Thesis/ Project Report, Master of Public Health (James P. Grant School of Public Health)

Permanent URI for this collectionhttps://hdl.handle.net/10361/15234

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Open Access
Burden, barriers, and behavioral adaptation: A mixed-method study of hypertension and diabetes management among the geriatric population in the drought-prone barind tract of Bangladesh
(BRAC University, 2026-06) Quadir, Kazi Maruf; Misha, Farzana; BRAC James P Grant School of Public Health
Background: Intense heat and extended periods of drought is a growing concern for the rural elderly in the north-western Barind tract of Bangladesh, both physiologically and economically. Bangladesh is currently experiencing an epidemiological transition, where geriatric population is suffering from non-communicable diseases such as hypertension and diabetes, and there is a need to understand the impact of environmental precarity on the management of chronic diseases. Objectives: Overall the goal was to determine the burden and climate sensitive management of HTN and DM in the geriatric population in the rural drought-prone Barind tract. Specific objectives were to establish prevalence of these conditions, exposure to predisposing risk factors and coping and challenges faced by the people in extreme climatic conditions. Methods: The study was conducted in Niamatpur Upazila, Naogaon District using mixed method study approach. The secondary data for phase 2 (quantitative) was obtained from a climate-sensitive surveillance database for 225 geriatric subjects (60 years old and above) through the two-stage stratification random sampling technique. Purposive sampling was used to select 12 in-depth interviews (IDIs) with patients and 3 key informant interviews (KIIs) with healthcare providers. Thematic analysis with a hybrid coding structure was used for the qualitative data, and descriptive statistics were used to analyze the quantitative data using Stata. Results: Diagnosed cases of hypertension presented 37.33% and diabetes 10.67%. A critical treatment gap was identified with 47.62% of hypertensive patients reporting not taking treatment medication and 41.67% of diabetic patients reported doing the same. 58.3% among the diabetic individuals and 60.7% among the hypertensive individuals are on low level of physical activity. Qualitative results emphasized a reactive care tendency whereby patients are dependent on physical signs and not routine screening. The significant obstacles to care were high carrying costs of treatment, institutional friction (long queues) and forgetfulness. The seasonal adaptation was to range across dietary behavior change to physical activity moderation to cope with seasonal extremities. Conclusions: The geriatric population in Barind tract is exposed to various risk factors due to aging, chronic metabolic diseases and environmental stress factors. The large treatment gaps stem from the lack of resources and the dysfunction of the primary health care supply chain. Public health implications include the need for climate-resilient health infrastructure, subsidized geriatric medications and seasonally focused health education to offset the cumulative effects of drought and heat on the outcomes of chronic diseases.
Open Access
A voice in the choice: Adolescent girls' participation in menstrual material decisions and its association with reduced unmet needs — evidence from the AMEHC study
(BRAC University, 2026-06) Neha, Raisa Azim; Quayyum, Zahidul; BRAC James P Grant School of Public Health
Background: Adolescent schoolgirls in low-resource settings face extensive structural and social barriers to managing menstruation with dignity. While economic constraints are frequently studied, the protective value of adolescent individual voice and household-level purchasing autonomy remains under-researched. This study evaluated the cross-sectional association between adolescent girls’ participation in menstrual material purchasing choices and their ability to meet comprehensive menstrual practice needs in the Khulna district of Bangladesh. Methods: A complete-case analysis was conducted using cross-sectional data collected in 2024 for the Adolescent Menstrual Experiences and Health Cohort (AMEHC) study. From a baseline enrollment of 2,015 Class 6 schoolgirls, the final analytical sample was restricted to n = 1,464 post-menarche students who possessed non-missing covariate responses. This stabilization followed the sequential exclusion of 385 participants who were pre-menarche at Wave 1, 95 with missing data on purchasing decisions, 70 with incomplete responses on the outcome scale, and 1 case with missing social support data. Menstrual practice needs were measured using the validated 18-item Menstrual Practice Needs Scale–Short Form (MPNS-SF). Primary exposure agency was operationalized as a binary indicator tracking independent or joint adolescent participation in purchasing choices. To account for institutional school-level clustering across 101 physical school sites, multi-level mixed-effects logistic regression models were developed to estimate adjusted odds ratios (aOR) at a 95% confidence interval (CI). Results: The mean age of the post-menarche sample was 12.4 years, and 56.4% of the cohort actively participated in material purchasing decisions. After adjusting simultaneously for age, geographic setting, household wealth quintiles, parental baseline gender norms, and individual beliefs, active adolescent purchasing participation was significantly associated with a 31% lower odds of experiencing comprehensive unmet menstrual needs (aOR = 0.69; 95% CI: [0.52, 0.93]; p = 0.014). Strong negative statistical associations with the outcome were also observed for the background adjustment covariates of higher maternal social support (aOR = 0.17; 95% CI: [0.11, 0.26]; p < 0.001) and equitable personal gender norms (aOR = 0.56; 95% CI: [0.39, 0.80]; p = 0.002). Household wealth and geographic region setting did not maintain independent statistical associations within the fully adjusted multi-level specification. Conclusions: Individual purchasing agency and supportive social networks demonstrate strong negative statistical correlations with unmet menstrual needs. Because this model adjusted for psychosocial traits and decision-making access simultaneously, the null findings for household wealth may reflect statistical mediation paths rather than a true absence of economic influence. Public health interventions should move beyond basic material aid to focus on increasing supportive household communication with the adolescent girls, shifting restrictive personal gender beliefs, and expanding girls' active participation in health-related material choices.
Open Access
Factors associated with anxiety and depression among caregivers of children with non-communicable diseases in Bangladesh: A cross-sectional study at Bangladesh Medical University
(BRAC University, 2026-06) Chowdhury, Nil Mayuri; Ahmed, Syed Masud; BRAC James P Grant School of Public Health
Background: Non-communicable diseases (NCDs) in children require long-term care that causes physical, emotional and financial burdens on families. The mental health of caregiver is still underexplored in the Bangladeshi context even though their psychological well being directly affects the quality of care a child receives as well as overall functioning of the family.. Objectives: To assess the mental health status of caregivers of children with NCDs and identify the socio-demographic and disease-related factors associated with anxiety and depression. Methods: A hospital-based cross-sectional study was conducted at the Department of Paediatrics, Bangladesh Medical University, between January to June 2026. A total of 310 primary caregivers of children under 18 years diagnosed with thalassemia, congenital heart disease, nephrotic syndrome, bronchial asthma, type 1 diabetes mellitus and epilepsy were recruited through convenience sampling. Anxiety and depression were assessed using the GAD-7 and PHQ-9, with a cut-off of ≥ 10 indicating clinically significant symptoms. Data were analyzed in STATA 17.0 using chi-square tests and multivariable logistic regression (p <0 .05). Results: Most respondents were female (77%), mothers (76%), housewives (67%), and aged over 30 years (53%); 65% earned less than BDT 25,000 per month and 44% cared for children aged five years or younger. Overall, 61% of caregivers screened positive for anxiety and 60% for depression. In the multivariable analysis, financial stress was the strongest independent predictor of both anxiety (AOR = 4.94, 95% CI: 2.37–10.33) and depression (AOR = 4.67, 95% CI: 2.31–9.45). Caregivers of children aged five years or younger had over seven times higher odds of anxiety (AOR = 7.33) and over three times higher odds of depression (AOR = 3.40). Mothers had twice the odds of depression compared to fathers (AOR = 2.14), and caregivers in the lowest income group had five times higher odds of anxiety (AOR = 5.01). Conclusions: Three out of five caregivers of children with NCDs in experience clinically significant anxiety or depression. Financial stress, young child age and being the mother are key independent predictors. Routine caregiver mental health screening and combined clinical and financial support should be integrated into paediatric NCD services.
Open Access
Lived experience of occupational health and safety among street sweepers in Dhaka city: A qualitative study
(BRAC University, 2026-06) Hassan, Mahira; Quayyum, Zahidul; BRAC James P Grant School of Public Health
Background: Street sweepers play a critical role in urban waste management, but are still a marginalized occupational group in low and middle-income countries. Dhaka, being one of the most densely populated cities, generates large volumes of waste every day, putting this group of people in the front line of urban sanitation under hazardous conditions. The street sweepers are continuously exposed to various physical, chemical, biological, and ergonomic hazards due to their working conditions and poor institutional support. While existing studies have documented health hazards and disease prevalence, limited qualitative evidence exists on how street sweeper in Dhaka perceive their health risks, seek care or manage with the ongoing demand of the occupation. Objectives: To explore the lived experiences of occupational health and safety, perceived health risk, occupation-related health problems, health-seeking behaviour, and coping mechanisms among the street sweepers in Dhaka city. Methods: A qualitative study was conducted with six wards of Dhaka North City Corporation (DNCC) in Badda, Mohakhali, Rampura, and Mirpur. 22 In-depth interviews with street sweepers, 7 key informant interviews with their direct supervisors, and 4 non-participant observations were held using snowball sampling, guided by the principle of data saturation. Thematic analysis approach was used for conducting the data analysis using deductive and inductive coding. Results: Four themes emerged from the data analysis:1) Perceived health risks, 2) Health problems, 3) Health-seeking behaviour, 4) Coping and adaptation mechanisms. The perceived health risks were mixed among the street sweepers, where some could identify their workplace hazards while others underestimated the risks or perceived illness as a matter of fate. Musculoskeletal pain was the most frequently reported health concern, followed by respiratory illness, chronic disease, skin diseases, and gastrointestinal problems. The street sweepers described mental exhaustion, financial tension, restlessness, and loss of peace of mind, showing up through irritability, anger, crying, and family conflict rather than being separately named as a mental health issue. Health care seeking was consistently delayed or avoided, primarily due to low income, time constraints, and cost of care, with pharmacies serving as the first and often only point of care, followed by public and private facilities if felt necessary. Street sweepers coped through normalising hardship, self-medication, peer support, and religious faith. Conclusions: Street sweepers in Dhaka face increasing occupational health hazards and safety issues. Despite existing legal protection, there are unenforced labour laws, limited access to healthcare, and organizational support being absent in practice. Ensuring permanent employment benefits, provision of workplace facilities, enforcement of existing labour laws, and focused occupational health interventions are in urgent need to protect the safety and health of the overlooked occupational group, street sweepers.
Open Access
Assessment of cognition and psychological capacity of older adults: A cross-sectional study
(BRAC University, 2026-06) Anan, Aysha; Mridha, Malay Kanti; BRAC James P Grant School of Public Health
Background: The ageing population is increasing globally, with the number of older adults aged 60 years or more expected to reach 2.1 billion by 2050. Bangladesh is no exception, with a current older population of approximately 15.3 million, projected to double by 2050. Cognitive decline and reduced psychological capacity are two important yet under-recognised challenges of ageing. However, no assessment of these domains using the World Health Organization’s Integrated Care for Older People (ICOPE) has been conducted in Bangladesh. Objectives: To assess the status of cognition and psychological capacity in older adults in rural Bangladesh and identify factors associated with the decline of these domains. Methods: A cross-sectional study was conducted among 402 older adults aged ≥ 60 years in three wards within the Sujalpur union of Birganj subdistrict, Dinajpur, Bangladesh, from March to April 2026. A simple random sampling technique was used to select the study participants. Bangla adaptation of the Mini-Mental State Examination (BAMSE) and Patient Health Questionnaire-9 (PHQ-9) were used to assess cognitive status and depressive symptoms. A score of less than 24 on the BAMSE was considered to indicate cognitive decline, and a score of more than 10 on the PHQ-9 was considered to indicate depressive symptoms. Data were analysed using Stata V.17.0, and descriptive and multivariable logistic regression analyses were performed. Results: The prevalence of cognitive decline was 41.8 % (n=168), and the prevalence of depressive symptoms was 46.8% (n=188). Female sex (adjusted odds ratio (aOR): 2.84, 95% CI: 1.57-5.12) and adequate physical activity (aOR: 0.59, 95% CI: 0.37-0.95) were associated with cognitive decline. Socio-economic factors related to depressive symptoms were the highest household wealth tertile (aOR: 0.57, 95% CI: 0.32-0.99) and female sex (aOR: 2.14, 95% CI: 1.17-3.93), malnutrition (aOR: 3.42, 95% CI: 1.65-7.12), and adequate sleep ≥7 hours (aOR: 0.40, 95% CI: 0.24-0.66) were associated with depressive symptoms. Conclusions: A high prevalence of cognitive decline and depressive symptoms was observed among older adults in rural Bangladesh. Factors such as sex, household wealth, physical activity, sleep, and nutritional status emerged as key determinants and should be considered when developing targeted interventions for older adults. These findings underscore an urgent need to integrate cognitive and psychological care into primary healthcare using the ICOPE framework.
Open Access
Extreme heat and child health care practices in drought-prone rural Bangladesh: A mixed-method study
(BRAC University, 2026-06) Khwaja, Atiya; Misha, Farzana; BRAC James P Grant School of Public Health
Background: Extreme heat is an increasing public health concern in Bangladesh, particularly for children under 5. However, existing peer-reviewed studies have not adequately examined how caregivers in drought-prone rural settings recognise, manage, and seek care for childhood illnesses during extreme heat. Objectives: This study aimed to assess child healthcare practices during extreme heat among children under 5 in drought-prone rural Bangladesh by estimating selected illness prevalence, exploring caregivers’ perceptions and home-based coping practices, and identifying reasons influencing care-seeking. Methods: A mixed-methods study was conducted in Niamatpur Upazila, Naogaon District. The quantitative component used secondary data of 239 children under 5 from the BRAC Health Program surveillance project dataset and was analyzed descriptively using STATA/MP 17.0. The qualitative component included 12 in-depth interviews and 2 focus group discussions with total 27 primary caregivers, all mothers, selected through purposive sampling. Qualitative data were collected using semi-structured guidelines and vignette-based scenarios, and were analyzed thematically. Results: Fever was the most commonly reported illness (43.9%), followed by cold/cough (33.5%), heat-related illnesses (6.7%), diarrhea (6.3%), and acute respiratory illness (2.5%). Qualitative findings showed that caregivers understood extreme heat through bodily discomfort and recognised children’s heat-related illness through crying, irritability, sweating, thirst, reduced movement, and seasonal illness patterns. Home-based cooling and indigenous practices were the first line of care, followed by informal providers and, finally, formal facilities when illness became severe or unresolved. Financial constraints, transport difficulties, distance, uncertainty at facilities, perceived discrimination, and gendered caregiving burden shaped care-seeking decisions. Conclusions: Extreme heat affects child health as both an environmental exposure and a household caregiving stressor. Interventions should strengthen community-level heat-health messages, promote safe home-based practices, engage informal providers and household decision-makers, and improve timely access to respectful formal healthcare in heat-vulnerable rural communities.
Open Access
Utilization, acceptability, and satisfaction regarding reproductive health services at rehabilitated community clinics in climate disaster prone chars in Bogura: A mixed-method research among women of reproductive age
(BRAC University, 2026-06) Muang, Pau Sian; Barua, Mrittika; BRAC James P Grant School of Public Health
Background: Bangladesh reduced its maternal mortality ratio to 115 per 100,000 live births in 2023 but remains above SDG target. Women in char areas consistently face compound barriers to reproductive health (RH) services. Community Clinics (CCs) are the primary community-level RH service delivery, yet evidence on how rehabilitated CCs in climate-vulnerable settings particularly from women’s perspective remains limited. Objectives: This study evaluated how women of reproductive age experience RH services delivered through rehabilitated CCs under the JAMUNA Project in the char areas of Bogura District, Bangladesh. Specific objectives were to assess utilization trends, measure client satisfaction, explore acceptability of RH services and identify barriers and facilitators to service use. Methods: A convergent parallel mixed-methods design was used at two rehabilitated CCs. The quantitative part included a cross-sectional client survey (N = 101 women aged 18--49 years; simple random sampling) using 18-item Patient Satisfaction Questionnaire (PSQ-18) and a secondary trend analysis of routine RH services across 26-months period (12 months pre- and 14 months postrehabilitation). The qualitative part included ten in-depth interviews (IDIs) guided by the Theoretical Framework of Acceptability and non-participant facility observation. Quantitative data were analyzed using Stata/BE 19.5; qualitative data through Framework Analysis. Both strands were combined at interpretation. Results: The PSQ-18 overall mean satisfaction score was 3.94 (SD = 0.26, scale 1-5) with 60.4% of participants classified as satisfied (95% CI: 50.2% - 70.0%). Interpersonal Manner had the highest score (mean = 4.29) while Accessibility and Convenience had the lowest (mean = 3.71). Clinic site was the only variable significantly associated with satisfaction (χ² = 8.110, p = 0.004, Cramér's V = 0.283) while women at partially rehabilitated Tengra Kura CC reported higher satisfaction (73.6%) than those at fully rehabilitated Pakuria CC (45.8%). Age, education, and type of RH service received were not significantly associated. Utilization trends were mixed. FP volumes increased at both sites (Pakuria CC: +6.2%; Tengra Kura CC: +6.8%) while ANC volumes diverged as +11.3% at Tengra Kura CC and -12.8% at Pakuria CC. PNC showed the weakest uptake, 22.9% declined at Pakuria CC with a marginal +7.1% at Tengra Kura CC. Qualitative findings pointed provider courtesy and geographic proximity as the primary acceptability facilitators. Seasonal flooding compounded persistent infrastructure deficits, irregular provider attendance, opportunity costs and limited awareness of the full RH service package. Conclusions: Physical rehabilitation of community clinics in flood-prone char areas is meaningful as client satisfaction reached 60.4% and FP utilization grew consistently. However, PNC declined at the fully rehabilitated site and ANC trends diverged indicating structural completion alone does not reliably translate into increased utilization. The provider-client relationship, gender-responsive staffing, climate-resilient service continuity and basic diagnostic capacity were the factors most consistently associated with whether rehabilitated CCs services are acceptable and accessible. Climate-resilient CC policy should incorporate minimum quality standards with construction metrics and seasonal contingency frameworks.
Open Access
Understanding implementers’ perspectives on the barriers and facilitators of wash interventions under the JAMUNA project in climate-vulnerable char areas of Bogura, Bangladesh: A qualitative implementation research study
(BRAC University, 2026-06) Urboshi, Ismat Zaman; Barua, Mrittika; BRAC James P Grant School of Public Health
Background: Bangladesh's riverine char communities are among its most climate-vulnerable populations, where recurrent flooding and erosion repeatedly destroy water and sanitation infrastructure and raise the burden of diarrhoeal disease. The JAMUNA project, a joint venture by BDRCS and Swiss Red Cross, delivers WASH interventions here, yet implementers' experiences of delivery remain largely undocumented. Objectives: To identify the barriers and facilitators experienced by implementers of WASH interventions under the JAMUNA project, and the adaptive strategies they used to overcome challenges in the char areas of Bogura. Methods: A qualitative exploratory study was conducted in Chaluabaria and Kazla unions, Sariakandi Upazila, Bogura. Between March and April 2026, 17 key informant interviews were conducted with implementers from multiple project tiers. Participants were selected purposively until data saturation was reached, using six semi-structured guides based on the CFIR domains. Interviews were held in Bangla, transcribed verbatim, and analysed using the Framework Method in Dedoose, producing 657 coded excerpts. Results: Facilitators included dismantlable, displacement-friendly latrines and raised DRR tubewells suited to flooding; community co-financing that strengthened ownership; organisational coverage of field-staff travel costs; school-based hygiene sessions; and revitalization of the Ward Disaster Management Committee, anchoring delivery in local governance. Barriers included geographic isolation, recurrent displacement, poverty, political and kinship influence over beneficiary selection, and workforce shortages from reliance on unpaid volunteers. Adaptive strategies included multi-step beneficiary verification, engaging religious leaders, instalmentbased bKash payments, and locally tailored session delivery. Conclusions: This study demonstrates that WASH delivery in the char areas is not a discrete technical task but a continuous process of adaptation to displacement, poverty, and local power dynamics. Although portable, raised infrastructure was essential, its effectiveness depended on community co-financing, digital payment mechanisms, the engagement of trusted local leaders, and an adequately supported frontline workforce. Together, these social and organisational factors were as central to implementation as the infrastructure itself.
Open Access
Association between household food production diversity and minimum dietary diversity of women in rural Bangladesh: A secondary analysis from BIHS 2018-19
(BRAC University, 2026-06) Apu, Apurbo Aham; Ireen, Santhia; BRAC James P Grant School of Public Health
Background: Despite advances in food production in the last decade, rural Bangladeshi women of reproductive age (15-49 years) still suffer from micronutrient deficiency due to inadequate dietary diversity. A growing number of literatures suggest a positive association between production diversity and dietary diversity of women in rural Bangladesh. However, evidence from Bangladesh remains limited on the association between production diversity and dietary diversity indicators, particularly at a national scale. This knowledge gap has important implications for national nutrition and agriculture policies and programmes. Objectives: To investigate the association between household food production diversity and the dietary diversity among women of reproductive age 15-49 years in rural Bangladesh. Methods: A quantitative, cross-sectional study was done using the data from the third round of Bangladesh Integrated Household Survey (BIHS, 2018-19). Non-pregnant, non-lactating rural women of reproductive age 15-49 years were included for the analyses (n=3687) with complete dietary, production and household level data. Women’s dietary diversity was measured by Minimum Dietary Diversity of women (MDD-W) and dietary diversity score (WDDS). Production diversity was measured by Minimum Food Group Production Diversity (MFGPD) and Food Group Production Diversity Score (FGPDS) based on the same 10 food group as MDD-W. The survey weighted descriptive, bivariate and multivariate regression analyses were done to assess the association between dichotomous minimum food group production diversity with Minimum Dietary Diversity, whereas a secondary analysis using their continuous counterparts was done to assess robustness. Results: The dietary diversity was low among the women in rural Bangladesh, with only 37% women achieving minimum dietary diversity with a mean score of 4.24. However, household food group-based production diversity was positively associated with dietary diversity, though the strength of the association was modest. Factors such as gender of the household head, household size, and wealth index were significant predictors of dietary diversity in both models, with land type and women’s education emerging as additional significant predictors in secondary analysis. Conclusions: Food consumption diversity among women in rural Bangladesh is low, suggesting persistent inadequate micronutrient intake. The relationship between dietary diversity of women and household food-group production diversity was positive but modest. This suggests that household food production diversification is not enough to enhance women's nutritional status. An integrated approach is required, and nutrition-sensitive agriculture programmes should combine production diversification with efforts to improve other associated factors, including women's access to nutritious foods, household consumption of produced foods, market access, financial affordability and women's involvement in food decision making.
Exploring the experiences of community health workers during covid-19 pandemic in urban slums of Dhaka city
(BRAC University, 2021) Nyara, Baba James; Rashid, Sabina Faiz; Aktar, Bachera; BRAC James P Grant School of Public Health
Introduction: Community Health Workers (CHWs) are largely female who are employed by different private and public organizations with an aim to bridge the gap between formal healthcare and community, primarily working in rural and urban settings in Bangladesh. However the COVID-19 pandemic has posed unique challenges in urban slums of Dhaka because dwellers live in overcrowded spaces, lack access to WASH facilities and experience poverty which undermine COVID-19 prevention measures. In this context, CHWs play vital roles such as awareness, relief distribution and contact tracing to combat the spread of COVID-19. This study explored their experiences during the shutdown for service delivery organizations to recognize them as essential workforce. Method: The study drawn from 19 qualitative data transcripts from a larger research conducted by James P. Grant School of Public health at BRAC University which explored experiences of urban slums dwellers including CHWs during the COVID-19 shutdown in urban slums of Dhaka. Data was collected on phone from participants and coded inductively after organizing and categorizing according to themes and later placed on data matrix for easy visualization, analysis and interpretation. Findings: CHWs play key role in fighting COVID-19 in urban slums by linking the community and formal health care but they face challenges that include, disrupted personal and social lives, non-recognition and mistrust, increased workload, community expectations, poor remuneration and mental and emotional distress. Conclusion: The current COVID-19 situation has resulted to unprecedented challenges that affect the health and wellbeing of CHWs in urban slums in Dhaka, therefore government and service delivery organizations are urged to recognize CHWs as essential health workforce and implement feasible measures such as work shifts and leaves, improved remuneration, counseling support and regular training to enhance their performance. It is important to conduct additional exploratory research in other slums to generate more evidence.
Barriers and facilitators in implementing human papillomavirus vaccination for adolescent girls: qualitative insights from healthcare implementers in the Korail slum, Dhaka, Bangladesh
(BRAC University, 2025) Powjithan, Natkunarajah; Anwar, Humayra Binte; Barua, Mrittika; BRAC James P Grant School of Public Health
Introduction: Cervical cancer remains as a significant global health issue, ranking fourth among cancers among women. Low- and middle-income countries (LMICs) account for over 90% of related deaths due to limited access to prevention and treatment. The Human Papilloma (Virus) vaccine offers up to 97% protection against cervical cancer when given to women during adolescence, yet the uptake remains alarmingly low in disadvantaged communities. This study explores the qualitative insights from the implementors to identify the barriers and facilitators to HPV vaccination in the urban Korail slum in Dhaka, Bangladesh. Method: A qualitative exploratory design was employed, involving Key Informant Interviews (KIIs) with nine healthcare implementers, including vaccinators, school principals, and field-level supervisors. Data were analyzed using thematic analysis framed by the Consolidated Framework for Implementation Research (CFIR), highlighting contextual and systemic challenges in the Korail slum setting. Findings: The study identified significant facilitators, including high awareness among healthcare workers involved in HPV vaccination, parents and school teachers about cervical cancer prevention, free vaccine provision, and trust in schools as vaccination sites. Training programs boosted implementers' confidence, while stakeholder engagement involving local leaders, parents, and school teachers enhanced vaccine uptake. However, barriers such as misinformation among community members, the sociocultural stigma among adolescent girls and their parents, logistical constraints, and financial challenges faced by the healthcare workers impeded widespread coverage. Logistical hurdles, including the lack of male assistants and transportation support for healthcare workers, added operational inefficiencies. Conclusion: The study highlights the need to address sociocultural barriers through tailored, community-driven strategies. Enhancing implementers' capacity, combating misinformation with culturally sensitive campaigns, and ensuring sustained logistical support are pivotal to improving vaccine uptake. These insights contribute to refining HPV vaccination programs in resource-constrained settings, aligning with global goals to reduce cervical cancer-related morbidity and mortality. Future interventions should focus on sustainable models and scaling successful practices to similar LMIC contexts.
Challenges to dengue treatment access and delivery at Savar Upazila Health Complex, Dhaka, Bangladesh: a concurrent mixed-methods study
(BRAC University, 2025) Ahmadzai, Mahaz Rahman; Hasan, Md Tanvir; Ashrafi, Shah Ali Akbar; BRAC James P Grant School of Public Health
Introduction: Dengue remains a critical public health challenge in Bangladesh, particularly during peak seasons when healthcare facilities encounter high demand. A concurrent mixedmethods research examines the challenges that patients face in accessing treatment and healthcare providers experience in delivering care at the Savar Upazila Health Complex in Dhaka, Bangladesh. Method: Quantitative data on satisfaction with services were gathered from 167 dengue patients, through semi-structured surveys, while qualitative data were obtained from 8 key informant interviews with healthcare providers. Findings: Quantitative findings indicated that 64.07% of dengue patients received adequate details about diagnostic tests, and 77.25% of dengue patients perceived the facility as wellequipped. However, only 34.73% of patients expressed satisfaction with the healthcare services they received. Additionally, 55.09% of patients reported long waiting times, 57.49% rushed consultations, and 61.08% difficulties making appointments as important service delivery challenges that need to be addressed. More than half (52.10%) of patients shared financial issue as an important barrier to accessing treatment on time. Qualitative findings revealed critical shortages of resources, including beds, medical supplies, and diagnostic tools, particularly during peak dengue seasons as important challenges for the efficient delivery of services. The healthcare providers highlighted operational inefficiencies, overcrowded wards, and limited post-hours diagnostic services as key challenges. Conclusion: The results of this study demonstrate significant gaps in service delivery that influence patient satisfaction and effective care. These challenges include inadequate infrastructure, insufficient medical supplies, long waiting times, and rushed. Recommended interventions include expanding facility capacity to serve more patients, increasing healthcare staff, and ensuring consistent availability of diagnostic tools and other medical supplies. Engaging the community through focused awareness campaigns is also crucial to enhancing treatment-seeking and disease-prevention practices.
Healthcare seeking behaviors and control of clinical parameters among people with diabetes and hypertension comorbidity in Chirirbandar, Dinajpur, Bangladesh: a cross-sectional study
(BRAC University, 2025) Shuvo, Md Mashuk Shahriar; Mridha, Malay Kanti; Latif, Mahbub A.H.M; BRAC James P Grant School of Public Health
Introduction: The global burden of non-communicable diseases (NCDs), including diabetes and hypertension comorbidities, disproportionately affects low and middle-income countries (LMICs). This study investigates healthcare seeking behaviors and the control of clinical parameters among adults living with diabetes and hypertension comorbidity in Chirirbandar, Dinajpur, Bangladesh. Method: A cross-sectional study was conducted from November 20 to December 10, 2024, targeting adults aged 18 and above with diagnosed diabetes and hypertension co-morbidity. Data were collected from 387 participants using semi-structured questionnaires and clinical measurements, following the national and World Health Organization guidelines. Descriptive and multivariable logistic regression were performed to report prevalence and identify associated factors. Findings: The majority of the study participants were female. Approximately 60% of participants exhibited uncontrolled diabetes, while 89% showed uncontrolled hypertension. Healthcare seeking behaviors revealed a reliance on private dispensaries and rural practitioners, with limited adherence to recommended follow-ups and medication. Older age and retired individuals were associated with better blood sugar control. Behavioral risk factors, including sedentary behavior, and high BMI, were associated with poor hypertension control. Surprisingly, physical inactivity was associated with better hypertension control and increased fruits and vegetables intake correlated with worse diabetes control, warranting further investigation. Conclusion: The findings highlight significant gaps in the management of diabetes and hypertension comorbidity in rural Bangladesh. Strengthening healthcare infrastructure, promoting self-care practices, and targeted public health interventions are critical for improving blood pressure and blood sugar control among people with hypertension and diabetes co-morbidity.
Factors associated with depression and generalized anxiety disorder among adults living with diabetes and hypertension comorbidity in Chirirbandar, Bangladesh: a cross-sectional study
(BRAC University, 2025) Chakravartty, Meghna; Mridha, Malay Kanti; Latif, Mahbub A.H.M; BRAC James P Grant School of Public Health
Introduction: Coexistence of non-communicable diseases like diabetes and hypertension increases the risk of common mental health conditions such as depression and generalized anxiety disorder (GAD). Mental health is underexplored in general population of Bangladesh let alone among population with diabetes and hypertension comorbidity. This study aims to assess the prevalence of depression and GAD and explore the associated factors among adults with diabetes and hypertension comorbidity in Chirirbandar, Bangladesh. Method: A cross-sectional study was conducted from November 21, 2024 to December 10, 2024 in Chirirbandar, Dinajpur. Data from 387 adults diagnosed with both diabetes and hypertension were included in the final analysis. Data were collected using a pre-tested structured questionnaire, incorporating GAD-7 and PHQ-9 scales to screen GAD and depression respectively. Multivariable logistic regression was used to explore the factors associated with GAD and depression. Results: The prevalence of depression was 17.83%. Factors singnificantly associated with depression included marital status and wealth index. Higher odds of depression among participants with controlled hypertension (aOR =3.65, 95%CI: 1.70-7.81, p=0.001) was observed. The prevalence of GAD was 7.24%. Education level, sedentary time spent per day, and kitchen location were found to be associated with GAD. Behavioral factors, such as tobacco use, fruits and vegetable intake, physical activity were not significantly associated with either condition. Conclusion: A high prevalence of depression and GAD were observed among the adults with diabetes and hypertension comorbidity. The findings from the study emphasize the need to integrate mental health services into the existing non-communicable disease care, with particular attention to socio-demographic, behavioural and environmental factors. Further research is required to establish prospective associations in people with hypertension and diabetes comorbidity and develop targeted interventions in Bangladesh.
Healthcare worker perceived barriers and facilitators to implementing a tuberculosis preventive treatment (TPT) program in Dhaka BRAC TB centers
(BRAC University, 2025) Niki, Atqiya Faizah; Rahman, Ataur; Rahman, Atiya; Ireen, Santhia; Islam, Shayla; BRAC James P Grant School of Public Health
Introduction: Tuberculosis preventive Treatment (TPT) is a crucial step that will prevent the further development of latent tuberculosis infection (LTBI) into active tuberculosis. Yet, it faces numerous constraints when implemented in resource-limited urban environments, e.g., Dhaka, Bangladesh. This research analyzes the barriers and facilitators of TPT uptake at BRAC urban TB centers and provides direction for enhancing program delivery. Methods: Using an explanatory sequential mixed-methods design, qualitative and quantitative data were collected. In the above procedures, interviews with 17 healthcare providers were also conducted, and 41 Field Organizers (FOs) were polled through a survey. The qualitative data were coded thematically, and quantitative data were summarized using descriptive statistics. The Consolidated Framework for Implementation Research (CFIR) was applied to describe the study's outcome. Results: Barriers included resource constraints, such as drug shortages, funding gaps, and insufficient human resources. Logistical difficulties, stigmatization, lack of patient information, and inefficiencies in data capture also hampered the provision of TPT. Patient adherence was influenced by beliefs, pill size, side effects, and competing demands, including daily earnings. Factors included a willingness to use BRAC health care providers, adaptable TPT guidelines (e.g., 3HP regimen), suitable staffing, and working in partnership with the National Tuberculosis Program (NTP). Community support and engagement also emerged as critical enablers. Conclusion: Results underscore the need to take action on funding, staffing, and supply chains to enhance TPT delivery. Improvements to community education, private-sector collaboration, and streamlined documentation and monitoring practices can improve adherence and coverage. These recommendations offer a pathway to enhance TPT programs in settings with limited resources and help set targets to achieve the ambitious goal of TB elimination globally.
Air quality and respiratory health: prevalence, knowledge, and practices in Dhaka’s informal settlements - a cross-sectional study
(BRAC University, 2025) Akter, Rabeya; Quayyum, Zahidul; Saha, Priom; BRAC James P Grant School of Public Health
Background: Several studies suggest that air pollution causes morbidity and mortality, this problem is particularly severe in developing countries. However, little is known about the prevalence of respiratory symptoms among adults in informal settlements with varying air pollution and their practice and knowledge status regarding air pollution and its impact on health. The objective of this study is to explore the prevalence of respiratory symptoms in two informal settlements in Dhaka and the knowledge and practice status of the adult residents. Methods: The study design was cross-sectional and was conducted in Shyampur and Dakshinkhan areas. These study sites were selected based on air quality data collected from a study conducted in BRAC JPGSPH in 2023. Shyampur was selected for having comparatively high air pollution, whereas Dakshinkhan was chosen for having comparatively low air pollution. A total of 316 adult residents were interviewed. This study used multiple sequential logistic regression models to examine the relationship between respiratory symptoms, sociodemographic, and environmental factors, and knowledge and practice status. Results: The proportion of people having respiratory symptoms in Shyampur and Dashinkhan areas were 60.26% and 55.41% respectively. Knowledge status varied in the two areas, while the practice status was almost equal in Shyampur and Dakshinkhan. Results of the sequential multiple logistic regression revealed that the participants in Dakshinkhan had lower odds of having respiratory symptoms (OR= 0.61; 95% CI: 0.36-1.01) compared to Shyampur area. The odds of suffering from respiratory symptoms were significantly associated with individuals who are aged 50 years and above ( OR= 2.31; 95% CI: 1.07-4.98); those who were aged 30-39 years old (OR= 2.05; 95% CI: 1.11-3.82); exposure to indoor smoking (OR= 1.53; 95% CI:0.93-2.50), higher income level ( OR=1.91; 95% CI:1.04-3.49), knowledge status (Good level) ( OR= 2.07; 95% CI: 1.06-4.05), knowledge status (moderate level) ( OR = 2.07, 95% CI: 1.06-4.05). In stratified logistic regression analysis age, income, and exposure to smoking indoors showed a significant association, while in Dakshinkhan resident’s knowledge status was significantly associated with respiratory symptoms. Conclusion: The impact on respiratory symptoms is higher in areas with comparatively high pollution than in areas with comparatively low pollution. Along with socio-demographic and environmental factors, housing conditions, and participant’s knowledge status emerged as significant variables in predicting respiratory symptoms in informal settlements.
Understanding healthcare pathways of patients with diabetes: insights from an exploratory study in a government sub-district hospital of Bangladesh
(BRAC University, 1/5/2025) Hasan, Sadah; Ahmed, Syed Masud; Naher, Nahitun; BRAC James P Grant School of Public Health
Introduction: The prevalence of diabetes mellitus in Bangladesh was 13.75% in 2018. The healthcare system of Bangladesh makes it challenging to deliver integrated non-communicable disease service. There is a lack of resources at the primary healthcare level, a difficult pluralistic healthcare system to navigate, and limited evidence on diabetic care pathways in the context of Bangladesh. As diabetes mellitus is a leading cause of morbidity and mortality, understanding these pathways is vital for developing an equitable healthcare system tailored to chronic disease management. Methods: This facility-based qualitative exploratory study was conducted at the Upazila Health Complex in Keraniganj, Dhaka, Bangladesh. By applying convenient sampling, a total of 22 in-depth interviews were conducted with respondents visiting the NCD corner of the UHC, from November 22, 2024 to December 11, 2024. Descriptive statistics about the respondents were evaluated using STATA V17. Thematic analysis of the interviews were done. Results: The majority of the respondents were aged 40-69 years (81.8%) and female (68.2%), married (86.4%), Muslim (91%) and living in peri-urban areas (91%). 45.5% of the respondents had no formal education, 72,7% were unemployed and most household incomes were generally less than 15,000 BDT. 59% of respondents have lived with diabetes for 2-5 years and 77.3% had other comorbidities too. Respondents navigated complex care pathways, involving both formal and informal healthcare providers, with the longest pathway having five points of care. Most participants delayed seeking care due to attributing symptoms to other diseases, minimal perceived severity, or beliefs about diabetes, with many managing symptoms through home remedies. Delays were longest among women. Triggers that prompted seeking care were worsening symptoms, advice from social networks, or referrals from providers. The common initial points of care were private providers and drug-sellers, with UHCs generally becoming the final care provider by the third point of care. UHCs were preferred for their affordability, accessibility, and ability to manage comorbidities. Most respondents rated UHC services as good, yet unavailable essential medicine or diagnostic tests, short consultation times, disrespectful behavior, and insufficient privacy impacted patient experiences. Elderly and women with children struggled with access to distant hospitals. Private care was expensive and often led to discontinuation, while informal providers were chosen for affordability. One respondent took service from parallel providers. Expenses, especially for those with comorbidities, caused financial strain, often forcing difficult decisions between managing diabetes and other health conditions. Conclusion: Respondents with diabetes navigated complex care pathways and encountered various categories of healthcare providers. While PHC facilities serve as critical hubs, there is a need to address challenges such as inconsistent medicine supply, unavailability of diagnostic facilities, inadequate consultation practices, and the financial burden of respondents to create equitable, patient-centered care for diabetes chronic diseases in resource-limited settings.
Resource allocation and system efficiency in dengue management: a mixed methods study at Savar Upazila Health Complex
(BRAC University, 2025) Sultana, Salma; Hasan, Md Tanvir; Ashrafi, Shah Ali Akbar; BRAC James P Grant School of Public Health
Introduction: Dengue fever, a mosquito-borne disease, is a significant public health issue in Bangladesh, with outbreaks exacerbated by urban density, inadequate resources, and seasonal patterns. The country reported over 203,000 cases and 989 deaths in 2023, with rising hospitalizations and fatalities in 2024. Challenges include ICU shortages, insufficient diagnostic tools, and economic impacts. Despite national protocols for dengue management, gaps in adherence at primary healthcare facilities hinder effective response, necessitating focused research and interventions. Method: This study utilized a concurrent mixed-method design at the Savar Upazila Health Complex, combining an observation checklist, supply chain mapping, and qualitative interviews with 12 healthcare providers. The checklist assessed facility resources and dengue management practices, while supply chain mapping identified bottlenecks in resource flow. Interviews explored challenges in protocol adherence, resource limitations, and patient care. Data analysis integrated thematic and quantitative methods, revealing critical deficiencies. Ethical considerations ensured confidentiality, informed consent, and minimal disruption at the UHC. Findings: The health complex has 50 beds but struggles to accommodate dengue patients during peak seasons, often using floor spaces due to overcrowding. Inadequate isolation facilities increase cross-contamination risks. Staff shortages, particularly nurses and health assistants, compromise care quality, though training on dengue protocols exists. Essential supplies, such as diagnostic kits and PPE, face frequent shortages due to inefficiencies in the government-led supply chain. While IV fluids and medicines are generally available, mosquito repellents and equipment are inconsistent. Proactive measures, like sanitation and mosquito control, are limited by resource constraints. Improved infrastructure, staffing, training, and supply chain management are critical for effective dengue care. Conclusion: Resource constraints, staffing shortages, and inefficient procurement hinder dengue management at Savar Upazila Health Complex, compromising patient care. Addressing these challenges requires a comprehensive national policy, intersectoral coordination, and increased funding. Integrating dengue management into broader public health frameworks is essential to improve system capacity and ensure sustained preparedness.
Knowledge, perceptions and practices regarding human papillomavirus (HPV) vaccination among 10 to 14 years school going adolescent girls and parents of Korail slum in Dhaka, Bangladesh
(BRAC University, 2025) Akash, Sheikh Mohammad Rafi; Anwar, Humayra Binte; Barua, Mrittika; BRAC James P Grant School of Public Health
Cervical cancer remains a leading cause of mortality among women in low- and middle-income countries (LMICs), including Bangladesh. However, the Human Papillomavirus (HPV) vaccine provides up to 97% protection against cervical cancer when given to women during adolescence. Barriers such as limited healthcare access, misinformation and cultural norms hinder HPV vaccination efforts. This study aimed to explore the knowledge, perceptions and practices regarding HPV vaccination among adolescent girls aged 10 to14 years and their parents in Korail slum, Dhaka by using the Behavioral and Social Drivers (BeSD) framework. A mixed-method approach was adopted. Quantitative data were collected through a census survey of 161 school-going adolescent girls aged 10 to 14 years. On the other hand, qualitative insights were derived from three focus group discussions (FGDs), two with mothers and one with fathers. Challenges in conducting FGDs with fathers arose due to their work schedules and heightened political tensions in the area, limiting their participation. Data analysis combined descriptive statistics for the quantitative findings and thematic analysis for the qualitative data. Quantitative results revealed that while 99.38% of participants had heard about the HPV vaccine, primarily through schools, only 62.73% understood its purpose. Schools (95.71%) and the perceived health benefits of vaccination (96.43%) were key motivators for uptake. However, barriers like fear of side effects (20%), lack of parental approval (13.33%) and misinformation (71.43%) persisted. Qualitative findings emphasized the role of trusted figures, such as teachers and healthcare workers, in addressing misconceptions. Community members valued the vaccine’s preventive benefits and it's free availability but stressed the need for clearer communication and community outreach. In conclusion, high awareness of HPV vaccination was observed. Yet detailed knowledge and acceptance were limited among the residents by misinformation and logistical challenges. Effective interventions must focus on targeted health education campaigns, community engagement and strategies to overcome socio-political barriers to improve vaccine uptake and reduce cervical cancer prevalence in underserved communities.
Infant and young child feeding knowledge and practices among lactating mothers attending an urban health care facility in Dhaka, Bangladesh
(BRAC University, 1/5/2025) Tabassum, Tasbiha; Ireen, Santhia; Akter, Fahmida; BRAC James P Grant School of Public Health
Introduction: The first 1,000 days of a child’s life are critical for growth and development as proper nutrition during this period plays a significant role in health outcomes in future. In Bangladesh, though breastfeeding rates are relatively high, challenges persist in achieving optimal Infant and Young Child Feeding (IYCF) practices. Concerning stunting and wasting rates with lack of data in urban areas like Dhaka highlights the need for understanding the influencing factors of IYCF adherence. This study examines IYCF knowledge and practices among lactating mothers of children aged 0-6 months attending an urban MNCH facility in Dhaka. Method: A cross-sectional, quantitative study was conducted at two Maternal Neonatal and Child Health (MNCH) facilities in Dhaka City from November 24 to December 11, 2024. The participants included 342 lactating mothers of infants aged 0-6 months, selected through convenience sampling. Data were collected via a semi-structured questionnaire on socio-demographic factors, antenatal and postnatal care utilization, and IYCF knowledge, practices and barriers. Data analyses included descriptive statistics, chi-squared tests, and multivariable regression analysis. Findings: The study found that overall IYCF knowledge among the mothers was quite well, specifically regarding early breastfeeding initiation (90.4%) and colostrum feeding (99.1%). Knowledge gaps existed in complementary feeding, proper breastfeeding techniques and understanding broader benefits of exclusive breastfeeding. Out of 342 mothers, 100% breastfed their child at least once, 62.6% initiated breastfeeding within 1 hour, 81.6% exclusively breastfed and 17.0% practiced mixed feeding. Barriers such as low milk secretion, post-C-section complications, and cultural factors were significant challenges to optimal IYCF practices. Conclusion: The findings highlight the need for targeted interventions to improve optimal IYCF practices. Addressing barriers as well as strengthening of healthcare service are crucial for enhancing child nutrition in urban Bangladesh.

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