Demographic, socioeconomic, and biological correlates of hypertension in an adult population: evidence from the Bangladesh demographic and health survey 2017-18.

BACKGROUND: Bangladesh is well advanced in the epidemiologic transition from communicable to noncommunicable diseases, which now account for two out of three deaths annually. This paper examines the latest nationally representative hypertension prevalence estimates, awareness, treatment, and control-to identify their association with potential correlates. METHODS: The analyses are based on the recent Bangladesh Demographic and Health Survey 2017-18 data. Univariate analyses and bivariate analyses between the outcome variables and individual covariates were carried out. Then chi-square tests were done to see the proportional differences between them. To examine the demographic, socioeconomic and biological factors affecting hypertension, awareness, treatment and control, we used multivariate logistic regression models. RESULTS: We found that prevalence of hypertension for females and males together aged 35 or more has risen by half between 2011 (25.7%) to 2017 (39.4%). With the broader age range used in 2017, the prevalence is now 27.5% in the population aged 18 years or more. The factors associated with hypertension included older age, being female, urban residence, higher wealth status, minimal education, higher body mass index and high blood glucose level. Following multivariate analyses, many of these characteristics were no longer significant, leaving only age, being female, nutritional status and elevated blood glucose level as important determinants. Over half (58%) of females and males who were found to be hypertensive were not aware they had the condition. Only one in eight (13%) had the condition under control. CONCLUSION: In the coming years, a rising trend in hypertension in Bangladeshi adults is expected due to demographic transition towards older age groups and increase in overweight and obesity among the population of Bangladesh. With more women being hypertensive than men, a targeted approach catering to high risk groups should be thoroughly implemented following the Multisectoral NCD Action Plan 2018-2025. Acting in close collaboration with other ministries/relevant sectors to bring an enabling environment for the citizens to adopt healthy lifestyle choices is a prerequisite for adequate prevention. While screening the adult population is essential, the public sector cannot possibly manage the ever-expanding numbers of hypertensives. The private sector and NGOs need to be drawn into the program to assist.

Reducing Inequity in Urban Health: Have the Intra-urban Differentials in Reproductive Health Service Utilization and Child Nutritional Outcome Narrowed in Bangladesh?

Bangladesh is undergoing a rapid urbanization process. About one-third of the population of major cities in the country live in slums, which are areas that exhibit pronounced concentrations of factors that negatively affect health and nutrition. People living in slums face greater challenge to improve their health than other parts of the country, which fuels the growing intra-urban health inequities. Two rounds of the Bangladesh Urban Health Survey (UHS), conducted in 2013 and 2006, were designed to examine the reproductive health status and service utilization between slum and non-slum residents. We applied an adaptation of the difference-in-differences (DID) model to pooled data from the 2006 and 2013 UHS rounds to examine changes over time in intra-urban differences between slums and non-slums in key health outcomes and service utilization and to identify the factors associated with the reduction in intra-urban gaps. In terms of change in intra-urban differentials during 2006-2013, DID regression analysis estimated that the gap between slums and non-slums for skilled birth attendant (SBA) during delivery significantly decreased. DID regression analysis also estimated that the gap between slums and non-slums for use of modern contraceptives among currently married women also narrowed significantly, and the gap reversed in favor of slums. However, the DID estimates indicate a small but not statistically significant reduction in the gap between slums and non-slums for child nutritional status. Results from extended DID regression model indicate that availability of community health workers in urban areas appears to have played a significant role in reducing the gap in SBA. The urban population in Bangladesh is expected to grow rapidly in the coming decades. Wide disparities between urban slums and non-slums can potentially push country performance off track during the post-2015 era, unless the specific health needs of the expanding slum communities are addressed. To our knowledge, this is the first systematic explanation and quantification of the role of various factors for improving intra-urban health equity in Bangladesh using nationally representative data. The findings provide a strong rationale for continuing and expanding community-based reproductive health services in urban areas by the NGOs with a focus on slum populations.

Comparing tariff and medical assistant assigned causes of death from verbal autopsy interviews in Matlab, Bangladesh: implications for a health and demographic surveillance system.

BACKGROUND: Deaths in developing countries often occur outside health facilities, making it extremely difficult to gather reliable cause of death (COD) information. Automated COD assignment using a verbal autopsy instrument (VAI) has been proposed as a reliable and cost-effective alternative to traditional physician-certified verbal autopsy, but its performance is still being evaluated. The purpose of this study was to compare the similarity of diagnosis by Medical Assistants (MA) in the Matlab Health and Demographic Surveillance System (HDSS) with the SmartVA Analyze 1.2 (Tariff 2.0) diagnosis. METHODS: This study took place between January 2011 and April 2014 in Matlab, Bangladesh. MA with 3 years of medical training assigned COD to Matlab residents by reviewing the information collected using the Population Health Metrics Research Consortium (PHMRC) long-form VAI. Smart VA Analyze 1.2 automatically assigned COD using the same questionnaire. COD agreement and cause-specific mortality fractions (CSMFs) were compared for MA and Tariff. RESULTS: Of the 4969 verbal autopsy cases reviewed, 4328 were adults, 296 were children, and 345 were neonates. Cohen's kappa was 0.38 (0.36, 0.40) for adults, 0.43 (0.38, 0.49) for children, and 0.27 (0.22, 0.33) for neonates. For adults, the top two COD for MA were stroke (29.6%) and ischemic heart diseases (IHD) (14.2%) and for Tariff these were stroke (32.0%) and IHD (14.0%). For children, the top two COD for MA were drowning (33.5%) and pneumonia (13.2%) and for Tariff these were also drowning (36.8%) and pneumonia (12.4%). For neonates, the top two COD for MA were birth asphyxia (41.2%) and meningitis/sepsis (22.3%) and for Tariff these were birth asphyxia (37.0%) and preterm delivery (30.9%). CONCLUSION: The CSMFs for Tariff and MA showed very close agreement across all age categories but some differences were observed for neonate preterm delivery and meningitis/sepsis. Given the known advantages of automated methods over physician certified verbal autopsy, the SmartVA software, incorporating the shortened VAI questionnaire and Tariff 2.0, could serve as a cost-effective alternative to Matlab MA to routinely collect and analyze verbal autopsy data in a HDSS to generate essential population level COD data for planning.

Collecting verbal autopsies: improving and streamlining data collection processes using electronic tablets.

BACKGROUND: There is increasing interest in using verbal autopsy to produce nationally representative population-level estimates of causes of death. However, the burden of processing a large quantity of surveys collected with paper and pencil has been a barrier to scaling up verbal autopsy surveillance. Direct electronic data capture has been used in other large-scale surveys and can be used in verbal autopsy as well, to reduce time and cost of going from collected data to actionable information. METHODS: We collected verbal autopsy interviews using paper and pencil and using electronic tablets at two sites, and measured the cost and time required to process the surveys for analysis. From these cost and time data, we extrapolated costs associated with conducting large-scale surveillance with verbal autopsy. RESULTS: We found that the median time between data collection and data entry for surveys collected on paper and pencil was approximately 3 months. For surveys collected on electronic tablets, this was less than 2 days. For small-scale surveys, we found that the upfront costs of purchasing electronic tablets was the primary cost and resulted in a higher total cost. For large-scale surveys, the costs associated with data entry exceeded the cost of the tablets, so electronic data capture provides both a quicker and cheaper method of data collection. CONCLUSIONS: As countries increase verbal autopsy surveillance, it is important to consider the best way to design sustainable systems for data collection. Electronic data capture has the potential to greatly reduce the time and costs associated with data collection. For long-term, large-scale surveillance required by national vital statistical systems, electronic data capture reduces costs and allows data to be available sooner.

The quality of medical death certification of cause of death in hospitals in rural Bangladesh: impact of introducing the International Form of Medical Certificate of Cause of Death.

BACKGROUND: Accurate and timely data on cause of death are critically important for guiding health programs and policies. Deaths certified by doctors are implicitly considered to be reliable and accurate, yet the quality of information provided in the international Medical Certificate of Cause of Death (MCCD) usually varies according to the personnel involved in certification, the diagnostic capacity of the hospital, and the category of hospitals. There are no published studies that have analysed how certifying doctors in Bangladesh adhere to international rules when completing the MCCD or have assessed the quality of clinical record keeping. METHODS: The study took place between January 2011 and April 2014 in the Chandpur and Comilla districts of Bangladesh. We introduced the international MCCD to all study hospitals. Trained project physicians assigned an underlying cause of death, assessed the quality of the death certificate, and reported the degree of certainty of the medical records provided for a given cause. We examined the frequency of common errors in completing the MCCD, the leading causes of in-hospital deaths, and the degree of certainty in the cause of death data. RESULTS: The study included 4914 death certificates. 72.9% of medical records were of too poor quality to assign a cause of death, with little difference by age, hospital, and cause of death. 95.6% of death certificates did not indicate the time interval between onset and death, 31.6% required a change in sequence, 13.9% required to include a new diagnosis, 50.7% used abbreviations, 41.5% used multiple causes per line, and 33.2% used an ill-defined condition as the underlying cause of death. 99.1% of death certificates had at least one error. The leading cause of death among adults was stroke (15.8%), among children was pneumonia (31.7%), and among neonates was birth asphyxia (52.8%). CONCLUSION: Physicians in Bangladeshi hospitals had difficulties in completing the MCCD correctly. Physicians routinely made errors in death certification practices and medical record quality was poor. There is an urgent need to improve death certification practices and the quality of hospital data in Bangladesh if these data are to be useful for policy.

Maternal mortality in Bangladesh: a Countdown to 2015 country case study.

BACKGROUND: Bangladesh is one of the only nine Countdown countries that are on track to achieve the primary target of Millennium Development Goal (MDG) 5 by 2015. It is also the only low-income or middle-income country with two large, nationally-representative, high-quality household surveys focused on the measurement of maternal mortality and service use. METHODS: We use data from the 2001 and 2010 Bangladesh Maternal Mortality Surveys to measure change in the maternal mortality ratio (MMR) and from these and six Bangladesh Demographic and Health Surveys to measure changes in factors potentially related to such change. We estimate the changes in risk of maternal death between the two surveys using Poisson regression. FINDINGS: The MMR fell from 322 deaths per 100,000 livebirths (95% CI 253-391) in 1998-2001 to 194 deaths per 100,000 livebirths (149-238) in 2007-10, an annual rate of decrease of 5·6%. This decrease rate is slightly higher than that required (5·5%) to achieve the MDG target between 1990 and 2015. The key contribution to this decrease was a drop in mortality risk mainly due to improved access to and use of health facilities. Additionally, a number of favourable changes occurred during this period: fertility decreased and the proportion of births associated with high risk to the mother fell; income per head increased sharply and the poverty rate fell; and the education levels of women of reproductive age improved substantially. We estimate that 52% of maternal deaths that would have occurred in 2010 in view of 2001 rates were averted because of decreases in fertility and risk of maternal death. INTERPRETATION: The decrease in MMR in Bangladesh seems to have been the result of factors both within and outside the health sector. This finding holds important lessons for other countries as the world discusses and decides on the post-MDG goals and strategies. For Bangladesh, this case study provides a strong rationale for the pursuit of a broader developmental agenda alongside increased and accelerated investments in improving access to and quality of public and private health-care facilities providing maternal health in Bangladesh. FUNDING: United States Agency for International Development, UK Department for International Development, Bill & Melinda Gates Foundation.

Cost-effectiveness of invitation to food supplementation early in pregnancy combined with multiple micronutrients on infant survival: analysis of data from MINIMat randomized trial, Bangladesh.

BACKGROUND: Absence of cost-effectiveness (CE) analyses limits the relevance of large-scale nutrition interventions in low-income countries. We analyzed if the effect of invitation to food supplementation early in pregnancy combined with multiple micronutrient supplements (MMS) on infant survival represented value for money compared to invitation to food supplementation at usual time in pregnancy combined with iron-folic acid. METHODS: Outcome data, infant mortality (IM) rates, came from MINIMat trial (Maternal and Infant Nutrition Interventions, Matlab, ISRCTN16581394). In MINIMat, women were randomized to early (E around 9 weeks of pregnancy) or usual invitation (U around 20 weeks) to food supplementation and daily doses of 30 mg, or 60 mg iron with 400 µgm of folic acid, or MMS with 15 micronutrients including 30 mg iron and 400 µgm of folic acid. In MINIMat, EMMS significantly reduced IM compared to UFe60F (U plus 60 mg iron 400 µgm Folic acid). We present incremental CE ratios for incrementing UFe60F to EMMS. Costing data came mainly from a published study. RESULTS: By incrementing UFe60F to EMMS, one extra IM could be averted at a cost of US$907 and US$797 for NGO run and government run CNCs, respectively, and at US$1024 for a hypothetical scenario of highest cost. These comparisons generated one extra life year (LY) saved at US$30, US$27, and US$34, respectively. CONCLUSIONS: Incrementing UFe60F to EMMS in pregnancy seems worthwhile from health economic and public health standpoints. TRIAL REGISTRATION: Maternal and Infant Nutrition Interventions, Matlab; ISRCTN16581394 ; Date of registration: Feb 16, 2009.

Causes of adult female deaths in Bangladesh: findings from two National Surveys.

BACKGROUND: Assessment of causes of death and changes in pattern of causes of death over time are needed for programmatic purposes. Limited national level data exist on the adult female causes of death in Bangladesh. METHOD: Using data from two nationally representation surveys, the 2001 and 2010 Bangladesh Maternal Mortality Surveys (BMMS), the paper examines the causes of adult female death, aged 15-49 years, and changes in the patterns of these deaths. In both surveys, all household deaths three years prior to the survey were identified. Adult female deaths were then followed by a verbal autopsy (VA) using the WHO structured questionnaire. Two physicians independently reviewed the VA forms to assign a cause of death using the ICD-10; in case of disagreement, a third physician made an independent review and assigned a cause of death. RESULTS: The overall mortality rates for women aged 15-49 in 2001 and 2010 were 182 per 100,000 and 120 per 100,000 respectively. There is a shift in the pattern of causes of death during the period covered by the two surveys. In the 2001 survey, the main causes of death were maternal (20 %), followed by diseases of the circulatory system (15 %), malignancy (14 %) and infectious diseases (13 %). However, in the 2010 survey, malignancies were the leading cause (21 %), followed by diseases of the circulatory system (16 %), maternal causes (14 %) and infectious diseases (8 %). While maternal deaths remained the number one cause of death among 20-34 years old in both surveys, unnatural deaths were the main cause for teenage deaths, and malignancies were the main cause of death for older women. Although there is an increasing trend in the proportion of women who died in hospitals, in both surveys most women died at home (74 % in 2001 and 62 % in 2010). CONCLUSION: The shift in the pattern of causes of adult female deaths is in agreement with the overall change in the disease pattern from communicable to non-communicable diseases in Bangladesh. Suicide and other violent deaths as the primary cause of deaths among teenage girls demands specific interventions to prevent such premature deaths. Prevention of deaths due to non-communicable diseases should also be a priority.

Equity in adherence to and effect of prenatal food and micronutrient supplementation on child mortality: results from the MINIMat randomized trial, Bangladesh.

BACKGROUND: Evidence is often missing on social differentials in effects of nutrition interventions. We evaluated the adherence to and effect of prenatal food and micronutrient supplementations on mortality before the age of five years in different social groups as defined by maternal schooling. METHODS: Data came from the MINIMat study (Maternal and Infant Nutrition Interventions, Matlab), a randomized trial of prenatal food supplementation (invitation early, about 9 weeks [E], or at usual time, about 20 weeks [U] of pregnancy) and 30 mg or 60 mg iron with 400 µgm folic acid, or multiple micronutrients (Fe30F, Fe60F, MMS) resulting in six randomization groups, EFe30F, UFe30F, EFe60F, UFe60F, EMMS, and UMMS (n = 4436). Included in analysis after omissions (fetal loss and out-migration) were 3625 women and 3659 live births of which 3591 had information on maternal schooling. The study site was rural Matlab, Bangladesh. The main stratifying variable was maternal schooling dichotomized as <6 years and ≥6 years. We used Cox proportional hazard model for survival analyses. RESULTS: Overall, women having <6 years of schooling adhered more to food (81 vs. 69 packets, P=0.0001) but a little less to micronutrient (104 vs. 120 capsules, P = 0.0001) supplementation compared to women having more schooling, adjusted for maternal age (years), parity and body mass index (BMI, kg/m2) at week 8 pregnancy. Children of mothers with ≥6 years of schooling had lower under-five mortality, but the EMMS supplementation reduced the social difference in mortality risk (using standard program and schooling <6 years as reference; standard program and schooling ≥6 years HR 0.54, 95% CI 0.27-1.11; EMMS and schooling ≥6 years HR 0.28, 95% CI 0.12-0.70; EMMS and schooling <6 years HR 0.26, 95% CI 0.11-0.63), adjusted for maternal age (years), parity and body mass index (kg/m2) at week 8 pregnancy. CONCLUSIONS: The combination of an early invitation to prenatal food supplementation and multiple micronutrient supplementation lowered mortality in children before the age of five years and reduced the gap in child survival chances between social groups. The pattern of adherence to the supplementations was complex; women with less education adhered more to food supplementation while those with more education had higher adherence to micronutrients. TRIAL REGISTRATION: ISRCTN16581394.

A prospective cohort study of stroke mortality and arsenic in drinking water in Bangladeshi adults.

BACKGROUND: Arsenic in drinking water causes increased coronary artery disease (CAD) and death from CAD, but its association with stroke is not known. METHODS: Prospective cohort study with arsenic exposure measured in well water at baseline. 61074 men and women aged 18 years or older on January 2003 were enrolled in 2003. The cohort was actively followed for an average of 7 years (421,754 person-years) through December 2010. Based on arsenic concentration the population was categorized in three groups and stroke mortality HR was compared to the referent. The risk of stroke mortality Hazard Ratio (HR) and 95% Confidence Interval was calculated in relation to arsenic exposure was estimated by Cox proportional hazard models with adjustment for potential confounders. RESULTS: A total of 1033 people died from stroke during the follow-up period, accounting for 23% of the total deaths. Multivariable adjusted HRs (95% confidence interval) for stroke for well water arsenic concentrations <10, 10-49, and ≥50 µg/L were 1.0 (reference), 1.20 (0.92 to 1.57), and 1.35 (1.04 to 1.75) respectively (Ptrend=0.00058). For men, multivariable adjusted HRs (95%) for well water arsenic concentrations <10, 10-49, and ≥50 µg/L were 1.0 (reference), 1.12 (0.78 to 1.60), and 1.07 (0.75 to 1.51) respectively (Ptrend=0.45) and for women 1.0 (reference),1.31 (0.87 to 1.98), and 1.72 (1.15 to 2.57) respectively (Ptrend=0.00004). CONCLUSION: The result suggests that arsenic exposure was associated with increased stroke mortality risk in this population, and was more significant in women compared to men.

Do self-reported health indicators predict mortality? Evidence from Matlab, Bangladesh.

In order to understand current and changing patterns of population health, there is a clear need for high-quality health indicators. The World Health Organization Study on Global AGEing and Adult Health (SAGE) survey platform and the International Network for the Demographic Evaluation of Populations and Their Health in developing countries (INDEPTH) generated data for this study. A total of 4300 people aged 50 years or older were selected randomly from the Matlab Health and Demographic Surveillance System of the International Centre for Diarrhoeal Disease Research, Bangladesh. The health indicators derived from these survey data are self-rated general health, overall health state, quality of life and disability levels. The outcome of the study is mortality over a 2-year follow-up since the survey. Among the four health indicators, only self-rated health was significantly associated with subsequent mortality irrespective of sex: those who reported bad health had higher mortality than those who reported good health, even after controlling for socio-demographic factors. For all other three health indicators, such associations exist but are significant only for males, while for females it is significant only for 'quality of life'.

Stagnation of maternal mortality decline in Bangladesh between 2010 and 2016 in spite of an increase in health services utilisation: Examining data from three large cross-sectional surveys.

Background: After a 40% reduction in maternal mortality ratio (MMR) during 2001-2010 in Bangladesh, the MMR level stagnated between 2010 and 2016 despite a steady increase in maternal health services use and improvements in overall socioeconomic status. We revisited the factors that contributed to MMR decline during 2001-2010 and examined the changes in these factors between 2010 and 2016 to explain the MMR stagnation in Bangladesh. Methods: We used data from the 2001, 2010, and 2016 Bangladesh Maternal Mortality Surveys, which sampled 566 115 households in total, to estimate the changes in the risk of dying of maternal causes associated with a pregnancy or birth between 2001-2010 and 2010-2016. We carried out Poisson regression analyses with random effects at the sub-district level to explore the relationship between the change in risk of maternal death from 2001 to 2016 and a range of demographic, socioeconomic, and health care factors. Results: Between 2001 and 2016, the proportion of high-risk pregnancies decreased, except for teenage pregnancies. Meanwhile, there were notable improvements in socioeconomic status, access to health services, and the utilisation of maternal health services. A comparison of factors affecting the risk of maternal death between 2001-2010 and 2010-2016 indicated that first pregnancies continued to offer significant protection against maternal deaths. However, subsequent pregnancies among girls under 20 years became a significant risk factor during 2010-2016, increasing the risk of maternal deaths by nearly 3-fold. Among the key maternal health services, only skilled birth attendants (SBA) were identified as a key contributor to MMR reduction during 2001-2010. However, SBA is no longer significantly associated with reducing mortality risk during 2010-2016. Conclusions: Despite continued improvements in the overall socioeconomic status and access to maternal health services in Bangladesh, the stagnation of MMR decline between 2010 and 2016 is associated with multiple teenage pregnancies and the lack of capacity in health facilities to provide quality delivery services, as SBA has been primarily driven by facility delivery. The findings provide a strong rationale for targeting at-risk mothers and strengthening reproductive health services, including family planning, to further reduce maternal mortality in Bangladesh.

Smoking-attributable mortality in Bangladesh: proportional mortality study.

OBJECTIVE: To directly estimate how much smoking contributes to cause-specific mortality in Bangladesh. METHODS: A case-control study was conducted with surveillance data from Matlab, a rural subdistrict. Cases (n = 2213) and controls (n = 261) were men aged 25 to 69 years who had died between 2003 and 2010 from smoking-related and non-smoking-related causes, respectively. Cause-specific odds ratios (ORs) were calculated for "ever-smokers" versus "never-smokers", with adjustment for education, tobacco chewing status and age. Smoking-attributable deaths among cases, national attributable fractions and cumulative probability of surviving from 25 to 69 years of age among ever-smokers and never-smokers were also calculated. FINDINGS: The fraction of ever-smokers was about 84% among cases and 73% among controls (OR: 1.7; 99% confidence interval, CI: 1.1-2.5). ORs were highest for cancers and lower for respiratory, vascular and other diseases. A dose-response relationship was noted between age at smoking initiation and daily number of cigarettes or bidis smoked and the risk of death. Among 25-year-old Bangladeshi men, 32% of ever-smokers will die before reaching 70 years of age, compared with 19% of never-smokers. In 2010, about 25% of all deaths observed in Bangladeshi men aged 25 to 69 years (i.e. 42,000 deaths) were attributable to smoking. CONCLUSION: Smoking causes about 25% of all deaths in Bangladeshi men aged 25 to 69 years and an average loss of seven years of life per smoker. Without a substantial increase in smoking cessation rates, which are low among Bangladeshi men, smoking-attributable deaths in Bangladesh are likely to increase.

Protective benefits of deep tube wells against childhood diarrhea in Matlab, Bangladesh.

OBJECTIVES: We investigated whether deep tube wells installed to provide arsenic-free groundwater in rural Bangladesh have the added benefit of reducing childhood diarrheal disease incidence. METHODS: We recorded cases of diarrhea in children younger than 5 years in 142 villages of Matlab, Bangladesh, during monthly community health surveys in 2005 and 2006. We surveyed the location and depth of 12,018 tube wells and integrated these data with diarrhea data and other data in a geographic information system. We fit a longitudinal logistic regression model to measure the relationship between childhood diarrhea and deep tube well use. We controlled for maternal education, family wealth, year, and distance to a deep tube well. RESULTS: Household clusters assumed to be using deep tube wells were 48.7% (95% confidence interval = 27.8%, 63.5%) less likely to have a case of childhood diarrhea than were other household clusters. CONCLUSIONS: Increased access to deep tube wells may provide dual benefits to vulnerable populations in Matlab, Bangladesh, by reducing the risk of childhood diarrheal disease and decreasing exposure to naturally occurring arsenic in groundwater.

Population and family planning in Bangladesh.

INTRODUCTION: The family planning programme (FPP) in Bangladesh and its role in reducing the fertility rate in the country has been at the centre of much scholarly debate. The current contraceptive prevalence rate (CPR) is 61%- double the rate observed in Pakistan, while the total fertility rate is 2.3 children per woman. This paper highlights both the supply-and demand-side factors explaining trends in contraceptive use over the last four decades. It identifies the challenges plaguing the programme today that range from funding and staffing deficiencies to bottlenecks in procurement processes. METHODOLOGY: The paper uses secondary data sources such as Bangladesh Demographic and Health Survey (BDHS) 2004 and 2011 to show Family Planning trends in Bangladesh and uses the Spectrum software to forecast trends for the year 2015. RESULTS: The central message is that the current contraceptive method mix, which is heavily biased towards temporary methods, cannot support a sustained decline in fertility. The authors' projected estimates reveal that in order to achieve replacement-level fertility by 2016, users of long-acting and permanent methods would need to be increased by 8-9 million. Drawing on global experiences, the paper outlines greater flexibility in the use of funds and a regionally-targeted approach, among other options, that could be adopted to ensure that national population targets are met.

Adult mortality trends in Matlab, Bangladesh: an analysis of cause-specific risks.

OBJECTIVE: With socioeconomic development, improvement in preventing and curing infectious diseases, and increased exposure to non-communicable diseases (NCDs) risk factors (eg, overweight/obesity, sedentary lifestyle), the majority of adult deaths in Bangladesh in recent years are due to NCDs. This study examines trends in cause-specific mortality risks using data from the Matlab Health and Demographic Surveillance System (HDSS). DESIGN, SETTINGS AND PARTICIPANTS: We conducted a follow-up study from 2003 to 2017 using data from Matlab HDSS, which covers a rural population of 0.24 million (in 2018) in Chandpur, Bangladesh. HDSS assessed the causes of all deaths using verbal autopsy and classified the causes using the 10th revision of the International Statistical Classification of Diseases. We examined 19 327 deaths involving 2 279 237 person-years. METHODS: We calculated annual cause-specific mortality rates and estimated adjusted proportional HRs using a Cox proportional hazards model. RESULTS: All-cause mortality risk declined over the study period among people aged 15 and older, but the risk from stroke increased, and from heart disease and cancers remained unchanged. These causes were more common among middle-aged and older people and thus bore the most burden. Mortality from causes other than NCDs-namely, infectious and respiratory diseases, injuries, endocrine disorders and others-declined yet still constituted over 30% of all deaths. Thus, the overall mortality decline was associated with the decline of causes other than NCDs. Mortality risk sharply increased with age. Men had higher mortality than women from heart disease, cancers and other causes, but not from stroke. Lower household wealth quintile people have higher mortality than higher household wealth quintile people, non-Muslims than Muslims. CONCLUSION: Deaths from stroke, heart disease and cancers were either on the rise or remained unchanged, but other causes declined continuously from 2003 to 2017. Immediate strengthening of the preventive and curative healthcare systems for NCDs management is a burning need.

Beliefs and practices during pregnancy and childbirth in urban slums of Dhaka, Bangladesh.

BACKGROUND: Worldwide urbanization has become a crucial issue in recent years. Bangladesh, one of the poorest and most densely-populated countries in the world, has been facing rapid urbanization. In urban areas, maternal indicators are generally worse in the slums than in the urban non-slum areas. The Manoshi program at BRAC, a non governmental organization, works to improve maternal, newborn, and child health in the urban slums of Bangladesh. This paper describes maternal related beliefs and practices in the urban slums of Dhaka and provides baseline information for the Manoshi program. METHODS: This is a descriptive study where data were collected using both quantitative and qualitative methods. The respondents for the quantitative methods, through a baseline survey using a probability sample, were mothers with infants (n = 672) living in the Manoshi program areas. Apart from this, as part of a formative research, thirty six in-depth semi-structured interviews were conducted during the same period from two of the above Manoshi program areas among currently pregnant women who had also previously given births (n = 18); and recently delivered women (n = 18). RESULTS: The baseline survey revealed that one quarter of the recently delivered women received at least four antenatal care visits and 24 percent women received at least one postnatal care visit. Eighty-five percent of deliveries took place at home and 58 percent of the deliveries were assisted by untrained traditional birth attendants. The women mostly relied on their landladies for information and support. Members of the slum community mainly used cheap, easily accessible and available informal sectors for seeking care. Cultural beliefs and practices also reinforced this behavior, including home delivery without skilled assistance. CONCLUSIONS: Behavioral change messages are needed to increase the numbers of antenatal and postnatal care visits, improve birth preparedness, and encourage skilled attendance at delivery. Programs in the urban slum areas should also consider interventions to improve social support for key influential persons in the community, particularly landladies who serve as advisors and decision-makers.

Socioeconomic disparities in diabetes prevalence and management among the adult population in Bangladesh.

BACKGROUND: Diabetes, one of the major metabolic disorders, is rising in Bangladesh. Studies indicate there is inequality in prevalence and care-seeking behavior, which requires further exploration to understand the socioeconomic disparities in the pathophysiology of diabetes. This study examined the latest nationally representative estimates of diabetes prevalence, awareness, and management among adults aged 18 years and above in Bangladesh and its association with socioeconomic status in 2017-18. METHODS: We used the 2017-18 Bangladesh Demographic and Health Survey data. Diabetic status of 12,092 adults aged 18 years and above was measured in the survey using fasting plasma glucose levels. We applied multivariate logistic regressions to examine the role of socioeconomic status on diabetes prevalence, awareness, and management, after controlling for relevant covariates. RESULTS: Overall, 10% of adults had diabetes in Bangladesh in 2017-18, with the highest prevalence of 16% in the age group 55-64 years. Our analyses found statistically significant disparities by socioeconomic status in the prevalence of diabetes as well as the person's awareness of his/her diabetic condition. However, the effect of socioeconomic status on receiving anti-diabetic medication only approached significance (p = 0.07), and we found no significant association between socioeconomic status and control of diabetes. CONCLUSIONS: We expect to see an 'accumulation' of the number of people with diabetes to continue in the coming years. The rising prevalence of diabetes is only the tip of an iceberg; a large number of people with uncontrolled diabetes and a lack of awareness of their condition will lead to increased morbidity and mortality, and that could be the real threat. Immediate measures to increase screening coverage and exploration of poor control of diabetes are required to mitigate the situation.

Effect of single session counselling on partner referral for sexually transmitted infections management in Bangladesh.

OBJECTIVES: This study evaluated the role of single session counselling on partner referral among index cases diagnosed as having sexually transmitted infections (STIs) in Bangladesh. METHODS: A quasirandomised trial was conducted in 1339 index cases with symptomatic STIs in 3 public and 3 non-government organisation operated clinics. RESULTS: Out of 1339 index cases, partner referral was achieved by 37% in the counselling group and 27% in the non-counselling group. Index cases in the counselling group and non-counselling group were similar in terms of condom use rates, STI symptoms and duration of disease. A quarter of the index cases reported having more than one sex partner in last 3 months, and 39% reported having commercial sex partners. Only 8% of the index cases reported using condoms during their last sex act. Partner referral rates were higher among index clients with higher age, higher income, those who attended NGO clinics, those who had only one partner and among those who had no commercial partners, but counselling had significantly positive impact in all of these subgroups. In multivariate analysis, the probability of partner referral was 1.3 times higher among index cases in the counselling group (prevalence ratio 1.3; 95% CI 1.1 to 1.6) as compared to index cases in the non-counselling group. CONCLUSIONS: Patient-oriented single session counselling was found to have a modest but significant effect in increasing partner referral for STIs in Bangladesh, greater emphasis should be placed on examining further development and dissemination of partner referral counselling in STI care facilities.

Impact of tubewell access and tubewell depth on childhood diarrhea in Matlab, Bangladesh.

BACKGROUND: During the past three decades in Bangladesh, millions of tubewells have been installed to reduce the prevalence of diarrheal disease. This study evaluates the impacts of tubewell access and tubewell depth on childhood diarrhea in rural Bangladesh. METHODS: A total of 59,796 cases of diarrhea in children under 5 were recorded in 142 villages of Matlab, Bangladesh during monthly community health surveys between 2000 and 2006. The location and depth of 12,018 tubewells were surveyed in 2002-04 and integrated with diarrhea and other data in a geographic information system. A proxy for tubewell access was developed by calculating the local density of tubewells around households. Logistic regression models were built to examine the relationship between childhood diarrhea, tubewell density and tubewell depth. Wealth, adult female education, flood control, population density and the child's age were considered as potential confounders. RESULTS: Baris (patrilineally-related clusters of households) with greater tubewell density were associated with significantly less diarrhea (OR (odds ratio) = 0.87, 95% confidence interval (CI): 0.85-0.89). Tubewell density had a greater influence on childhood diarrhea in areas that were not protected from flooding. Baris using intermediate depth tubewells (140-300 feet) were associated with more childhood diarrhea (OR = 1.24, 95% CI: 1.19-1.29) than those using shallow wells (10-140 feet). Baris using deep wells (300-990 feet) had less diarrheal disease than those using shallow wells, however, the difference was significant only when population density was low (< 1000 person/km(2)) or children were at the age of 13-24 months. CONCLUSIONS: Increased access to tubewells is associated with a lower risk of childhood diarrhea. Intermediate- depth wells are associated with more childhood diarrhea compared to shallower or deeper wells. These findings may have implications for on-going efforts to reduce exposure to elevated levels of arsenic contained in groundwater that is pumped in this study area primarily from shallow tubewells.