Journal Articles (2019)

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Mapping disparities in education across low- and middle-income countries
(Nature, 12/25/2019) Local Burden of Disease Educational Attainment Collaborators; BRAC James P Grant School of Public Health
Educational attainment is an important social determinant of maternal, newborn, and child health1–3 . As a tool for promoting gender equity, it has gained increasing traction in popular media, international aid strategies, and global agenda-setting4–6 . The global health agenda is increasingly focused on evidence of precision public health, which illustrates the subnational distribution of disease and illness7,8 ; however, an agenda focused on future equity must integrate comparable evidence on the distribution of social determinants of health9–11. Here we expand on the available precision SDG evidence by estimating the subnational distribution of educational attainment, including the proportions of individuals who have completed key levels of schooling, across all low- and middle-income countries from 2000 to 2017. Previous analyses have focused on geographical disparities in average attainment across Africa or for specifc countries, but—to our knowledge—no analysis has examined the subnational proportions of individuals who completed specifc levels of education across all low- and middle-income countries12–14. By geolocating subnational data for more than 184 million person-years across 528 data sources, we precisely identify inequalities across geography as well as within populations.
Determinants of health seeking behavior for chronic non-communicable diseases and related out-of-pocket expenditure: results from a cross-sectional survey in northern Bangladesh
(BMC, 12/23/2019) Binte Rasul, Fatema; Kalmus, Olivier; Sarker, Malabika; Adib, Hossain Ishrath; Hossain, Md Shahadath; Hasan, Md Zabir; Brenner, Stephan; Nazneen, Shaila; Islam, Muhammed Nazmul; De Allegri, Manuela; BRAC James P Grant School of Public Health
Background: In spite of high prevalence rates, little is known about health seeking and related expenditure for chronic non-communicable diseases in low-income countries. We assessed relevant patterns of health seeking and related out-of-pocket expenditure in Bangladesh. Methods: We used data from a household survey of 2500 households conducted in 2013 in Rangpur district. We employed multinomial logistic regression to assess factors associated with health seeking choices (no care or selfcare, semi-qualified professional care, and qualified professional care). We used descriptive statistics (5% trimmed mean and range, median) to assess related patterns of out-of-pocket expenditure (including only direct costs). Results: Eight hundred sixty-six (12.5%) out of 6958 individuals reported at least one chronic non-communicable disease. Of these 866 individuals, 139 (16%) sought no care or self-care, 364 (42%) sought semi-qualified care, and 363 (42%) sought qualified care. Multivariate analysis confirmed that the following factors increased the likelihood of seeking qualified care: a higher education, a major chronic non-communicable disease, a higher socio-economic status, a lower proportion of chronic household patients, and a shorter distance between a household and a subdistrict public referral health facility. Seven hundred fifty-four (87 %) individuals reported out-of-pocket expenditure, with drugs absorbing the largest portion (85%) of total expenditure. On average, qualified care seekers encountered the highest out-of-pocket expenditure, followed by those who sought semi-qualified care and no care, or self-care. Conclusion: Our study reveals insufficiencies in health provision for chronic conditions, with more than half of all affected people still not seeking qualified care, and the majority still encountering considerable out-of-pocket expenditure. This calls for urgent measures to secure better access to care and financial protection.
Estimated societal costs of stroke in the UK based on a discrete event simulation
(Oxford Academic, 12/17/2019) Patel, Anita; Berdunov, Vladislav; Quayyum, Zahidul; King, Derek; Knapp, Martin; Wittenberg, Raphael; BRAC James P Grant School of Public Health
Background: there are around 100,000 new stroke cases and over a million people living with its consequences annually in the UK. This has large impacts on health and social care, unpaid carers and lost productivity. We aimed to estimate associated costs. Methods: we estimated 2014/2015 annual mean cost per person and aggregate UK cost of stroke for individuals aged ≥40 from a societal perspective. Health and social care costs in the first and subsequent years after stroke were estimated from discrete event simulation modelling, with probability of progression and length of receipt of different health and social care services obtained from routine registry and audit data. Unpaid care hours and lost productivity were obtained from trial data. UK unit costs were applied to estimate mean costs. Epidemiological estimates of stroke incidence and prevalence were then applied to estimate aggregate costs for the UK. Results: mean cost of new-onset stroke is £45,409 (95% CI 42,054-48,763) in the first year after stroke and £24,778 (20,234– 29,322) in subsequent years. Aggregate societal cost of stroke is £26 billion per year, including £8.6 billion for NHS and social care. The largest component of total cost was unpaid care (61%) and, given high survival, £20.6 billion related to ongoing care. Conclusion: the estimated aggregate cost of stroke substantially exceeds previous UK estimates. Since most of the cost is attributed to unpaid care, interventions aimed at rehabilitation and reducing new and recurrent stroke are likely to yield substantial benefits to carers and cost savings to society
Prevalence of multimorbidity among Bangladeshi adult population: A nationwide cross-sectional study
(BMJ Journals, 11/28/2018) Khan, Nusrat; Rahman, Mahfuzar; Mitra, Dipak; Afsana, Kaosar; BRAC James P Grant School of Public Health
Objective This study aimed to report prevalence and evaluate the association between multimorbidity and associated risk factors in the adult population of Bangladesh. Design A cross-sectional study was conducted using a multistage clustered random sampling strategy. Setting The study was conducted among the general population of 58 districts in Bangladesh. Participants A total of 12 338 male and female individuals aged ≥35 were included for analysis in this study. Identified through a household listing conducted prior to the study, from 15 297 individuals meeting the inclusion criteria, 12 338 participants were included based on availability during data collection, consent and health condition. Outcome measures Multimorbidity in terms of hypertension, diabetes, cancer, cardiovascular diseases, stroke and chronic obstructive pulmonary disease. Results Approximately 8.4% (95% CI 7.0 to 9.7) of individuals suffer from multimorbidity, of which hypertension accounted for (30.1%) followed by diabetes (10.6%). The mean age of the population was 58.6 (SD ±9.2) years. The prevalence of multimorbidity was lower among men (7.7%) compared with women (8.9%). The likelihood of having multimorbidity among obese individuals were more than double than people with normal body mass index (BMI). Physical activity protected individuals from developing multimorbidity: however, the physical activity adjusted OR was 0.5 (95% CI 0.2 to 1.2). After adjusting for all covariates, higher age, higher educational status, economic status, and higher BMI were found to be significantly associated with the odds of developing multimorbidity, with an overall adjusted OR of 0.02 (95% CI 0.01 to 0.02). Conclusion This study reported a high prevalence of multimorbidity in Bangladesh, although it explored the burden and identified risk factors considering only six chronic diseases. Further detailed exploration through longitudinal studies considering a wider range of diseases is needed to document the actual burden, develop effective preventive measures and clinical guidelines to improve the quality of life of the population.
Association between height and hypertension in the adult Nepalese population: Findings from a nationally representative survey
(Wiley, 11/7/2019) Gupta, Rajat Das; Haider, Shams Shabab; Hashan, Mohammad Rashidul; Rahman, Muhammad Aziz; Sarker, Malabika; BRAC James P Grant School of Public Health
Background and aims The burden of hypertension is increasing in Nepal. Different studies have evaluated the relationship between height and blood pressure in different regions, with mixed results. The relationship between height and hypertension has not yet been explored in the Nepalese context. Given this knowledge gap, this study aims to determine the relationship between height and hypertension among Nepalese adults (aged ≥18 years). Methods This study utilized the dataset from the Nepal Demographic and Health Survey (NDHS) 2016. Hypertension was defined as systolic blood pressure ≥ 140 mmHg and/or a diastolic blood pressure ≥ 90 mmHg. Height, measured in centimeters (cm), was analyzed as a continuous variable. Based on previous evidence, the following covariates were considered: age, sex, presence of overweight or obesity, educational status, household wealth status, and place, province, and ecological zone of residence. Multilevel multivariable logistic regression was done to evaluate the association between height and hypertension. Both crude odds ratio (COR) and adjusted odds ratio (AOR) are reported, along with a 95% confidence interval (CI). Sample weight of NDHS was adjusted during analysis. Results Among 13 393 weighted individuals over the age of 18 years, the prevalence of hypertension in Nepal was found to be 21.1% (95% CI, 19.9%‐22.4%). In the final multivariable model, after adjusting for relevant covariates, it was found that height was inversely associated with hypertension. For a Nepalese adult, the odds of hypertension decreased by 10% with each 10‐cm increase in height (AOR 0.9; 95% CI 0.8‐0.9; P = 0.003). Conclusion Awareness should be raised among people with low stature for prevention of hypertension. Longitudinal studies are recommended to include genetic and social/environmental determinants of stature in the analyses.
Health shock and preference instability: Assessing health-state dependency of willingness-to-pay for corrective eyeglasses
(BMC, 11/7/2019) Islam, Muhammed Nazmul; Rabbani, Atonu; Sarker, Malabika; BRAC James P Grant School of Public Health
Background: Differences in contingent valuation (CV) estimates for identical healthcare goods can cast considerable doubt on the true economic measures of consumer preferences. Hypothetical nature of CV methods can potentially depend on the salience, context and perceived relevance of the good or service under consideration. Thus, the high demand elasticity for healthcare goods warrants careful selection of study population as the contexts of valuation significantly changes after experiencing health shock. Methods: In this study, using triple-bounded dichotomous choice (TBDC) experiments, we test how negative health shock (namely, being diagnosed with refractive errors), can alter preference over a common health good (namely, corrective eyeglasses). We compared elicited WTP of diagnosed patients with a synthetically constructed comparable cohort without the same health shock, controlling for the possible self-selection using a number of matching techniques based on the observable socio-demographic characteristics. Results: The consumers diagnosed with vision problems exhibit a rightward shift in their demand curve compared to observationally identical consumers without such problems resulting in about 17% higher consumer surplus. The consumers without the health shock are willing to pay about BDT 762.4 [95% CI: BDT 709.9 - BDT 814.9] for corrective eyeglasses, which gets 15–30% higher for the matched with-health-shock consumers. Multivariable analyses suggest more educated and wealthier individuals are willing to pay respectively BDT 208 and BDT 119 more for corrective eyeglasses. We have tested the models for different matching protocols. Our results are fairly robust to alternate specifications and various matching techniques. Conclusion: The preferences for healthcare goods, such as eyeglasses, can significantly depend upon the respondent being diagnosed with refractive errors. Our findings have implications for general cost-benefit analyses often relying on WTP, which can vary depending on the contexts. There are also increasing interests in cost recovery models, which require understanding the demand for healthcare goods and services. We find eliciting the demand needs to consider the health status of the population from which the respondents are sampled.
Study protocol to assess the impact of an integrated nutrition intervention on the growth and development of children under two in rural Bangladesh
(BMC, 11/1/2019) Ara, Gulshan; Sanin, Kazi Istiaque; Khanam, Mansura; Sarker, Shafiqul Alam; Khan, Sihan Sadat; Rifat, Mahfuza; Chowdhury, Imran Ahmed; Askari, Sufia; Afsana, Kaosar; Ahmed, Tahmeed; BRAC James P Grant School of Public Health
Background: The period from birth to two years is the “critical window” for achieving optimal growth and development. An inadequate quality and quantities of complementary foods, poor child-feeding practices and infection negatively impact the growth of under-twos. Approximately one-third of under-fives in developing countries are stunted; many are also micronutrient deficient. An estimated 6% of mortalities among under-fives can be prevented by ensuring optimal complementary feeding. The objective of the study was to assess the ability of a 12-month integrated nutrition intervention to improve the nutritional status (length-for-age Z-score) of 6 to 12- month-old children in rural Bangladesh. Methods: In this community-based randomized controlled trial, the intervention group received a package of interventions that includes, food vouchers; to prepare egg-based nutritious snacks (suji firni for < 1-year-olds, suji halwa for > 1-year-olds), micronutrient powder to fortify children’s food at home, child feeding counselling and water, sanitation and hygiene (WASH), behaviour change communication. The control group received routine health messages provided by the government. Baseline and endline surveys were conducted; Data collection was performed monthly on children’s growth, food voucher utilization, child feeding and morbidity. In addition, we assessed the cognitive development of the children after 12 months of intervention. Conclusion: This trial aims to explore whether an integrated nutrition intervention can mitigate childhood stunting during the critical window of opportunity in rural Bangladesh. The results may provide robust evidence to improve the linear growth of children in developing countries.
Putting health equity at heart of universal coverage—the need for national programmes of action
(BMJ, 10/25/2019) Friedman, Eric A; Gostin, Lawrence O; Kavanagh, Matthew M; Periago, Mirta Roses; Marmot, Michael; Coates, Anna; Binagwaho, Agnes; Mukherjee, Joia; Chowdhury, Mushtaque; Robinson, Tracy; Veloso, Valdiléa G; Wang, Chenguang; Were, Miriam; BRAC James P Grant School of Public Health
Income inequality is growing,1 fuelling both right wing populism2 and demands for progressive, inclusive policies. Global disquiet over inequality prompted the United Nations to pledge in the sustainable development goals (SDGs) that “no one will be left behind.”3 Health inequities present a defining challenge of our time,4 and governments need to adopt and rigorously implement national programmes of action to respond across multiple dimensions so that economic and social status no longer determine human health and wellbeing. Most of the data collected on health has been at national and global levels. Such aggregated data may mask deep unfairness in the distribution of good health, much as a growing gross domestic product can mask highly unequal distribution of wealth. For example, a baby born in a largely white, wealthy suburb of St Louis in the US can expect to live 35 more years than one born in a mostly black, lower income suburb a few miles away; the average life expectancy in Saint Louis County is close to 79 years, but ranges from 56 to 91across neighbourhoods.56 Globally, life expectancy is 72 years but people in the United Kingdom live an average of 81 years while those in Sierra Leone average only 54.7 There have been few actionable, inclusive national initiatives expressly designed to achieve health equity—a missed opportunity as countries create national development strategies and develop health plans that include precise national health targets. Despite some important work on health equity, international institutions have not brought equity to the centre through concrete, actionable strategies. The political declaration on universal health coverage agreed at the 2019 UN high level meeting on universal health coverage, for example, reiterated the pledge to leave no one behind. but set out neither specific targets on, nor specific strategies to achieve, health equity.60 We examine the reasons and suggest how to put health inequalities sat the centre of the agenda and fulfil the SDGs’ central promise.
Newborn physical condition and breastfeeding behaviours: Secondary outcomes of a cluster-randomized trial of prenatal lipid-based nutrient supplements in Bangladesh
(Wiley, 2019-10) Ullah, Md Barkat; Mridha, Malay K; Arnold, Charles D; Matias, Susana L; A Khan, Md Showkat; Siddiqui, Zakia; Hossain, Mokbul; Paul, Rina Rani; Dewey, Kathryn G; BRAC James P Grant School of Public Health
Prenatal nutritional supplements may improve birth outcomes. This study aims to examine the effect of prenatal lipid-based nutrient supplements (LNS), compared with iron and folic acid (IFA), on general newborn physical condition and feeding behaviours. We conducted a cluster-randomized effectiveness trial that enrolled 4,011 pregnant women at ≤20 gestational weeks. LNS and IFA were provided to women in 48 and 16 clusters, respectively, for daily consumption until delivery. We collected data on household socio-economic, food insecurity, and maternal characteristics during early pregnancy and on newborn condition and feeding within 72 hr of delivery. We analysed intervention effects on these secondary outcomes using mixed models with analysis of covariance for continuous outcomes and logistic regression for dichotomous outcomes. Among 3,664 live births, intervention groups did not differ in newborn response, mother's rating of the general condition of her newborn, early initiation of breastfeeding (EIBF), suckling ability, or frequency and exclusivity of breastfeeding in the first 24 hr. If the mother perceived her infant to be healthy, EIBF was more likely (OR [95% CI]: 2.08 [1.46, 2.97]) and frequency of breastfeeding in the first 24 hr was greater (mean difference [95% CI]: 3.0 [1.91, 4.01]), but there was no difference in exclusive breastfeeding in the first 24 hr. Newborn condition and early breastfeeding practices were not affected by giving mothers prenatal LNS versus IFA. However, early breastfeeding practices were related to maternal perception of her newborn's condition. Thus, interventions to improve breastfeeding practices for newborns with poorer perceived health status may be useful.
Gestational weight gain and newborn anthropometric outcomes in rural Bangladesh
(Wiley Online Library, 2019-10) Kac, Gilberto; Arnold, Charles D.; Matias, Susana L.; Mridha, Malay K.; Dewey, Kathryn G.; BRAC James P Grant School of Public Health
Low gestational weight gain (GWG) is a known predictor of fetal growth restriction in higher income countries, but there is little information on this association in lower income countries. Our objective is to describe the association between GWG and birth outcomes among pregnant women in rural Bangladesh. Pregnant women were identified in a community-based programme and enrolled into the study at an average of 13 weeks' gestation (n = 4,011). Maternal weight and height were measured at enrolment, maternal weight was measured at 36 weeks' gestation, and newborns were measured after birth. Rate of GWG (g/weeks) was calculated, and women were categorized as having adequate or inadequate GWG (Institute of Medicine recommendations). Newborn anthropometric outcomes included weight-for-age z score (WAZ), length-for-age z score (LAZ), head-circumference-for-age z score (HCZ), body mass index (BMI)-for-age z score (BMIZ), low birthweight (LBW < 2,500 g), WAZ < −2, LAZ < −2, HCZ < −2, BMIZ < −2, and small for gestational age (SGA: <10th percentile). Multivariate models were adjusted for confounders. Only 26% of the 2,562 women in these analyses had adequate GWG. Compared with newborns of women with inadequate GWG, infants of women with adequate GWG had a lower risk of adverse anthropometric outcomes (relative risk [95% confidence interval]: LBW = 0.68 [0.59, 0.80], LAZ < −2 = 0.64 [0.51, 0.80], HCZ < −2 = 0.75 [0.60, 0.93], BMIZ < −2 = 0.70 [0.59, 0.83], and SGA = 0.80 [0.73, 0.86]), but there was no significant difference in mean (SE) duration of gestation, 39.7 (0.08) versus 39.7 (0.05) weeks. In this population, GWG rate is a strong predictor of newborn anthropometric outcomes, but not duration of gestation.
Factors associated with diarrhea and acute respiratory infection in children under two years of age in rural Bangladesh
(Springer Link, 10/27/2019) Ullah, Md Barkat; Mridha, Malay K.; Arnold, Charles D.; Matias, Susana L.; Khan, Md Showkat A.; Siddiqui, Zakia; Hossain, Mokbul; Paul, Rina Rani; Dewey, Kathryn G.; BRAC James P Grant School of Public Health
Background: Diarrhea and acute respiratory infection (ARI) are major causes of child mortality. We aimed to identify risk factors associated with diarrhea and ARI among children under 2 years of age in rural northern Bangladesh. Method: We collected information on diarrhea and ARI in the previous 14 days and the previous 6 months at 6, 12, 18 and 24 months of age as part of a longitudinal, cluster randomized effectiveness trial, the Rang-Din Nutrition Study which enrolled 4011 pregnant women at ≤20 gestational weeks. Women and their children were followed up until 2 years postpartum. Information on household socioeconomic status, type of toilet, garbage disposal system, food insecurity, number of under-five children in the household, type of family, maternal characteristics and child characteristics was collected at baseline and/or at 6, 12, 18 and 24 months postpartum. Data on newborn health and feeding behaviors were collected within 72 h of delivery. Associations between potential risk factors and morbidity prevalence outcomes were assessed using logistic regression controlling for potential confounders. Results: Out of 3664 live born children, we collected information from ~ 3350 children at 6, 12, 18 and 24 months of age. Diarrhea in the previous 14 days, and in the previous 6 months, was associated with maternal depression score and food insecurity; diarrhea in the previous 6 months was also associated with family type (nuclear vs. joint). ARI in the previous 14 days was associated with maternal depression score, type of toilet and garbage disposal, household food insecurity and sex. Cough or nasal discharge in the past 6 months was associated with maternal depression score, type of toilet and garbage disposal, household food insecurity, sex and perceived overall physical condition of the infant after birth. Conclusion: Maternal depression and food insecurity appear to be important risk factors for diarrhea and respiratory infection among children under 2 years of age in this setting. These findings suggest that policies and programs that include strategies to address maternal mental health and household food insecurity may contribute to improved child health. Trial registration: The trial was registered with the US National Institutes of Health at ClinicalTrials.gov, # NCT01715038, with registration completed October 26, 2012
Determinants of diabetes in Bangladesh using two approaches: An analysis of the Demographic and Health Survey 2011
(Cambridge University Press, 10/21/2019) Swasey, Krystal K.; Gupta, Rajat Das; Nayeem, Jannatun; Al Kibria, Gulam Muhammed; BRAC James P Grant School of Public Health
This cross-sectional study analysed data from the Bangladesh Demographic and Health Survey 2011 to investigate factors associated with diabetes in Bangladesh. Data were analysed using logistic and log-binomial regressions to estimate odds ratios (ORs) and prevalence ratios (PRs), respectively. Among the 7544 respondents aged ≥35 years, the estimated prevalence of diabetes was 11.0%. In the adjusted analysis, survey participants in the age group 55–64 years (adjusted PR [APR]: 1.8, 95% Confidence Interval (CI): 1.4, 2.2; adjusted OR [AOR]: 1.9, 95% CI: 1.5, 2.5) and those with at least secondary education level (APR: 1.3, 95% CI: 1.0, 1.6; AOR: 1.3, 95% CI: 1.0, 1.7) were more likely to have diabetes than those in the age group 35–44 years and those with no education. Furthermore, respondents living in Khulna (APR: 0.5, 95% CI: 0.4, 0.6; AOR: 0.4, 95% CI: 0.3, 0.6) were less likely to have diabetes than people living in Barisal. While adjusted estimates of PR and OR were similar in terms of significance of association, the magnitude of the point estimate was attenuated in PR compared with the OR. Nevertheless, the measured factors still had a significant association with diabetes in Bangladesh. The results of this study suggest that Bangladeshi adults would benefit from increased education on, and awareness of, the risk factors for diabetes. Focused public health intervention should target these high-risk populations.
Mapping 123 million neonatal, infant and child deaths between 2000 and 2017
(Nature, 10/16/2019) Burstein, Roy; Hay, Simon I; BRAC James P Grant School of Public Health
Since 2000, many countries have achieved considerable success in improving child survival, but localized progress remains unclear. To inform efforts towards United Nations Sustainable Development Goal 3.2-to end preventable child deaths by 2030-we need consistently estimated data at the subnational level regarding child mortality rates and trends. Here we quantified, for the period 2000-2017, the subnational variation in mortality rates and number of deaths of neonates, infants and children under 5 years of age within 99 low- and middle-income countries using a geostatistical survival model. We estimated that 32% of children under 5 in these countries lived in districts that had attained rates of 25 or fewer child deaths per 1,000 live births by 2017, and that 58% of child deaths between 2000 and 2017 in these countries could have been averted in the absence of geographical inequality. This study enables the identification of high-mortality clusters, patterns of progress and geographical inequalities to inform appropriate investments and implementations that will help to improve the health of all populations.
Non-communicable disease (NCD) corners in public sector health facilities in Bangladesh: A qualitative study assessing challenges and opportunities for improving NCD services at the primary healthcare level
(BMJ Journals, 10/7/2019) Rawal, Lal B; Kanda, Kie; Biswas, Tuhin; Tanim, Md. Imtiaz; Poudel, Prakash; Renzaho, Andre M N; Abdullah, Abu S; Shariful Islam, Sheikh Mohammed; Ahmed, Syed Masud; BRAC James P Grant School of Public Health
Objective To explore healthcare providers’ perspective on non-communicable disease (NCD) prevention and management services provided through the NCD corners in Bangladesh and to examine challenges and opportunities for strengthening NCD services delivery at the primary healthcare level. Design We used a grounded theory approach involving in-depth qualitative interviews with healthcare providers. We also used a health facility observation checklist to assess the NCD corners’ service readiness. Furthermore, a stakeholder meeting with participants from the government, non-government organisations (NGOs), private sector, universities and news media was conducted. Setting Twelve subdistrict health facilities, locally known as upazila health complex (UHC), across four administrative divisions. Participants Participants for the in-depth qualitative interviews were health service providers, namely upazila health and family planning officers (n=4), resident medical officers (n=6), medical doctors (n=4) and civil surgeons (n=1). Participants for the stakeholder meeting were health policy makers, health programme managers, researchers, academicians, NGO workers, private health practitioners and news media reporters. Results Participants reported that diabetes, hypertension and chronic obstructive pulmonary disease were the major NCD-related problems. All participants acknowledged the governments’ initiative to establish the NCD corners to support NCD service delivery. Participants thought the NCD corners have contributed substantially to increase NCD awareness, deliver NCD care and provide referral services. However, participants identified challenges including lack of specific guidelines and standard operating procedures; lack of trained human resources; inadequate laboratory facilities, logistics and medications; and poor recording and reporting systems. Conclusion The initiative taken by the Government of Bangladesh to set up the NCD corners at the primary healthcare level is appreciative. However, the NCD corners are still at nascent stage to provide prevention and management services for common NCDs. These findings need to be taken into consideration while expanding the NCD corners in other UHCs throughout the country
Maternal nutrition intervention and maternal complications in 4 districts of Bangladesh: a nested cross-sectional study
(PLOS Medicine, 10/4/2019) Todd, Catherine S.; Chowdhury, Zakaria; Mahmud, Zeba; Islam, Nazia; Shabnam, Sadia; Parvin, Musarrat; Bernholc, Alissa; Martinez, Andres; Aktar, Bachera; Afsana, Kaosar; Sanghvi, Tina; BRAC James P Grant School of Public Health
Background Maternal morbidity is common in Bangladesh, where the maternal mortality rate has plateaued over the last 6 years. Maternal undernutrition and micronutrient deficiencies contribute to morbidity, but few interventions have measured maternal outcomes. We compared reported prevalence of antepartum, intrapartum, and postpartum complications among recently delivered women between maternal nutrition intervention and control areas in Bangladesh. Methods and findings We conducted a cross-sectional assessment nested within a population-based cluster-randomized trial comparing a nutrition counseling and micronutrient supplement intervention integrated within a structured home-based maternal, newborn, and child health (MNCH) program to the MNCH program alone in 10 sub-districts each across 4 Bangladesh districts. Eligible consenting women, delivering within 42–60 days of enrollment and identified by community-level health workers, completed an interviewer-administered questionnaire detailing the index pregnancy and delivery and allowed review of their home-based care register. We compared pooled and specific reported antepartum, intrapartum, and postpartum complications between study groups using hierarchical logistic regression. There were 594 women in the intervention group and 506 in the control group; overall, mean age was 24 years, 31% were primiparas, and 39% reported facility-based delivery, with no significant difference by study group. There were no significant differences between the intervention and control groups in household-level characteristics, including reported mean monthly income (intervention, 6,552 taka, versus control, 6,017 taka; p = 0.48), having electricity (69.6% versus 71.4%, p = 0.84), and television ownership (41.1% versus 38.7%, p = 0.81). Women in the intervention group had higher recorded iron and folic acid and calcium supplement consumption and mean dietary diversity scores, but reported anemia rates were similar between the 2 groups (5.7%, intervention; 6.5%, control; p = 0.83). Reported antepartum (69.4%, intervention; 79.2%, control; p = 0.12) and intrapartum (41.4%, intervention; 48.5%, control; p = 0.18) complication rates were high and not significantly different between groups. Reported postpartum complications were significantly lower among women in the intervention group than the control group (33.5% versus 48.2%, p = 0.02), and this difference persisted in adjusted analysis (adjusted odds ratio [AOR] = 0.51, 95% CI 0.32–0.82; p < 0.001). For specific conditions, odds of retained placenta (AOR = 0.35, 95% CI 0.19–0.67; p = 0.001), postpartum bleeding (AOR = 0.37, 95% CI 0.15–0.92; p = 0.033), and postpartum fever/infection (AOR = 0.27, 95% CI 0.11–0.65; p = 0.001) were significantly lower in the intervention group in adjusted analysis. There were no significant differences in reported hospitalization for antepartum (49.8% versus 45.1%, p = 0.37), intrapartum (69.9% versus 59.8%, p = 0.18), or postpartum (36.1% versus 29.9%, p = 0.49) complications between the intervention and control groups. The main limitations of this study are outcome measures based on participant report, non-probabilistic selection of community-level workers’ catchment areas for sampling, some missing data for variables derived from secondary sources (e.g., dietary diversity score), and possible recall bias for reported dietary intake and supplement use. Conclusions Reported overall postpartum and specific intrapartum and postpartum complications were significantly lower for women in intervention areas than control areas, despite similar rates of facility-based delivery and hospitalization for reported complications, in this exploratory analysis. Maternal nutrition interventions providing intensive counseling and micronutrient supplements may reduce some pregnancy complications or impact women’s ability to accurately recognize complications, but more rigorous evaluation is needed for these outcomes.
Association between household livestock ownership and childhood stunting in Bangladesh – A spatial analysis
(Oxford Academic, 9/16/2019) Hossain, Md. Belal; Khan, Jahidur Rahman; BRAC James P Grant School of Public Health
Livestock is an integrated part of agriculture, yet the relationship between household livestock ownership and child nutrition is a significant knowledge gap. The present study aimed to assess the association between household livestock ownership and childhood stunting and to explore the geospatial variations at district level in Bangladesh. A complete data of 19 295 children aged below 5 years were extracted from the latest Bangladesh Multiple Indicator Cluster Survey 2012–13. The tropical livestock unit (TLU) score calculated as a weighted value for each livestock and categorized as low, medium, and high using tertile. A hierarchical Bayesian spatial logistic model was used to assess the association between TLU and childhood stunting. Children from the household with high TLU were 10% less likely to be stunted (adjusted posterior odds ratio: 0.90, 95% credible interval: 0.84– 0.97) after controlling for demographic, socioeconomic, morbidity, place of residence and spatial effects. There was also a substantial spatial variation in childhood stunting across districts in Bangladesh with the highest burden in the Northern and North-Eastern regions. The positive effect of household livestock ownership on reducing child stunting suggests that, in addition to nutritional intervention in Bangladesh, efforts to strengthen livestock production would be beneficial for improving child nutrition status. However, a small effect size may be owing to the lack of dietary diversity, livestock health and productivity data as well as the complexity of the relationship, requiring further study. Furthermore, a significant regional disparity in stunting highlighted the importance of spatial targeting during the design of interventions and implementation.
Impact of traffic variability on geographic accessibility to 24/7 emergency healthcare for the urban poor: A GIS study in Dhaka, Bangladesh
(PLOS ONE, 9/16/2019) Ahmed, Shakil; Adams, Alayne M.; Islam, Rubana; Hasan, Shaikh Mehdi; Panciera, Rocco; BRAC James P Grant School of Public Health
Ensuring access to healthcare in emergency health situations is a persistent concern for health system planners. Emergency services, including critical care units for severe burns and coronary events, are amongst those for which travel time is the most crucial, potentially making a difference between life and death. Although it is generally assumed that access to healthcare is not an issue in densely populated urban areas due to short distances, we prove otherwise by applying improved methods of assessing accessibility to emergency services by the urban poor that take traffic variability into account. Combining unique data on emergency health service locations, traffic flow variability and informal settlements boundaries, we generated time-cost based service areas to assess the extent to which emergency health services are reachable by urban slum dwellers when realistic traffic conditions and their variability in time are considered. Variability in traffic congestion is found to have significant impact on the measurement of timely access to, and availability of, healthcare services for slum populations. While under moderate traffic conditions all slums in Dhaka City are within 60-minutes travel time from an emergency service, in congested traffic conditions only 63% of the city's slum population is within 60-minutes reach of most emergency services, and only 32% are within 60-minutes reach of a Burn Unit. Moreover, under congested traffic conditions only 12% of slums in Dhaka City Corporation comply with Bangladesh's policy guidelines that call for access to 1 health service per 50,000 population for most emergency service types, and not a single slum achieved this target for Burn Units. Emergency Obstetric Care (EmOC) and First Aid & Casualty services provide the best coverage, with nearly 100% of the slum population having timely access within 60-minutes in any traffic condition. Ignoring variability in traffic conditions results in a 3-fold overestimation of geographic coverage and masks intra-urban inequities in accessibility to emergency care, by overestimating geographic accessibility in peripheral areas and underestimating the same for central city areas. The evidence provided can help policy makers and urban planners improve health service delivery for the urban poor. We recommend that taking traffic conditions be taken into account in future GIS-based analysis and planning for healthcare service accessibility in urban areas.
Developing a framework of core competencies in implementation research for low/middle-income countries
(BMJ Journals, 2019-09) Alonge, Olakunle; Rao, Aditi; Kalbarczyk, Anna; Maher, Dermot; Gonzalez Marulanda, Edwin Rolando; Sarker, Malabika; Ibisomi, Latifat; Dako-Gyeke, Phyllis; Mahendradhata, Yodi; Launois, Pascal; Vahedi, Mahnaz; BRAC James P Grant School of Public Health
The field of implementation research (IR) is growing. However, there are no recognised IR core competencies in low/middle-income countries (LMICs), nor consistent curriculum across IR training programs globally. The goal of this effort is to develop a framework of IR core competencies for training programs in LMICs. The framework was developed using a mixed-methods approach consisting of two online surveys with IR training coordinators (n = 16) and academics (n = 89) affiliated with seven LMIC institutions, and a modified-Delphi process to evaluate the domains, competencies and proficiency levels included in the framework. The final framework comprised of 11 domains, 59 competencies and 52 sub-competencies, and emphasised competencies for modifying contexts, strengthening health systems, addressing ethical concerns, engaging stakeholders and communication especially for LMIC settings, in addition to competencies on IR theories, methods and designs. The framework highlights the interconnectedness of domains and competencies for IR and practice, and training in IR following the outlined competencies is not a linear process but circular and iterative, and starting points for training may vary widely by the project, institution and challenge being addressed. The framework established the need for a theory-based approach to identifying proficiency levels for IR competencies (ie, to determine proficiency levels for IR based on generalisable educational theories for competency-based education), and the relevance of various IR competencies for LMICs compared with highincome settings. This framework is useful for identifying and evaluating competencies and trainings, and providing direction and support for professional development in IR.
Prevalence and risk factors of cardiovascular diseases among Bangladeshi adults: Findings from a cross-sectional study
(Atlantis Press, 2019-09) Khanam, Fouzia; Hossain, Md. Belal; Mistry, Sabuj Kanti; Afsana, Kaosar; Rahman, Mahfuzar; BRAC James P Grant School of Public Health
Ever rising prevalence of Cardiovascular Diseases (CVD) is a major challenge for the health sector in Bangladesh. This study aimed to explore the prevalence of CVD and sociodemographic and lifestyle factors associated with it in Bangladesh. The data were collected through a cross-sectional survey following a two-stage cluster random sampling procedure. The present analysis was performed among 12,338 respondents aged ≥35 years, selected from rural areas and urban slums. Information was gathered using a structured questionnaire, whereas measurements were taken using standardized procedures. Logistic regression with exchangeable correlation structure among clusters was executed to explore the association. About 30% of participants had hypertension, 5% diabetes, 20% obesity; 77% were either smokers or consumed smokeless tobacco, and 28% were physically inactive. The prevalence of CVD was 4.5% (stroke: 1.8% and heart diseases: 3.2%). After adjusting for potential confounders, hypertension, diabetes, body mass index, extra salt intake, daily sleep, tiredness, age, gender, occupation, administrative division, and wealth quintile were found to be significantly associated with CVD. The study highlighted that the prevalence of CVD is high in Bangladesh, and its associated risk factors such as hypertension and diabetes are on the rise, especially in the older population, women, and high-income groups. Therefore, immediate public health intervention is warranted to address the issue.
Gender differences in hypertension awareness, antihypertensive use and blood pressure control in Nepalese adults: Findings from a nationwide cross-sectional survey
(Cambridge University Press, 8/30/2019) Gupta, Rajat Das; Haider, Shams Shabab; Sutradhar, Ipsita; Hasan, Mehedi; Joshi, Hemraj; Haider, Mohammad Rifat; Sarker, Malabika; BRAC James P Grant School of Public Health
The objective of this cross-sectional study was to determine the gender differences in hypertension awareness, antihypertensive use and blood pressure (BP) control among the adult Nepalese population (≥18 years) using data from the nationally representative Nepal Demographic and Health Survey 2016. A weighted sample of 13,393 adults (5620 males and 7773 females) was included in the final analysis. After conducting descriptive analyses with the selective explanatory variable, multivariable logistic regression analysis was performed to assess the association between the outcome variable and the explanatory variables. The strength of the association was expressed in adjusted odds with 95% confidence intervals. A higher proportion of women had their BP checked (87.7% females vs 73.0% males, p<0.001) and were aware of their raised BP (43.9% females vs 37.1% males, p<0.001) compared with men. Although female hypertensive individuals had a higher prevalence of antihypertensive medication use than their male counterparts (50.1% females vs 47.5% males), a higher proportion of male hypertensive participants had their BP controlled (49.2% females vs 53.5% males). Women with the poorest wealth index had a lower prevalence of antihypertensive use than their male counterparts. The odds of having their own BP measured increased with age among men but decreased with age among women. The household wealth index was positively associated with the odds of BP measurement, awareness of own BP and antihypertensive use. This study revealed that although women had a higher prevalence of hypertension awareness and antihypertensive medication use, the practice did not translate into better BP control. Inequality in antihypertensive medication use was observed among the poorest wealth quintiles. Public health programmes in Nepal should focus on reducing these inequalities. Further research is needed to learn why females have poorer control of BP, despite having higher antihypertensive medication use.

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