Implementation barriers and facilitators to a COVID-19 intervention in Bangladesh: The benefits of engaging the community for the delivery of the programme

BACKGROUND

BRAC (Bangladesh Rural Advancement Committee), the largest NGO globally, implemented a community-based comprehensive social behavior communication intervention to increase community resilience through prevention, protection, and care for COVID-19. We conducted implementation research to assess fidelity and explore the barriers and facilitators of this intervention implementation.

METHODS

We adopted a concurrent mixed-method triangulation design. We interviewed 666 members of 60 Community Corona Protection Committees (CCPCs) and 80 members of 60 Community Support Teams (CSTs) through multi-stage cluster sampling using a structured questionnaire. The qualitative components relied on 54 key informant interviews with BRAC implementers and government providers.

RESULTS

The knowledge about wearing mask, keeping social distance, washing hands and COVID-19 symptoms were high (on average more than 70%) among CCPC and CST members. While 422 (63.4%) CCPC members reported they 'always' wear a mask while going out, 69 (86.3%) CST members reported the same practice. Only 247 (37.1%) CCPC members distributed masks, and 229 (34.4%) donated soap to the underprivileged population during the last two weeks preceding the survey. The key facilitators included influential community members in the CCPC, greater acceptability of the front-line health workers, free-of-cost materials, and telemedicine services. The important barriers identified were insufficient training, irregular participation of the CCPC members, favouritism of CCPC members in distributing essential COVID-19 preventive materials, disruption in supply and shortage of the COVID-19 preventative materials, improper use of handwashing station, the non-compliant attitude of the community people, challenges to ensure home quarantine, challenges regarding telemedicine with network interruptions, lack of coordination among stakeholders, the short duration of the project.

CONCLUSIONS

Engaging the community in combination with health services through a Government-NGO partnership is a sustainable strategy for implementing the COVID-19 prevention program. Engaging the community should be promoted as an integral component of any public health intervention for sustainability. Engagement structures should incorporate a systems perspective to facilitate the relationships, ensure the quality of the delivery program, and be mindful of the heterogeneity of different community members concerning capacity building. Finally, reaching out to the underprivileged through community engagement is also an effective mechanism to progress through universal health coverage.

A comprehensive intervention package improves the linear growth of children under 2-years-old in rural Bangladesh: a community-based cluster randomized controlled trial

Approximately one-third of children under the age of five are stunted in developing countries and many of them are micronutrient-deficient. We designed a comprehensive intervention package including egg/milk-based snacks to improve linear growth and dietary diversity among 6 to 12-month-old children in rural Bangladesh. In this 1-year community-based cluster randomized controlled longitudinal experiment, 412 mother-infant pairs were randomly assigned to receive either monthly food vouchers (for eggs, milk, semolina, sugar, and oil) to prepare egg and milk-based snacks for their children, along with multiple micronutrient powder (MNP), counseling on child feeding and handwashing, or regular government health communication alone (control; n = 206, treatment; n = 206). The trial was conducted in 12 clusters (small administrative units of sub-district). The primary inclusion criteria were ultra-poor households with limited resources and having children under 2-years-old. The primary and secondary outcomes were differences in children's length gain and dietary diversity. The effect of intervention on child growth was examined using a mixed effect linear regression model. Mean weight and length of the children did not significantly differ between groups at baseline. Around 90% of the children in both groups were breastfed. After receiving intervention for 12 months, LAZ score increased by 0.37 (CI 0.24, 0.51, p < 0.001) and risk of stunting reduced by 73% (OR: 0.27, CI 0.13, 0.58, p = 0.001). This comprehensive intervention package improved the growth and dietary diversity of children in extremely poor Bangladeshi households. A scaling-up of this intervention in contexts with limited resources should be taken into consideration.Trial registration: This trial registered retrospectively at ClinicalTrials.gov as NCT03641001, 21/8/2018.

Knowledge and practices related to COVID-19 among mothers of under-2 children and adult males: a cross-sectional study in Bangladesh

OBJECTIVES

To assess the knowledge and practices related to COVID-19 among Bangladeshi mothers with children aged 2 years or less and adult males.

DESIGN

We conducted a cross-sectional study to assess the knowledge and practices using a multistage cluster sampling technique.

SETTINGS

Six districts with high COVID-19 infection rates in Bangladesh.

PARTICIPANTS

2185 mothers of under-2 children and 657 adult males were surveyed in December 2020.

MAIN OUTCOME MEASURES

We constructed weighted composite knowledge and practice scores and examined associations between composite scores and background characteristics using linear regression models.

RESULTS

Knowledge on possible routes of transmission of the novel coronavirus and the critical handwashing and mask-wearing etiquettes was poor. On a scale of 100, the mean composite knowledge scores of mothers and adult males were respectively 33.5 (SD=15; 95% CI 32.9 to 34.1) and 38.2 (SD=14.8; 95% CI 37.1 to 39.4). In contrast to knowledge, adult males obtained lower practice scores than mothers, primarily due to poor physical distancing practices. The mean practice scores of mothers and adult males were 63.0 (SD=18.1; 95% CI 62.3 to 63.8) and 53.4 (SD=17.5; 95% CI 52.0 to 54.7). Moreover, education, household income and access to television and the internet are significantly associated with knowledge. People residing proximal to a city revealed higher knowledge than the relatively distant ones. This was also the case for practice scores; however, the other factors associated with knowledge did not have a significant association with practices.

CONCLUSIONS

In general, both mothers and adult males presented with poor knowledge and practices related to COVID-19. While local, national and international institutions should design and implement educational interventions to help improve knowledge, our research shows that mere knowledge may not be enough to ensure practice. Hence, authorities could reinforce positive social norms by setting benchmarks and introducing rewards or sanctions to improve practices.

Mandatory employer-sponsored health financing scheme for semiformal workers in Bangladesh: An experimental assessment

In this study, we present findings from an experimental evaluation of a mandatory employer-sponsored health insurance scheme in Bangladesh. We randomly introduced the scheme to female artisans to understand the impacts on healthcare utilisation, expenditure and subjective well-being using both survey and administrative data. Our findings suggest that the scheme broke even; however, it covered only six percent of the overall health expenditure and 16 percent of the hospitalisation costs. We find higher inpatient care utilisation, particularly among women, and in favour of empanelled hospitals causally associated with the intervention, consistent with the design of the scheme. We do not find significant healthcare savings or improvement in subjective well-being, consistent with low coverage. The findings suggest the scheme to be financially sustainable and it changes the healthcare seeking behaviours as the scheme incentivises. However, meaningful savings and protection against catastrophic health expenditures will require a higher level of coverage.

An Intervention Package Including Egg and Milk-Based Snack Improved Growth and Development of U-2 Children in Bangladesh: A Community-Based Randomized Controlled Trial

Objectives

We aimed to compare the effect of a comprehensive intervention package focusing on the animal-source protein (egg and milk)-based snack in conjunction with feeding counseling, water sanitation and hygiene, and supplementation with multiple micronutrient powder on linear growth and development of 6‒12-month old children in rural Bangladesh. Primary and secondary outcomes were differences in length-for-age Z score and cognitive development.

Methods

A community-based cluster randomized controlled longitudinal trial included 412 mother-infant pairs from 13 unions (small-administrative-unit) of Harirampur sub-district, allocating to receive treatment (n = 206) or regular health messages (n = 206) as control. The treatment group received monthly food vouchers (30 eggs, 12 L milk, 500 g semolina, 500 mL oil, 500 g sugar) to prepare nutritious children's snacks, micronutrient powder, child feeding and handwashing counseling for 12 months. The Control group received routine health messages from the government. Anthropometry, feeding and morbidity data were collected at baseline, monthly and endpoint. Children's development was assessed only once at an endpoint using Extended Ages and Stages Questionnaire (EASQ), Bayley III and Wolke's behavior rating scales. We used generalized linear regression modelling to conduct intention to treat analysis.

Results

Children's mean weight and length were similar between groups at baseline. At endpoint, compared to the control, treatment children had higher mean length (83.52 and 80.89 cm; difference: 2.62, P &lt; 0.001); higher LAZ score (β: 0.38, CI: 0.24, 0.51); 61% lower rate of stunting (IRR: 0.39, CI: 0.22, 0.67); higher cognitive (β: 4.01, CI: 2.08, 5.94), language (β: 2.94, CI: 0.94, 4.94) and motor (β: 4.53, CI: 1.87, 7.20) scores, all being statistically significant. The intervention also improved developmental EASQ outcomes of the treatment children (gross and fine motor, problem-solving, and socio-emotional scores).

Conclusions

A comprehensive intervention package focusing on egg and milk-based snacks improved child growth and development in poor households in Bangladesh. Reducing the intervention cost and scale-up to larger communities in resource-poor settings merit further research.

Funding Sources

Children Investment Fund Foundation funded the trial.

Study protocol to assess the impact of an integrated nutrition intervention on the growth and development of children under two in rural Bangladesh

Background

The period from birth to two years is the “critical window” for achieving optimal growth and development. An inadequate quality and quantities of complementary foods, poor child-feeding practices and infection negatively impact the growth of under-twos. Approximately one-third of under-fives in developing countries are stunted; many are also micronutrient deficient. An estimated 6% of mortalities among under-fives can be prevented by ensuring optimal complementary feeding. The objective of the study was to assess the ability of a 12-month integrated nutrition intervention to improve the nutritional status (length-for-age Z-score) of 6 to 12-month-old children in rural Bangladesh.

Methods

In this community-based randomized controlled trial, the intervention group received a package of interventions that includes, food vouchers; to prepare egg-based nutritious snacks (suji firni for < 1-year-olds, suji halwa for > 1-year-olds), micronutrient powder to fortify children’s food at home, child feeding counselling and water, sanitation and hygiene (WASH), behaviour change communication. The control group received routine health messages provided by the government. Baseline and endline surveys were conducted; Data collection was performed monthly on children’s growth, food voucher utilization, child feeding and morbidity. In addition, we assessed the cognitive development of the children after 12 months of intervention.

Conclusion

This trial aims to explore whether an integrated nutrition intervention can mitigate childhood stunting during the critical window of opportunity in rural Bangladesh. The results may provide robust evidence to improve the linear growth of children in developing countries.

Trial registration

The study was retrospectively registered on August 17, 2018 and is available online at ClinicalTrials.gov (ID: NCT02768181).

Prevalence of work related musculoskeletal disorders (WMSDs) and ergonomic risk assessment among readymade garment workers of Bangladesh: A cross sectional study

BACKGROUND

Work related Musculoskeletal Disorders (WMSDs) are one of the most common occupational diseases which mainly affects the lower back, neck and upper and lower extremities. The aim of this study was to determine prevalence of WMSDs in nine body regions among Ready Made Garment (RMG) workers in Bangladesh and ergonomics assessment of their exposure to risk factors for the development of WMSDs.

METHODS

This cross-sectional study was conducted among 232 RMG employees (male: 46; female: 186; age: >18yrs) from nine RMG factories in Dhaka division during October 2015 to February 2016. Data were collected using a structured questionnaire consist of demographic questions, Nordic Musculoskeletal Questionnaire-Extended (NMQ-E) for WMSDs assessment in nine body regions and Quick Exposure Check (QEC) method for ergonomic assessment. Prevalence of WMSDs for each body region was determined. The association between WMSDs and ergonomic assessment of their exposure to risk factors were also analyzed.

RESULTS

Respondents' mean age was 31.3 years (SD = 7). Their mean Body Mass Index (BMI) was 23.51 kg/m2 (SD = 3.74). Among 186 female respondents, 46 reported lower back pain (24.7%) and 44 reported neck pain (23.7%). Among 46 male respondents, 10 reported neck pain (21.7%) while 6 reported knee pain (13%). Statistically significant relationship was found between twelve month WMSDs in anatomical region in elbows (p = 0.02), hips (p = 0.01), knees (p = 0.01) and ankle (p = 0.05) with age; upper back (p = 0.001), elbows (p = 0.001), wrists (p = 0.03), hips (p = 0.001) and ankles (p = 0.01) with job experience; hips with BMI (p = 0.03); elbows (p = 0.04) with daily working hour. QEC assessment showed that level of exposure to WMSDs risk was high among 80% of the study population (p<0.003).

CONCLUSION

The study found that lower back and neck were the most affected areas among RMG workers. Moreover, QEC findings warned the level of exposure to WMSDs risks is high and ergonomics intervention along with investigation and change to decrease exposure level is essential. Addressing musculoskeletal risk factors through ergonomic interventions in terms of working space, workers sitting/standing posture, seat and hand position during work and work-rest cycle are encouraged in RMG sector and policy makers.

Autism Spectrum disorders (ASD) in South Asia: a systematic review

BACKGROUND

Autism spectrum disorders (ASD) are a group of complex neurodevelopmental disorders. The prevalence of ASD in many South Asian countries is still unknown. The aim of this study was to systematically review available epidemiological studies of ASD in this region to identify gaps in our current knowledge.

METHODS

We searched, collected and evaluated articles published between January 1962 and July 2016 which reported the prevalence of ASD in eight South Asian countries. The search was conducted in line with the PRISMA guidelines.

RESULTS

We identified six articles from Bangladesh, India, and Sri Lanka which met our predefined inclusion criteria. The reported prevalence of ASD in South Asia ranged from 0.09% in India to 1.07% in Sri Lanka that indicates up to one in 93 children have ASD in this region. Alarmingly high prevalence (3%) was reported in Dhaka city. Study sample sizes ranged from 374 in Sri Lanka to 18,480 in India. The age range varied between 1 and 30 years. No studies were found which reported the prevalence of ASD in Pakistan, Nepal, Bhutan, Maldives and Afghanistan. This review identifies methodological differences in case definition, screening instruments and diagnostic criteria among reported three countries which make it very difficult to compare the studies.

CONCLUSIONS

Our study is an attempt at understanding the scale of the problem and scarcity of information regarding ASD in the South Asia. This study will contribute to the evidence base needed to design further research and make policy decisions on addressing this issue in this region. Knowing the prevalence of ASD in South Asia is vital to ensure the effective allocation of resources and services.

An outbreak of hepatitis E in an urban area of Bangladesh

We investigated an outbreak of jaundice in urban Bangladesh in 2010 to examine the cause and risk factors and assess the diagnostic utility of commercial assays. We classified municipal residents reporting jaundice during the preceding 4 weeks as probable hepatitis E cases and their neighbours without jaundice in the previous 6 months as probable controls. We tested the sera collected from probable cases and probable controls for IgM anti-hepatitis E virus (HEV), and the IgM-negative sera for IgG anti-HEV using a commercial assay locally. We retested the IgM-positive sera for both IgM and IgG anti-HEV using another assay at the Centre for Disease Control and Prevention (CDC), USA. Probable cases positive for IgM anti-HEV were confirmed cases; probable controls negative for both IgM and IgG anti-HEV were confirmed controls. We explored the local water supply and sanitation infrastructure and tested for bacterial concentration of water samples. Probable cases were more likely than probable controls to drink tap water (adjusted odds ratio: 3.4; 95% CI: 1.2-9.2). Fifty-eight percentage (36/62) of the case sera were IgM anti-HEV positive; and 75% of the IgM-positive samples were confirmed positive on retesting with another assay at CDC. Compared to confirmed controls, cases confirmed using either or both assays also identified drinking tap water as the risk factor. Two tap water samples had detectable thermotolerant coliforms. Research exploring decentralized water treatment technologies for sustainable safe water might prevent HEV transmission in resource-poor cities. Detection of serological markers in a majority of probable cases implied that available diagnostic assays could adequately identify HEV infection during outbreaks.

Bangladesh moves from being a low-prevalence nation for HIV to one with a concentrated epidemic in injecting drug users

Bangladesh has been conducting annual serological surveillance for HIV and syphilis since 1998 among most at-risk populations including sex workers, males having sex with males, injecting drug users (IDUs) and heroin smokers. During the seventh round conducted between January and June 2006, 10,368 people were sampled and the overall HIV prevalence was 0.9%. The highest HIV rate was recorded in male IDUs from the capital city Dhaka (7%), and the rates have risen significantly over the rounds (P < 0.001). In Dhaka, most of the HIV-positive IDUs (10.5%) were localized in one neighbourhood, while in the remaining neighbourhoods 1% were positive (P < 0.001). In all other groups, HIV prevalence was <1%. Active syphilis rates were highest in female IDUs (9.9%) followed by female street-based sex workers (8.6%). However, rates in female sex workers in Dhaka declined significantly over the years (P < 0.001). Bangladesh has to act urgently to prevent escalation of the epidemic.

The relationship of arsenic levels in drinking water and the prevalence rate of skin lesions in Bangladesh

To determine the relationship of arsenic-associated skin lesions and degree of arsenic exposure, a cross-sectional study was conducted in Bangladesh, where a large part of the population is exposed through drinking water. Four villages in Bangladesh were identified as mainly dependent on wells contaminated with arsenic. We interviewed and examined 1,481 subjects [Greater/equal to] 30 years of age in these villages. A total of 430 subjects had skin lesions (keratosis, hyperpigmentation, or hypopigmentation). Individual exposure assessment could only be estimated by present levels and in terms of a dose index, i.e., arsenic levels divided by individual body weight. Arsenic water concentrations ranged from 10 to 2,040 microg/L, and the crude overall prevalence rate for skin lesions was 29/100. After age adjustment to the world population the prevalence rate was 30. 1/100 and 26.5/100 for males and females, respectively. There was a significant trend for the prevalence rate both in relation to exposure levels and to dose index (p < 0.05), regardless of sex. This study shows a higher prevalence rate of arsenic skin lesions in males than females, with clear dose-response relationship. The overall high prevalence rate in the studied villages is an alarming sign of arsenic exposure and requires an urgent remedy.

Relations between exposure to arsenic, skin lesions, and glucosuria

OBJECTIVES

Exposure to arsenic causes keratosis, hyperpigmentation, and hypopigmentation and seemingly also diabetes mellitus, at least in subjects with skin lesions. Here we evaluate the relations of arsenical skin lesions and glucosuria as a proxy for diabetes mellitus.

METHODS

Through existing measurements of arsenic in drinking water in Bangladesh, wells with and without arsenic contamination were identified. Based on a questionnaire, 1595 subjects > or = 30 years of age were interviewed; 1481 had a history of drinking water contaminated with arsenic whereas 114 had not. Time weighted mean arsenic concentrations and mg-years/l of exposure to arsenic were estimated based on the history of consumption of well water and current arsenic concentrations. Urine samples from the study subjects were tested by means of a glucometric strip. People with positive tests were considered to be cases of glucosuria.

RESULTS

A total of 430 (29%) of the exposed people were found to have skin lesions. Corresponding to drinking water with < 0.5, 0.5-1.0, and > 1.0 mg/l of arsenic, and with the 114 unexposed subjects as the reference, the prevalence ratios for glucosuria, as adjusted for age and sex, were 0.8, 1.4, and 1.4 for those without skin lesions, and 1.1, 2.2, and 2.6 for those with skin lesions. Taking exposure as < 1.0, 1.0-5.0, > 5.0-10.0 and > 10.0 mg-years/l of exposure to arsenic the prevalence ratios, similarly adjusted, were 0.4, 0.9, 1.2, and 1.7 for those without and 0.8, 1.7, 2.1, and 2.9 for those with skin lesions. All series of risk estimates were significant for trend, (p < 0.01).

CONCLUSIONS

The results suggest that skin lesions and diabetes mellitus, as here indicated by glucosuria, are largely independent effects of exposure to arsenic although glucosuria had some tendency to be associated with skin lesions. Importantly, however, glucosuria (diabetes mellitus) may occur independently of skin lesions.

Hypertension and arsenic exposure in Bangladesh

-A prevalence comparison of hypertension among subjects with and those without arsenic exposure through drinking water was conducted in Bangladesh to confirm or refute an earlier observation of a relation in this respect. Wells with and without present arsenic contamination were identified, and we interviewed and examined 1595 subjects who were depending on drinking water from these wells for living, all >/=30 years of age. The interview was based on a questionnaire, and arsenic exposure was estimated from the history of well-water consumption and current arsenic levels. Of the 1595 subjects studied, 1481 had a history of arsenic-contaminated drinking water, whereas 114 had not. Time-weighted mean arsenic levels (in milligrams per liter) and milligram-years per liter of arsenic exposure were estimated for each subject. Exposure categories were assessed as <0.5 mg/L, 0.5 to 1.0 mg/L, and >1.0 mg/L and alternatively as <1.0 mg-y/L, 1.0 to 5.0 mg-y/L, >5.0 but </=10.0 mg-y/L, and >10.0 mg-y/L, respectively. Hypertension was defined as a systolic blood pressure of >/=140 mm Hg in combination with a diastolic blood pressure of >/=90 mm Hg. Corresponding to the exposure categories, and using "unexposed" as the reference, the prevalence ratios for hypertension adjusted for age, sex, and body mass index were 1.2, 2.2, 2.5 and 0.8, 1.5, 2.2, 3.0, in relation to arsenic exposure in milligrams per liter and milligram-years per liter, respectively. The indicated dose-response relationships were significant (P<<0.001) for both series of risk estimates. These results suggest that arsenic exposure may induce hypertension in humans.