Availability and readiness of healthcare facilities and their effects on antenatal care services uptake in Bangladesh.

BACKGROUND: Sustainable Development Goal (SDG) 3.7 aims to ensure universal access to sexual and reproductive healthcare services, where antenatal care (ANC) is a core component. This study aimed to examine the influence of health facility availability and readiness on the uptake of four or more ANC visits in Bangladesh. METHODS: The 2017/18 Bangladesh Demographic and Health Survey data were linked with the 2017 Health Facility Survey and analyzed in this study. The associations of health facility-level factors with the recommended number of ANC uptakes were determined. A multilevel mixed-effect logistic regression model was used to determine the association, adjusting for potential confounders. RESULTS: Nearly 44% of mothers reported four or more ANC uptakes, with significant variations across several areas in Bangladesh. The average distance of mothers' homes from the nearest health facilities was 6.36 km, higher in Sylhet division (8.25 km) and lower in Dhaka division (4.45 km). The overall uptake of the recommended number of ANC visits was positively associated with higher scores for the management (adjusted odds ratio (aOR) 1.85; 95% CI, 1.16-2.82) and infrastructure (aOR, 1.59; 95% CI, 1.09-2.19) of health facilities closest to mothers' homes. The odds of using the recommended number of ANC in mothers increased by 3.02 (95% CI, 2.01-4.19) and 2.36 (95% CI, 2.09-3.16) folds for each unit increase in the availability and readiness scores to provide ANC services at the closest health facilities, respectively. Every kilometer increase in the average regional-level distance between mothers' homes and the nearest health facilities reduced the likelihood of receiving the recommended number of ANC visits by nearly 42% (aOR, 0.58, 95% CI, 0.42-0.74). CONCLUSION: The availability of healthcare facilities close to residence, as well as their improved management, infrastructure, and readiness to provide ANC, plays a crucial role in increasing ANC services uptake. Policies and programs should prioritize increasing the availability, accessibility, and readiness of health facilities to provide ANC services.

Effects of disability on adverse health outcomes and anthropometric deficits among under-five children in South Asian countries: evidence from multiple indicator cluster surveys.

Background: Children with disabilities face an increased risk of adverse health outcomes and poor anthropometric deficits, although the focus on them is limited in the South Asian context thus far and need newer and more evidence. This study investigates the effects of disability on adverse health outcomes and anthropometric deficits among 2-4 years aged children in South Asian countries. Methods: We analyzed data from 93,180 children aged 2-4 years across Bangladesh, Nepal, Pakistan, and Afghanistan using Multiple Indicator Cluster Surveys (2017-2023). Disability status was the primary exposure, and outcomes included adverse health outcome (acute respiratory infection, diarrhea, fever), anthropometric deficit (stunting, wasting, underweight), and healthcare service sources during adverse health events (care received from skilled healthcare personnel, care received from non-professional personnel, and care received from health facility workers other than skilled healthcare personnel). Using multilevel and multinomial logistic regression models, we examined associations between exposure and outcome variables, adjusting for covariates. Findings: We found average disability prevalence in South Asia was 8.7% (8.3-9.0; n = 8072), varying from 3.4% (3.0-3.8; n = 446) in Bangladesh to 12.3% (11.4-13.3; n = 1259) in Afghanistan. Common health issues included fever (n = 24,982, 26.8%, 26.2-27.4) and diarrhea (n = 14,081, 15.1%, 14.7-15.6), while prevalent poor anthropometric deficits were stunting (n = 39,766, 42.7%, 42.0-43.3) and underweight (n = 22,390, 24.0%, 23.5-24.5). Children with disability had 1.30 (95% CI: 1.21-1.40) to 1.60 (95% CI: 1.47-1.75) times and 1.17 (95% CI: 1.05-1.29) to 1.39 (95% CI: 1.30-1.48) times higher likelihoods of adverse health outcomes and anthropometric deficits, respectively, with variations observed among countries and different disability types. Individuals with disability were 1.16 (95% CI: 1.00-1.35) to 1.26 (95% CI: 1.01-1.58) times more likely to receive healthcare services from skilled healthcare personnel compared to health facility workers other than skilled healthcare personnel. Interpretation: This study findings emphasizes the need for community-level awareness programs to improve anthropometric well-being and healthcare of the children with disability. Funding: This research did not receive any specific funds.

Exploration of modern contraceptive methods using patterns among later reproductive-aged women in Bangladesh.

BACKGROUND: With the rapid increase in the number of women in their later reproductive years (aged 35 and above) in the present decade, the concern surrounding their contraceptive considerations has reached a critical point of importance. This study aims to examine the trends and determinants of modern contraceptive uptake among later reproductive-aged women in Bangladesh. METHODS: A total of 17,736 women aged 35 and above were included in the analysis, utilizing data from three consecutives Bangladesh Demographic and Health Surveys conducted in 2011, 2014, and 2017-18. The outcome variable was the uptake of modern contraceptive methods (yes or no). The explanatory variables encompassed survey years, individual characteristics of the women, as well as characteristics of their partners and the community. Multilevel logistic regression model was used to explore the association of the outcome variable with explanatory variables. RESULTS: We found that approximately 54% of women aged 35 and more do not use modern contraceptive methods, and there have been no significant shifts in their usage observed over the survey years. Compared to women aged 35-39, women aged 40-45 (aOR = 0.53, 95% CI: 0.49-0.57) and 45-49 (aOR = 0.24, 0.22-0.26) reported lower likelihoods of modern contraceptive method uptake. Higher education correlated with increased uptake of modern contraceptive methods (112%-142%), while partner's education showed a negative association. Later reproductive-aged women in richer (aOR = 0.83, 95% CI: 0.74-0.94) and richest (aOR = 0.76, 95% CI: 0.66-0.88) quintiles reported lower uptake of modern contraceptive methods compared to their counterparts in the poorest quintile. Later reproductive-aged women in Dhaka (aOR = 1.22, 95% CI: 1.07-1.38) and Rajshahi (aOR = 1.37, 95% CI: 1.19-1.59) regions had higher uptake of modern contraception than those residing in the Barishal division. Modern contraceptive methods uptake was 1.22 times higher among women who reported exposure to mass media and 1.19 times higher among women who reported engagement in paid work compared to among women who reported no exposure to mass media and participation in no formal work, respectively. Modern contraceptive methods uptake was 43% higher (aOR = 1.43, 95% CI: 1.32-1.55) in women with more than 2 children compared to those with ≤2 children. CONCLUSION: The study highlights no significant change in modern contraception uptake among later reproductive-aged women in Bangladesh. This raises concerns about the elevated risk of unintended pregnancies and shorter birth intervals, emphasizing the need for targeted interventions to address the specific needs and preferences of this demographic.

Effects of short birth interval on child malnutrition in the Asia-Pacific region: Evidence from a systematic review and meta-analysis.

Child malnutrition remains a significant concern in the Asia-Pacific region, with short birth intervals recognised as a potential risk factor. However, evidence of this association is inconclusive. This study aimed to systematically review the existing evidence and assess the summary effects of short birth interval on child malnutrition in the Asia-Pacific region. Five electronic databases were searched in May 2023 to identify relevant studies reporting the association between short birth interval and child malnutrition, including stunting, wasting, underweight, anaemia and overall malnutrition, in Asia-Pacific region between September 2000 and May 2023. Fixed-effects or random-effects meta-analysis was performed to estimate the summary effects of short birth interval on child malnutrition. Out of 56 studies meeting the inclusion criteria, 48 were included in quantitative synthesis through meta-analysis. We found a slightly higher likelihood of stunting (n = 25, odds ratio [OR] = 1.13; 95% confidence interval [CI]: 0.97-1.32) and overall malnutrition (n = 3, OR = 2.42; 95% CI: 0.88-6.65) among children born in short birth intervals compared to those with nonshort intervals, although the effect was not statistically significant. However, caution is warranted due to identified heterogeneity across studies. Subgroup analysis demonstrated significant effects of short birth intervals on child malnutrition in national-level studies and studies with larger sample sizes. These findings underscore short birth intervals as a significant contributor to child malnutrition in the Asia-Pacific region. Implementing effective policies and programs is vital to alleviate this burden, ultimately reducing child malnutrition and associated adverse outcomes, including child mortality.

Examining the influence of child nutritional disorders on early childhood development in Bangladesh: insights from the multiple indicator cluster survey.

OBJECTIVE: The objective of this study was to explore the relationship between various forms of child nutritional disorders and early childhood development in Bangladesh. DESIGN: We analysed data from the nationally representative cross-sectional 2019 Multiple Indicator Cluster Survey. Early childhood development was evaluated using the Early Childhood Development Index (ECDI), which comprised 10 yes-or-no questions across four domains: literacy-numeracy, physical well-being, socio-emotional development, and learning abilities. Nutritional disorders (e.g. stunting, wasting, and underweight) were measured based on the World Health Organization's height and weight guidelines. To investigate the relationships between child development and nutritional disorders, we used multilevel logistic regression models. SETTING: Bangladesh. PARTICIPANTS: Data of 9,455 children aged 3 and 4 years. RESULTS: Approximately 38 % of the children analysed experienced a nutritional disorder, with stunting being the most prevalent at 28·15 %. Overall, 25·27 % did not meet expected developmental progress measured by the ECDI. Stunted children were more likely to be off track developmentally, while those without any nutritional disorder were more likely to be on track. Socio-demographic factors, including age, sex, attendance in early childhood education programme, maternal education, maternal functional difficulties, region, and income, were identified as determinants of ECDI. CONCLUSIONS: Childhood nutrition and socio-demographic factors significantly affect multiple developmental domains and overall ECDI among children aged 3-4 years. Prioritising policies and programmes that improve nutrition and address these determinants are crucial for fostering optimal development in children.

Exploring the impact of preconception care and unintended pregnancy on access to antenatal healthcare services among Rohingya women: Insights from a cross-sectional survey.

Background: The low utilization of antenatal healthcare services among Rohingya refugee women contributes to high maternal and child mortality rates. The objective of this study was to evaluate the prevalence of antenatal healthcare services utilization and the impacts of preconception care and pregnancy intention on accessing these services among Rohingya refugee women in Bangladesh. Methods: We analyzed data from 708 women collected through a multistage cross-sectional survey conducted in April 2023. The outcome variable was the uptake of at least one antenatal healthcare services, while the exposure variables were preconception care uptake and unintended pregnancy. We used a multivariate logistic regression model to determine the effects of preconception care and unintended pregnancy on antenatal care utilization, adjusting for potential covariates. Results: Approximately 47 % of women reported not accessing any antenatal healthcare services during their most recent pregnancy. Moreover, around 68 % of women did not receive any preconception care, and nearly one-third of pregnancies were unintended at conception. We observed lower likelihoods of antenatal care utilization among women without preconception care or with unintended pregnancy. The negative effects were even more pronounced when women reported no use of preconception care along with experiencing mistimed (aOR, 0.61, 95 % CI: 0.45-0.77) and unwanted (aOR, 0.43, 95 % CI: 0.34-0.52) pregnancy for their most recent pregnancy. Conclusion: Maternal healthcare service utilization is alarmingly low among Rohingya refugees, with a significant lack of preconception care and a high prevalence of unintended pregnancies. This underscores the critical importance of implementing awareness-building programs to increase uptake of antenatal healthcare services.

Clustering of home delivery in Bangladesh and its predictors: Evidence from the linked household and health facility level survey data.

Around half of births in Bangladesh occur at home without skilled birth personnel. This study aims to identify the geographical hot spots and cold spots of home delivery in Bangladesh and associated factors. We analyzed data from the 2017/2018 Bangladesh Demographic and Health Survey and the 2017 Bangladesh Health Facility Survey. The outcome variable was home delivery without skilled personnel supervision (yes, no). Explanatory variables included individual, household, community, and healthcare facility level factors. Moran's I was used to determine hot spots (geographic locations with notably high rates of home delivery) and cold spots (geographic areas exhibiting significantly low rates of home delivery) of home delivery. Geographically weighted regression models were used to identify cluster-specific predictors of home delivery. The prevalence of without skilled personnel supervised home delivery was 53.18%. Hot spots of non-supervised and unskilled supervised home delivery were primarily located in Dhaka, Khulna, Rajshahi, and Rangpur divisions. Cold spots of home delivery were mainly located in Mymensingh and Sylhet divisions. Predictors of higher home births in hot spot areas included women's illiteracy, lack of formal job engagement, higher number of children ever born, partner's agriculture occupation, higher community-level illiteracy, and larger distance to the nearest healthcare facility from women's homes. The study findings suggest home delivery is prevalent in Bangladesh. Awareness-building programs should emphasize the importance of skilled and supervised institutional deliveries, particularly among the poor and disadvantaged groups.

Prevalence and patterns of comorbidities in people with disabilities and their associated socio-demographic factors.

The presence of comorbidities among individuals with disabilities worsens their already complex health and social circumstances. This study aims to explore prevalence and patterns of morbidities among persons with disabilities in Bangladesh and identify associated socio-demographic factors. Data from 4270 persons with disability was analysed extracted from the 2021 Bangladesh National Household Survey on Persons with Disability. Outcome variable considered was the occurrence of morbidity among persons with disabilities. Explanatory variables encompassed factors at the individual, household, and community levels. Adjusted and unadjusted multilevel mixed-effects logistic regression model was used to explore association of outcome variable with explanatory variables. We found that approximately half of individuals with disabilities experienced one or more morbidities, with chronic conditions being the most prevalent (44%). Around 42% of total persons with disability were unable to work. Specifically, hypertension (18.3%), diabetes (9.1%), and heart problems (17.1%) were prevalent chronic conditions. The likelihood of experiencing comorbidity was found to be higher among females (aOR 1.3, 95% CI 1.1, 1.7), increase year of education (aOR, 1.1, 95% CI 1.0-1.2), and those from wealthier households (aOR 1.6, 95% CI 1.2, 2.2). This underscores the need for targeted policies and interventions addressing their distinct healthcare needs.

Effects of parental migration on early childhood development of left-behind children in Bangladesh: Evidence from a nationally representative survey.

BACKGROUND: In Bangladesh, as in other low- and middle-income countries, parents frequently migrate to other areas, often for employment opportunities, leaving their children behind with the hope that their earnings will contribute to securing a better future for them. However, the absence of parents due to migration can have negative implications for the well-being of these left-behind children. Despite the existence of studies investigating this phenomenon, the evidence thus far has produced inconclusive findings, with no specific data available from Bangladesh. Therefore, the objective of this study was to examine the effects of parental migration on the early childhood development of left-behind children in Bangladesh. METHODS: The present study utilized data from the Bangladesh Multiple Indicator Cluster Survey (MICS) conducted in 2019. A sample of 8,833 children aged 3-4 years was included in the analysis. The Early Childhood Development Index (ECDI) and its individual domains served as the outcome variables of interest. The primary explanatory variables considered in the analysis were father migration, mother migration, migration of both parents, and migration of either parent. To assess the association between the outcomes and explanatory variables, multilevel logistic regression analysis was employed, controlling for relevant covariates. RESULTS: Approximately 29% of all children in the study were not developmentally on track, as measured by the ECDI. When examining the individual domains of the ECDI, only 9% of the total children demonstrated developmental progress in the learning domain. Regarding the association between parental migration and ECDI outcomes, we observed a 26% decrease in the likelihood of overall ECDI among children with a migrated father (OR: 0.74, 95% CI: 0.54-0.93). This decrease became even more pronounced, reaching 37% (OR: 0.63, 95% CI: 0.48-0.97), among children with both parents migrated, compared to children with neither parent migrated. CONCLUSION: The findings of this study indicate that parental migration, especially when both parents are involved, has a substantial negative impact on the likelihood of achieving favourable ECDI outcomes for children in Bangladesh. To ensure the optimal development of children with migrating parents, it is crucial to strengthen early childhood development education programs and implement robust social safety nets. These efforts should specifically target the unique needs and challenges faced by children with migrated parents, providing them with the necessary support and resources for their holistic development.

Association between maternal high-risk fertility behaviour and perinatal mortality in Bangladesh: Evidence from the Demographic and Health Survey.

BACKGROUND: High-risk fertility behaviours including pregnancy early or late in the reproductive life course, higher parity and short birth intervals are ongoing concerns in Low- and Middle-Income Countries (LMICs) such as Bangladesh. Although such factors have been identified as major risk factors for perinatal mortality, there has been a lack of progress in the area despite the implementation of the Millennium and Sustatinable Development Goals. We therefore explored the effects of high-risk maternal fertility behaviour on the occurrence of perinatal mortality in Bangladesh. METHODS: A total of 8,930 singleton pregnancies of seven or more months gestation were extracted from 2017/18 Bangladesh Demographic and Health Survey for analysis. Perinatal mortality was the outcome variable (yes, no) and the primary exposure variable was high-risk fertility behaviour in the previous five years (yes, no). The association between the exposure and outcome variable was determined using a mixed-effect multilevel logistic regression model, adjusted for covariates. RESULTS: Forty-six percent of the total births that occurred in the five years preceding the survey were high-risk. After adjusting for potential confounders, a 1.87 times (aOR, 1.87, 95% CI, 1.61-2.14) higher odds of perinatal mortality was found among women with any high-risk fertility behaviour as compared to women having no high-risk fertility behaviours. The odds of perinatal mortality were also found to increase in line with an increasing number of high-risk behaviour. A 1.77 times (95% CI, 1.50-2.05) increase in odds of perinatal mortality was found among women with single high-risk fertility behaviour and a 2.30 times (95% CI, 1.96-2.64) increase in odds was found among women with multiple high-risk fertility behaviours compared to women with no high-risk fertility behaviour. CONCLUSION: Women's high-risk fertility behaviour is an important predictor of perinatal mortality in Bangladesh. Increased contraceptive use to allow appropriate birth spacing, educational interventions around the potential risks associated with high risk fertility behaviour (including short birth interval) in future pregnacies, and improved continuity of maternal healthcare service use among this population are required to improve birth outcomes in Bangladesh.

Spatial variation in the non-use of modern contraception and its predictors in Bangladesh.

This study aimed to investigate spatial variations in the non-use of modern contraception in Bangladesh and identify associated individual, household, and community-level factors. The analysis utilized data from 16,135 women, extracted from the 2017/18 Bangladesh Demographic and Health Survey. The study's main outcome was the prevalence of non-use of modern contraception (yes or no), while the explanatory variables included factors at the individual, household, and community level. To assess geographical heterogeneity in non-use of modern contraception, Moran's I statistics were applied. Additionally, the Gettis-Ord Gi* was calculated to measure spatial autocorrelation differences across various study locations. The relationship between non-use of modern contraception and location was further explored using a geographically weighted regression model at the cluster level. The results indicated that 42.8% (95% CI 41.6-43.8) of respondents reported non-use of modern contraception in Bangladesh, with significant variation across geographical locations (p < 0.001). Hot spots of high non-use were predominantly identified in the Sylhet, Barishal, and some areas of the Chattogram divisions, while cold spots of low use were concentrated in the Rangpur, Mymensingh, and some areas Rajshahi divisions. Notably, the likelihood of non-use was highest among women and partners with low levels of education. The analysis of other risk factors, such as partner occupation, community-level illiteracy, and poverty, revealed varying effects on non-use of modern contraception across different locations (clusters) within the country. The study's findings underscore the importance of targeted, area-specific policies and programs aimed at promoting knowledge and uptake of modern contraception in Bangladesh.

Effects of lower tiers of government healthcare facilities on unmet need for contraception and contraception use in Bangladesh.

BACKGROUND: In low- and middle-income countries (LMICs), including Bangladesh, modern contraception use remains lower than desired, resulting in a higher unmet need. A potential factor contributing to lower contraceptive use is reduced access to and use of lower tiers of government healthcare facilities, including home visits by family welfare assistants (FWAs), as well as women's visits to community and satellite clinics. These relationships, however, are still unexplored in Bangladesh and LMICs more broadly. The aim of this study was to explore the effects of lower tiers of government healthcare facilities on unmet needs for contraception and contraception use in Bangladesh. METHODS: Data from 17,585 sexually active married women were analyzed from the 2017 Bangladesh Demographic and Health Survey. The outcome variables were any contraceptive use, modern contraceptive use, unmet need for contraception, and unmet need for modern contraception. The explanatory variables considered were respondents' home visits by FWAs, respondents' visits to a community clinic, and respondents' visits to a satellite clinic. Multilevel mixed-effect Poisson regression with robust variance was used to determine the association between the outcome and explanatory variables, adjusted for individual-, household-, and community-level factors. RESULTS: Approximately 18% of respondents were visited by FWAs in the three months prior to the survey date and only 3.4% and 3.1% of women attended community and satellite clinics, respectively. Women who reported being visited by FWAs in the three months prior to the survey were approximately 36% less likely to report an unmet need for modern contraception and 42% more likely to report using modern contraception than women who did not report such a visit. A higher likelihood of unmet need for contraception and a lower likelihood of contraception use were found among women who did not visit these community or satellite clinics or visited these clinics for other reasons than collecting contraception as compared to women who visited these clinics to collect contraception. CONCLUSION: Home visits by FWAs to respondents' homes to provide contraception as well as respondents' visits to satellite and community clinics play a major role in Bangladesh to ensure contraception use and reduce the unmet need for contraception. However, their coverage is quite low in Bangladesh. The findings suggest an urgent need for greater government initiatives to increase the number of FWAs and proper monitoring of them at the field level.

Women's participation in childbearing decision-making and its effects on short-interval births in Rohingya refugee camps of Bangladesh.

Background: Women's involvement in family planning decision-making is significantly low among refugee women, potentially leading to an increased unintended and short interval pregnancies. This study aims to investigate the relationship between women's decision-making in childbearing and short-interval births among Rohingya refugee women in Bangladesh. Methods: Data from 719 women residing in three Rohingya refugee camps in Ukhiya, Cox's Bazar, Bangladesh, were analyzed. The outcome variable was birth spacing, categorized as short (<33 months between the two most recent births) or normal (≥33 months between the two most recent births). The primary explanatory variable was women's involvement in fertility decision-making with their partner, classified as never, sometimes, and always. Multivariate logistic regression analysis was conducted to assess the association between the outcome and explanatory variable while adjusting for potential covariates. Findings: 58% of births occurred within a short interval, while almost 48% of women reported no participation in fertility decision-making with their partner. Short interval birth was found to be increasing with decreasing women's participation in fertility decision-making with their partner. Women who sometimes or never made fertility decisions with their partner had 1.20 times (95% CI, 1.01-1.88) and 1.69 times (95% CI, 1.06-2.29) higher likelihood of short interval births, respectively, compared to women who always decided with their partner. Interpretation: Low women's participation in fertility decision-making with their partner among Rohingya refugees increases short interval births and adverse maternal and child health outcomes, including mortality. This highlights the need for counselling programs to educate and empower women, promoting joint fertility decision-making by couples. Funding: This research did not receive any specific funds.

Spatial distribution of caesarean deliveries and their determinants in Bangladesh: evidence from linked data of population and health facility survey.

Background: Health facility-level factors play a crucial role in women's access to and use of caesarean section (CS) services, but lacks relevant evidence. The study aimed to understand the effects of health facility-level factors on CS delivery in Bangladesh. Methods: The 2017-18 Bangladesh Demographic and Health Survey (2017-18 BDHS) and the 2017 Bangladesh Health Facility Survey (2017 BHFS) were linked and analysed in this study. The sample comprised of 4954 women gave at least one live birth within three years preceding the survey. The outcome variable was delivery through CS (yes, no) and the explanatory variables were health facility-level, individual-level, household-level, and community-level factors. Moran's I and Getis-Ord General G statistic were used to identify the hotspots of delivery through CS. Mixed-effect multilevel logistic regression was used to examine the association of the outcome variable with explanatory variables. Findings: Around 33% of women in Bangladesh underwent CS in their most recent pregnancies. The hotspots of delivery through CS are located primarily in Rajshahi, Dhaka, and Khulna divisions. The likelihood of delivered through CS increased with the rising scores of the management (Adjusted Odds Ratio (AOR), 1.83; 95% CI 1.04-2.07) and infrastructure (AOR, 3.14; 95% CI 1.40-5.12) of the nearest health facility. The readiness of health facilities to provide comprehensive obstetric care was significantly associated with an increased likelihood of delivery through CS (AOR, 2.18; 95% CI 1.15-3.28). These relationships were strong for private than non-government and government health facilities. Interpretation: The proximity of comprehensive obstetric care facilities to women's residences and their readiness to provide services play critical roles in the access to and use of CS in Bangladesh. The findings highlight the importance of necessary healthcare personnel, including midwives, availability of government hospitals where undue CS are avoided, and awareness-building programmes about the adverse effects of CS delivery. Funding: None.

Spatial pattern and influential factors for early marriage: evidence from Bangladesh Demographic Health Survey 2017-18 data.

BACKGROUND: Early marriage is highly prevalent in Bangladesh. It is linked with a range of adverse outcomes, including maternal and child mortality. However, research on regional variations and factors associated with early marriage is scarce in Bangladesh. This study aimed to explore the geographical variations and predictors of early marriage in Bangladesh. METHODS: Data of women aged 20-24 in the Bangladesh Demographic and Health Survey 2017-18 were analysed. The occurrence of early marriage was the outcome variable. Explanatory variables were several individual-, household- and community-level factors. Geographical hot spots and cold spots of early marriage were first determined using Global Moran's I statistic. Multilevel mixed-effect Poisson regression was used to determine the association of early marriage with individual-, household-, and community-level factors. RESULTS: Almost 59% of women aged 20-24 reported they were married before reached 18. The hotspots of early marriage were mainly concentrated in Rajshahi, Rangpur and Barishal, and the cold spots were in Sylhet and Chattogram divisions. The prevalence of early marriage was lower among higher educated (adjusted prevalence ratio (aPR): 0.45; 95% CI: 0.40, 0.52), and non-Muslim women (aPR: 0.89; 95% CI: 0.79, 0.99) than their counterparts. Higher community-level poverty was significantly associated with early marriage (aPR, 1.16; 95% CI: 1.04, 1.29). CONCLUSION: The study concludes that promoting girls' education, awareness-building programs about the adverse effects of early marriage and proper application of the child marriage restraint act, particularly in disadvantaged communities are recommended.

Loneliness and trust issues reshape mental stress of expatriates during early COVID-19: a structural equation modelling approach.

OBJECTIVES: To explore relationship among perceived stress regarding loneliness, interpersonal trust and institutional trust of expatriates during the early COVID-19 period (from 30th March to 30th May 2020). METHODS: Data from  21,439 expatriates were extracted from COVIDiSTRESS global survey. The outcome variable was perceived stress. The explanatory variables were age, perceived loneliness, trust (interpersonal and institutional). Pairwise correlation, and structural equation modelling were used to determine relationship among outcome and explanatory variables. RESULTS: The majority of the expatriates were female (73.85%), married (60.20%), had college degree (47.76%), and employed (48.72%). Over 63% of the total expatriates reported that the COVID-19 pandemic changed their lives. The average age of the respondents was 40.4 years (± 13.7), and the average score of perceived stress, loneliness, interpersonal and institutional trust were 25.5, 7.4, 14.2 and 40.4, respectively. We found a moderate correlation of perceived stress with age, perceived loneliness, interpersonal trust and institutional trust (p < 0.001). They were also found moderately related to each other. Structural equation modelling evaluated that a lack of trust can cause loneliness among expatriates, which later lead to perceived stress. Interpersonal trust was more likely to be associated with stress than institutional trust, whereas perceived loneliness mediated between both trusts and perceived stress. CONCLUSION: Perceived stress can be reduced through trusting others and alleviating the loneliness. Making strong linkage among migrants as well as between migrants and local community is important to ensure proper mental wellbeing of expatriates.