Publications by authors named "Lal B Rawal"

32 Publications

Effectiveness of community-based health education and home support program to reduce blood pressure among patients with uncontrolled hypertension in Nepal: A cluster-randomized trial.

PLoS One 2021 12;16(10):e0258406. Epub 2021 Oct 12.

Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia.

Background: Hypertension is a major global public health problem. Elevated blood pressure can cause cardiovascular and kidney diseases. We assessed the effectiveness of health education sessions and home support programs in reducing blood pressure among patients with uncontrolled hypertension in a suburban community of Nepal.

Methods: We conducted a community-based, open-level, parallel-group, cluster randomized controlled trial in Birendranagar municipality of Surkhet, Nepal. We randomly assigned four clusters (wards) into intervention and control arms. We provided four health education sessions, frequent home and usual care for intervention groups over six months. The participants of the control arm received only usual care from health facilities. The primary outcome of this study was the proportion of controlled systolic blood pressure (SBP). The analysis included all participants who completed follow-up at six months.

Results: 125 participants were assigned to either the intervention (n = 63) or the control (n = 62) group. Of them, 60 participants in each group completed six months follow-up. The proportion of controlled SBP was significantly higher among the intervention participants compared to the control (58.3% vs. 40%). Odds ratio of this was 2.1 with 95% CI: 1.01-4.35 (p = 0.046) and that of controlled diastolic blood pressure (DBP) was 1.31 (0.63-2.72) (p = 0.600). The mean change (follow-up minus baseline) in SBP was significantly higher in the intervention than in the usual care (-18.7 mmHg vs. -11.2 mmHg, p = 0.041). Such mean change of DBP was also higher in the intervention (-10.95 mmHg vs. -5.53 mmHg, p = 0.065). The knowledge score on hypertension improved by 2.38 (SD 2.4) in the intervention arm, which was significantly different from that of the control group, 0.13 (1.8) (p<0.001).

Conclusions: Multiple health education sessions complemented by frequent household visits by health volunteers can effectively improve knowledge on hypertension and reduce blood pressure among uncontrolled hypertensive patients at the community level in Nepal.

Trial Registration: ClinicalTrial.gov: NCT02981251.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0258406PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8509872PMC
October 2021

Health problems and utilization of health services among Forcibly Displaced Myanmar Nationals in Bangladesh.

Glob Health Res Policy 2021 Oct 11;6(1):39. Epub 2021 Oct 11.

Health Systems and Population Division, icddr,b, Dhaka, Bangladesh.

Background: Access to and utilization of health services have remained major challenges for people living in low- and middle-income countries, especially for those living in impaired public health environment such as refugee camps and temporary settlements. This study presents health problems and utilization of health services among Forcibly Displaced Myanmar Nationals (FDMNs) living in the southern part of Bangladesh.

Methods: A mixed-method (quantitative and qualitative) approach was used. Altogether 999 household surveys were conducted among the FDMNs living in makeshift/temporary settlements and host communities. We used a grounded theory approach involving in-depth interviews (IDIs), focus group discussions (FGDs), and key informant interviews (KIIs) including 24 IDIs, 10 FGDs, and 9 KIIs. The quantitative data were analysed with STATA.

Results: The common health problems among the women were pregnancy and childbirth-related complications and violence against women. Among the children, fever, diarrhoea, common cold and malaria were frequently observed health problems. Poor general health, HIV/AIDS, insecurity, discrimination, and lack of employment opportunity were common problems for men. Further, 61.2% women received two or more antenatal care (ANC) visits during their last pregnancy, while 28.9% did not receive any ANC visit. The majority of the last births took place at home (85.2%) assisted by traditional birth attendants (78.9%), a third (29.3%) of whom suffered pregnancy- and childbirth-related complications. The clinics run by the non-governmental organizations (NGOs) (76.9%) and private health facilities (86.0%) were the most accessible places for seeking healthcare for the FDMNs living in the makeshift settlements. All participants heard about HIV/AIDS. 78.0% of them were unaware about the means of HIV transmission, and family planning methods were poorly used (45.2%).

Conclusions: Overall, the health of FDMNs living in the southern part of Bangladesh is poor and they have inadequate access to and utilization of health services to address the health problems and associated factors. Existing essential health and nutrition support programs need to be culturally appropriate and adopt an integrated approach to encourage men's participation to improve utilization of health and family planning services, address issues of gender inequity, gender-based violence, and improve women empowerment and overall health outcomes.
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http://dx.doi.org/10.1186/s41256-021-00223-1DOI Listing
October 2021

Weight Gain After Smoking Cessation and Risk of Major Chronic Diseases and Mortality.

JAMA Netw Open 2021 04 1;4(4):e217044. Epub 2021 Apr 1.

School of Social Sciences and Psychology, Western Sydney University, Sydney, Australia.

Importance: Smoking cessation is frequently followed by weight gain; however, whether weight gain after quitting reduces the health benefits of quitting is unclear.

Objective: To examine the association between weight change after smoking cessation and the risk of cardiovascular diseases (CVD), type 2 diabetes, cancer, chronic obstructive pulmonary disease (COPD), and all-cause mortality.

Design, Setting, And Participants: This cohort study analyzed data from a nationally representative sample of Australian adults aged 18 years or older who were studied between 2006 and 2014. Smoking status and anthropometric measurements were self-reported annually. Cox proportional hazards regressions were used to determine the hazard ratios (HRs) for the association between changes in weight and body mass index (BMI) and the risk of CVD, type 2 diabetes, cancer, COPD, and mortality. Data were analyzed in January 2019.

Exposures: Annual self-reported smoking status; years since quitting.

Main Outcomes And Measures: Weight gain after quitting, incident CVD, type 2 diabetes, cancer, COPD, and all-cause mortality.

Results: Of a total 16 663 participants (8082 men and 8581 women; mean [SD] age, 43.7 [16.3] years), those who quit smoking had greater increases in weight (mean difference [MD], 3.14 kg; 95% CI, 1.39-4.87) and BMI (MD, 0.82; 95% CI, 0.21-1.44) than continuing smokers. Compared with continuing smokers, the HRs for death were 0.50 (95% CI, 0.36-0.68) among quitters who lost weight, 0.79 (95% CI, 0.51-0.98) among quitters without weight change, 0.33 (95% CI, 0.21-0.51) among quitters who gained 0.1 to 5.0 kg, 0.24 (95% CI, 0.11-0.53) among quitters who gained 5.1 to 10 kg, and 0.36 (95% CI, 0.16-0.82) among quitters who gained more than 10 kg. The HRs for death were 0.61 (95% CI, 0.45-0.83) among quitters who lost BMI, 0.86 (95% CI, 0.51-1.44) among quitters without change in BMI, 0.32 (95% CI, 0.21-0.50) among quitters who gained up to 2 in BMI, and 0.26 (95% CI, 0.16-0.45) among quitters who gained more than 2 in BMI.

Conclusions And Relevance: This cohort study found that smoking cessation was accompanied by a substantial weight gain; however, this was not associated with an increased risk of chronic diseases or an attenuation of the mortality benefit of cessation.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.7044DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8080225PMC
April 2021

Factors influencing place of delivery: Evidence from three south-Asian countries.

PLoS One 2021 8;16(4):e0250012. Epub 2021 Apr 8.

Institute for Physical Activity and Nutrition, Deakin University, Burwood, VIC, Australia.

Background: High maternal mortality is still a significant public health challenge in many countries of the South-Asian region. The majority of maternal deaths occur due to pregnancy and delivery-related complications, which can mostly be prevented by safe facility delivery. Due to the paucity of existing evidence, our study aimed to examine the factors associated with place of delivery, including women's preferences for such in three selected South-Asian countries.

Methods: We extracted data from the most recent demographic and health surveys (DHS) conducted in Bangladesh (2014), Nepal (2016), and Pakistan (2017-18) and analyzed to identify the association between the outcome variable and socio-demographic characteristics. A total of 16,429 women from Bangladesh (4278; mean age 24.57 years), Nepal (3962; mean age 26.35 years), and Pakistan (8189; mean age 29.57 years) were included in this study. Following descriptive analyses, bivariate and multivariate logistic regressions were conducted.

Results: Overall, the prevalence of facility-based delivery was 40%, 62%, and 69% in Bangladesh, Nepal, and Pakistan, respectively. Inequity in utilizing facility-based delivery was observed for women in the highest wealth quintile. Participants from Urban areas, educated, middle and upper household economic status, and with high antenatal care (ANC) visits were significantly associated with facility-based delivery in all three countries. Interestingly, watching TV was also found as a strong determinant for facility-based delivery in Bangladesh (aOR = 1.31, 95% CI:1.09-1.56, P = 0.003), Nepal (aOR = 1.42, 95% CI:1.20-1.67, P<0.001) and Pakistan (aOR = 1.17, 95% CI: 1.03-1.32, P = 0.013). Higher education of husband was a significant predictor for facility delivery in Bangladesh (aOR = 1.73, 95% CI:1.27-2.35, P = 0.001) and Pakistan (aOR = 1.19, 95% CI: 0.99-1.43, P = 0.065); husband's occupation was also a significant factor in Bangladesh (aOR = 1.30, 95% CI:1.04-1.61, P = 0.020) and Nepal (aOR = 1.26, 95% CI:1.01-1.58, P = 0.041).

Conclusion: Our findings suggest that the educational status of both women and their husbands, household economic situation, and the number of ANC visits influenced the place of delivery. There is an urgent need to promote facility delivery by building more birthing facilities, training and deployment of skilled birth attendants in rural and hard-to-reach areas, ensuring compulsory female education for all women, encouraging more ANC visits, and providing financial incentives for facility deliveries. There is a need to promote facility delivery by encouraging health facility visits through utilizing social networks and continuing mass media campaigns. Ensuring adequate Government funding for free maternal and newborn health care and local community involvement is crucial for reducing maternal and neonatal mortality and achieving sustainable development goals in this region.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0250012PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8031333PMC
October 2021

Prevalence of non-communicable chronic conditions, multimorbidity and its correlates among older adults in rural Nepal: a cross-sectional study.

BMJ Open 2021 02 25;11(2):e041728. Epub 2021 Feb 25.

Centre for Primary Health Care and Equity, University of New South Wales, Sydney, New South Wales, Australia.

Objectives: This study's objectives were to estimate the prevalence of major non-communicable conditions and multimorbidity among older adults in rural Nepal and examine the associated socioeconomic and behavioural risk factors.

Design: This was a community-based cross-sectional study conducted between January and April 2018.

Setting: Rural municipalities of Sunsari and Morang districts in eastern Nepal.

Participants: 794 older Nepalese adults, 60 years and older, were recruited using a multistage cluster sampling approach.

Primary Outcome Measures: Prevalence of four major non-communicable chronic conditions (osteoarthritis, cardiovascular disease, diabetes and chronic obstructive pulmonary disease (COPD) and multimorbidity.

Results: Almost half (48.9%: men 45.3%; women 52.4%) of the participants had at least one of four non-communicable chronic conditions, and 14.6% (men 12.5%; women 16.8%) had two or more conditions. The prevalence of individual conditions included: osteoarthritis-41.7% (men 37.5%; women 45.9%), cardiovascular disease-2.4% (men 2.8%; women 2.0%), diabetes-5.3% (men 6.0%; women 4.6%) and COPD-15.4% (men 13.3%; women 17.5%). In the adjusted model, older adults aged 70-79 years (adjusted OR (AOR): 1.62; 95% CI: 1.04 to 2.54), those from Madhesi and other ethnic groups (AOR: 1.08; 95% CI: 1.02 to 1.72), without a history of alcohol drinking (AOR: 1.53; 95% CI: 1.18 to 2.01) and those physically inactive (AOR: 5.02; 95% CI: 1.47 to 17.17) had significantly higher odds of multimorbidity.

Conclusions: This study found one in seven study participants had multimorbidity. The prevalence of multimorbidity and associated socioeconomic and behavioural correlates need to be addressed by integrating social programmes with health prevention and management at multiple levels. Moreover, a longitudinal study is suggested to understand the temporal relationship between lifestyle predictors and multimorbidity among older Nepalese adults.
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http://dx.doi.org/10.1136/bmjopen-2020-041728DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7908905PMC
February 2021

Factors associated with low adherence to medication among patients with type 2 diabetes at different healthcare facilities in southern Bangladesh.

Glob Health Action 2021 01;14(1):1872895

ARC Centre of Excellence for Children and Families over the Life Course, The University of Queensland , Brisbane, Australia.

: Diabetic individuals must adhere to their medications to control their glucose levels and prevent diabetes-related complications. However, there is limited evidence of medication adherence in patients with type 2 diabetes in Bangladesh. : We assessed the level of adherence and factors associated with low adherence to anti-diabetic medication among patients with type 2 diabetes at different health facilities in southern Bangladesh. : This cross-sectional study included 2,070 patients with type 2 diabetes who presented at five health facilities in the Chittagong Division between November 2018 and June 2019. We assessed medication adherence using a self-reported, structured, eight-item questionnaire and performed multiple logistic regression to investigate the factors associated with low medication adherence. : The overall prevalence of low medication adherence was 46.3% (95% CI: 41.4-55.8%) of our study population. Multiple logistic regression analysis revealed that males (OR: 1.37; 95% CI: 1.13-1.67), those with a family income of < 233 USD (OR: 1.54, 95% CI: 1.17-2.03), and those with a diabetic ulcer (OR: 1.42, 95% CI: 1.04-1.94) showed low adherence. Diabetic ulcers, retinopathy, and obesity were relatively more elevated among diabetic patients with low medication adherence. : Low medication adherence among patients with type 2 diabetes in southern Bangladesh is a key public health challenge. Factors such as male sex, low annual family income, and diabetic ulcers were associated with low medication adherence. Patient counseling and awareness programs may enhance medication adherence among people with type 2 diabetes. Our findings will help physicians and public health workers to develop targeted strategies to increase awareness of the same among their patients.
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http://dx.doi.org/10.1080/16549716.2021.1872895DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7833014PMC
January 2021

A Policy Analysis Regarding Education, Career, and Governance of the Nurses in Bangladesh: A Qualitative Exploration.

Policy Polit Nurs Pract 2021 May 18;22(2):114-125. Epub 2021 Jan 18.

Centre of Excellence for Health Systems and Universal Health Coverage, BRAC James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh.

Nurses, short in production and inequitable in the distribution in Bangladesh, require the government's efforts to increase enrolment in nursing education and a smooth career progression. Given the importance of an assessment of the current nursing scenario to inform the decision makers and practitioners to implement the new policies successfully, we analyzed relevant policies on education, career, and governance of nurses in Bangladesh. We used documents review and qualitative methods such as key informant interviews ( = 13) and stakeholder analysis. We found that nursing education faced several backlashes: resistance from diploma nurses while attempting to establish a graduate (bachelor) course in 1977, and the reluctance of politicians and entrepreneurs to establish nursing institutions. Many challenges with the implementation of nursing policies are attributable to social, cultural, religious, and historical factors. For example, Hindus considered touching the bodily excretions as the task of the lower castes, while Muslims considered women touching the body of the men immoral. Nurses also face governance challenges linked with their performance and reward. For example, nurses have little voice over the decisions related to their profession, and they are not allowed to perform clinical duties unsupervised. To improve the situation, the government has made new policies, including upliftment of nurses' position in public service, the creation of an independent Directorate General, and improvement of nursing education and service. New policies often come with new apprehensions. Therefore, nurses should be included in the policy processes, and their capacity should be developed in nursing leadership and health system governance.
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http://dx.doi.org/10.1177/1527154420988003DOI Listing
May 2021

Community health workers for non-communicable disease prevention and control in Nepal: a qualitative study.

BMJ Open 2020 12 13;10(12):e040350. Epub 2020 Dec 13.

Global Health Program, Duke Kunshan University, Jiangsu 215347, China, Kunsan, China

Background/objective: The increasing burden of non-communicable diseases (NCDs) in Nepal underscores the importance of strengthening primary healthcare systems to deliver efficient care. In this study, we examined the barriers and facilitators to engaging community health workers (CHWs) for NCDs prevention and control in Nepal.

Design: We used multiple approaches including (a) review of relevant literature, (b) key personnel and stakeholders' consultation meetings and (c) qualitative data collection using semistructured interviews. A grounded theory approach was used for qualitative data collection and the data were analysed thematically.

Setting: Data were collected from health facilities across four districts in Nepal and two stakeholder consultative meetings were conducted at central level.

Participants: We conducted in-depth interviews with CHWs (Health Assistants, Auxiliary Health Workers, Auxiliary Nurse Midwife) (n=5); key informant interviews with health policymakers/managers (n=3) and focus group discussions (FGDs) with CHWs (four FGDs; total n=27). Participants in two stakeholder consultative meetings included members from the government (n=8), non-government organisations (n=7), private sector (n=3) and universities (n=6).

Results: The CHWs were engaged in a wide range of public health programmes and they also deliver NCDs specific programmes such as common NCDs screening, provisional diagnosis, primary care, health education and counselling, basic medication and referral and so on. These NCD prevention and control services are concentrated in those districts, where the WHO, Package for prevention and control of NCDs) program is being implemented. Some challenges and barriers were identified, including inadequate NCD training, high workload, poor system-level support, inadequate remuneration, inadequate supply of logistics and drugs. The facilitating factors included government priority, formation of NCD-related policies, community support systems, social prestige and staff motivation.

Conclusion: Engaging CHWs has been considered as key driver to delivering NCDs related services in Nepal. Effective integration of CHWs within the primary care system is essential for CHW's capacity buildings, necessary supervisory arrangements, supply of logistics and medications and setting up effective recording and reporting systems for prevention and control of NCDs in Nepal.
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http://dx.doi.org/10.1136/bmjopen-2020-040350DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7737104PMC
December 2020

Community health workers for non-communicable disease prevention and control in Nepal: a qualitative study.

BMJ Open 2020 12 13;10(12):e040350. Epub 2020 Dec 13.

Global Health Program, Duke Kunshan University, Jiangsu 215347, China, Kunsan, China

Background/objective: The increasing burden of non-communicable diseases (NCDs) in Nepal underscores the importance of strengthening primary healthcare systems to deliver efficient care. In this study, we examined the barriers and facilitators to engaging community health workers (CHWs) for NCDs prevention and control in Nepal.

Design: We used multiple approaches including (a) review of relevant literature, (b) key personnel and stakeholders' consultation meetings and (c) qualitative data collection using semistructured interviews. A grounded theory approach was used for qualitative data collection and the data were analysed thematically.

Setting: Data were collected from health facilities across four districts in Nepal and two stakeholder consultative meetings were conducted at central level.

Participants: We conducted in-depth interviews with CHWs (Health Assistants, Auxiliary Health Workers, Auxiliary Nurse Midwife) (n=5); key informant interviews with health policymakers/managers (n=3) and focus group discussions (FGDs) with CHWs (four FGDs; total n=27). Participants in two stakeholder consultative meetings included members from the government (n=8), non-government organisations (n=7), private sector (n=3) and universities (n=6).

Results: The CHWs were engaged in a wide range of public health programmes and they also deliver NCDs specific programmes such as common NCDs screening, provisional diagnosis, primary care, health education and counselling, basic medication and referral and so on. These NCD prevention and control services are concentrated in those districts, where the WHO, Package for prevention and control of NCDs) program is being implemented. Some challenges and barriers were identified, including inadequate NCD training, high workload, poor system-level support, inadequate remuneration, inadequate supply of logistics and drugs. The facilitating factors included government priority, formation of NCD-related policies, community support systems, social prestige and staff motivation.

Conclusion: Engaging CHWs has been considered as key driver to delivering NCDs related services in Nepal. Effective integration of CHWs within the primary care system is essential for CHW's capacity buildings, necessary supervisory arrangements, supply of logistics and medications and setting up effective recording and reporting systems for prevention and control of NCDs in Nepal.
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http://dx.doi.org/10.1136/bmjopen-2020-040350DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7737104PMC
December 2020

Physical Activity among Adults with Low Socioeconomic Status Living in Industrialized Countries: A Meta-Ethnographic Approach to Understanding Socioecological Complexities.

J Environ Public Health 2020 1;2020:4283027. Epub 2020 Apr 1.

School of Social Sciences, Western Sydney University, Sydney, Australia.

Method: Using MeSH keywords, we searched major electronic databases including Medline, EMBASE, CINAHL, and PsycINFO in order to identify relevant publications published between January 2000 and October 2018. We included 19 qualitative studies which met inclusion criteria and were focused on physical activity determinants among adults.

Results: Determinants emerging from these studies were grouped into six themes: (i) urban environment, (ii) financial constraints, (iii) work-life integration, (iv) community engagement, (v) social support, and (vi) psychosocial factors. After conceptualising these six themes into a social ecological model, we identified potential research gaps for physical activity among adults with low socioeconomic status living in industrialized countries.

Conclusion: Our major insight was that, in industrialized countries, physical activity overlooks potential strengths to maintain health and well-being of those people with low socioeconomic status. A more complex understanding of contradictions between positive and deficit frames would lead to more critical insights of research gaps of physical activity in adult population with low socioeconomic status.
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http://dx.doi.org/10.1155/2020/4283027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7152945PMC
October 2020

Wealth-related inequalities of women's knowledge of cervical cancer screening and service utilisation in 18 resource-constrained countries: evidence from a pooled decomposition analysis.

Int J Equity Health 2020 03 26;19(1):42. Epub 2020 Mar 26.

School of Social Sciences, Western Sydney University, Penrith-2751, New South Wales, Australia.

Introduction: Resource-constrained countries (RCCs) have the highest burden of cervical cancer (CC) in the world. Nonetheless, although CC can be prevented through screening for precancerous lesions, only a small proportion of women utilise screening services in RCCs. The objective of this study was to examine the magnitude of inequalities of women's knowledge and utilisation of cervical cancer screening (CCS) services in RCCs.

Methods: A total of 1,802,413 sample observations from 18 RCC's latest national-level Demographic and Health Surveys (2008 to 2017-18) were analysed to assess wealth-related inequalities in terms of women's knowledge and utilisation of CCS services. Regression-based decomposition analyses were applied in order to compute the contribution to the inequality disparities of the explanatory variables for women's knowledge and utilisation of CCS services.

Results: Overall, approximately 37% of women had knowledge regarding CCS services, of which, 25% belonged to the poorest quintile and approximately 49% from the richest. Twenty-nine percent of women utilised CCS services, ranging from 11% in Tajikistan, 15% in Cote d'Ivoire, 17% in Tanzania, 19% in Zimbabwe and 20% in Kenya to 96% in Colombia. Decomposition analyses determined that factors that reduced inequalities in women's knowledge of CCS services were male-headed households (- 2.24%; 95% CI: - 3.10%, - 1.59%; P < 0.01), currently experiencing amenorrhea (- 1.37%; 95% CI: - 2.37%, - 1.05%; P < 0.05), having no problems accessing medical assistance (- 10.00%; 95% CI: - 12.65%, - 4.89%; P < 0.05), being insured (- 6.94%; 95% CI: - 9.58%, - 4.29%; P < 0.01) and having an urban place of residence (- 9.76%; 95% CI: - 12.59%, - 5.69%; P < 0.01). Similarly, factors that diminished inequality in the utilisation of CCS services were being married (- 8.23%;95% CI: - 12.46%, - 5.80%; P < 0.01), being unemployed (- 14.16%; 95% CI: - 19.23%, - 8.47%; P < 0.01) and living in urban communities (- 9.76%; 95% CI: - 15.62%, - 5.80%; P < 0.01).

Conclusions: Women's knowledge and utilisation of CCS services in RCCs are unequally distributed. Significant inequalities were identified among socioeconomically deprived women in the majority of countries. There is an urgent need for culturally appropriate community-based awareness and access programs to improve the uptake of CCS services in RCCs.
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http://dx.doi.org/10.1186/s12939-020-01159-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7098106PMC
March 2020

Association of Psychosocial Factors With Risk of Chronic Diseases: A Nationwide Longitudinal Study.

Am J Prev Med 2020 02;58(2):e39-e50

School of Social Sciences and Psychology, Western Sydney University, Sydney, New South Wales, Australia; Translational Health Research Institute, Western Sydney University, Sydney, New South Wales, Australia.

Introduction: This study examines the prospective association between a range of psychosocial factors and common noncommunicable diseases.

Methods: In October 2018, nationally representative data were analyzed from 11,637 adults followed annually between 2003 and 2013. Participants reported on psychosocial factors they experienced in the 12 months preceding each wave. The onset of noncommunicable diseases was defined based on self-reported physician's diagnosis. Generalized estimating equations estimated the ORs and 95% CIs of psychosocial factors on noncommunicable diseases, controlling for other confounders.

Results: Social support index was inversely associated with the onset of anxiety or depression in men (OR=0.95, 95% CI=0.93, 0.98) and women (OR=0.96, 95% CI=0.95, 0.98) and with emphysema in women (OR=0.96, 95% CI=0.93, 0.99). Psychological distress was positively associated with the onset of heart diseases (OR=2.38, 95% CI=1.16, 4.89 for men; OR=2.30, 95% CI=1.10, 4.78 for women), emphysema (OR=1.11, 95% CI=1.03, 1.20 for men; OR=1.08, 95% CI=1.04, 1.12 for women), and circulatory diseases (OR=1.04, 95% CI=1.02, 1.08 for women). Financial stress increased the onset of anxiety or depression (OR=1.36, 95% CI=1.26, 1.63 for men; OR=1.30, 95% CI=1.10, 1.52 for women) and type 2 diabetes in women (OR=1.60, 95% CI=1.18, 2.18). Significant associations of parenting stress and the likelihood of the onset of anxiety or depression were only evident in women.

Conclusions: These findings suggest that several adverse psychosocial risk factors are independently associated with the onset of noncommunicable diseases.
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http://dx.doi.org/10.1016/j.amepre.2019.09.007DOI Listing
February 2020

Engaging village health workers in non-communicable disease (NCD) prevention and control in Vietnam: A qualitative study.

Glob Public Health 2020 04 20;15(4):611-625. Epub 2019 Oct 20.

Global Health Research Center, Duke Kunshan University, Kunshan, People's Republic of China.

The burden of non-communicable diseases (NCDs) continues to grow in Vietnam, and reducing the burden of NCDs is a national priority. This study explored perspective of community health workers (CHWs), known as Village Health Workers (VHWs) in Vietnam, and public health leaders towards potential of expanding VHWs' role to deliver NCDs prevention and control services, and determined barriers and facilitators. We conducted focus group discussions (FGDs) with VHWs ( = 24) and in-depth interviews (IDIs) with public health administrators ( = 13). The findings show that VHWs in Vietnam deliver multiple public health services, including several NCDs related services. Perceived barriers include lack of policy support, shortages of trained health personnel, lack of training, imbalanced workload and inadequate remuneration. Perceived barriers include lack of policy support, shortages of trained health personnel, lack of training, imbalanced workload and inadequate remuneration. Facilitators include government commitment to NCDs prevention and control, priority on capacity building, professional recognition and provision of incentives with availability of appropriate resources. While additional quantitative studies are needed to supplement the current qualitative findings, the current results inform the policy and intervention development in engaging VHWs in the delivery of community-based NCDs prevention and control initiatives in Vietnam.
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http://dx.doi.org/10.1080/17441692.2019.1678660DOI Listing
April 2020

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 Open 2019 10 7;9(10):e029562. Epub 2019 Oct 7.

Centre of Excellence for Universal Health Coverage (CoE-UHC), James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh.

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.
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http://dx.doi.org/10.1136/bmjopen-2019-029562DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6797278PMC
October 2019

'Connecting the dots' for generating a momentum for Universal Health Coverage in Bangladesh: findings from a cross-sectional descriptive study.

BMJ Open 2019 07 17;9(7):e024509. Epub 2019 Jul 17.

Centre of Excellence for Health Systems and UHC, James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh.

Objective: This study was conducted to explore how and whether, the strategic grants made by the Rockefeller Foundation (RF) in different sectors of health systems in the inception phase were able to 'connect the dots' for 'generating a momentum for Universal Health Coverage (UHC)' in the country.

Design: Cross-sectional descriptive study, using document review and qualitative methods.

Setting: Bangladesh, 17 UHC-related projects funded by the RF Transforming Health Systems (THS) initiative during 2010-2013.

Data: Available reports of the completed and on-going UHC projects, policy documents of the government relevant to UHC, key-informant interviews and feedback from grant recipients and relevant stakeholders in the policy and practice.

Outcome Measures: Key policy initiatives undertaken for implementing UHC activities by the government post grants disbursement.

Results: The RF THS grants simultaneously targeted and connected the academia, the public and non-profit development sectors and news media for awareness-building and advocacy on UHC, develop relevant policies and capacity for implementation including evidence generation. This strategy helped relevant stakeholders to come together to discuss and debate the core concepts, scopes and modalities of UHC in an attempt to reach a consensus. Additionally, experiences gained from implementation of the pilot projects helped in identifying possible entry points for initiating UHC activities in a low resource setting like Bangladesh.

Conclusions: During early years of UHC-related activities in Bangladesh, strategic investments of the RF THS initiative played a catalytic role in sensitising and mobilising different constituencies for concerted activities and undertaking necessary first steps. Learnings from this strategy may be of help to countries under similar conditions of 'low resource, apparent commitment, but poor governance,' on their journey towards UHC.
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http://dx.doi.org/10.1136/bmjopen-2018-024509DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6661671PMC
July 2019

Changes in inequality of childhood morbidity in Bangladesh 1993-2014: A decomposition analysis.

PLoS One 2019 19;14(6):e0218515. Epub 2019 Jun 19.

Health Economics and Policy Research, School of Commerce, Faculty of Business, Education, Law and Arts, Centre for Health, Informatics and Economic Research, University of Southern Queensland, Toowoomba, Queensland, Australia.

Introduction: Child health remains an important public health concern at the global level, with preventable diseases such as diarrheal disease, acute respiratory infection (ARI) and fever posing a large public health burden in low- and middle-income countries including Bangladesh. Improvements in socio-economic conditions have tended to benefit advantaged groups in societies, which has resulted in widespread inequalities in health outcomes. This study examined how socioeconomic inequality is associated with childhood morbidity in Bangladesh, and identified the factors affecting three illnesses: diarrhea, ARI and fever.

Materials And Methods: A total of 43,860 sample observations from the Bangladesh Demographic and Health Survey, spanning a 22-year period (1993-2014), were analysed. Concentration curve and concentration index methods were used to evaluate changes in the degree of household wealth-related inequalities and related trends in childhood morbidity. Regression-based decomposition analyses were used to attribute the inequality disparities to individual determinants for the three selected causes of childhood morbidity.

Results: The overall magnitude of inequality in relation to childhood morbidity has been declining slowly over the 22-year period. The magnitude of socio-economic inequality as a cause of childhood morbidity varied during the period. Decomposition analyses attributed the inequalities to poor maternal education attainment, inadequate pre-delivery care, adverse chronic undernutrition status and low immunisation coverage.

Conclusions: High rates of childhood morbidity were observed, although these have declined over time. Socio-economic inequality is strongly associated with childhood morbidity. Socio-economically disadvantaged communities need to be assisted and interventions should emphasise improvements of, and easier access to, health care services. These will be key to improving the health status of children in Bangladesh and should reduce economic inequality through improved health over time.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0218515PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6583970PMC
February 2020

Prevalence of underweight, overweight and obesity and their associated risk factors in Nepalese adults: Data from a Nationwide Survey, 2016.

PLoS One 2018 6;13(11):e0205912. Epub 2018 Nov 6.

Western Sydney University, Sydney, Australia.

Introduction: Over the past few decades, the total population of Nepal has increased substantially with rapid urbanization, changing lifestyle and disease patterns. There is anecdotal evidence that non-communicable diseases (NCDs) and associated risk factors are becoming key public health challenges. Using nationally representative survey data, we estimated the prevalence of underweight, overweight and obesity among Nepalese adults and explored socio-demographic factors associated with these conditions.

Materials And Methods: We used the Nepal Demographic Health Survey 2016 data. Sample selection was based on stratified two-stage cluster sampling in rural areas and three stages in urban areas. Weight and height were measured in all adult women and men. Body mass index (BMI) was calculated using Asian specific BMI cut-points.

Results: A total of 13,542 adults aged 18 years and above (women 58.19%) had their weight and height measured. The mean (±SD) age was 40.63±16.82 years (men 42.75±17.27, women 39.15±16.34); 41.13% had no formal education and 60.97% lived in urban areas. Overall, 17.27% (95% CI: 16.64-17.91) were underweight; 31.16% (95% CI: 30.38-31.94) overweight/obese. The prevalence of both underweight (women 18.30% and men 15.83%, p<0.001) and overweight/obesity (women 32.87% and men 28.77%, p<0.001) was higher among women. The older adults (≥65 years) (aOR: 2.40, 95% CI: 1.92-2.99, p<0.001) and the adults of poorest wealth quintile (aOR: 2.05, 95% CI: 1.62-2.59, p<0.001) were more likely to be underweight. The younger age adults (36-45 years) (aOR: 3.05, 95% CI: 2.61-3.57, p<0.001) and women (aOR: 1.53, 95% CI 1.39-1.68, p<0.001) were more likely to be overweight or obese. Also, all adults were twice likely to overweight/obese (p<0.001). No significant difference was observed for overweight/obesity by ecological regions and place of residence (urban vs. rural).

Conclusion: These findings confirm co-existence of double burden of underweight and overweight/obesity among Nepalese adults. These conditions are associated with increased risk of developing NCDs. Therefore, effective public health intervention approaches emphasizing improved primary health care systems for NCDs prevention and care and using multi-sectoral approach, is essential.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0205912PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6219769PMC
April 2019

Urban-rural and sex differentials in tuberculosis mortality in Bangladesh: results from a population-based survey.

Trop Med Int Health 2019 01 22;24(1):109-115. Epub 2018 Nov 22.

James P Grant School of Public Health, BRAC University, Mohakhali, Dhaka, Bangladesh.

Objective: To assess tuberculosis mortality in Bangladesh through a population-based survey using a Verbal Autopsy tool.

Methods: Nationwide mortality survey employing the WHO-recommended Verbal Autopsy (VA) tool, and using InsilicoVA, a data-driven method, to assign the cause of death. Using a three-stage cluster sampling method, 3997 VA interviews were conducted in both urban and rural areas of Bangladesh. Cause-specific mortality fractions (CSMF) were estimated using Bayesian probabilistic models.

Results: 6.8% of total deaths in the population were due to TB [95% CI: (5.1, 8.9)], comprising 12.0% [95% CI: (11.1, 12.8)] and 6.42% [95% CI: (5.4, 7.3)] of total male and female deaths, respectively. This proportion was highest among adults age 15-49 years [12.2%, 95% CI: (9.4, 14.6)]. The urban population is more likely to die from TB, and urban males have highest CSMF [13.6%, 95% CI: (9.1, 16.9)].

Conclusion: Our survey results show that TB is the fifth major cause of death in the general population and that sex and place of residence (urban/rural) have a significant effect on TB mortality in Bangladesh. The underlying causes of higher rates of TB-related deaths in urban areas and particularly among urban males, who have better knowledge and higher enrollment in the DOTS Program, need to be explored.
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http://dx.doi.org/10.1111/tmi.13171DOI Listing
January 2019

Integrating human rights approaches into public health practices and policies to address health needs amongst Rohingya refugees in Bangladesh: a systematic review and meta-ethnographic analysis.

Arch Public Health 2018 11;76:59. Epub 2018 Oct 11.

5School of Social Sciences and Psychology, Western Sydney University, Penrith, Australia.

Background: The Rohingya people of Myanmar are one of the most persecuted communities in the world and are forced to flee their home to escape conflict and persecution. Bangladesh receives the majority of the Rohingya refugees. On arrival they experience a number of human rights issues and the extent to which human rights approaches are used to inform public health programs is not well documented. The aim of this systematic review was to document human rights- human rights-related health issues and to develop a conceptual human rights framework to inform current policy practice and programming in relation to the needs of Rohingya refugees in Bangladesh.

Methods: This systematic review was conducted using the 2015 Preferred Reporting Items for Systematic reviews and Meta-Analysis guidelines. Eight computerized databases were searched: Academic Search complete, Embase, CINAHL, JStor, Pubmed, Scopus, SocIndex, and Proquest Central along with grey literature and Google Scholar. Of a total of 752 articles retrieved from the eight databases and 17 studies from grey literature, 31 studies met our inclusion criteria.

Results: Using meta-ethnographic synthesis, we developed a model that helps understand the linkages of various human rights and human rights-related health issues of Rohingya refugees. The model highlights how insufficient structural factors, poor living conditions, restricted mobility, and lack of working rights for extended periods of time collectively contribute to poor health outcomes of Rohingya refugees.

Conclusion: This review provides a human-rights approach to frame actions both at program and policy level in a sustained way to address the health needs of Rohingya refugees in Bangladesh. Such policy actions will focus on finding long term solutions for integrating the Rohingya population while addressing their immediate rights issue.

Trial Registration: This systematic review has not been registered.
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http://dx.doi.org/10.1186/s13690-018-0305-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6180399PMC
October 2018

Retaining Doctors in Rural Bangladesh: A Policy Analysis.

Int J Health Policy Manag 2018 09 1;7(9):847-858. Epub 2018 Sep 1.

Health Nutrition and Population, Human Development Network, The World Bank, Washington, DC, USA.

Background: Retaining doctors in rural areas is a challenge in Bangladesh. In this study, we analyzed three rural retention policies: career development programs, compulsory services, and schools outside major cities - in terms of context, contents, actors, and processes.

Methods: Series of group discussions between policy-makers and researchers prompted the selection of policy areas, which were analyzed using the policy triangle framework. We conducted document and literature reviews (1971-2013), key informant interviews (KIIs) with relevant policy elites (n=11), and stakeholder analysis/position-mapping.

Results: In policy-1, we found, applicants with relevant expertise were not leveraged in recruitment, promotions were often late and contingent on post-graduation. Career tracks were porous and unplanned: people without necessary expertise or experience were deployed to high positions by lateral migration from unrelated career tracks or ministries, as opposed to vertical promotion. Promotions were often politically motivated. In policy-2, females were not ensured to stay with their spouse in rural areas, health bureaucrats working at district and sub-district levels relaxed their monitoring for personal gain or political pressure. Impractical rural posts were allegedly created to graft money from applicants in exchange for recruitment assurance. Compulsory service was often waived for political affiliates. In policy-3, we found an absence of clear policy documents obligating establishment of medical colleges in rural areas. These were established based on political consideration (public sector) or profit motives (private sector).

Conclusion: Four cross-cutting themes were identified: lack of proper systems or policies, vested interest or corruption, undue political influence, and imbalanced power and position of some stakeholders. Based on findings, we recommend, in policy-1, applicants with relevant expertise to be recruited; recruitment should be quick, customized, and transparent; career tracks (General Health Service, Medical Teaching, Health Administration) must be clearly defined, distinct, and respected. In policy-2, facilities must be ensured prior to postings, female doctors should be prioritized to stay with the spouse, field bureaucrats should receive non-practising allowance in exchange of strict monitoring, and no political interference in compulsory service is assured. In policy-3, specific policy guidelines should be developed to establish rural medical colleges. Political commitment is a key to rural retention of doctors.
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http://dx.doi.org/10.15171/ijhpm.2018.37DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6186485PMC
September 2018

Non-communicable disease (NCD) risk factors and diabetes among adults living in slum areas of Dhaka, Bangladesh.

PLoS One 2017 3;12(10):e0184967. Epub 2017 Oct 3.

Western Sydney University Locked Bag 1797, Penrith, NSW Australia.

Background: Despite one-third of the urban population in Bangladesh living in urban slums and at increased risk of non-communicable diseases (NCDs), little is known about the NCD risk profile of this at-risk population. The aim of the study was to identify the prevalence of the NCD risk factors and the association of NCD risk factors with socio-demographic factors among the adults of urban slums in Dhaka, Bangladesh.

Method: A cross-sectional study was conducted among adult slum dwellers (aged 25 and above) residing in three purposively selected urban slums of Dhaka for at least six months preceding the survey. The risk factors assessed were- currently smoking, fruit and vegetable intake, physical activity, hypertension and body mass index (BMI). Information on self-reported diabetes was also taken. A total of 507 participants (252 females; 49.7%) were interviewed and their physical measures were taken using the WHO NCD STEPS instrument.

Result: The overall prevalence of NCD risk factors was: 36.0% (95% CI: 31.82-40.41) for smoking; 95.60% (95% CI: 93.60-97.40) for insufficient fruit and vegetable intake; 15.30% (95% CI:12.12-18.71) for low physical activity;13.70% (95% CI: 10.71-16.92) for hypertension; 22.70% (95% CI: 19.31-26.02) for overweight or obesity; and 5.00% (95%: 3.20-7.00) for self-reported diabetes. In the logistic regression model, the clustering of three or more NCD risk factors was positively associated with younger age groups (p = 0.02), no formal education (p <0.001) and primary education level (p = 0.01), but did not differ by sex of the participants, monthly income and occupation.

Conclusion: All NCD risk factors are markedly high among the urban slum adults. These findings are important to support the formulation and implementation of NCD-related polices and plan of actions that recognize urban slum populations in Bangladesh as a priority sub-population.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0184967PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5626026PMC
October 2017

Diabetes knowledge and utilization of healthcare services among patients with type 2 diabetes mellitus in Dhaka, Bangladesh.

BMC Health Serv Res 2017 Aug 22;17(1):586. Epub 2017 Aug 22.

James P. Grant School of Public Health (JPGSPH), BRAC University, Dhaka, Bangladesh.

Background: Diabetes is a significant global public health concern. Poor knowledge of disease and healthcare utilization is associated with worse health outcomes, leading to increasing burden of diabetes in many developing countries. This study aimed to determine diabetes related knowledge and factors affecting utilization of healthcare services among patients with type 2 diabetes mellitus in Bangladesh.

Methods: This analytical study was conducted among 318 patients with type 2 diabetes (T2DM) attending two large tertiary hospitals in Dhaka, Bangladesh between August 2014 and January 2015. Interviewer assisted semi-structured survey questionnaire was used to collect data on diabetes knowledge (measured by a validated Likert scale) and self-reported utilization of service for diabetes. Univariate and bivariate analyses were conducted to determine the factors associated with diabetes knowledge and healthcare utilization.

Results: The mean (±SD) age of participants was 52 (±10) years. Majority of the participants were females (58%) and urban residents (74%). Almost two-third (66%) of the participants had an average level of knowledge of T2DM. One-fifth (21%) of the participants had poor knowledge which was significantly associated with gender (P < 0.002), education (P < 0 .001) and income (P < 0.001). The median travel and waiting time at the facility was 30 and 45 min respectively. More than one-third (37%) of the participants checked their blood glucose monthly. Most patients were satisfied regarding the family (55%) and hospital (67%) support.

Conclusion: T2DM patients had average knowledge of diabetes which might affect the utilization of healthcare services for diabetes management. Innovations in increasing diabetes knowledge and health behavior change are recommended specially for females, those with lower education and less income.
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http://dx.doi.org/10.1186/s12913-017-2542-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5567438PMC
August 2017

The prevalence of underweight, overweight and obesity in Bangladeshi adults: Data from a national survey.

PLoS One 2017 16;12(5):e0177395. Epub 2017 May 16.

Health Systems and Population Studies Division, icddr,b, 68 Shaheed Tajuddin Ahmed Sharani, Mohakhali, 22 Dhaka, Bangladesh.

Background: Over the two last decades Bangladesh, a low-income country, has experienced a rapid demographic and epidemiological transition. The population has increased substantially with rapid urbanization and changing pattern of disease, which at least in part, can be explained by nutritional changes. However, the nutritional status of the adult population has not been previously described. Hence, the objective of this study was to estimate the prevalence and explore socio-demographic determinants of underweight, overweight and obesity among the Bangladeshi adult population.

Methods: This study is a secondary data analysis of the national 2011 Bangladesh Demographic and Health Survey. We determined the nutritional status of adults aged ≥35 years of age, who had a measured weight and height, using the Asian body mass index (BMI) cut-offs for underweight (BMI <18.5 kg/m2), overweight (BMI 23 to <27.5 kg/m2) and obesity (BMI ≥27.5 kg/m2). Logistic regression modeling was used to determine the association between socio-demographic factors and nutritional status.

Result: Of total sample (n = 5495), 30.4% were underweight, 18.9% were overweight and 4.6% were obese. Underweight was associated with age, education and wealth. The adjusted odd ratios for underweight were higher for older people (≥70 years) compared to younger, the least educated compared to the most educated and the poorest compared to the wealthiest were 2.51 (95%CI: 1.95-3.23, p<0.001), 3.59 (95%CI: 2.30-5.61, p<0.001) and 3.70 (95%CI: 2.76-4.96, p<0.001), respectively. Younger age (35-44 years), being female, higher education, wealthier and living in urban areas were associated with overweight/obesity with adjusted odds ratios of 1.73 (95%CI: 1.24-2.41, p<0.001), 2.48 (95%CI: 1.87-3.28, p<0.001), 3.98 (95%CI: 2.96-5.33, p<0.001), 7.14 (95%CI: 5.20-9.81, p<0.001) 1.27 (95%CI: 1.05-1.55, p-0.02), respectively.

Conclusion: Underweight and overweight/obesity are prevalent in Bangladeshi adults. Both conditions are associated with increased morbidity and mortality and increase the risk of developing non-communicable diseases. Effective public health intervention approaches are necessary to address both these conditions.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0177395PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5433717PMC
September 2017

Socio-demographic characteristics and tobacco use among the adults in urban slums of Dhaka, Bangladesh.

Tob Induc Dis 2017 5;15:26. Epub 2017 May 5.

James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh.

Background: Use of tobacco has become one of the major causes of premature deaths in most developing countries, including Bangladesh. The poorest and most disadvantaged populations, such as those living in slums, are considered to be extremely vulnerable to non-communicable diseases and their risk factors, especially tobacco use. The objective of this study was to assess the current status of tobacco consumption among slum dwellers and its association with socio-demographic factors.

Methods: A cross-sectional study was conducted in three slums of Dhaka city. Information about tobacco use as well as socio-demographic characteristics was collected from adult slum dwellers via face to face interviews using WHO STEPS questionnaire.

Result: Overall proportion of smoking, smokeless tobacco consumption and dual use of tobacco was 35% [95% CI: 31.6-39.8], 40.6% [95% CI: 36.5-45.2] and 12% [95% CI: 9.3-15.0] respectively. Elderly people (55-64 years) were more likely to smoke (OR: 2.34, 95% CI: 1.21-4.49) than younger people (aged 25-34 years). On the other hand, those who had no schooling history (OR: 2.95, 95% CI: 1.66-5.25) were more likely to consume smokeless tobacco than those who had higher education (secondary or above). At the same time, manual workers were more likely to indulge in dual use of tobacco (OR: 5.17, 95% CI: 2.82-9.48) as compared to non-manual workers.

Conclusion: The urban slum population of Dhaka city has a high prevalence of tobacco use, which increases their likelihood of developing non-communicable diseases. Proper attention needs to be directed towards addressing the risk factors related to non-communicable diseases within this vulnerable population.
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http://dx.doi.org/10.1186/s12971-017-0131-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5420145PMC
May 2017

Socio-Economic Inequality of Chronic Non-Communicable Diseases in Bangladesh.

PLoS One 2016 30;11(11):e0167140. Epub 2016 Nov 30.

Health Systems and Populations Studies Division, icddr,b, Mohakhali, Bangladesh.

Introduction: Chronic non-communicable diseases (NCDs) are a major public health challenge, and undermine social and economic development in much of the developing world, including Bangladesh. Epidemiologic evidence on the socioeconomic status (SES)-related pattern of NCDs remains limited in Bangladesh. This study assessed the relationship between three chronic NCDs and SES among the Bangladeshi population, paying particular attention to the differences between urban and rural areas.

Materials And Method: Data from the 2011 Bangladesh Demographic and Health Survey were used for this study. Using a concentration index (CI), we measured relative inequality across pre-diabetes, diabetes, pre-hypertension, hypertension, and BMI (underweight, normal weight, and overweight/obese) in urban and rural areas in Bangladesh. A CI and its associated curve can be used to identify whether socioeconomic inequality exists for a given health variable. In addition, we estimated the health achievement index, integrating mean coverage and the distribution of coverage by rural and urban populations.

Results: Socioeconomic inequalities were observed across diseases and risk factors. Using CI, significant inequalities observed for pre-hypertension (CI = 0.09, p = 0.001), hypertension (CI = 0.10, p = 0.001), pre-diabetes (CI = -0.01, p = 0.005), diabetes (CI = 0.19, p<0.001), and overweight/obesity (CI = 0.45, p<0.001). In contrast to the high prevalence of the chronic health conditions among the urban richest, a significant difference in CI was observed for pre-hypertension (CI = -0.20, p = 0.001), hypertension (CI = -0.20, p = 0.005), pre-diabetes (CI = -0.15, p = 0.005), diabetes (CI = -0.26, p = 0.004) and overweight/obesity (CI = 0.25, p = 0.004) were observed more among the low wealth quintiles of rural population. In the same vein, the poorest rural households had more co-morbidities compared to the richest rural households (p = 0.003), and prevalence of co-morbidities was much higher for the richest urban households compared to the poorest urban households. On the other hand in rural the "disachievement" of health indicators is more noticeable than the urban ones.

Conclusion: The findings indicate the high burden of selected NCDs among the low wealth quintile populations in rural areas and wealthy populations in urban areas. Particular attentions may be necessary to address the problem of NCDs among these groups.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0167140PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5130253PMC
September 2017

Cross-country analysis of strategies for achieving progress towards global goals for women's and children's health.

Bull World Health Organ 2016 May 2;94(5):351-61. Epub 2016 May 2.

Family, Women's and Children's Health, World Health Organization, Avenue Appia 20, 1211 Geneva 27, Switzerland .

Objective: To identify how 10 low- and middle-income countries achieved accelerated progress, ahead of comparable countries, towards meeting millennium development goals 4 and 5A to reduce child and maternal mortality.

Methods: We synthesized findings from multistakeholder dialogues and country policy reports conducted previously for the Success Factors studies in 10 countries: Bangladesh, Cambodia, China, Egypt, Ethiopia, the Lao People's Democratic Republic, Nepal, Peru, Rwanda and Viet Nam. A framework approach was used to analyse and synthesize the data from the country reports, resulting in descriptive or explanatory conclusions by theme.

Findings: Successful policy and programme approaches were categorized in four strategic areas: leadership and multistakeholder partnerships; health sector; sectors outside health; and accountability for resources and results. Consistent and coordinated inputs across sectors, based on high-impact interventions, were assessed. Within the health sector, key policy and programme strategies included defining standards, collecting and using data, improving financial protection, and improving the availability and quality of services. Outside the health sector, strategies included investing in girls' education, water, sanitation and hygiene, poverty reduction, nutrition and food security, and infrastructure development. Countries improved accountability by strengthening and using data systems for planning and evaluating progress.

Conclusion: Reducing maternal and child mortality in the 10 fast-track countries can be linked to consistent and coordinated policy and programme inputs across health and other sectors. The approaches used by successful countries have relevance to other countries looking to scale-up or accelerate progress towards the sustainable development goals.
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http://dx.doi.org/10.2471/BLT.15.168450DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4850533PMC
May 2016

Training mid-level health cadres to improve health service delivery in rural Bangladesh.

Prim Health Care Res Dev 2016 09 31;17(5):503-13. Epub 2016 Mar 31.

7Director, CoE-UHC,International Centre for Diarrheal Disease Research, Bangladesh,Dhaka,Bangladesh.

Unlabelled: Introduction In recent years, the government of Bangladesh has encouraged private sector involvement in producing mid-level health cadres including Medical Assistants (MAs). The number of MAs produced has increased significantly. We assessed students' characteristics, educational services, competencies and perceived attitudes towards health service delivery in rural areas.

Methods: We used a mixed method approach using quantitative (questionnaire survey) and qualitative (key informant interviews and roundtable discussion) methods. Altogether, five public schools with 238 students and 30 private schools with 732 students were included. Statistical analyses were performed using STATA v-12. Qualitative data were analyzed thematically. Findings The majority of the students in both public (66%) and private medical assistant training schools (MATS) (61%) were from rural backgrounds. They spent the majority of their time in classroom learning (public 45% versus private 42%) and the written essay exam was the common form of a students' performance assessment. Compared with students of public MATS, students of private MATS were more confident in different aspects of educational areas, including managing emerging health needs (P<0.001); evidence-based practice (P=0.002); critical thinking and problem solving (P=0.02), and use of IT/computer skills (P<0.001). Students were aware of not having adequate facilities in rural areas (public 71%, private 65%), but they perceived working in rural areas will offer several benefits, including use of learnt skills; friendly rural people; and opportunities for real-life problem solving, etc.

Conclusion: This study provides a current picture of MATS students' characteristics, educational services, competencies and perception towards working in rural areas. The MA students in both private and public sectors showed a greater level of willingness to serve in rural health facilities. The results are promising to improve health service delivery, particularly in rural and hard-to-reach areas of Bangladesh.
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http://dx.doi.org/10.1017/S1463423616000104DOI Listing
September 2016

Prevalence of depression and its associated factors in patients with type 2 diabetes: A cross-sectional study in Dhaka, Bangladesh.

Asian J Psychiatr 2015 Oct 29;17:36-41. Epub 2015 Jul 29.

Centre for Applied Health Research and Delivery, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK. Electronic address:

Depression is a common feature in patients with type 2 diabetes and often remains undetected and untreated, causing increased morbidity and mortality. We explored the prevalence of co-morbid depression and its associated factors, including major life-events among patients with type 2 diabetes in Bangladesh. We conducted a cross-sectional study among 515 patients with type 2 diabetes between September 2013 and July 2014 in a tertiary hospital in Dhaka city. We assessed depression using Patient Health Questionnaire-9 (PHQ-9) with predefined cut-off scores of 5, 10, 15 and 20 to indicate minimal, mild, moderate, moderately-severe, and severe depression. Associations between depression and its associated factors were explored using univariate and multivariate regression. Overall, 61.9% participants had depressive symptoms, and the prevalence was higher among females (70.9%) compared to males (50.6%). One-third (35.7%) of participants had mild depression and 36.2% had moderate to severe depression. In the multivariate analysis, factors significantly associated with depression were: age≤60 years (OR: 2.1, 95% CI=1.2-3.6; p≤0.006), female gender (OR=1.9, 95% CI=1.3-3.0; p≤0.002), those having 1-3 complications (OR=2.3, 95% CI=1.2-4.3; p=0.010), experienced loss of business or crop failure (OR=2.1, 95% CI=1.2-3.6; p=0.006), major family conflicts (OR=2.2, 95% CI=1.4-3.5; p≤0.001), separation or deaths of family members or divorce (OR=2.2, 95% CI=1.4-3.5; p≤0.001), and those who experienced unavailability of food or medicines (OR=2.2, 95% CI=1.0-4.5; p=0.038). Patients with diabetes, especially females, those having other complications, and major life-events should routinely be screened for symptoms of depression with adequate management of these conditions.
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http://dx.doi.org/10.1016/j.ajp.2015.07.008DOI Listing
October 2015

Women Empowerment and Its Relation with Health Seeking Behavior in Bangladesh.

J Family Reprod Health 2015 Jun;9(2):65-73

International Center for Diarrheal Disease Research, Dhaka, Bangladesh AND Center for International Health, Ludwig Maximilian University of Munich, Germany.

Objective: Over the last few decades, Bangladesh has made significant progress towards achieving targets for the Millennium Development Goals (MDGs) and women empowerment. This study is aimed at identifying the levels and patterns of women empowerment in relation to health seeking behavior in Bangladesh.

Materials And Methods: We conducted a cross-sectional study among 200 rural married women in Cox's Bazar district in Bangladesh using multi stage sampling technique and face-to-face interview. Data was collected on socio-economic characteristics, proxy indicators for women empowerment in mobility and health seeking behavior related decision making. Bivariate and multivariate regression analyses were performed to identify associations between women empowerment in relation to health seeking behavior on mobility and decision making, controlling the effect of other independent variables.

Results: The results showed that only 12% women were empowered to decide on their own about seeking healthcare and 8.5% in healthcare seeking for their children. In multivariate analysis women empowerment in health seeking behavior was higher among age group 25-34 years (OR 1.76, [CI = 0.82-3.21]), women's education, husband's education, age at marriage > 18 years (OR 6.38, [CI = 0.98-4.21]) and women's working status (OR 16.44, [CI = 0.79-2.71]).

Conclusion: Women empowerment enhances their decision-making authority regarding health seeking behavior. Acknowledging and adopting the implications of these findings are essential for an integrated health and development strategy for Bangladesh and achieving the MDGs.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4500817PMC
June 2015

Developing effective policy strategies to retain health workers in rural Bangladesh: a policy analysis.

Hum Resour Health 2015 May 20;13:36. Epub 2015 May 20.

International Centre for Diarrheal Disease Research (icddr,b), Dhaka, Bangladesh.

Introduction: Retention of human resources for health (HRH), particularly physicians and nurses in rural and remote areas, is a major problem in Bangladesh. We reviewed relevant policies and provisions in relation to HRH aiming to develop appropriate rural retention strategies in Bangladesh.

Methods: We conducted a document review, thorough search and review of relevant literature published from 1971 through May 2013, key informant interviews with policy elites (health policy makers, managers, researchers, etc.), and a roundtable discussion with key stakeholders and policy makers. We used the World Health Organization's (WHO's) guidelines as an analytical matrix to examine the rural retention policies under 4 domains, i) educational, ii) regulatory, iii) financial, and iv) professional and personal development, and 16 sub-domains.

Results: Over the past four decades, Bangladesh has developed and implemented a number of health-related policies and provisions concerning retention of HRH. The district quota system in admissions is in practice to improve geographical representation of the students. Students of special background including children of freedom fighters and tribal population have allocated quotas. In private medical and nursing schools, at least 5% of seats are allocated for scholarships. Medical education has a provision for clinical rotation in rural health facilities. Further, in the public sector, every newly recruited medical doctor must serve at least 2 years at the upazila level. To encourage serving in hard-to-reach areas, particularly in three Hill Tract districts of Chittagong division, the government provides an additional 33% of the basic salary, but not exceeding US$ 38 per month. This amount is not attractive enough, and such provision is absent for those working in other rural areas. Although the government has career development and promotion plans for doctors and nurses, these plans are often not clearly specified and not implemented effectively.

Conclusion: The government is committed to address the rural retention problem as shown through the formulation and implementation of related policies and strategies. However, Bangladesh needs more effective policies and provisions designed specifically for attraction, deployment, and retention of HRH in rural areas, and the execution of these policies and provisions must be monitored and evaluated effectively.
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http://dx.doi.org/10.1186/s12960-015-0030-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4489117PMC
May 2015
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