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ObjectiveWe aimed to rapidly assess the health system impact of COVID-19 in the urban slums of Bangladesh.DesignSetting and participantsA cross-sectional survey among 476 households was conducted during October–December 2020 in five selected urban slums of Dhaka North, Dhaka South and Gazipur City Corporation. In-depth interviews with purposively selected 22 slum dwellers and key informant interviews with 16 local healthcare providers and four policymakers and technical experts were also conducted.Outcome measuresPercentage of people suffering from general illness, percentage of people suffering from chronic illness, percentage of people seeking healthcare, percentage of people seeking maternal care, health system challenges resulting from COVID-19.ResultsAbout 12% of members suffered from general illness and 25% reported chronic illness. Over 80% sought healthcare and the majority sought care from informal healthcare providers. 39% of the recently delivered women sought healthcare in 3 months preceding the survey. An overall reduction in healthcare use was reported during the lockdown period compared with prepandemic time. Mismanagement and inefficient use of resources were reported as challenges of health financing during the pandemic. Health information sharing was inadequate at the urban slums, resulting from the lack of community and stakeholder engagement (51% received COVID-19-related information, 49% of respondents knew about the national hotline number for COVID-19 treatment). Shortage of human resources for health was reported to be acute during the pandemic, resulting from the shortage of specialist doctors and uneven distribution of health workforce. COVID-19 test was inadequate due to the lack of adequate test facilities and stigma associated with COVID-19. Lack of strong leadership and stakeholder engagement was seen as the barriers to effective pandemic management.ConclusionThe findings of the current study are expected to support the government in tailoring interventions and allocating resources more efficiently and timely during a pandemic.

Background: Coronavirus disease 2019 (COVID-19) has spread globally, and the government of each affected country is publishing the number of deaths every day. This official figure is an underestimate as it excludes anybody who did not die in a hospital, who did not test positive, who had a false result, or those who recovered on their own without a test.Objective: This study aimed to measure the community level excess mortality using health and demographic surveillance in a rural area of Bangladesh.Method: The study was conducted in Matlab, in a rural area of Bangladesh, with a Health and Demographic Surveillance System (HDSS) covering a population of 239,030 individuals living in 54,823 households in 142 villages. We examined the mortality in January-April from 2015 to 2020 and compared the mortality in 2020 with the historical trend of 2015–2019. Between 2015 and 2020, we followed 276,868 people until migration or death, whichever occurred first. We analyzed mortality using crude mortality rate ratio (MRR) and adjusted MRR (aMRR) from a Cox proportional hazard model. Mortality was analyzed according to age, sex, and period.Results: During follow-up, 3,197 people died. The mortality rate per 1,000 person-years increased from 10 in 2019 to 12 in 2020. Excess mortality was observed among the elderly population (aged 65 years and above). The elderly mortality rate per 1,000 person-years increased from 80 in 2019 to 110 in 2020, and the aMRR was 1.40 (95% CI: 1.19–1.64). Although an increasing tendency in mortality was observed between 2015 and 2019, it was statistically insignificant.Conclusions: The study reported a 28% increase in excess deaths among the elderly population during the first months of the pandemic. This all-cause mortality estimation at the community level will urge policymakers, public health professionals, and researchers to further investigate the causes of death and the underlying reasons for excess deaths in the older age-group.

Background The government of Bangladesh initiated community clinics (CC) to extend the reach of public health services and these facilities were planned to be run through community participation. However, utilisation of CC services is still very low. Evidence indicates community score card is an effective tool to increase utilisation of services from health facility through regular interface meeting between service providers and beneficiary. We investigated whether community scorecards (CSC) improve utilisation of health services provided by CCs in rural area of Bangladesh. Methods This study was conducted from December 2017 to November 2018. Three intervention and three control CCs were selected from Chakaria, a rural sub-district of Bangladesh. CSC was introduced with the Community Groups and Community Support Groups in intervention CCs between January to October 2018. Data were collected through observation of CCs during operational hours, key informant interviews, focus group discussions, and from DHIS2. Utilisation of CC services was compared between intervention and control areas, pre and post CSC intervention. Results Post CSC intervention, community awareness about CC services, utilisation of clinic operational hours, and accountability of healthcare providers have increased in the intervention CCs. Utilisation of primary healthcare services including family planning services, antenatal care, postnatal care and basic health services have significantly improved in intervention CCs. Conclusion CSC is an effective tool to increase the service utilization provided by CCs by ensuring community awareness and participation, and service providers’ accountability. Policy makers and concerned authorities may take necessary steps to integrate community scorecard in the health system by incorporating it in CCs.

Diphtheria-tetanus-pertussis (DTP) vaccine may be associated with excess female deaths. There are few studies of possible nonspecific effects of the DTP-containing vaccine Penta (DTP-hepatitis B-Haemophilus influenzae type b). We therefore investigated whether Penta vaccinations were associated with excess female deaths in rural Bangladesh. Between June 29, 2011 and April 20, 2016, we examined the mortality rates of 7644 children followed between 6 weeks and 9 months of age. We analyzed mortality using crude mortality rate ratio (MRR) and age-adjusted MRR (aMRR) from a Cox proportional hazards model. Mortality was analyzed according to sex, number of doses of Penta, and the order in which BCG and Penta were administered. During follow-up, 43 children died. For children who were only BCG vaccinated (BCG-only), the adjusted F/M MRR was 0.47 (0.09–2.48). However, among children who had Penta as their most recent vaccination, the adjusted F/M MRR was 9.91 (1.16–84.44). Hence, the adjusted F/M MRR differed significantly for BCG-only and for Penta as the most recent administered vaccination. Although the mortality rate was low in rural Bangladesh, there was a marked difference between adjusted F/M MRR’s for children vaccinated with BCG-only compared with children where Penta was the most recent administered vaccination. Although usually ascribed to differential treatment and access to care, DTP-containing vaccines may be part of the explanation for the excessive female mortality reported in some regions.

Background: West African studies have suggested that national immunisation campaigns with oral polio vaccine (C-OPV) may non-specifically reduce all-cause child mortality rate by 15-25%. We investigated whether C-OPVs had similar non-specific effects in rural Bangladesh from 2004 to 2019. Methods: Chakaria, is a health and demographic surveillance system (HDSS) in Southern Bangladesh. From 2004-2011 the HDSS covered a random sample of households; from 2012-2019 it covered a random sample of villages. Using Cox proportional hazards models, we calculated hazard ratios (HR) comparing mortality for children under 3 years of age after campaigns with OPV-only (C-OPV) versus before C-OPV to assess the “intention-to-treat”-effect of C-OPV. We allowed for different baseline hazard function in the two periods (2004-2011, 2012-2019), with separate models for each period. In the main analysis children were only followed prospectively. Findings: In the main analysis, including 736 deaths (2.0%) among 36,155 children, the HR for after C-OPV was 0.68 (95% confidence interval: 0.51-0.90). No other type of health campaign had similar beneficial results. Each additional dose of C-OPV lowered the mortality rate by 8% (0 to 15%). The number needed to treat (NNT) with C-OPV to save one life between 0-35 months of age was only 109 (100-119) (data not shown). Interpretation: This is the fourth study to show that C-OPV has huge beneficial non-specific effects on child survival. No study has found the opposite. Stopping OPV as planned could have detrimental effects for overall child health in low-income countries. Funding Statement: This research study is funded by core donors who provide unrestricted support to icddr,b for its operations and research. icddr,b is grateful to the Government of Bangladesh, Canada, Sweden and the UK for providing core/unrestricted support. The work on non-specific effects of vaccines has been supported by the Danish Council for Development Research, Ministry of Foreign Affairs, Denmark [grant number 104.Dan.8.f.], Novo Nordisk Foundation and European Union FP7 support for OPTIMUNISE (grant: Health-F3-2011-261375). Declaration of Interests: Nothing to declare. Ethics Approval Statement: Ethical Review Committee of International Centre of Diarrhoeal Disease Research, Bangladesh provided approval for the study.

Background: Improving maternal health is a major development goal, with ambitious targets set for high-mortality countries like Bangladesh. Following a steep decline in the maternal-mortality ratio over the past decade in Bangladesh, progress has plateaued at 196/100,000 live births. A voucher scheme was initiated in 2007 to reduce financial, geographical and institutional barriers to access for the poorest. The current paper reports the effect of vouchers on the use of continuum of maternal care.Methods: Cross-sectional surveys were carried out in the Chattogram and Sylhet divisions of Bangladesh in 2017 among 2400 women with children aged 0-23 months. Using Cluster analysis groups were formed based on utilization of antenatal care, facility delivery and postnatal care. Clusters were regressed on voucher receipt to identify the underlying relationship between voucher receipt and utilisation of care while controlling for possible confounders.Results: Four clusters with varying levels of utilization were identified. A significantly higher proportion of voucher-recipients belonged to the high-utilisation cluster compared to non-voucher recipients (43.5% vs. 15.4%). For the poor voucher-recipients, the probability of belonging to the high-utilisation cluster was higher compared to poor non-voucher recipients (33.3% vs. 6.8%) and the probability of being in the low-utilisation cluster was lower than poor non-voucher recipients (13.3% vs. 55.4%).Discussion and conclusion: The voucher programme enhanced uptake of the complete continuum of maternal care and the benefits extended to the most vulnerable women. However, a lack of continued transition through the continuum of maternal care was identified. This insight can assist in designing effective interventions to prevent intermittent or interrupted care-seeking. Programs that improve access to quality 38 healthcare in pregnancy, childbirth and the postnatal period can have wide-ranging benefits. A coherent continuum-based approach to understanding maternal care-seeking behaviour is thus expected to have a greater impact on maternal, newborn and child health outcomes.

Introduction Evidence in favor of mHealth for healthcare delivery in settings where trained health workforce is limited or unavailable is accumulating. With rapid growth in access to mobile phones and an acute shortage of health workforce in Bangladesh, mHealth initiatives are increasing with more than 20 current initiatives in place. “Readiness” is a crucial prerequisite to the successful implementation of telehealth programs. However, systematic assessment of the community readiness for mHealth-based services in the country is lacking. We report on a recent study describing the influence of community readiness for mHealth of a rural Bangladesh community. Methods A conceptual framework for mHealth readiness was developed, which included three categories: technological, motivational and resource readiness. This guided the questionnaire development for the survey conducted in the Chakaria sub-district of Bangladesh from November 2012 to April 2013. Multivariate logistic regression was used to examine ownership of mobile phones, use of the technology, and knowledge regarding awareness of mHealth services as predictors of the community readiness to adopt mHealth. Results A total of 4915 randomly selected household members aged 18 years and over completed the survey. The data explained the sub-categories of the readiness dimensions. In terms of access, 45% of respondents owned a mobile phone with ownership higher among males, younger participants and those in the highest socioeconomic quintiles. Results related to technological readiness showed that among mobile phone owners, 50% were aware of SMS but only sending and receiving SMS. Only 37% generally read the received SMS. Only 5% of respondents used the internet capabilities on their phone and 25% used voice messages. The majority (73%) of the participants were interested in joining mHealth programs in the future. Multivariate analysis showed that ownership of a mobile phone (aOR 1.3, 95% CI 1.1–1.5), younger age (aOR 2.6, 95% CI 2.1–3.3), males (aOR 1.8, 95% CI 1.6–2.1), educated respondents (11 years or more education) (aOR 11.1, 95% CI 6.2–19.2) and those belonging to the highest socio-economic group (aOR 3.7, 95% CI 2.9–4.7) were significantly independently associated with knowledge regarding awareness of current mHealth services. Conclusions We developed a conceptual framework to assess community readiness for mHealth. We described three high level dimensions of readiness and have partially tested the conceptual framework in a rural sub-district in Bangladesh. We found that the community has some technological readiness but inequity was observed for human resource readiness and technological capabilities. The study population is motivated to use mHealth. Our conceptual framework is a promising tool to assist policy-makers in planning and implementing mHealth programs.

Background Immunization is one of the most successful and effective health intervention to reduce vaccine preventable diseases for children. Recently, Bangladesh has made huge progress in immunization coverage. In this study, we compared the recent immunization coverage between boys and girls in a rural area of Bangladesh. Setting The study is based on data from Chakaria Health and Demographic Surveillance System (HDSS) of icddr,b, which covers a population of 90,000 individuals living in 16,000 households in 49 villages. Methods We calculated the coverage of fully immunized children (FIC) for 4584 children aged 12–23 months of age between January 9, 2012 and January 19, 2016. We analyzed immunization coverage using crude FIC coverage ratio (FCR) and adjusted FCR (aFCR) from binary regression models. The dynamic of gender inequality was examined across sociodemographic and economic conditions. Main outcome measure The adjusted female/male (F/M) FIC coverage ratios in various sociodemographic and economic categories. Results Among children who lived below the lower poverty line, the F/M aFCR was 0.89 (0.84–0.94) compared to 0.98 (0.95–1.00) for children from the households above lower poverty line (p = 0.003, test for interaction). For children of mothers with no high school education, the F/M aFCR was 0.94 (0.91–0.97), whereas it was 1.00 (0.96–1.04) for children of mothers who attended high school (p = 0.04, test for interaction). The F/M aFCR was 1.01 (0.96–1.06) for first born children but 0.95 (0.93–0.98) for second or higher birth order children (p = 0.04, test for interaction). Conclusions Fewer girls than boys were completely vaccinated by their first birthday due to girls’ lower coverage for measles vaccine. The tendency was most marked for children living below the poverty line, for children whose mothers did not attend high school, and for children of birth order two or higher. In the study setting and similar areas, sex differentials in coverage should be taken into account in ongoing immunization programmes.

Background and objectivesmHealth offers a new opportunity to ensure access to qualified healthcare providers. Therefore, to better understand its potential in Bangladesh, it is important to understand how young people use mobile phones for healthcare. Here we examine the knowledge, attitudes and intentions to use mHealth services among young population.DesignPopulation based cross sectional household survey.Setting and participantsA total of 4909 respondents, aged 18 years and above, under the Chakaria Health and Demographic Surveillance System (HDSS) area, were interviewed during the period November 2012 to April 2013.MethodsParticipants younger than 30 years of age were defined as young (or generation Y). To examine the level of knowledge about and intention towards mHealth services in generation Y compared with their older counterparts, the percentage of the respective outcome measure from a 2×2 contingency table and adjusted odds ratio (aOR), which controls for potential confounders such as mobile ownership, sex, education, occupation and socioeconomic status, were estimated. The aOR was estimated using both the Cochran–Mantel–Haenszel approach and multivariable logistic regression models controlling for confounders.ResultsGeneration Y had significantly greater access to mobile phones (50%vs40%) and better knowledge about its use for healthcare (37.8%vs27.5%;aOR 1.6 (95% CI1.3 to 2.0)). Furthermore, the level of knowledge about two existing mHealth services in generation Y was significantly higher compared with their older counterparts, with aOR values of 3.2 (95% CI 2.6 to 5.5) and 1.5 (95% CI 1.1 to 1.8), respectively. Similarly, generation Y showed significantly greater intention towards future use of mHealth services compared with their older counterparts (aOR 1.3 (95% CI 1.1 to 1.4)). The observed associations were not modified by sociodemographic factors.ConclusionThere is a greater potential for mHealth services in the future among young people compared with older age groups. However, given the low overall use of mHealth, appropriate policy measures need to be formulated to enhance availability, access, utilisation and effectiveness of mHealth services.

Background Traditional gender roles result in women lagging behind men in the use of modern technologies, especially in developing countries. Although there is rapid uptake of mobile phone use in Bangladesh, investigation of gender differences in the ownership, access and use of mobile phones in general and mHealth in particular has been limited. This paper presents gender differentials in the ownership of mobile phones and knowledge of available mHealth services in a rural area of Bangladesh. Methods We interviewed 4915 randomly selected respondents aged 18 years and above. Associations between gender and knowledge of available mHealth services, use of existing mHealth services and intentions to use mHealth services in the future were examined by multivariate logistic regression analysis, controlling for the effect of categorised covariates. Results Of the 4915 respondents to the survey, 61.8% of men (1213/1964) and 34.4% of women (1015/2951) owned a mobile phone. For men, mobile phone ownership was highest among those aged 18–29 years (n = 663, 76.3%), and for women among those aged 30–39 years (n = 825, 44.7%). A higher proportion of men owned phones compared to women, irrespective of socioeconomic status (SES) as indicated by asset index (p

Background Socioeconomic inequality in health and mortality remains a disturbing reality across nations including Bangladesh. Inequality drew renewed attention globally. Bangladesh though made impressive progress in health, it makes an interesting case for learning. This paper examined the trends and changing pattern of socioeconomic inequalities in under-five mortality in rural Bangladesh. It also examined whether mother’s education had any effect in reducing socioeconomic inequalities. Methods Data from rural samples of seven Bangladesh Demographic Health Surveys, carried out so far, were used. Children born alive during 5 years preceding the surveys were included in the analysis. Univariate, bivariate and multivariate analyses were carried out. Results Under-five mortality rate steadily declined over the years from 128/1000 in 1994 to 48 in 2014. Females had 8% lower mortality rates than males. Children of mothers with no schooling had 1.88 times higher mortality than those whose mother had six or more years of schooling. Similarly, children from low asset category households had on an average 1.17 times higher mortality rate than those from high asset category households. Inequality by mother’s education disappeared in the recent years, and inequality by household socioeconomic condition persisted all through. The pattern of inequality by sex, mother’s education, and household socioeconomic status was not changed statistically significantly over the years, and mothers’ education did not reduce socioeconomic inequalities. Discussion The reduction in mortality was consistent with changes in the proximate determinants of child survival in the country. Proximate determinants included maternal factors, environmental contamination, nutrient deficiency, personal illness control, and injury. Health and population programmes have been effective in increasing immunization coverage, use of ORS for managing diarrhoeal diseases, and increasing contraceptive use. Development activities on the other hand raised the literacy, especially among females, demand for modern health services, and reduction of poverty. However, socioeconomic inequality still exists in both under-five mortality and proximate determinants of child survival. Conclusions The socioeconomic inequality in under-five mortality is showing resistance against further reduction. An assessment of the adequacy of the existing programmes taking the proximate determinants of child survival into consideration will be useful for further improvement.

Background Health literacy (HL) helps individuals to make effective use of available health services. In low-income countries such as Bangladesh, the less than optimum use of services could be due to low levels of HL. Bangladesh’s health service delivery is pluralistic with a mix of public, private and informally trained healthcare providers. Emphasis on HL has been inadequate. Thus, it is important to assess the levels of HL and service utilization patterns. The findings from this study aim to bridge the knowledge gap. Materials and Methods The data for this study came from a cross-sectional survey carried out in September 2014, in Chakaria, a rural area in Bangladesh. A total of 1500 respondents were randomly selected from the population of 80,000 living in the Chakaria study area of icddr, b (International Centre for Diarrhoeal Disease Research, Bangladesh). HL was assessed in terms of knowledge of existing health facilities and sources of information on health care, immunization, diabetes and hypertension. Descriptive and cross-tabular analyses were carried out. Results Chambers of the rural practitioners of allopathic medicine, commonly known as ‘village doctors’, were mentioned by 86% of the respondents as a known health service facility in their area, followed by two public sector community clinics (54.6%) and Union Health and Family Welfare Centres (28.6%). Major sources of information on childhood immunization were government health workers. Almost all of the respondents had heard about diabetes and hypertension (97.4% and 95.4%, respectively). The top three sources of information for diabetes were neighbours (85.7%), followed by relatives (27.9%) and MBBS (Bachelor of Medicine and Bachelor of Surgery) doctors (20.4%). For hypertension, the sources were neighbours (78.0%), followed by village doctors (38.2%), MBBS doctors (23.2%) and relatives (15%). The proportions of respondents who knew diabetes and hypertension control measures were 40.9% and 28.0%, respectively. More females knew about the control of diabetes (44.4% to 36.6%) and hypertension (31.1% to 24.2%) than males. Conclusions A low level of HL in terms of modern health service facilities, diabetes and hypertension clearly indicated the need for a systematic HL programme. The relatively high levels of literacy concerning immunization show that it is possible to enhance HL in areas with low levels of education through systematic awareness-raising programmes, which could result in higher service coverage.

Background People’s participation in health, enshrined in the 1978 Alma Ata declaration, seeks to tap into community capability for better health and empowerment. One mechanism to promote participation in health is through participatory action research (PAR) methods. Beginning in 1994, the Bangladeshi research organization ICDDR,B implemented a project “self-help for health,” to work with existing rural self-help organizations (SHOs). SHOs are organizations formed by villagers for their well-being through their own initiatives without external material help. This paper describes the project’s implementation, impact, and reflective learnings. Methods Following a self-help conceptual framework and PAR, the project focused on building the capacity of SHOs and their members through training on organizational issues, imparting health literacy, and supporting participatory planning and monitoring. Quarterly activity reports and process documentation were the main sources of qualitative data used for this paper, enabling documentation of changes in organizational issues, as well as the number and nature of initiatives taken by the SHOs in the intervention area. Health and demographic surveillance system (HDSS) data from intervention and comparison areas since 1999 allowed assessment of changes in health indicators over time. Results Villagers and members of the SHOs actively participated in the self-help activities. SHO functionality increased in the intervention area, in terms of improved organizational processes and planned health activities. These included most notably in convening more regular meetings, identifying community needs, developing and implementing action plans, and monitoring progress and impact. Between 1999 and 2015, while decreases in infant mortality and increases in utilization of at least one antenatal care visit occurred similarly in intervention and comparison areas, increases in immunization, skilled birth attendance, facility deliveries and sanitary latrines were substantially more in intervention than comparison areas. Conclusion Building community capability by working with pre-existing SHOs, encouraging them to place health on their agendas, strengthening their functioning and implementation of health activities led to sustained improvements in utilization of services for over 20 years. Key elements underpinning success include efforts to build and maintain trust, ensuring social inclusion in project activities, and balancing demands for material resources with flexibility to be responsive to community needs.

Background: Out-of-pocket (OOP) healthcare expenditure is a major obstacle for achieving universal health coverage in low-income countries including Bangladesh. Sixty-three percent of the USD 27 annual per-capita healthcare expenditure in Bangladesh comes from individuals’ pockets. Although health insurance is a financial tool for reducing OOP, use of such tools in Bangladesh has been limited to some small-scale voluntary micro health insurance (MHI) schemes run by non-governmental organizations (NGO). The MHI, however, can orient people on health insurance concept and provide learning for product development, implementation, barriers to enrolment, membership renewal, and other operational challenges and solutions. Keeping this in mind, icddr,b in 2012 initiated a pilot MHI, Amader Shasthya, in Chakaria, Bangladesh. This paper explores the determinants of membership renewal in this scheme, which is a perpetual challenge for MHI. Objective: Identify socioeconomic and programmatic determinants and their effects on membership renewal in a voluntary MHI scheme. Methods: Data came from the online management information system of the scheme and Health and Demographic Surveillance System of Chakaria, covering the period February 2012–May 2015. Association between renewal and independent variables was examined using cross-tabular and logistic regression analyses. Results: Nearly 20% of households in the catchment area ever enroled in the scheme, and 38% renewed membership over the initial 3 years of operation. Frequency of consultation with healthcare providers, benefits received, proximity of member’s residence to health facility, socioeconomic status, educational level, and age of the household head showed significant positive association with renewal of membership. Conclusions: Villagers’ enrolment in the scheme indicated that even in poor economic and literacy conditions people can be motivated to enrol in insurance schemes. Degree of service utilization and benefits received can greatly enhance the probability of membership renewal, which can be ensured with good quality of services and ease of access.

Background The health hazards associated with the use of smokeless tobacco (SLT) are similar to those of smoking. However, unlike smoking, limited initiatives have been taken to control the use of SLT, despite its widespread use in South and Southeast Asian countries including Bangladesh. It is therefore important to examine the prevalence of SLT use and its social determinants for designing appropriate strategies and programmes to control its use. Objective To investigate the use of SLT in terms of prevalence, pattern and sociodemographic differentials in a rural area of Bangladesh. Design Population-based cross-sectional household survey. Setting and participants A total of 6178 individuals aged ≥13 years from 1753 households under the Chakaria HDSS area were interviewed during October–November 2011. Methods The current use of SLT, namely sadapatha (dried tobacco leaves) and zarda (industrially processed leaves), was used as the outcome variable. The crude and net associations between the sociodemographic characteristics of respondents and the outcome variables were examined using cross-tabular and multivariable logistic regression analysis, respectively. Results 23% of the total respondents (men: 27.0%, women: 19.3%) used any form of SLT. Of the respondents, 10.4% used only sadapatha,13.6% used only zarda and 2.2% used both. SLT use was significantly higher among men, older people, illiterate, ever married, day labourers and relatively poorer respondents. The odds of being a sadapatha user were 3.5-fold greater for women than for men and the odds of being a zarda user were 3.6-fold greater for men than for women. Conclusions The prevalence of SLT use was high in the study area and was higher among socioeconomically disadvantaged groups. The limitation of the existing regulatory measures for controlling the use of non-industrial SLT products should be understood and discussion for developing new strategies should be a priority.

Background High salt consumption is an important risk factor of elevated blood pressure. In Bangladesh about 20 million people are at high risk of hypertension due to climate change induced saline intrusion in water. The objective of this study is to assess beliefs, perceptions, and practices associated with salt consumption in coastal Bangladesh. Methods The study was conducted in Chakaria, Bangladesh between April-June 2011. It was a cross sectional mixed method study. For the qualitative study 6 focus group discussions, 8 key informant interviews, 60 free listing exercises, 20 ranking exercises and 10 observations were conducted. 400 adults were randomly selected for quantitative survey. For analysis we used SPSS for quantitative data, and Anthropac and Nvivo for qualitative data. Results Salt was described as an essential component of food with strong cultural and religious roots. People described both health benefits and risks related to salt intake. The overall risk perception regarding excessive salt consumption was low and respondents believed that the cooking process can render the salt harmless. Respondents were aware that salt is added in many foods even if they do not taste salty but did not recognize that salt can occur naturally in both foods and water. Conclusions In the study community people had low awareness of the risks associated with excess salt consumption and salt reduction strategies were not high in their agenda. The easy access to and low cost of salt as well as unrecognised presence of salt in drinking water has created an environment conducive to excess salt consumption. It is important to design general messages related to salt reduction and test tailored strategies especially for those at high risk of hypertension.

Smoking is one of the leading causes of death and two-thirds of the world’s smokers live in 10 countries, including Bangladesh. This study examines the trend and differentials in smoking in Chakaria, Bangladesh. Data from 2 surveys conducted in 1994 and 2008 in Chakaria were used. Results showed that smoking declined from 41% in 1994 to 27% in 2008. However, the decline was lower among the poor and the rate remained the same for the female illiterate. Interventions to prevent smoking need to be designed such that they are effective in disadvantaged groups and do not contribute to widening of socioeconomic inequalities in smoking prevalence and tobacco-related ill health and death.

Objective Village doctors, informal health care providers practicing modern medicine, are dominant health care providers in rural Bangladesh. Given their role, it is important to examine their prescription pattern and inappropriate use of medication. Methods These cross-sectional study data were collected through surveys of patients seen by village doctors during 2008 and 2010 at Chakaria, a typical rural area of Bangladesh. Categorization of appropriate, inappropriate, and harmful prescriptions by disease conditions was based on guidelines defined by the World Health Organization (WHO), the United Nations Children’s Fund (UNICEF), and the Government of Bangladesh. Analytical categorization of polypharmacy was defined when five or more medications were prescribed for a patient at a single visit. Findings A total of 2,587 prescriptions were written by village doctors during the survey periods. Among the prescriptions were appropriate (10%), inappropriate (8%), combination of appropriate and inappropriate (63%), and harmful medications (19%). Village doctors with more than high school education were 53% less likely (odds ratio [OR]: 0.47, 95% confidence interval [CI]: 0.26–0.86) to give polypharmacy prescriptions than those with less than high school education. While exploring determinants of prescribing inappropriate and harmful medications, this study found that polypharmacy prescriptions were six times more likely [OR: 6.00, 95% CI: 3.88–9.29] to have harmful medications than prescriptions with, Video abstract

IntroductionBangladesh has a serious shortage of qualified health workforce. The limited numbers of trained service providers are based in urban areas, which limits access to quality healthcare for the rural population. mHealth provides a new opportunity to ensure access to quality services to the population. A recent review suggested that there are 19 mHealth initiatives in the country. This paper reports findings on people's knowledge, perception, use, cost and compliance with advice received from mHealth services from a study carried out during 2012-13 in Chakaria, a rural sub-district in Bangladesh.MethodsA total of 4,915 randomly-chosen respondents aged 18 years and above were interviewed.ResultsHousehold ownership of mobile phones in the study area has increased from 2% in 2004 to 81% in 2012; 45% of the respondents reported that they had mobile phones. Thirty-one percent of the respondents were aware of the use of mobile phones for healthcare. Very few people were aware of the available mHealth services. Males, younger age group, better educated, and those from richer households were more knowledgeable about the existing mHealth services. Among the respondents who sought healthcare in the preceding two weeks of the survey, only 2% used mobile phones for healthcare. Adherence to the advice from the healthcare providers in terms of purchasing and taking the drugs was somewhat similar between the patients who used mobile phone for consultation versus making a physical visit.ConclusionsThe high penetration of mobile phones into the society provides a unique opportunity to use the mHealth technology for consulting healthcare providers. Although knowledge of the existence of mHealth services was low, it was encouraging that the compliance with the prescriptions was almost similar for advice received through mobile phone and physical visits. The study revealed clear indications that society is looking forward to embracing the mHealth technology.

Equity and gender, despite being universal concerns for all health programmes in Bangladesh, are often missing in many of the health agenda. The health programmes fail to address these important dimensions unless these are specifically included in the planning stage of a programme and are continually monitored for progress. This paper presents the situation of equity in health in Bangladesh, innovations in monitoring equity in the use of health services in general and by the poor in particular, and impact of targeted non-health interventions on health outcomes of the poor. It was argued that an equitable use of health services might also result in enhanced overall coverage of the services. The findings show that government services at the upazila level are used by the poor proportionately more than they are in the community, while at the private facilities, the situation is reverse. Commonly-used monitoring tools, at times, are not very useful for the programme managers to know how well they are doing in reaching the poor. Use of benefit-incidence ratio may provide a quick feedback to the health facility managers about their extent of serving the poor. Similarly, Lot Quality Assurance Sampling can be an easy-to-use tool for monitoring coverage at the community level requiring a very small sample size. Although health problems are biomedical phenomena, their solutions may include actions beyond the biomedical framework. Studies have shown that non-health interventions targeted towards the poor improve the use of health services and reduce mortality among children in poor households. The study on equity and health deals with various interlocking issues, and the examples and views presented in this paper intend to introduce their importance in design­ing and managing health and development programmes. Key words: Equity; Gender; Health; Health services; Monitoring tools; Bangladesh doi:10.3329/jhpn.v26i3.1902 J Health Popul Nutr 2008 Sept:26(3):378-383

Background : Bangladesh has achieved remarkable gains in health indicators during the last four decades despite low levels of economic development. However, the persistence of inequities remains disturbing. This success was also accompanied by health and demographic transitions, which in turn brings new challenges for a nation that has yet to come to terms with pre-transition health challenges. It is therefore important to understand the causes of death and their relationship with socioeconomic status (SES). Objective : The paper aims to assess the causes of death by SES based on surveillance data from a rural area of Bangladesh, in order to understand the situation and inform policy makers and programme leaders. Design : We analysed population-based mortality data collected from the Chakaria Health and Demographic Surveillance System in Bangladesh. The causes of death were determined by using a Bayesian-based programme for interpreting verbal autopsy findings (InterVA-4). The data included 1,391 deaths in 217,167 person-years of observation between 2010 and 2012. The wealth index constructed using household assets was used to assess the SES, and disease burdens were compared among the wealth quintiles. Results : Analysing cause of death (CoD) revealed that non-communicable diseases (NCDs) were the leading causes of deaths (37%), followed by communicable diseases (CDs) (22%), perinatal and neonatal conditions (11%), and injury and accidents (6%); the cause of remaining 24% of deaths could not be determined. Age-specific mortality showed premature birth, respiratory infections, and drowning were the dominant causes of death for childhood mortality (0–14 years), which was inversely associated with SES ( p

Background Evidence from numerous studies suggests that salt intake is an important determinant of elevated blood pressure. Robust data about salt consumption among adults in Bangladesh is sparse. However, much evidence suggests saline intrusion due to sea level rise as a result of climate change exposes more than 20 million people to adverse effects of salinity through the food and water supply. The objective of our study was to assess salt consumption among adults in a coastal region of Bangladesh. Methods Our study was cross sectional and conducted during October-November 2011. A single 24 hour urine was collected from 400 randomly selected individuals over 18 years of age from Chakaria, a rural, coastal area in Southeastern Bangladesh. Logistic regression was conducted to identify the determinants of high salt consumption. Results The mean urinary sodium excretion was 115 mmol/d (6.8 g salt). Based on logistic regression using two different cutoff points (IOM and WHO), housewives and those living in the coastal area had a significantly higher probability of high salt intake compared with people who were engaged in labour-intensive occupations and who lived in hilly areas. Conclusion It is important to create awareness about the implication of excessive salt intake on health and to develop strategies for reducing salt intake that can be implemented at the community-level. A sustainable policy for salt reduction in the Bangladeshi diet should be formulated with special emphasis on coastal areas.