Female unmarried adolescents' knowledge on selected reproductive health issues in two low performing areas of Bangladesh: an evaluation study.

BACKGROUND: In Bangladesh, 24 % of the total populations are adolescents. Twelve months intervention was implemented under Demand-Based Reproductive Health Commodity Project (DBRHCP) in two low performing areas: rural Sub-district Nabiganj (population 323,357) and an urban slum in Dhaka city (population 141,912). We evaluated the changes in knowledge of female unmarried adolescents on selected reproductive health issues over the project period in two low performing areas of Bangladesh. METHODS: A pre-post study design was adopted. Under DBRHCP, interventions were focused on training of government service providers, disseminating behaviour change materials within the targeted communities, and employing community-based health promoters (Community Support Group and Peer Promoters) to foster linkages between the community and providers. All households were enumerated. A baseline survey was conducted during November 2006 to March 2007 and an end-line survey was conducted during November 2008 to March 2009. Eight hundred female unmarried adolescents (12-19 years) were selected independently for each survey from each study area through systematic random sampling, capturing changes over the 12 months intervention period. Data was analyzed using SPSS. A chi-square test was used to assess the changes in knowledge between baseline and end-line among the female unmarried adolescents. RESULTS: Female unmarried adolescents had significantly increased knowledge at the end-line about measures to be taken during menstruation like: using clean and dry cloths. Overall, two-third of female unmarried adolescents knew about Family Planning (FP) methods in both study areas but had significantly increased knowledge on injectables and condoms at the end-line. Overall knowledge on Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDs) was markedly different in the urban and rural areas, but a significantly higher proportion of female unmarried adolescents knew about HIV/AIDs from relatives and school curricula, and had increased knowledge about mode of transmission of HIV/AIDs, like: receiving blood from an HIV infected person and using a HIV infected needle or syringe, at the end-line. A significantly higher proportion of female unmarried adolescents reported sexually transmitted infection (STI) related symptoms at the end-line compared to baseline. Overall variation in knowledge about Government healthcare facilities, Non-Government Organization (NGO) healthcare facilities and private healthcare facilities was found in both study areas, but awareness was increased about the type of healthcare facilities at the end-line. CONCLUSION: The improvement of the female unmarried adolescents' knowledge on selected Reproductive Health (RH) issues suggest that the interventions affected RH related knowledge reported in the study. These interventions can be adapted in the health service delivery system to enhance people's knowledge on RH issues to achieve RH for adolescents.

Changes in the selected reproductive health indicators among married women of reproductive age in low performing areas of Bangladesh: findings from an evaluation study.

BACKGROUND: Three-year duration Demand-Based Reproductive Commodity Project (DBRHCP) was launched in three low performing areas: rural Nabiganj (population 323,357), Raipur (population 260,983) and urban slum in Dhaka (population 141,912). OBJECTIVES: Assessing changes in knowledge among married women of reproductive age on selected reproductive health issues and to explore their service utilization patterns over the project period in selected low performing areas of Bangladesh. METHODS: The study adopted a pre- posts design. In the project areas, the entire chain of service provision were modified through the interventions under the DBRHCP, including training of the providers, enhanced behavioral change communication activities, follow-up and counseling, record keeping, reporting and monitoring, as well as improvement in logistics and supplies. Peer promoters were established as linkages between clients and service providers. All households were enlisted. Baseline and end line surveys were done using representative simple random sampling method, capturing changes over one year intervention period. Descriptive analysis was done using SPSS package, version 10. Proportional tests using Stata, version 8 were done to assess changes from baseline to end line. RESULTS: The overall contraceptive prevalence was markedly different in the three study areas but significantly increased in both Dhaka urban slums and Nabiganj. In the rural areas, a higher proportion of the women in endline compared to baseline obtained contraceptive methods from the public sectors. Irrespective of study sites, significantly higher proportion of women received ANC (Antenatal Care) and PNC (Post natal care) in endline compared to baseline. In all study sites higher proportions of women were aware of maternal complications at endline. Services were obtained from qualified persons for reported symptoms of sexually transmitted infections by a higher proportion of women at endline compared to baseline. There were improvements in other RH indicators, such as use of skilled birth attendants and overall utilization of health care facilities by women. CONCLUSIONS: The improvements in several important RH indicators in the intervention areas suggest that the interventions affected selected outcomes reported in the study. The study findings also suggest that investment in the reproductive health sector, particularly in existing government programs, improves RH outcomes.

Treatment-seeking for selected reproductive health problems: behaviours of unmarried female adolescents in two low-performing areas of Bangladesh.

PURPOSE: The reproductive health needs of unmarried adolescents in Bangladesh are largely unmet. This study aimed to explore treatment-seeking behaviour of unmarried female adolescents for selected reproductive health (RH) concerns in two low-performing areas of Bangladesh. METHODS: As part of a large community based-project, a cross-sectional survey was conducted from November 2006 to March 2007. From each of two select study areas, 800 unmarried female adolescents aged 12-19 years were selected for participation by simple random sampling through household listing and were recruited into the study. Trained interviewers administered a structured questionnaire to participating female adolescents. Descriptive and bivariate analytic methods were used compare RH conditions and healthcare seeking behaviour of adolescents across urban and rural settings. RESULTS: Approximately 50% of the sample reported experiencing menstrual problems in the last year. The predominant problems reported by participants included: lower abdominal pain, back pain, irregular menstruation, and excessive bleeding during menstruation. Irrespective of study area, only 40% of the female adolescents with menstrual problems sought treatment from qualified physicians. Otherwise, utilization of healthcare facilities and care providers for reported problems varied significantly by rural and urban areas. Higher proportions of adolescents in the urban setting (15%) also reported recent symptoms of sexually transmitted infections (STIs), compared to those in the rural setting (9%; p<0.001). Across sites, however, self-treatment was the most commonly reported method of care for those who experienced any symptoms of STI. CONCLUSIONS: In general, treatment-seeking behaviours by unmarried female adolescents was low for menstrual problems. A vast majority of unmarried female adolescents practiced self-care for symptoms of STIs while only small proportions sought treatment from qualified physicians. These findings emphasize the need for offering relevant information on RH issues and introducing confidential adolescent-friendly reproductive healthcare facilities to enable unmarried female adolescents access to RH services when necessary.

Impact of training of teachers on their ability, skills, and confidence to teach HIV/AIDS in classroom: a qualitative assessment.

BACKGROUND: Considering the significant impact of school-based HIV/AIDS education, in 2007, a curriculum on HIV/AIDS was incorporated in the national curriculum for high school students of Bangladesh through the Government's HIV-prevention program. Based on the curriculum, an intervention was designed to train teachers responsible for teaching HIV/AIDS in classes. METHODS: In-depth interviews were conducted with teachers to understand their ability, skills, and confidence in conducting HIV/AIDS classes. Focus-group discussions (FGDs) were conducted with students who participated in HIV/AIDS classes. HIV/AIDS classes were also observed in randomly-selected schools. Thematic assessment was made to analyze data. RESULTS: The findings showed that the trained teachers were more comfortable in using interactive teaching methods and in explaining sensitive issues to their students in HIV/AIDS classes. They were also competent in using interactive teaching methods and could ensure the participation of students in HIV/AIDS classes. CONCLUSIONS: The findings suggest that cascading training may be scaled up as it helped increase ability, skills, and confidence of teachers to successfully conduct HIV/AIDS classes.

Association of programmatic factors with low contraceptive prevalence rates in a rural area of Bangladesh.

OBJECTIVE: The study was conducted to identify selected programmatic factors relating to low contraceptive-use in a low-performing rural sub-district in Sylhet division of Bangladesh. METHODS: A cross-sectional survey was carried out among 6983 currently-married women of reproductive age (MWRA) (15-49 years). To estimate the association between current contraceptive-use and other selected factors, multivariate analyse were performed, estimating the crude and adjusted odds ratios (OR), including 95% confidence intervals (CI). RESULTS: The use of health facility by the MWRA in the last three months, distance from the residence to the nearest health facility, and contact with field workers in the last six months was significantly associated with contraceptive prevalence rate (CPR). There were potential differences regarding CPR, sources of contraceptive supply and Family Welfare Assistant (FWA) visit between hard to reach and non-hard to reach unions of Nabiganj sub-district. CONCLUSION: Strategies should be devised to increase the accessibility of MWRA to contraceptive methods by increased partnership with non-public sector and increased contacts with outreach workers through introducing community volunteers, and mobile phones help lines, by organizing frequent satellite clinics (SCs) and making community clinics (CCs) functional. Innovative strategies should be piloted for improving use of contraception in such hard to reach and low performing locality.

A systematic review of economic evaluations of health and health-related interventions in Bangladesh.

BACKGROUND: Economic evaluation is used for effective resource allocation in health sector. Accumulated knowledge about economic evaluation of health programs in Bangladesh is not currently available. While a number of economic evaluation studies have been performed in Bangladesh, no systematic investigation of the studies has been done to our knowledge. The aim of this current study is to systematically review the published articles in peer-reviewed journals on economic evaluation of health and health-related interventions in Bangladesh. METHODS: Literature searches was carried out during November-December 2008 with a combination of key words, MeSH terms and other free text terms as suitable for the purpose. A comprehensive search strategy was developed to search Medline by the PubMed interface. The first specific interest was mapping the articles considering the areas of exploration by economic evaluation and the second interest was to scrutiny the methodological quality of studies. The methodological quality of economic evaluation of all articles has been scrutinized against the checklist developed by Evers Silvia and associates. RESULT: Of 1784 potential articles 12 were accepted for inclusion. Ten studies described the competing alternatives clearly and only two articles stated the perspective of their articles clearly. All studies included direct cost, incurred by the providers. Only one study included the cost of community donated resources and volunteer costs. Two studies calculated the incremental cost effectiveness ratio (ICER). Six of the studies applied some sort of sensitivity analysis. Two of the studies discussed financial affordability of expected implementers and four studies discussed the issue of generalizability for application in different context. CONCLUSION: Very few economic evaluation studies in Bangladesh are found in different areas of health and health-related interventions, which does not provide a strong basis of knowledge in the area. The most frequently applied economic evaluation is cost-effectiveness analysis. The majority of the studies did not follow the scientific method of economic evaluation process, which consequently resulted into lack of robustness of the analyses. Capacity building on economic evaluation of health and health-related programs should be enhanced.

The effect of social franchising on access to and quality of health services in low- and middle-income countries.

BACKGROUND: Social franchising has developed as a possible means of improving provision of health services through engaging the non-state sector in low- and middle-income countries. OBJECTIVES: To examine the evidence that social franchising has on access to and quality of health services in low- and middle-income countries. SEARCH STRATEGY: We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register (up to October 2007), Cochrane Central Register of Controlled Trials (The Cochrane Library 2007, Issue 3), MEDLINE, Ovid (1950 to September Week 3 2007), EMBASE, Ovid (1980 to 2007 Week 38), CINAHL, Ovid (1982 to September Week 3 2007), EconLit, WebSPIRS (1969 to Sept 2007), LILACS, Science Citation Index Expanded and Social Sciences Citation Index (1975 to March 2008), Sociological Abstracts, CSA Illumnia (1952 September 2007), WHOLIS (1948 November 2007). SELECTION CRITERIA: Randomized controlled trials, non-randomized controlled trials, controlled before and after studies and interrupted time series comparing social franchising models with other models of health service delivery, other social franchising models or absence of health services. DATA COLLECTION AND ANALYSIS: Two review authors independently applied the criteria for inclusion and exclusion of studies to scan titles and abstracts. The same two review authors independently screened full reports of selected citations . At each stage, results were compared and discrepancies settled through discussion. MAIN RESULTS: No studies were found which were eligible for inclusion in this review. AUTHORS' CONCLUSIONS: There is a need to develop rigorous studies to evaluate the effects of social franchising on access to and quality of health services in low- and middle-income countries. Such studies should be informed by the wider literature to identify models of social franchising that have a sound theoretical basis and empirical research addressing their reach, acceptability, feasibility, maintenance and measurability.

Impact of an in-built monitoring system on family planning performance in rural Bangladesh.

BACKGROUND: During 1982-1992, the Maternal and Child Health Family Planning (MCH-FP) Extension Project (Rural) of International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), in partnership with the Ministry of Health and Family Welfare (MoHFW) of the Government of Bangladesh (GoB), implemented a series of interventions in Sirajganj Sadar sub-district of Sirajganj district. These interventions were aimed at improving the planning mechanisms and for reviewing the problem-solving processes to build an effective monitoring system of the interventions at the local level of the overall system of the MOHFW, GoB. METHODS: The interventions included development and testing of innovative solutions in service-delivery, provision of door-step injectables, and strengthening of the management information system (MIS). The impact of an in-built monitoring system on the overall performance was assessed during the period from June 1995 to December 1996, after the withdrawal of the interventions in 1992. RESULTS: The results of the assessment showed that Family Welfare Assistants (FWAs) increased household-visits within the last two months, and there was a higher use of service-delivery points even after the withdrawal of the interventions. The results of the cluster surveys, conducted in 1996, showed that the selected indicators of health and family-planning services were higher than those reported by the Bangladesh Demographic and Health Survey (BDHS) 1996-1997. During June 1995-December, 1996, the contraceptive prevalence rate (CPR) increased by 13 percentage points (i.e. from 40% to 53%). Compared to the national CPR (49%), this increase was statistically significant (p < 0.05). CONCLUSION: The in-built monitoring systems, including effective MIS, accompanied by rapid assessments and review of performance by the programme managers, have potentials to improve family planning performance in low-performing areas.

Impact of teachers training on HIV/AIDS education program among secondary school students in Bangladesh: A cross-sectional survey.

BACKGROUND: In 2007, the Government of Bangladesh incorporated a chapter on HIV/AIDS into the national curriculum for an HIV-prevention program for school students. For the efficient dissemination of knowledge, an intervention was designed to train the teachers and equip them to educate on the topic of HIV/AIDS. The present study intended to understand the impact of this intervention by assessing the knowledge, attitudes and behaviours related to HIV/AIDS, among the targeted students. METHODS: A cross-sectional survey was conducted with the students at randomly selected schools from two adjacent districts. Considering exposure to intervention, one district was assigned for intervention and the other as a control. In total, 1,381 students, aged 13-18 years (or above) were interviewed, 675 from the control areas and 706 from the intervention areas. Univariate and bivariate analyses were performed on the collected data. RESULTS: A significantly higher proportion (p<0.001) of students in the intervention areas attended HIV/AIDS classes, demonstrated better knowledge and fewer misconceptions regarding the transmission and prevention of HIV. The same was derived regarding their attitude towards people living with HIV, as a higher proportion (p<0.001) responded positively, compared to the control groups of the study. Additionally, multinomial logistic regression analysis showed that students in intervention area were more likely to have good knowledge on HIV transmission (OR 2.71, 95% CI 1.74-4.22) and prevention (OR 2.15, 95% CI 1.41-3.26) compared to the students in the control areas. CONCLUSIONS: The training programme needs to be scaled up, since it is likely to have an impact among students; we have witnessed that the interventions particularly helped increase HIV/AIDS knowledge among students and positively change the students' attitudes towards HIV/AIDS.

Provider views on the acceptability of an IUD checklist screening tool.

INTRODUCTION: Family Health International developed a simple checklist to help family planning providers apply the new medical eligibility criteria (MEC) of the World Health Organization (WHO) for the use of the intrauterine device (IUD) contraceptive method. METHODS: One hundred thirty-five providers in four countries participated in focus groups to field test the checklist. Before participating in a discussion about the checklist, each provider was given a copy of the checklist, its instructions and hypothetical client scenarios. Providers used the checklist to answer questions about the client scenarios in order to determine if they understood the checklist and if they would correctly determine IUD eligibility for women in updated categories of eligibility on the basis of the checklist. RESULTS: Providers found the checklist easy to use and thought that it would enhance identification of eligible IUD users. Nevertheless, many providers relied on prior knowledge of IUD eligibility rather than the checklist recommendations. Providers only correctly determined eligibility for new categories of IUD use 69% of the time. CONCLUSIONS: The IUD checklist is a useful job tool for providers, but training and effective dissemination of the WHO MEC should precede its introduction to ensure that it is correctly used.

Effects of occupational illness on labor productivity: A socioeconomic aspect of informal sector workers in urban Bangladesh.

OBJECTIVES: The informal sector is the dominant area of employment and the economy for any developing country including Bangladesh. The cost of productivity loss due to absence from work or presenteeism with illness has rarely been examined in the Bangladesh context. This current study, therefore, attempted to examine the impact of ill health of informal sector workers on labor productivity, future earning, and healthcare-related expenditure. METHODOLOGY: A cross-sectional survey was conducted among three occupational groups of informal workers (rickshaw pullers, shopkeepers and restaurant workers) that were generally found in all urban areas in Bangladesh. A total of 557 informal workers were surveyed for this study. RESULTS: Most of the respondents (57%) reported that they had been affected by some type of illness for the last six months. The overall average healthcare expenditure of informal workers was US$48.34, while restaurant workers expended more (US$53.61). Self reported sickness absenteeism was highest (50.37days) in the case of shop keepers, followed by rickshaw pullers (49.31 days), in the last six months. Considering the income loss due to illness in the past six months, the rickshaw pullers were exposed to the highest income loss (US$197.15), followed by the shop keepers (US$151.39). CONCLUSIONS: Although the informal sector contributes the most to the economy of Bangladesh, the workers in this sector have hardly any financial protection. This study provides critical clues to providing financial and social protection to informal sector workers in Bangladesh.

Willingness-to-Pay for Community-Based Health Insurance among Informal Workers in Urban Bangladesh.

INTRODUCTION: Reliance on out-of-pocket payment for healthcare may lead poor households to undertake catastrophic health expenditure, and risk-pooling mechanisms have been recommended to mitigate such burdens for households in Bangladesh. About 88% of the population of Bangladesh depends on work in the informal sector. We aimed to estimate willingness-to-pay (WTP) for CBHI and identify its determinants among three categories of urban informal workers rickshaw-pullers, shopkeepers and restaurant workers. METHODS: The bidding game version of contingent valuation method was used to estimate weekly WTP. In three urban locations 557 workers were interviewed using a structured questionnaire during 2010 and 2011. Multiple-regression analysis was used to predict WTP by demographic and household characteristics, occupation, education level and past illness. RESULTS: WTP for a CBHI scheme was expressed by 86.7% of informal workers. Weekly average WTP was 22.8 BDT [Bangladeshi Taka; 95% confidence interval (CI) 20.9-24.8] or 0.32 USD and varied significantly across occupational groups (p = 0.000) and locations (p = 0.003). WTP was highest among rickshaw-pullers (28.2 BDT or 0.40 USD; 95% CI: 24.7-31.7), followed by restaurant workers (20.4 BDT 0.29 USD; 95% CI: 17.0-23.8) and shopkeepers (19.2 BDT or 0.27 USD; 95% CI: 16.1-22.4). Multiple regression analysis identified monthly income, occupation, geographical location and educational level as the key determinants of WTP. WTP increased 0.196% with each 1% increase in monthly income, and was 26.9% lower among workers with up to a primary level of education versus those with higher than primary, but less than one year of education. CONCLUSION: Informal workers in urban areas thus are willing to pay for CBHI and socioeconomic differences explain the magnitude of WTP. The policy maker might think introducing community-based model including public-community partnership model for healthcare financing of informal workers. Decision making regarding the implementation of such schemes should consider worker location and occupation.

Effectiveness of depot-holders introduced in urban areas: evidence from a pilot in Bangladesh.

Depot-holders are women from the community who promote good health practice and use of clinics. They keep a stock of contraceptives and oral rehydration salts to supply other women and are paid some incentives. In 2003, the NGO Service Delivery Program (NSDP) introduced depot-holders in three types of urban area in Bangladesh as a pilot. This evaluation study was carried out to: (a) establish a baseline for measuring the impact of activities of depot-holders on a comprehensive range of indicators in the long-term, (b) make a preliminary assessment of the impact on the use of selected services of the essen-tial services package (ESP) and other indicators at the end of the pilot phase, and (c) assess the cost of introducing depot-holders and running their activities for a year. Data from the baseline and end of pilot household surveys, together with service statistics from the intervention and comparison areas, were used for assessing the changes in clinic use and commodity distribution. The study found evidence that the depot-holders transferred knowledge to women in the community, provided services, and referred women to clinics run by non-governmental organizations (NGOs). There was a large increase in the number of client contacts at the NGO clinics and in the quantity of oral contraceptive pills and oral re-hydration salts distributed by the NGOs, mostly attributable to the activities of the depot-holders. The estimated cost per depot-holder per year was Tk 15,241 (U.S. dollars 262). Overall, the performance of the depot-holders in the pilot phase suggests that they can be introduced in different types of urban area and can be effective in their dual role as providers and promoters of services.

Costs of integrating demand-based reproductive health commodity model into the Government and NGO service delivery systems in Bangladesh: a supply side perspective.

To estimate additional total cost and average cost of integrating the demand-based reproductive health commodity model into the existing Government and NGO facilities in Bangladesh. Activity based cost analysis was conducted during 2006-2008 in two low performing rural sub-districts (Nabigong and Raipur sub-district) and one urban slum area in Dhaka city, Bangladesh. Activity-based cost data were collected using ingredient approach, which comprised of listing all types of inputs by activity, quantities and prices for each input. Total cost was presented according to capital and recurrent items. The supply side perspective was considered for entire analysis. The total cost of integrating demand-based reproductive health commodity (DBRHC) model into the Government and NGO service delivery system was estimated to BDT 18,667,634 (US$274,524). The proportion of capital cost was 59 % and the recurrent cost was 41 % of the total cost. The average cost per beneficiaries was BDT 230 (US$3.38) only for introducing this model into the existing health system. The built-in interventions of DBRHC model were doable at low-cost at the selected Government and NGO settings at the grass-root level. The model has potential of further cost containment during scaling up-if the intervention costs are adjusted with the existing functionaries of the Government and NGOs.

Feasibility, acceptability, and programme effectiveness of misoprostol for prevention of postpartum haemorrhage in rural bangladesh: a quasiexperimental study.

We explored the feasibility of distributing misoprostol tablets using two strategies in prevention of postpartum haemorrhage (PPH) among women residing in the Abhoynagar subdistrict of Bangladesh. We conducted a quasiexperimental study with a posttest design and nonequivalent comparison and intervention groups. Paramedics distributed three misoprostol tablets, one delivery mat (Quaiyum's delivery mat), a packet of five standardized sanitary pads, and one lidded plastic container with detailed counseling on their use. All materials except misoprostol were also provided with counseling sessions to the control group participants. Postpartum blood loss was measured by paramedics using standardized method. This study has demonstrated community acceptability to misoprostol tablets for the prevention of PPH that reduced overall volume of blood loss after childbirth. Likewise, the delivery mat and pad were found to be useful to mothers as tools for assessing the amount of blood loss after delivery and informing care-seeking decisions. Further studies should be undertaken to explore whether government outreach health workers can be trained to effectively distribute misoprostol tablets among rural women of Bangladesh. Such a study should explore and identify the programmatic requirements to integrate this within the existing reproductive health program of the Government of Bangladesh.

Programmatic aspects of dropouts in child vaccination in Bangladesh: findings from a prospective study.

The present study investigated prospectively programmatic factors relating to dropouts in child vaccination in 6 subdistricts of Bangladesh. A cross-sectional survey (n = 2700) was conducted estimating overall coverage of immunization using cluster sampling. The eligible subsample of children (n = 1064) was followed up prospectively to understand reasons for dropouts. In-depth interviews (n = 73) with mothers/caregivers and service providers were done and EPI (Expanded Programme on Immunization) sessions were observed (n = 131). Irregular EPI sessions were the prime cause of dropouts particularly in low-performing subdistricts. The other programmatic factors linked with dropouts were (a) no reminder about subsequent session/doses, (b) unfriendly behavior or absence of vaccinator, ( c) refusal due to lost card or vaccine exhausted, and (d) short duration of sessions. Providers highlighted constraints such as financial problems for transportation, particularly in the hard-to-reach areas and vacancies of the posts of health assistants. The barriers to completing full schedules of vaccination can be removed to a large extent through programmatic adjustments.

An assessment of vulnerability to HIV infection of boatmen in Teknaf, Bangladesh.

BACKGROUND: Mobile population groups are at high risk for contracting HIV infection. Many factors contribute to this risk including high prevalence of risky behavior and increased risk of violence due to conflict and war. The Naf River serves as the primary border crossing point between Teknaf, Bangladesh and Mynamar [Burma] for both official and unofficial travel of people and goods. Little is known about the risk behavior of boatmen who travel back and forth between Teknaf and Myanmar. However, we hypothesize that boatmen may act as a bridging population for HIV/AIDS between the high-prevalence country of Myanmar and the low-prevalence country of Bangladesh. METHODS: Methods included initial rapport building with community members, mapping of boatmen communities, and in-depth qualitative interviews with key informants and members from other vulnerable groups such as spouses of boatmen, commercial female sex workers, and injecting drug users. Information from the first three stages was used to create a cross-sectional survey that was administered to 433 boatmen. RESULTS: Over 40% of the boatmen had visited Myanmar during the course of their work. 17% of these boatmen had sex with CSW while abroad. There was a significant correlation found between the number of nights spent in Myanmar and sex with commercial sex workers.In the past year, 19% of all boatmen surveyed had sex with another man. 14% of boatmen had participated in group sex, with groups ranging in size from three to fourteen people. Condom use was rare {0 to 4.7% during the last month}, irrespective of types of sex partners. Regression analysis showed that boatmen who were 25 years and older were statistically less likely to have sexual intercourse with non- marital female partners in the last year compared to the boatmen aged less than 25 years. Similarly deep-sea fishing boatmen and non-fishing boatmen were statistically less likely to have sexual intercourse with non- marital female partners in the last year compared to the day long fishing boatmen adjusting for all other variables. Boatmen's knowledge regarding HIV transmission and personal risk perception for contracting HIV was low. CONCLUSION: Boatmen in Teknaf are an integral part of a high-risk sexual behaviour network between Myanmar and Bangladesh. They are at risk of obtaining HIV infection due to cross border mobility and unsafe sexual practices. There is an urgent need for designing interventions targeting boatmen in Teknaf to combat an impending epidemic of HIV among this group. They could be included in the serological surveillance as a vulnerable group. Interventions need to address issues on both sides of the border, other vulnerable groups, and refugees. Strong political will and cross border collaboration is mandatory for such interventions.

Retention, perceived usefulness, and use of family health card in the Bangladesh Health and Population Sector Programme.

A client-retained Family Health Card (FHC) was distributed to all households of 2 districts of Bangladesh under the Health and Population Sector Programme. This study assessed the extent and factors relating to retention of FHC, its perceived usefulness, and the extent of use. Quantitative and qualitative data were collected from randomly selected subdistricts. Nearly half of clients retained FHC. The card retainers were married, females, and educated, and sought services for their children. Multivariate analysis confirmed that educational attainments, sex, clients' perceived usefulness of FHC, and enforcement by service providers for bringing FHC were significantly associated with retention of FHC. Both clients and service providers perceived FHC as a useful tool that supports the service-delivery system. The client provider observations identified some omissions made by the providers in filling up the sections contained screening checklists thus they missed the opportunity asking about the additional needs of the family. FHC was used for referring about one-fifth of clients. More orientation of service providers with particular emphasis on sections containing screening checklists in FHC is needed for better identification of additional family-health needs. Ample opportunities exist promoting FHC for tapping the missed opportunities to address unmet needs of a whole family.