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.

Midwifery centers as enabled environments for midwifery: A quasi experimental design assessing women's birth experiences in three models of care in Bangladesh, before and during covid.

BACKGROUND: The midwifery model of care is a human rights-based approach (HRBA) that is unique and appropriate for the majority of healthy pregnant women, yet full expression may be limited within the medical model. Midwifery centers are facilities designed specifically to enable the practice of midwifery. In high resource countries, they have been shown to be cost effective, evidence-based, avoid over medicalization, and provide safe, efficient and satisfying care. METHODS: A quasi-experimental design was used to assess the impact of three models of care on women's experiences of respect, and trust in maternity care provision, both before and during the pandemic in Bangladesh, as well as their fear and knowledge around COVID-19, during the pandemic. The models were: "fully enabled midwifery" ("FEM") in freestanding midwifery centers; "midwifery and medicine" ("MAM") in medical facilities with midwives working alongside nurses and doctors; and "no midwifery" ("NoM") in medical facilities without midwives. Phone survey data were collected and analyzed from all women (n = 1,191) who delivered from Jan 2020-June 2020 at seven health care facilities in Bangladesh. Comparison of means, ANOVA, post hoc Tukey, and effect size were used to explore the differences in outcomes across time periods. FINDINGS: Pre-pandemic, women served by the FEM model reported significantly higher rates of trust and respect (p<0·001) compared to the NoM model, and significantly higher rates of trust (p<0·001) compared to MAM. During the pandemic, in the FEM model, the experiences of respect and trust did not change significantly from the pre-pandemic rates, and were significantly higher than both the MAM and NoM models (p < 0·001). Additionally, during the pandemic, women served by the FEM model had the lowest experience of COVID fear (p<0·001). INTERPRETATION: Fully enabled midwifery in midwifery centers had a significantly positive effect on woman's experience of respect and trust in care compared to the other models, even in the context of a pandemic.

Prevalence and correlates of knowledge and practices regarding infection prevention and control, and triage in primary healthcare settings: A cross-sectional study in Bangladesh.

Background: Despite the high prevalence of healthcare-acquired infection in resource-limited settings, healthcare workers' (HCWs') knowledge and practices of infection prevention and control (IPC) and triage are not well-researched. We examined thisin Bangladesh's primary healthcare facilities (HCFs) during the COVID-19 pandemic. Methods: We surveyed 312 HCWs in 94 community clinics (CCs) and 90 family welfare centres (FWCs) in six districts from February to April 2021. We assessed HCWs' self-reported knowledge and observed practices in four domains: personal hygiene, medical instrument processing, waste management, and triage. We constructed a weighted composite knowledge score and estimated the association between knowledge and background characteristics using a generalised linear mixed effects model. Practices were described through univariate analysis. Findings: On a scale of 100, the mean composite knowledge score was 38.3 (SD: 13.3) overall and 44.0 (SD: 13.1) and 33.8 (SD: 11.6) for FWCs and CCs, respectively. The HCWs of FWCs were more aged, experienced, and educated than those of CCs. Knowledge score was the highest in personal hygiene and the lowest in medical waste segregation. Knowledge was significantly associated with HCWs' designation and education. Concerning practices, not more than one-third of the HCWs or HCFs, on average, followed the recommended protocols, except for wearing face masks while on duty (87.1%) and referring potential COVID-19 patients to higher-level facilities (68.3%). Conclusions: HCWs' capacity in instrument processing, waste management, and triage needs to be improved through formal education and training initiatives. Our study can contribute to the under-researched IPC and triage domains in resource-limited settings.

Community-based referral transportation system for accessing emergency obstetric services in the Rohingya refugee camp during the COVID-19 pandemic in Bangladesh: facilitators and barriers through beneficiaries' and providers' lens using a mixed-method design.

BACKGROUND: Delays in seeking timely maternity care from health care professionals are crucial to address among the Rohingya population where many preventable pregnancy-related deaths occur within the camps when care is not sought. To address the challenges related to the referral of emergency and routine Sexual and Reproductive Health and Rights (SRHR) cases, United Nations Population Fund, through its partners, implemented a community-based referral transportation project called Referral hub. This paper presents the barriers and facilitators to the implementation of this referral transportation system from the perspectives of the beneficiaries and providers. METHODS: The research adopted a sequential explanatory mixed-method design. The quantitative phase consisted of a survey among 100 women while the qualitative phase comprised of in-depth interviews with a total of 12 mothers who used the services and key informant interviews with 21 providers. RESULTS: The barriers identified for referral hub are discordant understanding of emergency, strict gender norms and practices, distrust in providers, poor roads and mobile phone networks. The facilitators are partnership with the community, within and other organizations. CONCLUSION: The study observed that the referral hub has a high potential to increase the utilization of SRHR services. Despite the barriers, the facilitating factors show a scope of improvement for these services.

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.

Implementation of a community-based referral project to improve access to emergency obstetric and newborn care in Rohingya population during COVID-19 pandemic in Bangladesh

Introduction The delay in seeking emergency obstetric care leads to significant maternal morbidity and mortality and can worsen during pandemics, especially in humanitarian conflict settings with low uptake of obstetric services. To mitigate the challenges related to the second delay caused by lack of transport in the COVID-19 pandemic, the organisation United Nations Population Fund implements a community-based referral project called Referral Hub in the Rohingya refugee population in Bangladesh. The objective of the paper is to describe the implementation process of the Referral hub and present clients’ utilisation and perception of the service. Methods Findings from part of a larger mixed-method study, the analysis of the standard operating protocol of the intervention, secondary data of routine utilisation of the 12 referral hubs between January and August 2020, 21 key informant interviews and a community survey among 100 pregnant women are presented in this paper. Results The findings show an increasing trend in the referral hub utilisation and a strong recommendation of the service. Conclusion Due to a robust referral mechanism by collaborating with the community and engaging accessible and free of cost transport service, the intervention has high potential to improve access to facility care in low-resource and humanitarian contexts, especially during pandemics.

Healthcare system resilience in Bangladesh and Haiti in times of global changes (climate-related events, migration and Covid-19): an interdisciplinary mixed method research protocol.

BACKGROUND: Since climate change, pandemics and population mobility are challenging healthcare systems, an empirical and integrative research to studying and help improving the health systems resilience is needed. We present an interdisciplinary and mixed-methods research protocol, ClimHB, focusing on vulnerable localities in Bangladesh and Haiti, two countries highly sensitive to global changes. We develop a protocol studying the resilience of the healthcare system at multiple levels in the context of climate change and variability, population mobility and the Covid-19 pandemic, both from an institutional and community perspective. METHODS: The conceptual framework designed is based on a combination of Levesque's Health Access Framework and the Foreign, Commonwealth and Development Office's Resilience Framework to address both outputs and the processes of resilience of healthcare systems. It uses a mixed-method sequential exploratory research design combining multi-sites and longitudinal approaches. Forty clusters spread over four sites will be studied to understand the importance of context, involving more than 40 healthcare service providers and 2000 households to be surveyed. We will collect primary data through questionnaires, in-depth and semi-structured interviews, focus groups and participatory filming. We will also use secondary data on environmental events sensitive to climate change and potential health risks, healthcare providers' functioning and organisation. Statistical analyses will include event-history analyses, development of composite indices, multilevel modelling and spatial analyses. DISCUSSION: This research will generate inter-disciplinary evidence and thus, through knowledge transfer activities, contribute to research on low and middle-income countries (LMIC) health systems and global changes and will better inform decision-makers and populations.

Consent Requirements for Testing Health Policies: An Intercontinental Comparison of Expert Opinions.

Individual informed consent is a central requirement for clinical research on human subjects, yet whether and how consent requirements should apply to health policy experiments (HPEs) remains unclear. HPEs test and evaluate public health policies prior to implementation. We interviewed 58 health experts in Tanzania, Bangladesh and Germany on informed consent requirements for HPEs. Health experts across all countries favored a strong evidence base, prior information to the affected populations, and individual consent for 'risky' HPEs. Differences pertained to individual risk perception, how and when consent by group representatives should be obtained and whether HPEs could be treated as health policies. The study adds to representative consent options for HPEs, yet shows that more research is needed in this field - particularly in the present Covid-19 pandemic which has highlighted the need for HPEs nationally and globally.

Clinical profile and short-term outcomes of RT-PCR- positive patients with COVID-19: a cross-sectional study in a tertiary care hospital in Dhaka, Bangladesh.

OBJECTIVE: The COVID-19 pandemic is still raging worldwide. While there is significant published evidence on the attributes of patients with COVID-19 from lower-income and middle-income countries, there is a dearth of original research published from Bangladesh, a low-income country in Southeast Asia. Based on a case series from a tertiary healthcare centre, this observational study has explored the epidemiology, clinical profile of patients with COVID-19 and short-term outcomes in Dhaka, Bangladesh. DESIGN AND SETTING: A total of 422 COVID-19-confirmed patients (via reverse transcription-PCR test) were enrolled in this study (male=271, female=150, 1 unreported). We have compiled medical records of the patients and descriptively reported their demographic, socioeconomic and clinical features, treatment history, health outcomes, and postdischarge complications. RESULT: Patients were predominantly male (64%), between 35 and 49 years (28%), with at least one comorbidity (52%), and had COVID-19 symptoms for 1 week before hospitalisation (66%). A significantly higher proportion (p<0.05) of male patients had diabetes, hypertension and ischaemic heart disease, while female patients had asthma (p<0.05). The most common symptoms were fever (80%), cough (60%), dyspnoea (41%) and sore throat (21%). The majority of the patients received antibiotics (77%) and anticoagulant therapy (56%) and stayed in the hospital for an average of 12 days. Over 90% of patients were successfully weaned, while 3% died from COVID-19, and 41% reported complications after discharge. CONCLUSION: The diversity of clinical and epidemiological characteristics and health outcomes of patients with COVID-19 across age groups and gender is noteworthy. Our result will inform the clinicians and epidemiologists of Bangladesh of their COVID-19 mitigation effort.

Association between television viewing and overweight and obesity among women of reproductive age in Timor-Leste: evidence from the demographic health survey 2016.

OBJECTIVE: This study aimed to assess the possible relationship between television viewing and overweight and obesity among Timorese women of reproductive age. METHODS: This cross-sectional study analysed the Timor-Leste Demographic and Health Survey 2016 dataset. A weighted sample of 11 398 Timorese women aged 15-49 years was chosen using a two-stage stratified random sampling technique. Asian criteria-based body mass index (BMI) cut-offs were used to define overweight (BMI 23.0 to <27.5 kg/m2) and obesity (BMI ≥27.5 kg/m2). Frequency of TV viewing was categorised into three groups: (1) not at all, (2) less than once a week and (3) at least once a week. Multilevel ordered logistic regression was performed to identify the correlates of overweight and obesity. Both crude and adjusted odds ratios (AOR) along with a 95% CI were calculated to show the strength of association. RESULTS: Among 11 398 respondents, 19.4% were overweight or obese (overweight: 15.7% and obese: 3.8%). Although about half of the respondents reportedly did not watch TV at all, just over two-thirds watched TV at least once a week. Women who watched TV at least once a week were found to have 1.3 times the odds of being overweight or obese compared with those who never watched TV (AOR: 1.3, 95% CI: 1.1 to 1.5; p<0.001). However, when stratified by settlement type, the statistical significance stood for the rural women only (AOR: 1.5, 95% CI: 1.2 to 1.8; p<0.001), after adjusting for the covariates. CONCLUSION: Watching TV at least once a week was found to be a significant correlate of overweight and obesity in rural Timorese women of reproductive age. Further studies need to be undertaken to assess physical activity, sedentary and dietary patterns to clarify the possible mechanism through which TV viewing may influence BMI in those groups.

Healthcare worker attendance during the early stages of the COVID-19 pandemic: A longitudinal analysis of fingerprint-verified data from all public-sector secondary and tertiary care facilities in Bangladesh.

BACKGROUND: The COVID-19 pandemic has overwhelmed hospitals in several areas in high-income countries. An effective response to this pandemic requires health care workers (HCWs) to be present at work, particularly in low- and middle-income countries (LMICs) where they are already in critically low supply. To inform whether and to what degree policymakers in Bangladesh, and LMICs more broadly, should expect a drop in HCW attendance as COVID-19 continues to spread, this study aims to determine how HCW attendance has changed during the early stages of the COVID-19 pandemic in Bangladesh. METHODS: This study analyzed daily fingerprint-verified attendance data from all 527 public-sector secondary and tertiary care facilities in Bangladesh to describe HCW attendance from January 26, 2019 to March 22, 2020, by cadre, hospital type, and geographic division. We then regressed HCW attendance onto fixed effects for day-of-week, month, and hospital, as well as indicators for each of three pandemic periods: a China-focused period (January 11, 2020 (first confirmed COVID-19 death in China) until January 29, 2020), international-spread period (January 30, 2020 (World Health Organization's declaration of a global emergency) until March 6, 2020), and local-spread period (March 7, 2020 (first confirmed COVID-19 case in Bangladesh) until the end of the study period). FINDINGS: On average between January 26, 2019 and March 22, 2020, 34.1% of doctors, 64.6% of nurses, and 70.6% of other health care staff were present for their scheduled shift. HCWs' attendance rate increased with time in 2019 among all cadres. Nurses' attendance level dropped by 2.5% points (95% confidence interval (CI) = -3.2% to -1.8%) and 3.5% points (95% CI = -4.5% to -2.5%) during the international-spread and the local-spread periods of the COVID-19 pandemic, relative to the China-focused period. Similarly, the attendance level of other health care staff declined by 0.3% points (95% CI = -0.8% to 0.2%) and 2.3% points (95% CI = -3.0% to -1.6%) during the international-spread and local-spread periods, respectively. Among doctors, however, the international-spread and local-spread periods were associated with a statistically significant increase in attendance by 3.7% points (95% CI = 2.5% to 4.8%) and 4.9% points (95% CI = 3.5% to 6.4%), respectively. The reduction in attendance levels across all HCWs during the local-spread period was much greater at large hospitals, where the majority of COVID-19 testing and treatment took place, than that at small hospitals. CONCLUSIONS: After a year of significant improvements, HCWs' attendance levels among nurses and other health care staff (who form the majority of Bangladesh's health care workforce) have declined during the early stages of the COVID-19 pandemic. This finding may portend an even greater decrease in attendance if COVID-19 continues to spread in Bangladesh. Policymakers in Bangladesh and similar LMICs should undertake major efforts to achieve high attendance levels among HCWs, particularly nurses, such as by providing sufficient personal protective equipment as well as monetary and non-monetary incentives.

Low uptake of COVID-19 prevention behaviours and high socioeconomic impact of lockdown measures in South Asia: Evidence from a large-scale multi-country surveillance programme.

BACKGROUND: South Asia has become a major epicentre of the COVID-19 pandemic. Understanding South Asians' awareness, attitudes and experiences of early measures for the prevention of COVID-19 is key to improving the effectiveness and mitigating the social and economic impacts of pandemic responses at a critical time for the Region. METHODS: We assessed the knowledge, behaviours, health and socio-economic circumstances of 29,809 adult men and women, at 93 locations across four South Asian countries. Data were collected during the national lockdowns implemented from March to July 2020, and compared with data collected prior to the pandemic as part of an ongoing prospective surveillance initiative. RESULTS: Participants were 61% female, mean age 45.1 years. Almost half had one or more chronic disease, including diabetes (16%), hypertension (23%) or obesity (16%). Knowledge of the primary COVID-19 symptoms and transmission routes was high, but access to hygiene and personal protection resources was low (running water 63%, hand sanitisers 53%, paper tissues 48%). Key preventive measures were not widely adopted. Knowledge, access to, and uptake of COVID-19 prevention measures were low amongst people from disadvantaged socio-economic groups. Fifteen percent of people receiving treatment for chronic diseases reported loss of access to long-term medications; 40% reported symptoms suggestive of anxiety or depression. The prevalence of unemployment rose from 9.3% to 39.4% (P < 0.001), and household income fell by 52% (P < 0.001) during the lockdown. Younger people and those from less affluent socio-economic groups were most severely impacted. Sedentary time increased by 32% and inadequate fruit and vegetable intake increased by 10% (P < 0.001 for both), while tobacco and alcohol consumption dropped by 41% and 80%, respectively (P < 0.001), during the lockdown. CONCLUSIONS: Our results identified important knowledge, access and uptake barriers to the prevention of COVID-19 in South Asia, and demonstrated major adverse impacts of the pandemic on chronic disease treatment, mental health, health-related behaviours, employment and household finances. We found important sociodemographic differences for impact, suggesting a widening of existing inequalities. Our findings underscore the need for immediate large-scale action to close gaps in knowledge and access to essential resources for prevention, along with measures to safeguard economic production and mitigate socio-economic impacts on the young and the poor.