Development of an Optical Method to Monitor Nitrification in Drinking Water.

Nitrification is a common issue observed in chloraminated drinking water distribution systems, resulting in the undesirable loss of monochloramine (NH2Cl) residual. The decay of monochloramine releases ammonia (NH3), which is converted to nitrite (NO2-) and nitrate (NO3-) through a biological oxidation process. During the course of monochloramine decay and the production of nitrite and nitrate, the spectral fingerprint is observed to change within the wavelength region sensitive to these species. In addition, chloraminated drinking water will contain natural organic matter (NOM), which also has a spectral fingerprint. To assess the nitrification status, the combined nitrate and nitrite absorbance fingerprint was isolated from the total spectra. A novel method is proposed here to isolate their spectra and estimate their combined concentration. The spectral fingerprint of pure monochloramine solution at different concentrations indicated that the absorbance difference between two concentrations at a specific wavelength can be related to other wavelengths by a linear function. It is assumed that the absorbance reduction in drinking water spectra due to monochloramine decay will follow a similar pattern as in ultrapure water. Based on this criteria, combined nitrate and nitrite spectra were isolated from the total spectrum. A machine learning model was developed using the support vector regression (SVR) algorithm to relate the spectral features of pure nitrate and nitrite with their concentrations. The model was used to predict the combined nitrate and nitrite concentration for a number of test samples. Out of these samples, the nitrified sample showed an increasing trend of combined nitrate and nitrite productions. The predicted values were matched with the observed concentrations, and the level of precision by the method was ± 0.01 mg-N L-1. This method can be implemented in chloraminated distribution systems to monitor and manage nitrification.

Knowledge of pharmacy workers on antihypertensive and anticonvulsant drugs for managing pre-eclampsia and eclampsia in Bangladesh.

BACKGROUND: Pharmacy workers in Bangladesh play an important role in managing pregnancy complications by dispensing, counselling and selling drugs to pregnant women and their families. This study examined pharmacy workers' drug knowledge and practice for pre-eclampsia and eclampsia (PE/E) management, including antihypertensives and anticonvulsants, and determine factors associated with their knowledge. METHODS: A cross-sectional survey with 382 pharmacy workers in public facilities (government) and private pharmacies and drug stores assessed their knowledge of antihypertensive and anticonvulsant drugs. 'Pharmacy workers' include personnel who work at pharmacies, pharmacists, family welfare visitors (FWVs), sub-assistant community medical officers (SACMOs), drug storekeepers. Exploratory and multivariate logistic models were used to describe association between knowledge of medicines used in pregnancy and demographic characteristics of pharmacy workers. RESULTS: Overall, 53% pharmacy workers interviewed were drug store owners in private pharmacies while 27% FWVs/SACMOs, who are government service providers also work as drug prescribers and/or dispensers in public facility pharmacies. Majority of pharmacy workers had poor knowledge compared to correct knowledge on both antihypertensive (77.8% vs 22.3%; p < 0.001) and anticonvulsant drugs (MgSO4) (82.2% vs 17.8%; p < 0.001). Multivariate analysis showed SACMOs and FWVs were greater than 4 times more likely to have correct knowledge on anti-hypertensives (AOR = 4.2, 95% CI:1.3-12.3, P < 0.01) and anticonvulsant drugs (AOR = 4.9, 95% CI:1.3-18.1, P < 0.01) compared to pharmacists. Pharmacy workers who had received training were more likely to have correct knowledge on antihypertensive and anticonvulsant drugs than those who had no training. CONCLUSIONS: Pharmacy workers' knowledge and understanding of antihypertensive and anticonvulsant drugs, particularly for prevention and management of PE/E is limited in Bangladesh. Most pharmacies surveyed are private and staffed with unskilled workers with no formal training on drugs. Expansion of maternal and newborn health programs should consider providing additional skills training to pharmacy workers, as well as regulating these medicines at informal pharmacies to mitigate any harmful practices or adverse outcomes of unauthorized and incorrectly prescribed and used drugs. It is important that correct messaging and medicines are available as drug stores are often the first point of contact for most of the women and their families.

A primary health care model for managing pre-eclampsia and eclampsia in low- and middle- income countries.

BACKGROUND: Hypertensive disorders in pregnancy, specifically pre-eclampsia and eclampsia (PE/E), are the second biggest killer of pregnant women globally and remains the least understood and most challenging maternal morbidity to manage. Although great strides were made in reducing maternal and newborn mortality between 1990 and 2015, this was clearly not enough to achieve the global health goals. To reduce maternal deaths: 1) early detection of PE needs to be improved; 2) effective management of PE/E needs to occur at lower health system levels and should encourage timely care-seeking; and 3) prioritizing the scale up of a comprehensive package of services near to where women live. FINDINGS: This commentary describes a pragmatic approach to test scalable and sustainable strategies for expanding access to quality under-utilized maternal health commodities, interventions and services. We present a primary health care (PHC) PE/E Model based on implementation research on identified gaps in care in several countries, accepted global best practice and built on the basic premise that PHC providers can take on additional skills with adequate capacity building, coaching and supervision, and community members desire control over their own health. The PHC PE/E model displays the linkages and opportunities to prevent and treat PE/E in a simplified way; however, there are numerous interlinking factors, angles, and critical points to consider including leadership, policies and protocols; relevant medicines and commodities, ongoing capacity building strategies at lower levels and understanding what women and their communities want for safe pregnancies. CONCLUSION: The PHC model described here uses PE/E as an entry to improve the quality of ANC and by extension the pregnancy continuum. Bringing preventive and treatment services nearer to where pregnant women live makes sense.

Spectrophotometric Online Detection of Drinking Water Disinfectant: A Machine Learning Approach.

The spectra fingerprint of drinking water from a water treatment plant (WTP) is characterised by a number of light-absorbing substances, including organic, nitrate, disinfectant, and particle or turbidity. Detection of disinfectant (monochloramine) can be better achieved by separating its spectra from the combined spectra. In this paper, two major focuses are (i) the separation of monochloramine spectra from the combined spectra and (ii) assessment of the application of the machine learning algorithm in real-time detection of monochloramine. The support vector regression (SVR) model was developed using multi-wavelength ultraviolet-visible (UV-Vis) absorbance spectra and online amperometric monochloramine residual measurement data. The performance of the SVR model was evaluated by using four different kernel functions. Results show that (i) particles or turbidity in water have a significant effect on UV-Vis spectral measurement and improved modelling accuracy is achieved by using particle compensated spectra; (ii) modelling performance is further improved by compensating the spectra for natural organic matter (NOM) and nitrate (NO3) and (iii) the choice of kernel functions greatly affected the SVR performance, especially the radial basis function (RBF) appears to be the highest performing kernel function. The outcomes of this research suggest that disinfectant residual (monochloramine) can be measured in real time using the SVR algorithm with a precision level of ± 0.1 mg L-1.

Reproductive health and desire for children among young female sex workers in Bangladesh brothels.

Globally, reproductive health research among female sex workers (FSWs) often focuses on pregnancy prevention, but many women who sell sex aspire to have children in the future. In Bangladesh, where early marriage and parenthood is the norm, we examine reproductive histories and childbearing desires of young women who sell sex in brothels. We interviewed 1061 FSWs aged 18 to 24 in eight brothels in three Bangladesh divisions. Interviewers elicited information on sociodemographic characteristics, contraceptive use, pregnancy history, and childbearing desire. Bivariate and multivariate analyses were conducted to examine correlates of wanting to have a child within 24 months.

Construction of a Defined Biomimetic Matrix for Long-Term Maintenance of Mouse Induced Pluripotent Stem Cells.

The existing in vitro culture systems often use undefined and animal-derived components for the culture of pluripotent stem cells. Artificial bioengineered peptides have the potential to become alternatives to these components of extracellular matrix (ECM). Integrins and cadherins are two cell adhesion proteins important for stem cell self-renewal, differentiation, and phenotype stability. In the present study, we sought to mimic the physico-biochemical properties of natural ECMs that allow self-renewal of mouse induced pluripotent stem cells (iPSCs). We develop a genetically engineered ECM protein (ERE-CBP) that contains (i) an integrin binding peptide sequence (RGD/R), (ii) an E-/N-cadherin binding peptide sequence (SWELYYPLRANL/CBP), and (iii) 12 repeats of APGVGV elastin-like polypeptides (ELPs/E).While ELPs allow efficient coating by binding to nontreated hydrophobic tissue culture plates, RGD/R and CBP support integrin- and cadherin-dependent cell attachment, respectively. Mouse iPSCs on this composite matrix exhibit a more compact phenotype compared to cells on control gelatin substrate. We also demonstrated that the ERE-CBP supports proliferation and long-term self-renewal of mouse iPSCs for up to 17 passages without GSK3ß (CHIR99021) and Erk (PD0325901) inhibitors. Overall, our engineered ECM protein, which is cost-effective to produce in prokaryotic origin and flexible to modify with other cell adhesion peptides or growth factors, provides a novel approach for expansion of mouse iPSCs in vitro.

Bile acids increase levels of microRNAs 221 and 222, leading to degradation of CDX2 during esophageal carcinogenesis.

BACKGROUND & AIMS: Bile reflux contributes to development of Barrett's esophagus (BE) and could be involved in its progression to esophageal adenocarcinoma (EAC). We investigated whether bile acids affect levels or functions of microRNAs (MIRs) 221 and 222, which bind to the 3'-UTR of p27Kip1 messenger RNA to inhibit its translation. Reduced p27Kip1 increases degradation of the transcription factor CDX2; levels of CDX2 have been reported to decrease during progression of BE to EAC. METHODS: We used quantitative reverse transcriptase polymerase chain reaction to compare levels of MIRs 221 and 222 and immunohistochemistry to compare levels of p27Kip1 and CDX2 proteins in areas of BE and EAC from each of 11 patients. We examined the effects of bile acid exposure on levels of MIRs 221 and 222 and CDX2 in EAC cells. We investigated the effects of inhibitors of MIRs 221 and 222 on growth of human EAC xenograft tumors in NOD/SCID/IL-2Rγ(null) mice. RESULTS: Levels of MIRs 221 and 222 increased and levels of p27Kip1 and CDX2 decreased in areas of EAC vs BE. Levels of MIRs 221 and 222 increased, along with activity of nuclear bile acid receptor/farnesoid X receptor (FXR), when cultured cells were exposed to bile acids. Incubation of cells with bile acids increased degradation of CDX2; this process was reduced when cells were also incubated with proteasome inhibitors. Overexpression of MIRs 221 and 222 reduced levels of p27Kip1 and CDX2, and knockdown of these MIRs increased levels of these proteins in cultured cells. Inhibitors of MIRs 221 and 222 increased levels of p27Kip1 and CDX2 in EAC cells and reduced growth of xenograft tumors in NOD/SCID/IL-2Rγ(null) mice. CONCLUSIONS: We observed increased levels of MIRs 221 and 222 in human EAC tissues, compared with areas of BE from the same patient. We found that exposure of esophageal cells to bile acids activates FXR and increases levels of MIRs 221 and 222, reducing levels of p27Kip1 and promoting degradation of CDX2 by the proteasome. Our work opened the perspective of therapeutically targeting this pathway either via FXR antagonists or inhibitors of MIRs as a treatment option for BE and EAC.

Antibody Response after Homologous and Heterologous Prime-Boost COVID-19 Vaccination in a Bangladeshi Residential University Cohort.

COVID-19 vaccination strategies, including heterologous prime-boost regimens and additional booster doses, aim to optimize immune responses. However, seroepidemiological studies on immune responses to different COVID-19 vaccine types and schedules remain limited. This study investigated antibody levels following homologous and heterologous prime-and-boost COVID-19 vaccination in Bangladesh. In a cohort of 606 participants who received first/second/booster doses of vaccines (AstraZeneca, Moderna, Pfizer-BioNTech, and Sinopharm), anti-spike IgG and anti-nucleocapsid IgG levels were measured. Antibody titer variations with respect to age, gender, intervals between doses, and prior infection status were analyzed. mRNA vaccines elicited the highest antibody levels after homologous and heterologous boosting. The AstraZeneca booster resulted in a sharp titer decline rate of ~0.04 units per day. Second or booster vaccine doses significantly increased antibody levels, especially in males (p < 0.05). Older age correlated with higher titers, likely reflecting previous infection, which was further confirmed by the elevation of anti-nucleocapsid IgG levels. About 95.5% of non-Sinopharm recipients were anti-nucleocapsid IgG positive, suggesting prior exposure exceeding self-reported infections (12.5%). mRNA and heterologous COVID-19 boosting enhances humoral immunity over homologous prime-boost vector/inactivated vaccination. However, waning immunity merits further investigation across vaccine platforms.

Assessment of biosecurity measures in commercial poultry farms of Rajshahi district in Bangladesh.

The application of biosecurity measures in the poultry sector are essential. Developing and implementing daily biosecurity activities are considered effective methods to prevent infectious diseases on poultry farms. Appropriate farm settings and management reduce the possibility of disease transmission between farms. This study aimed to assess the current biosecurity status of commercial poultry farms in the Rajshahi district of Bangladesh. A cross-sectional study was conducted from June to November 2021, involving 204 poultry farmers in the Rajshahi district, using a multistage sampling technique. Data were collected through face-to-face interviews using a semi-structured questionnaire. The statistically significant (p < 0.05) results found were: most farmers reported that the visitors could not access their farms (broiler vs. layer: 68.1%, 77.0%). A higher proportion of broilers compared to layer farms used company's supplied feed (81.2% vs. 66.7%). A higher proportion of layer (97.8%) farms cleaned the farm's litter within 24 h compared to broiler farms (72.5%). Broiler farms had better records animal mortality than layer farms (76.8% vs. 60.0%). More layer (96.3%) farms compared to broiler (87.0%) farms implemented a vaccination program. The findings of this study revealed that biosecurity measures are well-practiced and implemented in most broiler and layer farms in this region except in a small number of farms. Government authorities should strictly enforce and monitor biosecurity measures in farms that do not practice essential biosecurity measures.

Knockdown of PLC-gamma-2 and calmodulin 1 genes sensitizes human cervical adenocarcinoma cells to doxorubicin and paclitaxel.

BACKGROUND: RNA interference (RNAi) is a powerful approach in functional genomics to selectively silence messenger mRNA (mRNA) expression and can be employed to rapidly develop potential novel drugs against a complex disease like cancer. However, naked siRNA being anionic is unable to cross the anionic cell membrane through passive diffusion and therefore, delivery of siRNA remains a major hurdle to overcome before the potential of siRNA technology can fully be exploited in cancer. pH-sensitive carbonate apatite has recently been developed as an efficient tool to deliver siRNA into the mammalian cells by virtue of its high affinity interaction with the siRNA and the desirable size distribution of the resulting siRNA-apatite complex for effective cellular endocytosis. Moreover, internalized siRNA was found to escape from the endosomes in a time-dependent manner and efficiently silence gene expression. RESULTS: Here we show that carbonate apatite-mediated delivery of siRNA against PLC-gamma-2 (PLCG2) and calmodulin 1 (CALM1) genes has led to the sensitization of a human cervical cancer cell line to doxorubicin- and paclitaxel depending on the dosage of the individual drug whereas no such enhancement in cell death was observed with cisplatin irrespective of the dosage following intracellular delivery of the siRNAs. CONCLUSION: Thus, PLCG2 and CALM1 genes are two potential targets for gene knockdown in doxorubicin and paclitaxel-based chemotherapy of cervical cancer.

Examining Roles, Support, and Experiences of Community Health Workers During the COVID-19 Pandemic in Bangladesh: A Mixed Methods Study.

INTRODUCTION: Understanding community health workers' (CHWs) experiences of sustaining routine health care promotion and provision activities as well as their challenges in adopting new responsibilities within a dynamic context is critical. This study explored the roles and perspectives of CHWs within the government-led coronavirus disease (COVID-19) community health response in Bangladesh. METHODS: We conducted a mixed methods study to explore the government's response to COVID-19 and its association with community health programming through a telephone-based survey of 370 government-employed CHWs. We also conducted 28 in-depth interviews with policy makers, program managers, CHW supervisors, and CHWs. We conducted exploratory and regression analysis of survey data and qualitative analysis of interview data. RESULTS: The majority of CHWs reported receiving training related to COVID-19, including community-based prevention strategies from government and nongovernment stakeholders. Access to infection prevention supplies differed significantly by CHW cadre, and perspectives on the provision of adequate supplies varied qualitatively. CHWs reported slight decreases in routine work across all health areas early in the pandemic, and a majority reported added COVID-19-related responsibilities as the pandemic continued, including advising on signs/symptoms in their communities and referring suspected cases of COVID-19 for advanced facility care. Regression analyses showed that government support and integration of CHWs into their response-particularly being trained on COVID-19-predicted CHW capacity to advise communities on symptoms and provide routine services. DISCUSSION: Government-employed CHWs in Bangladesh continued to provide health education and routine services in their communities despite pandemic- and response-related challenges. Varied support and differential CHW cadre-specific effects on COVID-19 awareness building in the community, referral, and routine service provision merit attention in Bangladesh's pluralistic community health system. While COVID-19 infection and government-mandated lockdowns restricted CHW mobility, the workers' capacity to continue service provision and education can be leveraged in vaccination and surveillance efforts moving forward.

Review of Nitrification Monitoring and Control Strategies in Drinking Water System.

Nitrification is a major challenge in chloraminated drinking water systems, resulting in undesirable loss of disinfectant residual. Consequently, heterotrophic bacteria growth is increased, which adversely affects the water quality, causing taste, odour, and health issues. Regular monitoring of various water quality parameters at susceptible areas of the water distribution system (WDS) helps to detect nitrification at an earlier stage and allows sufficient time to take corrective actions to control it. Strategies to monitor nitrification in a WDS require conducting various microbiological tests or assessing surrogate parameters that are affected by microbiological activities. Additionally, microbial decay factor (Fm) is used by water utilities to monitor the status of nitrification. In contrast, approaches to manage nitrification in a WDS include controlling various factors that affect monochloramine decay rate and ammonium substrate availability, and that can inhibit nitrification. However, some of these control strategies may increase the regulated disinfection-by-products level, which may be a potential health concern. In this paper, various strategies to monitor and control nitrification in a WDS are critically examined. The key findings are: (i) the applicability of some methods require further validation using real WDS, as the original studies were conducted on laboratory or pilot systems; (ii) there is no linkage/formula found to relate the surrogate parameters to the concentration of nitrifying bacteria, which possibly improve nitrification monitoring performance; (iii) improved methods/monitoring tools are required to detect nitrification at an earlier stage; (iv) further studies are required to understand the effect of soluble microbial products on the change of surrogate parameters. Based on the current review, we recommend that the successful outcome using many of these methods is often site-specific, hence, water utilities should decide based on their regular experiences when considering economic and sustainability aspects.

Confirming-and testing-bonds of trust: A mixed methods study exploring community health workers' experiences during the COVID-19 pandemic in Bangladesh, Haiti and Kenya.

Amidst the COVID-19 pandemic and national responses, trust (one's belief that a system acts in one's best interest) is important to consider. In community health systems, trust is embedded in relationships between clients, CHWs, and health system stakeholders. This mixed-methods study explores trust through the evolving COVID-19 crisis in Bangladesh, Haiti, and Kenya, where multi-country community health research was underway. We investigate the extent and ways trust between communities, community health workers (CHWs), and health system actors shift, including its relation to community fear and hostility, through self-reported positive and negative experiences of CHWs and policy/program stakeholders on a phone-based survey with 2,025 CHWs and 72 key informant interviews, including CHWs, in late 2020. On surveys, CHWs reported high levels of community trust (8/10 in Bangladesh and Kenya; 6/10 in Haiti) with over 60% reporting client relief in seeing their CHWs. About one-third of CHWs across countries reported experiencing instances of hostility from community members during the pandemic in the form of refused home-entry, ignored advice, or being shouted at. Multivariate analyses revealed that CHWs reporting more positive and fewer negative experiences is consistently associated with continuing routine work, doing COVID-19-related work, and greater community trust. Qualitative interviews showed that existing pre-pandemic trusting relationships withstood the early phase of COVID-19, mitigating negative community reactions toward CHWs and stigma towards COVID-positive individuals, maintaining routine health services, and sustaining appreciation for CHW-provided prevention information and emotional support. CHW-community and CHW-health system actor trust is strengthened when CHWs are well-resourced; CHW-community trust is strained by public frustration at the pandemic, associated restrictions, and sociopolitical stressors. Our study suggests that with adequate institutional support, bonds of trust can promote resilient community health systems during extended public health crises, through CHWs' commitment to mitigating misinformation, reducing stigma, maintaining routine service provision, and promoting COVID-19 prevention.

Pathways to service access for pre-eclampsia and eclampsia in rural Bangladesh: Exploring women's care-seeking.

BACKGROUND: While women in low- and middle-income countries face a range of barriers to accessing care for hypertensive disorders of pregnancy, there is little understanding of the pathways taken to overcome these constraints and reach the services they need. This study explores the perspectives of women and communities on the influences that impact care-seeking decisions and pathways to health services. METHODS: To understand individual perspectives, we conducted 22 in-depth interviews (IDIs) with pre-eclampsia and eclampsia survivors (PE/E) in a tertiary hospital, where they received care after initiating PE/E services in different parts of the country. In four districts, we conducted one male and one female focus group discussion (FGD) to unearth care-seeking pathways and explore normative perspectives and the range of internal and external influences. Careful thematic analysis using Atlas-ti was applied. RESULTS: Prevailing views of women and communities across settings in Bangladesh indicate varied pathways to care throughout their pregnancy, during childbirth, and in the postnatal period influenced by internal and external factors at the individual, familial, social, and health systems levels. Internal influences draw on women's own awareness of hypertension complications and options, and their ability to decide to seek care. External factors include social influences like family and community norms, culturally-accepted alternatives, and community perceptions of the health system's capacity to provide quality care. The interaction of these factors often delay care seeking and can lead to complex pathways to care. CONCLUSION: Women's individual pathways to care were diverse, despite the homogenous community perceptions of the influences on women's care-seeking behaviors. This finding supports the need for improving quality of care in primary healthcare facilities and strengthening gender equity and community-based promotion activities through targeted policy and programming.

Measuring quality of care at the community level using the contraceptive method information index plus and client reported experience metrics in Bangladesh.

BACKGROUND: Low rates of contraceptive continuation in Bangladesh are a symptom of poor quality family planning (FP) counseling. Improving family planning counseling by the country's community health care workers (CHWs) could improve contraceptive continuation. This study explores client experiences of care from CHWs, as measured by the method information index plus (MII+) and communication quality metric. METHODS: Conducted in a peri-urban sub-district with low contraceptive use rates, this mixed methods study explores FP client experiences with community-based counseling and referrals by Family Welfare Assistants (FWAs), a CHW cadre providing FP services. Client- and patient-reported experience with community FP services was measured by the MII+ and communication quality metric. A quantitative post-service exit survey was coupled with observations of the interactions between 62 FWAs and 692 female clients to measure FWA and client FP knowledge, FWA capacities, attitudes, quality of FP communication, FP referrals, and contraceptive uptake. RESULTS: Summary MII+ scores suggest that only 20% of clients reported adequate provision of information for informed decisions. Observations and self-reporting alike suggest moderate to high quality of communication during FWA and client interactions. Despite FWAs' theoretical knowledge of long-acting reversible and permanent FP methods, few clients were referred to facilities for them; 81% of clients who preferred a pill received it, while only 34% of clients seeking long-acting methods received needed referrals. CONCLUSIONS: Quality community-based FP counseling could help address rising contraceptive discontinuation rates in Bangladesh. While MII and MII+ scores in this study were low, and FWA evinced numerous misconceptions, FWAs demonstrated strong communication skills that facilitate rapport and trust with their clients and communities. Bangladesh's policy and programs should capitalize upon these relationships and enhance CHWs' knowledge of all method types, and side effects management, with updated job aids, refresher training, and supervision.

Measuring client trust in community health workers: A multi-country validation study.

BACKGROUND: Client trust in community health workers (CHWs) is integral for improving quality and equity of community health systems globally. Despite its recognized conceptual and pragmatic importance across health areas, there are no quantitative measures of trust in the context of community health services. In this multi-country study, we aimed to develop and validate a scale that assesses trust in CHWs. METHODS: To develop the scale, we used a consultative process to conceptualize and adapt items and domains from prior literature to the CHW context. Content validity and comprehension of scale items were validated through 10 focus group discussions with 75 community members in Haiti, and Kenya. We then conducted 1939 surveys with clients who interacted with CHWs recently in Bangladesh (n = 1017), Haiti (n = 616), and Kenya (n = 306). To analyze the 15 candidate scale items we conducted a split sample exploratory/confirmatory factor analysis (EFA/CFA), and then assessed internal consistency reliability of resulting set of items. Finally, we assessed convergent validity via multivariable models examining associations between final scale scores with theoretically related constructs. RESULTS: Factor analyses resulted in a 10-item Trust in CHWs Scale with two factors (sub-scales): Health care competence (5 items) and Respectful communication (5 items). The qualitative data also underscored these two sub-domains. The full scale had good internal consistency reliability in Bangladesh, Haiti and Kenya (alphas 0.87, 0.86, and 0.92, respectively; all alphas for subscales were also > 0.7, most > 0.8). Greater scores on Trust in CHWs were positively associated with increased client empowerment, familiarity with CHWs, satisfaction with recent client-CHW interaction, and positive influence of CHW on client empowerment. Scale scores were not influenced by the age, sex, parity, education, and wealth quintiles in across countries and may be affected by contextual factors. CONCLUSIONS: The Trust in CHWs Scale, which includes Health care competence and Respectful communication sub-scales, is the first such scale developed and validated globally. Our findings suggest this 10-item scale is a reliable and valid tool for quantifying clients' trust in CHWs, with potential utility for tracking and improving CHW and health systems performance over time.

The Client Empowerment in Community Health Systems Scale: Development and validation in three countries.

BACKGROUND: Effectively measuring client empowerment is critical for monitoring and supporting empowerment through interventions, including via community health workers (CHWs) on the front line. Yet a comprehensive measure capturing the multidimensional aspects of client empowerment is not currently available. We aimed to develop and validate the Client Empowerment in Community Health Systems (CE-CHS) Scale in three countries. METHODS: We used data from cross-sectional surveys from 2019-2020 with clients of CHWs in Bangladesh (n = 1384), Haiti (n = 616), and Kenya (n = 306). Nineteen candidate CE-CHS Scale items were adapted from existing health empowerment and sociopolitical control scales. Items spanned three hypothesized sub-domains: personal agency around health (eg, "I feel in control of my health"), agency in sharing health information with others (eg, "I feel confident sharing health information with my family/friends"), and empowerment in community health systems (eg, "Most facility/managers would listen to any concerns I raise"). Face and content validity of items were assessed via two focus group discussions in Haiti. For each country, we conducted split-sample exploratory/confirmatory factor analyses (EFA/CFA) and assessed internal consistency reliability. We assessed convergent validity by comparing final full-scale and sub-dimension scores to theoretically related variables. RESULTS: All participants in Bangladesh and Kenya were female, as were 85% in Haiti. Mean age in Bangladesh and Kenya was around 25 years; 40 in Haiti. EFA/CFA resulted in a final 16-item CE-CHS Scale representing the three hypothesized sub-scales. Three items were dropped in EFA due to poor performance. CFA fit statistics were good for the full-scale and each sub-scale. The mean CE-CHS score (range 1 to 4) was 2.4 in in Bangladesh, 2.8 in Haiti, and 3.0 in Kenya. Cronbach's alpha and ordinal theta of the full and sub-scales were greater than 0.7. Increased empowerment was associated with increased trust in CHWs, influence of CHWs on empowerment, satisfaction with CHW services, number of CHW interactions, civic engagement, and education, with slight variations in magnitude and significance by country. CONCLUSIONS: Findings suggest that the 16-item CE-CHS Scale is valid and reliable. This scale can be used to assess levels and determinants of, and changes in, client empowerment in future implementation research and monitoring of community health systems.

Beyond Institutionalization: Planning for Sustained Investments in Training, Supervision, and Support of Community Health Worker Programs in Bangladesh.

INTRODUCTION: Bangladesh has a long history of mature and institutionalized community health worker (CHW) programs in primary health care. However, there is a lot of variability in the performance of the CHW programs in Bangladesh, as well as challenges associated with retention of CHWs. This study describes the challenges for CHWs, which in turn affect their motivation and performance. METHODS: This study was conducted from December 2019 to January 2020 in 4 districts in Bangladesh: Cox's Bazar, Khulna, Rajshahi, and Sylhet. Twenty focus group discussions were conducted with 121 participants, including family welfare assistants (FWA), health assistants (HA), and their direct supervisors. Thirty in-depth interviews were conducted with upazila and district-level stakeholders. Data were analyzed using a thematic approach with a particular focus on CHW motivation, job satisfaction, and incentive preferences for improving morale and performance. RESULTS: Several nonmonetary and monetary factors affect CHWs' motivation, performance, and job satisfaction. Recognition by the community, availability of promotions and technical recognition, increased training opportunities, reduced workloads, identification as government employees, access to transportation, provision of working tools, and improvements in the workplace environment were identified as important nonmonetary incentives. CHWs also discussed the importance of sufficient salaries and allowances. DISCUSSION: Several factors impede the effectiveness of the CHW programs in Bangladesh. Changes to technical ranks and wages for the health care sector need to take a sector-wide lens to enable systematic calibration of wages for all health care workers. This study highlights that institutionalization of CHWs without adequate and sustained support for continued training, compensation, supervision, access to working tools, and recognition is insufficient to drive change. Identifying pragmatic strategies that can be supported through existing government budgets to address these factors is vital to sustaining the community health workforce in Bangladesh.

Development and validation of a multi-dimensional scale to assess community health worker motivation.

BACKGROUND: Ensuring that Community Health Workers (CHWs) are motivated is critical to their performance, retention and well-being - and ultimately to the effectiveness of community health systems worldwide. While CHW motivation is as multi-dimensional construct, there is no multi-dimensional measure available to guide programming. In this study, we developed and validated a pragmatic, multi-dimensional measure of CHW motivation. METHODS: Scale validation entailed qualitative and survey research in Mali and Bangladesh. We developed a pool of work satisfaction items as well as several items assessing the importance of hypothesized sub-dimensions of motivation, based on the literature and expert consultations. Qualitative research helped finalize scale sub-dimensions and items. We tested the scale in surveys with CHWs in Mali (n = 152, 40% female, mean age 32) and Bangladesh (n = 76 women, mean age 46). We applied a split-sample exploratory/confirmatory factor analysis (EFA/CFA) in Mali, and EFA in Bangladesh, then assessed reliability. We also gauged convergent/predictive validity, assessing associations between scale scores with conceptually related variables. RESULTS: The final 22-item scale has four sub-dimensions: Quality of supervision, Feeling valued and capacitated in your work, Peer respect and support, and Compensation and workload. Model fit in CFAs was good, as were reliabilities for the full scale (alpha: 0.84 in Mali, 0.93 in Bangladesh) and all sub-dimensions. To construct scores for the final scale, we weighted the scores for each sub-dimension by CHW-reported importance of that sub-dimension. Final possible range was -6 to +6 (sub-dimensions), -24 to +24 (full scale). Mean (standard deviation) of full-scale scores were 5.0 (3.3) in Mali and 14.5 (5.3) in Bangladesh. In both countries, higher motivation was significantly associated with higher overall interest in their work, feeling able to improve health/well-being in their community, as well as indicators of higher performance and retention. CONCLUSIONS: We found that the Multi-dimensional Motivation (MM) scale for CHWs is a valid and reliable measure that comprehensively assesses motivation. We recommend the scale be employed in future research around CHW performance and community health systems strengthening worldwide. The scale should be further evaluated within longitudinal studies assessing CHW performance and retention outcomes over time.

Influences of electrolytes and glucose on formulation of carbonate apatite nanocrystals for efficient gene delivery to mammalian cells.

Genetic manipulation of human cells through delivery of a functional gene or a gene-silencing element is an attractive approach to treat critical diseases very precisely and effectively. Extensive research on the genetic basis of human diseases with complete sequencing of human genome has revealed many vital genes as possible targets in gene therapy programs. On the other hand, to facilitate cell- or tissue-directed delivery of genes and gene-silencing nucleic acid sequences, both genetic and chemical engineering approaches have led to the generation of various viral and nonviral carriers. However, considering the issues of both safety and efficacy, none of the existing vectors is an ideal candidate for clinical use. We recently established pH-sensitive inorganic nanocrystals of carbonate apatite with capability of efficient intracellular delivery and release of associated DNA molecules for subsequent protein expression. Here we show a new synthetic approach for carbonate apatite crystals with stronger affinity toward DNA, leading to significant increment in both transgene delivery and expression. Moreover, CaCl(2) and NaCl, existing as the major electrolytes in the bicarbonate-buffered solution, dose-dependently govern particle size and eventually internalization and expression of particle-associated DNA.