Research Reports (2013): Health Studies, Vol - XLV

Permanent URI for this collectionhttps://hdl.handle.net/10361/13171

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Oral administration of misoprostol reduces postpartum Haemorrhage in urban slums of Bangladesh
(BRAC Research and Evaluation Division (RED), 2013-04) Banu, Morsheda; Nahar, Shamsun; Hashima-E-Nasreen
To avert deaths from postpartum haemorrhage (PPH), Manoshi initiated community health workers (CHW) administered oral misoprostol (400~g) to women following childbirth either at delivery centers or home in slums of Dhaka and under Gazipur City Corporation in 2009. To study whether the supervised use of misoprostol would reduce primary PPH following childbirth including its feasibility and community acceptability. A non-randomized control trial was undertaken among 3,900 women in urban slums of Dhaka and Gazipur City Corporation during January-August 2011 . Oral misoprostol was prophylactically given to the treatment group following childbirth, while the control group did not receive it. The misoprostol significantly reduced incidence of primary PPH in the intervention group (4.5%) compared to the control group (7.5%). The median blood loss of PPH cases was 868 ml in the treatment and 928 ml in control group. It reduced the rate of bleeding-related emergency transfer, additional medical interventions compared to control group. However, no significant difference was found in blood transfusion between the two groups. We found one-third of the women were aware about misoprostol in intervention while none were aware in the control. The median risk for developing PPH was lesser in the intervention and prolonged third stage of labour found significantly higher in the control group. Misoprostol was found to be widely accepted in the community and feasible to offer parturient by CHWs within 5 minutes following childbirth in intervention group. Prophylactic use of misoprostol administered by CHWs is feasible and effective in reducing the incidence of primary PPH in the parturient of slums of Bangladesh. Besides, community-based education on misoprostol and iron intake throughout pregnancy to reduce the need for blood transfusion should be ensured.
Tuberculosis in 'hard to reach' areas: misperceptions, knowledge, health-seeking behaviour, and challenges
(BRAC Research and Evaluation Division (RED), 2013-03) Islam, Qazi Shafayetul; Ahmed, Syed Masud; Islam, Md. Akramul; Roy, Sanjit; Rifat, Mahfuza
This study was conducted to explore the knowledge and perceptions of health workers and community people about tuberculosis in geographically inaccessible (hard-to-reach) tuberculosis (TB) programme areas of BRAG. The study also explored the health seeking behaviour of TB suspects (having cough >3weeks) and challenges faced by the programme in this particular situation. This cross-sectional survey was conducted in 15 'hard-to-reach' upazilas (out of 30 such upazilas), and another 15 upazilas, adjacent to the above upazilas and selected randomly for comparison. The study included 338 health workers (Shasthya Shebika or SS), 3,600 community people, 1,800 TB suspects and 1,800 non-suspects. Two modules of questionnaires (structured and semistructured) were developed for the health workers and the community people. The study found that the misperception that TB is 'a disease of only male' was common among the health workers (44%) and community people (46-57%). Further, many of them misperceived the common ways of acquiring TB such as by sharing patients' utensils (46-49%), smoking (80-87%), and that TB could be prevented by avoiding smoking (58- 63%). Almost half of the SSs (49%) could not recall at least four messages on TB that they learned from training. Many of the SSs confessed that they were not involved (64%) in delivering TB messages in the community, and a significant numbers of SS (41 %) were not motivated to work in the TB control programme. The community people lacked basic information on TB. Further, almost about half of the community people ( 41-4 7%) were afraid of TB in both the study areas, and a majority of community people (52-56%) reported that they wanted to stay away from the TB patients. The study further found that one-third did not take any treatment for their illness (median duration of illness being six weeks), and two-third did not undergo sputum test. The main sources of treatment of TB suspects were village doctors (26-35%) and attendants at drug shops (35-36%). The geographical distance, treatment noncompliance, and lack of trust in SSs' management were identified as the major constraints in hard-to-reach areas for implementing TB programme efficiently. The implications of these in management of TB control programme are discussed and recommendations are made.
Knowledge and practice of formal physicians regarding control and prevention of TB in light of national guidelines
(BRAC Research and Evaluation Division (RED), 2013) Islam, Qazi Shafayetul; Ahmed, Syed Masud; Islam, Md. Akramul; Islam, Shayla
The study explored the current knowledge and practice of interns and general physicians regarding control and prevention of tuberculosis in light of national guidelines. The study was conducted on 13 public and seven private medical college hospitals to collect information from intern physicians, and the general physicians who were practicing in a half kilometer radius of each medical college. A total of 1474 intern physicians and 539 general physicians participated in the study. It was a self-administered survey. About three-fourth of physicians (75%) had knowledge about community based TB control programme. However, Only 36% reported that they knew details about the programme. Despite majority (90-96%) had comprehensive knowledge on TB as a major public health problem in Bangladesh but, many of them (70%) did not express their intention to become involved in TB control. Because 92% did not know that the main vision of TB control programme (TB would no more as a public health problems). The knowledge score was constructed on 17 knowledge variables regarding basic and clinical aspects of TB. 61% of intern physicians had adequate knowledge (mean scores~ 1 0.82) unlike among general physicians where as it was 44%, (p<0.0001). The logistic regression depicts that physicians were more likely to be knowledgeable when they were aware of national guidelines for TB control (AOR 2.16, 95% Cl: 1.36, 3.44), when physician had access to more sources of TB information (AOR 1.43, 95%CI: 1.1 0, 2.36), more duration of TB information sharing (>6 hours) (AOR 3.10, 95% Cl: 2.37,.07). We also found, male physicians were less knowledgeable than that of female physician (AOR 0.77, 95% Cl: 0.63, 0.95). The majority of physicians treated TB suspects with antibiotics (40-6%), and only advised for further tests (39-44%). Majority of interns and general physicians did not follow the NTP guideline of three mandatory visits of patients to health facilities for follow up during treatment period. Still significant proportion of physicians (37 -50%) did not refer TB patients and suspects for further investigations and services to the nearest DOTS corner. Majority would not ask for X-ray for further investigation when they got two negative results out of three sputum examinations. Onethird of physicians (39%) perceived that medical curriculum was not sufficient for practicing TB (39%). A great majority of physicians (75%) confessed that they sought TB information beyond classroom. In conclusion, they seriously lacked knowledge regarding its clinical aspect of TB management in light of national guidelines. Most of them did not know the details activities of TB control programmes, and did not follow the national guidelines in managing TB patients. Activities of National TB progamme should be visible more. Guidelines should be incorporated in the final year medical curriculum. Appropriate tools, protocols and customized training packages need to be developed for intern and general physicians.
Mother knowledge and health-seeking behavior towards childhood TB
(BRAC Research and Evaluation Division (RED), 2013-03) Islam, Qazi Shafayetul; Ahmed, Syed Masud; Islam, Md. Akramul; Shatil, Tanvir; Siddique, Zakia Sultana
Introduction: BRAC in association with NTP recently started the community-based child TB programme. So far, no independent study has been conducted to explore the extent to which the objectives of the programme have been achieved in terms of raising knowledge about child TB, and changing health-seeking behavior. This study uses quantitative method to evaluate the knowledge, attitude and practices of mothers towards childhood TB. Methods: The study was a cross-sectional in nature and it included mothers (257 in numbers) as respondents on behalf of child TB patients. Structured and semi-structured questionnaires were applied to elicit information. The study involved interviewing 157 BRAG health workers (Shasthya Sebika. SS) to explore their knowledge regarding childhood TB. Results: Both BRAG health workers (47%) and mothers (35%) did not have adequate knowledge about the primary risk source for child TB (closeness of contact). The knowledge of SSs (13-38%) and mothers (7-40%) regarding BCG and isoniazid therapy as a preventive strategy of TB was inadequate and similar. Both the health workers and the mothers had comprehensive knowledge about sputum test (67-78%) and X-ray (63-77%) for detecting TB in children except about tuberculin test (27-28%). Clinical symptoms like low grade fever (80-88%) and chronic cough (73-83%) were well known to them, but weight loss was not noted profusely (20-54%). Majority of SSs (61 %) and the mothers (47%) perceived that TB in children was dangerous. About half of SSs (50%) had high stigma. One-fourth of mothers (27%) did not want to disclose their child's TB due to fear and 35% of them became frustrated due to it. The time between the onset of symptoms and diagnosis of TB among children was 60 days (mean). The majority of child TB patients were aged between 11-14 years (46-65%) followed by 6-10 years (23-28%). More than one-third of the children (38%) had exposure to TB patients at home, and 16% to neighborhood TB patients. About 4 7% of mothers' children received treatment from informal providers at first time. The providers commonly prescribed cough syrup (41%), tablet for fever (40%) and antibiotics (37%). About 55% of mothers went to providers more than four times before diagnosis of her child's TB. The majority of detected cases were diagnosed at district (23%) and private hospitals (30%). A significant majority of children (85%) referred to BRAG for treatment. Conclusion: Programme should organize special training on child TB for awareness of health workers. Strong collaboration between NTP and local communities are required to develop social mobilization, and sensitization in disseminating childhood TB information. Healthcare providers need to set schedule to provide education, increase awareness of contact case screening, early identifying and treating TB infection and disease in children.
Contributing factors for low consumption of animal food among children aged 6-23 months in alive and thrive intervention areas of Bangladesh
(BRAC Research and Evaluation Division (RED), 2013-03) Mukta, Umme Salma; Chakraborty, Barnali; Sayka, Umme; Haque, Md. Raisul; Mia, Md. Moslem Uddin
Introduction: In Bangladesh about two-thirds of total food consumption is rice as main staple food, especially for the poor, in addition to some vegetables, pulses and small quantities of fish, meat, egg, etc. if and when available. The similar dietary pattern and practices were found for under-two children in the intervention areas of Alive and Thrive (A& T) project where mothers were counseled on appropriate complementary feeding practice as a component of Infant and Young Child Feeding (IYCF). BRAG-RED intended to explore these issues to recognize the gaps that might be addressed to increase the consumption of protein from animal foods among the children through the IYCF interventions in A& T areas. Objective: This study aims to identify the barriers leading to low consumption of animal foods by children aged 6-23 months in A & T intervention areas; and to assess their knowledge and practices of dietary intake through 24-hour recall. Methods: Mixed methods were chosen to find comprehensive information in 12 upazi/as, 3 from each of Barguna, Sylhet, Chittagong and Dinajpur districts. The Pusti Kormi (PK), Shasthya Shebika (SS), and mothers/caregivers enrolled in the A& T intervention areas were selected for interview; and those who had involvement in providing the services. In addition, other programme staff from the supervisory level who involved in providing services was also interviewed. Findings: The study revealed from the quantitative findings that, in intervention areas intake from animal sources was 7 -12g at 1 years and 18g at 2 years where the recommended dietary average (RDA) was 14g for less than one years and 16g for less than 2 years. On the other hand in control areas at both age groups the intake ratio was lower. From the qualitative findings majors contributing factors for feeding from animal sources was, lack of knowledge, lack of awareness on protein deficiency, barriers from the family members, myth, etc. Almost similar barriers was found from the quantitative findings like; financial crisis (80.3%), mothers lack of knowledge and awareness (67%), unavailability of the products in near local market (5%), etc. Conclusion: Food consumption from animal sources might be increased among less than two years children by reducing those barriers, by strengthening efforts in the awareness development process in creating demand for appropriate IYCF services at household level especially intake foods from animal sources to improve children's nutritional status.
Beyond drugs: TB patients in Bangladesh need urgent attention for nutrition support during convalescence
(BRAC Research and Evaluation Division (RED), 2013-03) Islam, Qazi Shafayetul; Ahmed, Syed Masud; Islam, Md. Akramul; Kamruzzaman, Md.; Rifat, Mahfuza
Tuberculosis (TB) is a global disease, which is responsible for 1.4 million deaths each year (WHO 2010). Bangladesh is the sixth highest TB-burden country in the world. TB treatment may be complicated when malnutrition also coexists in patients. TB has been found to coexist with malnutrition among patients at the beginning of treatment in both developed and developing countries (Zachariah eta/. 2002, Onwubalili JK 1988, Kennedy et at. 1996, Harries et a/. 1988). Nutrition supplementation can play an important role in improving the disease condition to reduce further morbidity and mortality. Some TB-burden countries have already started food supplementation programme for patients' healthy life (Farmer eta/. 1991, Karyadi et a/. 2002, Paton et a/. 2004, Aye and Wyss 2009). There is no nutrition intervention programme for patients in DOTS (Directly observed treatment, short course) approach to TB treatment under National TB Control Programme (NTP) of Bangladesh, where malnutrition is prevalent. Even, Bangladesh does not have much information about the nutritional situation of TB patients to formulate nutrition intervention. To fill-in this knowledge gap and help in informed design of a nutrition intervention for TB patients, this study measured the nutritional status (using Body Mass Index or BMI) of TB patients before, at two months, and after completion of TB treatment (DOTS) to study the changes during treatment and its relation with various socioeconomic and demographic factors including household food availability and consumption.
BRAC Health Centres (CLINIC): current scenario and future prospects
(BRAC Research and Evaluation Division (RED), 2013-06) Shatil, Tanvir; Hossain, Shamim
OBJECTIVE This study was conducted to understand the current state of affairs in the upgraded BRAC Health Centres (now BRAC clinics) with in terms of infrastructure, operation, access, utilization of services and client satisfaction. METHODS A qualitative research was carried out in four BRAC clinics that have been selected out of the thirteen clinics that are currently in operation. Inventory, observation, exit-interviews, lOis (Indepth Interview), FGDs (Focus group Discussion) and informal discussions were used for collecting relevant information. FINDINGS All clinics were established in rented, multi-storied buildings that have been built for residential purposes. Therefore, they posed a problem in delivering health services. BRAC clinics provided maternal, neonatal and child healthcare that included services for common illnesses like fever, diarrhoea, TB and malaria, at a comparatively lower cost. Interestingly, the clinics were not oriented towards providing emergency care services (e.g. for road traffic accidents, for drowning, poisoning, first aid etc.) Routine diagnostic tests were available in the clinics. Prescribed medicine was mostly available in the clinic pharmacy at a nominal mark-up price. Waiting time for patients was also within reasonable limits. The doctors and staff were found to be modest and professional. BRAC HNPP's community health workers were found to play an important role in referring patients from the community to the clinics. Shortage of health professionals was a problem in all the clinics. Most of the patients were satisfied with the services. However, the common perception of the community was that the clinics were only for poor, pregnant women; that the clinic was mainly a maternal and child healthcare centre. Most of the community members did not know about the range of services provided at the clinics. The community members related the goodwill of BRAC to the BRAC clinics and hence perceived its services to be of good quality. CONCLUSION The study indicates that BRAC clinics are working in the community to meet the health challenges of community members. However, several barriers do exit. These include lack of community awareness regarding the activities and the range of services provided, shortage of skilled health professionals for the delivery of such services and poor infrastructure. However, clients were satisfied with the services and BRAC's goodwill has played a determinate role in / shaping the clinics' image in the community.
Current status of maternal and child health indicators in BRAC EHC Programme areas of Bangladesh
(BRAC Research and Evaluation Division (RED), 2013-02) Chowdhury, Anita Sharif; Islam, Qazi Shafayetul; Ahmed, Syed Masud
Essential Health Programme (EHC) is one of many development efforts of BRAC providing an integrated package of preventive, promotive and basic curative services at a minimum cost to improve health and nutrition of the poor especially reproductive age women and children under-five. The BRAC community-based health workers: Shasthya Shebikas (SSs) and Shasthya Kormis (SKs) provide these services through fortnightly household visits. EHC started its new phase Ill in January 2011 . Therefore, a survey was done to record benchmark data on some selected indicators among·EHC upazilas in align with MDG four and MDG five. The study randomly selected 1200 mothers of under-two children from 30 EHC Upazilas. Data were collected in March 2013.The mothers in this study represented a young age group (25 years) with higher literacy rate. Seventy one per cent were currently using modern family planning (FP) method. The majority (52%) bought pill/condom from drug shop while very few (5%) reported SSs as their source of supplies. One third of the sample households reported that they were visited once in a month by the BRAC SS, while less than a quarter (22.5%) of the households had received no visits. Forty seven per cent of the mothers received ANCs four or more times, while 42 per cent received one PNC during their last pregnancy. Less than two-third of the mothers had heard about micronutrients and had insufficient knowledge of its effect on children's health and use pattern such as appropriate age to initiate and duration of use. Ninety two per cent of the children were found to have received complete immunization. The findings revealed a better status of indicators (e.g . immunization coverage, family planning, antenatal and delivery care, and infant and young child feeding practices) in EHC upazilas than that of national average. The challenge for the programme will be to sustain the current good practices and invest further effort to achieve the desired levels to reach the MDG health goals.
Assessment of knowledge of community health workers and mothers on infant and young child feeding and practices of mothers
(BRAC Research and Evaluation Division (RED), 2013-10) Chowdhury, Anita Sharif; Islam, Qazi Shafayetul; Roy, Sanjit
Poor infant feeding practices are some of major causes of under-nutrition in children under five years of age in Bangladesh. In order to address the issue, BRAC ·has implemented the Alive and Thrive (A&T) programme to promote adequate infant and young child feeding (IYCF) practices in rural Bangladesh. The programme had already been in operation in 22 upazilas in nine districts for more than one-and a half years before the time of the survey (October 2011). We tried to understand the level of knowledge and practices of mothers in IYCF in A& T programme areas. In addition, the study also investigated the Shashthya Shebikas' (SS) (health volunteer) knowledge of IYCF. The study was a post-test cross-sectional study to compare areas with and without A & T intervention as no baseline data was available. Both structured and semi-structured tools were used to collect information. The respondents were: women with children aged under one year (n=1 ,224) and SSs (n=120). Findings reveal that both mothers and SSs had reasonably good knowledge of breast-feeding. For example, 95% of mothers knew about colostrum feeding and the duration of exclusive breast-feeding (without water). Breast-feeding practice was commendable as 89% of mothers fed colostrum immediately after birth, moreover, 75% of mothers practised exclusive breast-feeding. Gapes in knowledge were found regarding the types as well as the nature of complementary food among both mothers and SSs. For example, gaps in knowledge existed in offering age appropriate food, in the frequency of serving and in the quantity to be served to children under one year. In conclusion, it can be said that A& T had progressed well in terms of some important IYCF indicators such as breast-feeding practices. However, it more effort needs to be given to improve complementary feeding practices.

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