous (A/G vs. A/A + GG) (OR = 0.491 (0.667-1.215); P = 0.49), and additive model (OR = 0.826 (0.665-1.027); P = 0.08) showed insignificant distribution of the genotypes among the cases and controls. These findings suggest that the AFF3 gene (rs10865035) has no significant role in the onset of RA in the Pakistani population.

Association study of CCR6 rs3093024 with Rheumatoid Arthritis in a Pakistani cohort.

C-C Chemokine receptor 6 (CCR6), an important protein in inflammatory and immunological responses, has been previously reported to be associated with rheumatoid arthritis (RA). Therefore, in order to replicate these findings, a case-control study was conducted on 500 subjects (including 250 RA patients and 250 healthy controls) of Pakistani origin. The aim of this study was to determine the association of CCR6 rs3093024 variant with RA and identify its role in splicing events using bioinformatics tools. The clinical and demographic characteristics of the patients were collected using a well-designed questionnaire. The genotype frequencies of CCR6 rs3093024 variant were determined using tetra-primer ARMS-PCR (amplification of refractory mutation system-polymerase chain reaction) method. A significant difference was found between CCR6 rs3093024 genotype frequencies [P = 0.0016, χ 2  = 12.915]. Similarly, a significant difference in the allele frequencies between RA patients and healthy controls was also observed [P = 0.0003 and OR (95% CI) = 0.63 (0.49-0.80)]. The stratification of patients showed that there was a significant increase in AA genotype against AG + GG in patients [P = 0.0014, OR (95% CI) = 2.0 (1.32-3.02)]. Furthermore, using bioinformatics analysis, it was found that CCR6 rs3093024 variant might create a potential splicing enhancer motif (SF2/ASF (IgM-BRCA1) with score of 77.92; Threshold 70.53), which might have important impact on the product of this gene. This study suggests that the A variant of CCR6 rs3093024 variant is significantly associated with RA-risk and its G variant is protective in Pakistani population but a multi-cohort large sized population study is needed to elucidate these results. Moreover, functional studies are needed to highlight the effects of this polymorphism on the function of CCR6 gene.

Treating Hyperglycemia From Eryngium caeruleum M. Bieb: In-vitro α-Glucosidase, Antioxidant, in-vivo Antidiabetic and Molecular Docking-Based Approaches.

Natural-based drugs are believed to be safe, effective and economical. Based on the medicinal importance of the genus Eryngium and unexplored nature of Eryngium caeruleum, we have evaluated its antidiabetic and antioxidant potentials. Both in-vitro and in-vivo assays have been carried out for antidiabetic assays. The antioxidant activity was determined by using different free radicals [i.e., 1,1-diphenyl,2-picrylhydrazyl (DPPH), 2,2-azinobis[3-ethylbenzthiazoline]-6-sulfonic acid (ABTS), and hydrogen peroxide (H2O2)]. Moreover, different phytoconstituents were identified in the most active solvent fraction by GC-MS analysis. Furthermore, comparative fingerprints of methanolic extract and chloroform fraction were also analyzed via High Performance Liquid Chromatography coupled with Diode Array Detector (HPLC-DAD). The crude methanolic extract of E. caeruleum (Ec.Cr) and its sub-fractions [i.e., n-hexane (Ec.Hex), chloroform (Ec.Chf), ethyl acetate (Ec.EtAc), and aqueous (Ec.Aq) were employed in this study]. In the α-glucosidase inhibition assay, a concentration-dependent inhibitory response was observed against the enzyme. The most active sample was Ec.Chf which revealed an IC50 of 437 µg/ml in comparison to the standard acarbose (IC50 25 µg/ml). The rest of the samples showed moderate inhibition of α-glucosidase. In antioxidant assays, Ec.Chf and Ec.Cr exhibited a considerable scavenging effect against all the free radicals. The IC50 values recorded for Ec.Chf were 112, 109, and 150 µg/ml against DPPH, ABTS, and H2O2 respectively. Based on the in-vitro potential of Ec.Chf, this was subjected to the in-vivo model experiment. The Ec.Chf lowered the blood glucose level up to 10.3 mmol/L at 500 µg/Kg. The Ec.Chf was also subjected to GC-MS analysis. The GC-MS analysis confirmed the presence of 60 compounds. The identified phytoconstituents consist of some essential compounds previously reported with antidiabetic and antioxidant studies, which include thymol, tocopherol, phytol, nerolidol, (I)-neophytadiene, linolenic acid, and falcarinol. Similarly, the HPLC-DAD chromatograms of Ec.Cr and Ec.Chf exhibited a variety of peaks, which further demonstrates the possibility of important phytochemicals. In a nutshell, we can conclude that Eryngium caeruleum is a potential source of bioactive compounds which may be beneficial for the management of ailments like diabetes and free radicals mediated disorders. Molecular docking was performed to explore the possible role of all the identified bioactive compounds in the chloroform fraction of Eryngium caeruleum into active sites of the homology model of α-glucosidase.

Willingness to pay for oral cholera vaccines in urban Bangladesh.

INTRODUCTION: Cholera is a highly infectious disease and remains a serious public health burden in Bangladesh. The objective of the study was to measure the private demand for oral cholera vaccines (OCV) in Bangladesh and to investigate the key determinants of this demand, reflected in the household's willingness to pay (WTP) for oral cholera vaccine. METHODS: A contingent valuation method was employed in an urban setting of Bangladesh during December 2015 to January 2016. All respondents (N = 1051) received a description of World Health Organization (WHO) prequalified OCV, Shanchol™. Interviews were conducted with either the head of households or their spouse or a major economic contributor of the households. Respondents were asked about how much at maximum they were willing to pay for OCV for their own and their household members' protection. Results are presented as the average and median of the reported maximum WTP of the respondents with standard deviations and 95% confidence interval. Natural log-linear regression model was employed to examine the factors influencing participants' WTP for OCV. RESULTS: About 99% of the respondents expressed WTP for OCV with a maximum mean and median WTP per vaccination (2 doses) of US$ 2.23 and US$ 1.92 respectively. On the household level with an average number of 4.62 members, the estimated mean WTP was US$ 10 (median: US$ 7.69) which represents the perceived demand for OCV of a household to vaccinate against cholera. CONCLUSIONS: The demand of vaccination further indicates that there is a potential scope for recovering a certain portion of the expenditure of immunization program by introducing direct user fees for future cholera vaccination in Bangladesh. Findings from this study will be useful for the policy-makers to make decision on cost-recovery in future oral cholera vaccination programs in Bangladesh and in similar countries.

Do employer-sponsored health insurance schemes affect the utilisation of medically trained providers and out-of-pocket payments among ready-made garment workers? A case-control study in Bangladesh.

OBJECTIVE: We estimated the effect of an employer-sponsored health insurance (ESHI) scheme on healthcare utilisation of medically trained providers and reduction of out-of-pocket (OOP) expenditure among ready-made garment (RMG) workers. DESIGN: We used a case-control study design with cross-sectional preintervention and postintervention surveys. SETTINGS: The study was conducted among workers of seven purposively selected RMG factories in Shafipur, Gazipur in Bangladesh. PARTICIPANTS: In total, 1924 RMG workers (480 from the insured and 482 from the uninsured, in each period) were surveyed from insured and uninsured RMG factories, respectively, in the preintervention (October 2013) and postintervention (April 2015) period. INTERVENTIONS: We tested the effect of a pilot ESHI scheme which was implemented for 1 year. OUTCOME MEASURES: The outcome measures were utilisation of medically trained providers and reduction of OOP expenditure among RMG workers. We estimated difference-in-difference (DiD) and applied two-part regression model to measure the association between healthcare utilisation, OOP payments and ESHI scheme membership while controlling for the socioeconomic characteristics of workers. RESULTS: The ESHI scheme increased healthcare utilisation of medically trained providers by 26.1% (DiD=26.1; p<0.01) among insured workers compared with uninsured workers. While accounting for covariates, the effect on utilisation significantly reduced to 18.4% (p<0.05). The DiD estimate showed that OOP expenditure among insured workers decreased by -3700 Bangladeshi taka and -1100 Bangladeshi taka compared with uninsured workers when using healthcare services from medically trained providers or all provider respectively, although not significant. The multiple two-part models also reported similar results. CONCLUSION: The ESHI scheme significantly increased utilisation of medically trained providers among RMG workers. However, it has no significant effect on OOP expenditure. It can be recommended that an educational intervention be provided to RMG workers to improve their healthcare-seeking behaviours and increase their utilisation of ESHI-designated healthcare providers while keeping OOP payments low.

The effect of a community-based health insurance on the out-of-pocket payments for utilizing medically trained providers in Bangladesh.

BACKGROUND: We aimed to estimate the effect of the community-based health insurance (CBHI) scheme on the magnitude of out-of-pocket (OOP) payments for the healthcare of the informal workers and their dependents. The CBHI scheme was piloted through a cooperative of informal workers, which covered seven unions in Chandpur Sadar Upazila, Bangladesh. METHODS: A quasi-experimental study was conducted using a case-comparison design. In total 1292 (646 insured and 646 uninsured) households were surveyed. Propensity score matching was done to minimize the observed baseline differences in the characteristics between the insured and uninsured groups. A two-part regression model was applied using both the probability of OOP spending and magnitude of such spending for healthcare in assessing the association with enrolment status in the CBHI scheme while controlling for other covariates. RESULTS: The OOP payment was 6.4% (p < 0.001) lower for medically trained provider (MTP) utilization among the insured compared with the uninsured. However, no significant difference was found in the OOP payments for healthcare utilization from all kind of providers, including the non-trained ones. CONCLUSIONS: The CBHI scheme could reduce OOP payments while providing better quality healthcare through the increased use of MTPs, which consequently could push the country towards universal health coverage.

Protocol for a quasiexperimental study testing the effectiveness of strengthening growth monitoring and promotion in community clinics for improving the nutritional status of under-two children in rural Bangladesh.

INTRODUCTION: The Government of Bangladesh is implementing growth monitoring and promotion (GMP) through community clinics (CC) to improve the nutritional status of children. However, little primary evidence is available on the effectiveness of GMP when delivered through CCs. We aim to examine the effectiveness of GMP activities strengthened in CCs to improve the nutritional status of children under 2 years of age. METHODS AND ANALYSIS: This is a quasiexperimental, two-arm, mixed methods study. In the intervention arm, a non-governmental organisation is providing support to strengthen GMP implementation in the 30 CCs. The comparison arm has no intervention to strengthen GMP implementation in the 30 CCs. Study participants will be under-two children and their caregivers, and CC service providers (community healthcare provider, CHCP). We will collect quantitative information on children and mothers' anthropometry, sociodemographic condition, food security, children's feeding practices, morbidity and vaccination history at baseline, and follow them up every third month thereafter for 12 months. We will collect qualitative information on (1) knowledge, skill and practice of CHCPs to implement GMP; (2) mothers/caregivers' perception, knowledge and experience of GMP from CCs; (3) experience and suggestions of programme managers about operational challenges and for improving quality of GMP service delivery; and (4) views of the concerned policy planners to strengthen GMP at the CC level. Qualitative information will be collected through key informant and in-depth interviews at baseline and endline. The primary outcome will be the change observed in length-for-age Z-score of children. A difference-in-difference and linear mixed effects analysis of quantitative data will be done. Thematic analysis will be conducted for qualitative information. Triangulation of data derived from different methods will be carried out. ETHICS AND DISSEMINATION: This study received ethical approval from the Institutional Review Board of International Centre for Diarrhoeal Disease Research, Bangladesh, and results will be disseminated via peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER: NCT03824756.

Correction: Group prenatal care experiences among pregnant women in a Bangladeshi community.

[This corrects the article DOI: 10.1371/journal.pone.0218169.].

Effectiveness of Workplace Nutrition Programs on Anemia Status among Female Readymade Garment Workers in Bangladesh: A Program Evaluation.

Eight in ten female readymade garment (RMG) workers in Bangladesh suffer from anemia, a condition which damages both health and productivity. This study evaluated the effectiveness of a workplace nutrition program on anemia reduction in female RMG workers of Bangladesh. A quasi-experimental mixed method study was conducted on 1310 non-pregnant female RMG workers from four factories. Two types of intervention packages (A and C) were tested against their respective controls (B and D) over a 10-month period. Among factories that already provided lunch to workers with regular behavior change counseling (BCC), one intervention (A) and one control (B) factory were selected, and among factories that did not provide lunches to their workers but provided regular BCC, one intervention (C) and one control (D) factory were selected: (A) Lunch meal intervention package: daily nutritionally-enhanced (with fortified rice) hot lunch, once weekly iron-folic acid (IFA) supplement and monthly enhanced (with nutrition module) behavior change counseling (BCC) versus (B) Lunch meal control package: regular lunch and BCC; and (C) Non-meal intervention package: twice-weekly IFA and enhanced BCC versus (D) Non-meal control package: BCC alone. Body weight and capillary hemoglobin were measured. Changes in anemia prevalence were estimated by difference-in-difference (DID) method. Thematic analysis of qualitative in-depth interviews with RMG workers was performed and findings were triangulated. Anemia was reduced significantly in both lunch meal and non-meal intervention (A and C) group (DID: 32 and 12 percentage points, p: <0.001 and <0.05 respectively). The mean hemoglobin concentration also significantly increased by 1 gm/dL and 0.4 gm/dL in both A and C group (p: <0.001 respectively). Weight did not change in the intervention groups (A and C) but significantly increased by more than 1.5 kg in the comparison groups (B and D). The knowledge of different vitamin and mineral containing foods and their benefits was increased significantly among all participants. Workplace nutrition programs can reduce anemia in female RMG workers, with the greatest benefits observed when both nutritionally enhanced lunches and IFA supplements are provided.