Targeting strategies for balanced energy and protein (BEP) supplementation in pregnancy: study protocol for the TARGET-BEP cluster-randomized controlled trial in rural Bangladesh.

BACKGROUND: The World Health Organization (WHO) recommends balanced energy and protein (BEP) supplementation be provided to all pregnant women living in undernourished populations, usually defined as having a prevalence > 20% of underweight women, to reduce the risk of stillbirths and small-for-gestational-age neonates. Few geographies meet this threshold, however, and a large proportion of undernourished women and those with inadequate gestational weight gain could miss benefiting from BEP. This study compares the effectiveness of individual targeting approaches for supplementation with micronutrient-fortified BEP vs. multiple micronutrient supplements (MMS) alone as control in pregnancy in improving birth outcomes. METHODS: The TARGET-BEP study is a four-arm, cluster-randomized controlled trial conducted in rural northwestern Bangladesh. Eligible participants are married women aged 15-35 years old identified early in pregnancy using a community-wide, monthly, urine-test-based pregnancy detection system. Beginning at 12-14 weeks of gestation, women in the study area comprising 240 predefined sectors are randomly assigned to one of four intervention arms, with sector serving as the unit of randomization. The interventions involving daily supplementation through end of pregnancy are as follows: (1) MMS (control); (2) BEP; (3) targeted BEP for those with pre-pregnancy body mass index (BMI) < 18.5 kg/m2 and MMS for others; (4) targeted BEP for those with pre-pregnancy BMI < 18.5 kg/m2, MMS for others, and women with inadequate gestational weight gain switched from MMS to BEP until the end of pregnancy. Primary outcomes include birth weight, low birth weight (< 2500 g), and small for gestational age, defined using the 10th percentile of the INTERGROWTH-21st reference, for live-born infants measured within 72 h of birth. Project-hired local female staff visit pregnant women monthly to deliver the assigned supplements, monitor adherence biweekly, and assess weight regularly during pregnancy. Trained data collectors conduct pregnancy outcome assessment and measure newborn anthropometry in the facility or home depending on the place of birth. DISCUSSION: This study will assess the effectiveness of targeted balanced energy and protein supplementation to improve birth outcomes among pregnant women in rural Bangladesh and similar settings. TRIAL REGISTRATION: ClinicalTrials.gov NCT05576207. Registered on October 5th, 2022.

Perceptions and attitudes of Rohingya community stakeholders to pregnancy termination services: a qualitative study in camps of Cox's Bazar, Bangladesh.

BACKGROUND: Rohingya women suffer from inaccessibility to sexual and reproductive health services in Myanmar. After the forcible displacement of the Rohingya from Myanmar to Bangladesh in 2017, pregnancy termination services have been increasingly important and desired, while knowledge gaps and obstacles to access services still exist. The role of community stakeholders is critical as gatekeepers and decision-makers to improve and strengthen pregnancy termination services for women in camps. However, there is paucity of evidence on their perspectives about pregnancy termination. This qualitative study aims to understand the perception and attitudes of Rohingya community stakeholders to pregnancy termination in the camps of Cox's Bazar. METHODS: We used purposive sampling to select 48 participants from the community stakeholders, 12 from each group: majhis (Rohingya leaders), imams (religious leaders), school teachers, and married men. We conducted in-depth interviews of all the participants between May-June 2022 and October-November 2022. Data were coded on Atlas.ti and analysed using a thematic content analysis approach. RESULTS: Multiple socio-cultural and religious factors, gendered norms and stigma associated with pregnancy termination acted as barriers to women seeking services for it. From a religious stance, there was greater acceptance of pregnancy termination in the earlier period than in the later period of pregnancy. We observed that pregnancy termination among community stakeholders in earlier stages of pregnancy than later. However, circumstances, such as a woman's marital status, whether she sought her husband's permission or her ability of childcare capacity, were often framed by community stakeholders as 'acceptable' for pregnancy termination. Health concerns and social and contextual factors can influence community stakeholders supporting pregnancy termination. CONCLUSIONS: The community stakeholders perspectives on barriers and enablers of pregnancy termination were variable with the context. These perspectives may support or impede women's ability to choice to seek pregnancy termination services. To improve women's choice to pregnancy termination, it is critical to consider roles of community stakeholders in creating their supporting attitudes to women's choice and access, and to designing targeted culturally appropriate interventions with communities support and engagement.

Assessing implementation outcomes for launching balanced energy protein supplementation: A formative study in rural Bangladesh.

Balanced energy protein (BEP) supplementation is an efficacious intervention in pregnancy for improving birthweight and is recommended by World Health Organization (WHO) in countries with high maternal undernutrition. Few countries have implemented BEP programmes due in part to high cost, lack of data on acceptability and feasibility, and complexity of delivery. We sought to address implementation gaps in BEP interventions through a formative study designed to understand implementation outcomes. We conducted 52 in-depth interviews and 8 focus-group discussions with married women of reproductive age, family members, health care providers and pharmacists in three unions of the Gaibandha district in rural Bangladesh. Interviews were translated and transcribed in English and analysed using an analytic framework for implementation science in nutrition. BEP was viewed as an acceptable and appropriate intervention to combat undernutrition in this setting. There was a lack of clarity on who should or could be responsible for providing/distributing BEP in a way convenient to mothers. Many participants preferred door-to-door delivery and thought this approach could address social and gender inequities, but providers mentioned already being overworked and worried about adding new tasks. Participants were concerned about the affordability of BEP and opportunity costs associated with travel to proposed distribution sites such as ANC or pharmacies. Women in these communities do not always have the agency to travel without supervision or make purchasing decisions. BEP supplementation is a complex intervention; future trials seek to assess ways to overcome these implementation challenges and inform a long-term systems-owned BEP intervention.

Comparison of Meglumine Antimoniate and Miltefosine in Cutaneous Leishmaniasis.

OBJECTIVE: To compare the efficacy and safety of meglumine antimoniate and miltefosine in the treatment of cutaneous leishmaniasis in Pakistan. STUDY DESIGN: Randomised-controlled trial. Place and Duration of the Study: Department of Dermatology, Combined Military Hospital, Lahore and Peshawar, from January to December 2021. METHODOLOGY: Smear positive and/or skin biopsy-confirmed cases of cutaneous leishmaniasis in adult males aged between 18-60 years were enrolled after receiving informed consent. Patients were randomly divided into Group A and Group B by lottery method. Group A received intramuscular meglumine antimoniate 15-20mg/kg/day, and Group B received oral miltefosine 50 mg thrice a day for a duration of 28 days. Data were analysed by SPSS 22. Effectiveness and safety of therapeutic agents were calculated by Independent t-test and p-value of 0.05 or less was taken as significant. RESULTS: Sixty-six patients, 33 in each group, participated in the study. Total number of cutaneous leishmaniasis lesions were 77 in Group A and 76 in Group B. The duration of lesions was 3.5 months in Group A and 3.2 months in Group B. Treatment response, in terms of complete or near complete resolution of lesions, was significantly higher in Group A as compared to Group B (p = 0.011). Both therapeutic agents had considerable side-effects with more patients withdrawn from Group A as compared to Group B (p = 0.010). CONCLUSION: Intra-muscular meglumine antimoniate was more effective in comparison to oral miltefosine in the treatment of cutaneous leishmaniasis. However, efficacy of meglumine antimoniate is mired by its side-effect profile. KEY WORDS: Cutaneous leishmaniasis, Meglumine antimoniate, Miltefosine, Efficacy, Side-effects, Adverse effects, Safety, Treatment, Old world cutaneous leishmaniasis.

Acceptability of a balanced energy protein (BEP) supplement for pregnant women in Bangladesh.

Balanced energy protein (BEP) supplementation in pregnancy is recommended in the context of undernutrition for the reduction of small-for-gestational age neonates and stillbirths. To inform an effectiveness trial, we evaluated the acceptability of a packaged, ready-to-eat fortified BEP product among women of reproductive age and their health care providers (HCPs) in rural Bangladesh and explored the feasibility of adhering to daily supplementation. We implemented a formative study using focus groups discussions with women (n = 29) and HCPs (n = 17) to introduce the product and investigate components of acceptability. A "trials of improved practice" activity was conducted in subset of women (n = 16) to evaluate adherence to BEP over a 2-week period, followed by focus group discussions to identify challenges with adherence and strategies employed. Contributors to BEP acceptability included the product's sensory attributes, such as taste, smell and texture; the attractive packaging and informative labelling; and the perceived benefits of use. Participants also identified household and community level factors influencing the adoption of BEP, such as trust in the provider, cultural beliefs on supplement use in pregnancy, and family member tasting and approval. Over the 2-week period, women consumed over 80% of the supplements provided to them and identified strategies for adherence, including visual aids and reminders from family members or providers. HCPs recommended targeted communication messages for mothers-in-law to foster a supportive home environment. Findings informed changes to the BEP product to improve acceptability and shaped the content of communication messages to optimise adherence in a forthcoming effectiveness trial.

Community centred co-design methodology for designing and implementing socio-behavioural interventions to counter COVID-19 related misinformation among marginalized population living in the squatter settlements of Karachi, Pakistan: a methodology paper.

BACKGROUND: Misinformation regarding COVID-19 pandemic and vaccination is damaging COVID-19 vaccine trust and acceptance in Low- and Middle-Income Countries (LMIC). Identification of misinformation and designing locally acceptable solutions are needed to improve COVID-19 vaccine acceptance. This study aimed to utilize community-led co-design methodology to evaluate misinformation regarding COVID-19 and develop contextual interventions to address misinformation in a marginalized peri urban slum communities of Landhi town Karachi, Pakistan. METHODS: This study was conducted between January and December 2021, in marginalized peri-urban slum dwellers of Muslimabad Colony, Landhi Town Karachi, Pakistan. We used a community-centred co-design methodology embedded within mixed study design to identify misinformation, co-design, test and implement locally acceptable solutions. The co-design methodology involved five stages of the design thinking model: (1) Empathize, (2) Define, (3) Ideate, (4) Prototype, and (5) Test. The project involved active engagement and participation of wide range of stakeholders and community beneficiaries (end users) including local EPI vaccinators, informal healthcare workers, religious leaders (male and female), schoolteachers (male and female), local government representatives, community leaders, housewives, youth, and general population. To develop a trusting relationship, and understand local culture, values, practices, and traditions, we allowed one month of observation period (observe, engage, watch, and listen) in the beginning, followed by door-to-door survey along with focus group discussions (FGD) and in-depth interviews (IDI) at baseline. Co-design workshops (separate for male and female) were conducted at each stage of co-design methodology to design and test locally acceptable solutions. CONCLUSION: Community-centred co-design methodology was not only successful in designing, testing, and evaluating locally acceptable solutions but it also actively engaged and empowered the marginalized population living in peri urban slum communities of Karachi, Pakistan.

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Quality of Life Index in Patients with Vitiligo.

OBJECTIVE: To ascertain the quality of life (QoL) impairment among the Pakistani population with vitiligo and to determine the relationship between sociodemographic and clinical characteristics. STUDY DESIGN: Cross-sectional study. Place and Duration of the Study: Dermatology Outpatients at the Aga Khan University in collaboration with outpatients of seven tertiary care hospitals of Sindh, Punjab, KPK, Balochistan, and AJK to collect data from March 2015 to April 2019. METHODOLOGY: All clinically diagnosed patients of vitiligo, who signed consent and assent forms, were included in the study. A validated 25-item, QoL scale for vitiligo was used. Socio-economic status of the patients, clinical assessment of the disease and patients' engagement in social and domestic lives was noted. RESULTS: Five hundred and seventy-three patients were enrolled in the study, having mean age 29.8 ± 16.2 years. In 306 (53.4%) males and 267 (46.65%) females; 21.8% were below 18 years. Mean vitiligo QoL index was 38.4 ± 11.8. Patients of vitiligo with disease duration 5-10 years, those affected on exposed parts, more than five body sites, rapidly progressing disease and of female gender had a higher impairment of quality of life. These scores were found significantly higher as compared to other levels of these parameters (p<0.05). CONCLUSION: Patients with vitiligo experience low self-esteem. The disease adversely affects their quality of life. The authors recommend the use of disease-specific instruments to assess the quality of life which enables the treating physician to devise best possible management plan individually. KEY WORDS: Vitiligo, Quality of life, Pakistan, Vitiligo life quality index.

Comparison Of Oral Dapsone With Intramuscular Meglumine Antimoniate In Cutaneous Leishmaniasis.

BACKGROUND: Many drugs are effective are used as second line treatment for cutaneous leishmaniasis. Dapsone therapy is tolerated well and cost effective. The aim of present study is to determine the efficacy of oral dapsone in comparison with intramuscular meglumine antimoniate in patients with cutaneous leishmaniasis and thus find out an effective second line treatment agent. METHODS: This randomized controlled trial was carried out at dermatology department, of tertiary care centre Rawalpindi, Pakistan from November 2017 to June 2018. Hundred biopsy proven patients of cutaneous leishmaniasis completed the study with 50 patients in two group. Group A received intramuscular meglumine antimoniate (15 mg/kg/day). Group B received oral dapsone2.5 mg /kg/body weight /day (200 mg per day). Efficacy of therapeutic response was noted at the end of treatment. Data was analyzed with statistical analysis program (IBM-SPSS V22). Chi-square test was applied to compare efficacy, p value of ≤0.05 was significant. Stratification of data with respect to age, gender, duration of disease, number of lesions and weight was done to see their effect on treatment efficacy. Post stratification chi-square test for both groups was applied (p≤0.05 considered significant). RESULTS: A total of 100 participants took part in the study. Duration of treatment (p-value <0.001) and the efficacy of the drugs (p-value=0.020) were significant. Meglumine antimoniate therapy group displayed a comparatively fast-paced recovery in (21- 40 days) whereas Dapsone group showed better recovery in (41-60 days) in their lesions. CONCLUSIONS: Dapsone is an effective treatment for cutaneous Leishmaniasis.

Comparison Of Topical 0.1% Adapalene Gel Versus Cryotherapy In Patients With Plantar Warts.

BACKGROUND: Plantar wart is a common viral infection of the plantar surface of the foot. Multiple treatment modalities are available but there is no definitive management option. The aim of this study is to compare topical adapalene gel 0.1% with cryotherapy in patients presenting with plantar warts in terms of time taken for complete clearance of the lesions. METHODS: The study was conducted at the Department of Dermatology, PNS Shifa Hospital, Karachi from 28th April to 28th October 2020. Eighty-four patients with plantar warts who fulfilled the inclusion and exclusion criteria were included in the study. Approval from the institutional ethical review committee was sought and written informed consent was taken from all the patients. Patients were divided into two groups, A (Adapalene 0.1% gel) and B (Cryotherapy) of 42 patients each. Adapalene gel was applied twice daily under occlusion at home and cryotherapy was done at the clinic after every two weeks. Patients were followed weekly from the onset of treatment and days taken for complete clearance of plantar warts were noted. Both the groups were compared for the outcome, i.e., time taken for complete clearance of lesions. RESULTS: The mean time for complete clearance of plantar warts in group A was 35.619±3.154 days and in group B, it was 50.404±3.178 days. CONCLUSIONS: Adapalene gel 0.1% used for the treatment of plantar warts helped in complete clearance of lesions faster than cryotherapy.

Successful treatment of exanthematous lichen planus in a young adult with low dose oral corticosteroid and isotretinoin.

Lichen planus is an inflammatory disease affecting the skin and mucosal membranes often with a chronic course lasting months to years with episodes of relapses. Classically it presents as flat topped, purple, polygonal, pruritic papules on the volar aspect of wrists and forearms, ankles, lower legs, and lumbo-sacral spine. We report a young woman with an exanthematous/eruptive variant of lichen planus who had a sudden outbreak of multiple papules and plaques all over the body with relative sparing of head and neck region. Eruptive lichen planus is rarely reported in adults and effective treatments are not well documented. We prescribed a short course of oral corticosteroid to which the patient did not respond. This was followed by oral isotretinoin and there was dramatic improvement in her symptoms and cutaneous lesions. A short course of oral corticosteroid followed with oral isotretinoin may be considered as a valuable management plan for exanthematous lichen planus. This combination may avoid serious adverse effects of both drugs when prescribed in high doses.

Application of central composite design for the optimization of itraconazole loaded nail lacquer formulation.

Onychomycosis is a common fungal infection of the nails that mostly affects the elderly and athletes. Antifungal drug-like itraconazole is one of the therapeutic agents of choice for the topical treatment of onychomycosis. The current work aimed for the preparation and optimization of itraconazole-loaded nail lacquer formulation. Central composite design was employed; independent variables were polymer concentration (X1) and thioglycolic acid (TGA) concentration (X2). While the dependent variables were cumulative amount of drug permeated per unit area (CADP/A, Y1), drying time (Y2) and nonvolatile content (Y3). The optimized formulation was characterized for various parameters including ex-vivo permeation study, confocal laser scanning microscopy (CLSM) and antifungal study. The optimized nail lacquer formulation (F7) exhibited CADP/A of 198.23 µg/cm2, drying time of 185 s and nonvolatile content of 97.23%. The scanning electron microscopy of goat hoof treated with optimized nail lacquer formulation demonstrated loosening of the structure and marked increase in surface roughness. The CLSM micrograph of goat hoof treated with optimized nail lacquer formulation demonstrated that the probe dye was eventually distributed and penetrated through the hoof. Bio-adhesiveness analysis showed that the prepared nail lacquer film has ample adhesiveness to be maintained on the nail plate surface for a sufficient time. In antifungal study, the optimized nail lacquer, and marketed gel exhibited a zone inhibition of 21 mm, and 10 mm against Candida albicans, respectively. The stability study showed that the optimized nail lacquer is stable at storage condition. The prepared nail lacquers have been shown to serve as a useful dosage form for the delivery of itraconazole across nail plate for controlling the problems associated with onychomycosis.

Oral Tranexemic Acid With Triple Combination Cream (Flucinolone+Hydroquinone+Tretinoin) Versus Triple Combination Cream Alone In Treatment Of Melasma.

BACKGROUND: Melasma is an acquired cutaneous disorder characterized by hyperpigmentation of the face predominantly affecting the areas exposed to direct sun light. The triple combination cream, i.e., a mid-potency corticosteroid (Fluocinolone acetonide 0.01%), a retinoid (Tretinoin 0.05%), and Hydroquinone 4% is one of the widely used topical medicament for melasma treatment world over. Tranexamic acid is another agent found to be effective in melasma treatment when used topically, intra-lesionally or orally. This study has been conducted to compare mean decrease in Melasma Area Severity Index (MASI) score when tranexamic acid is combined with triple combination cream versus triple combination cream alone for melasma treatment. METHODS: A randomized controlled trial was conducted in a tertiary care hospital of Pakistan. Sixty-three patients of melasma who met the inclusion criteria and gave written informed consent for the study were enrolled. These patients were randomly divided into 2 treatment groups. Group A was given triple combination cream and oral tranxemic acid while Group B was given triple combination cream for duration of 8 weeks. Severity of melasma was assessed by MASI, which was calculated at baseline and at the end of week 8. Mean decrease in MASI score was calculated in both groups and statistically analysed employing SPSS 20. RESULTS: Sixty patients, 30 in both groups, completed the study. Study participants were predominantly female (81.67%), with mean age of 30.46±6.24 years in group A while 31.90±4.53 in group B. No statistically significant difference was noted in both treatment groups for mean decrease in the MASI score (6.4933±4.38358 in group A compared to 5.7833±5.04251 in the group B; p-value 0.56). CONCLUSIONS: The addition of oral tranexamic acid did not contribute significantly in decrease in MASI score when used in combination with topical triple regimen. It may have a role as an adjuvant to topical triple combination cream.

Impact of acne on quality of life in young Pakistani adults and its relationship with severity: A multicenter study.

OBJECTIVES: The current study aimed to determine the effect of acne vulgaris on quality of life of young adults and to assess the correlation between acne severity and impairment of quality of life (QOLI). METHODS: In this multi-center cross-sectional study, 163 young adults with acne vulgaris were assessed for severity and quality of life impairment between December 2016 and May 2017 at three tertiary care hospitals. Cardiff Acne Disability Index (CADI) was used to assess the quality of life while the severity of acne measured by Global Acne Grading System (GAGS). Data were collected on standardized forms, with CADI, GAGS scores, and sociodemographic data and analyzed using SPSS version 9. The quantitative variables were presented as means, median and qualitative variables expressed as frequency and percentages. P-value ≤0.05 was considered as statistically significant. RESULTS: Out of 163 patients enrolled in this study, the mean age was 21.6 ± 4.9 years and 124 were females and 39 males. In mild QOLI, 56 (87.5%) cases were affected with mild, 11 (13.4%) with moderate and 1 (1.5%) case had severe acne. While, in moderate QOLI, 8(12.5%) cases were of mild, 60 (73.2%) were moderate and 6 (35.3%) cases affected with severe acne. The severe impairment of QOL noted in 11 (13.4%) moderate and 10 (58.8%) severe acne cases. The relationship between sex was statistically significant, (P<0.001). The result showed significant correlation between severity of acne vulgaris and the quality of life impairment of these patients (P<0.001). CONCLUSION: This study showed significant correlation between acne vulgaris and quality of life impairment. Cardiff acne disability index has proven to be a reliable tool to assess the quality of life. It is recommended to be used routinely in dermatology clinics to provide tailored treatment to individuals because mild disease may be disproportionately distressing for patients.

Identifying climatic and non-climatic determinants of malnutrition prevalence in Bangladesh: A country-wide cross-sectional spatial analysis.

Child malnutrition is indisputably a multi-faceted phenomenon. Comprehending the aforesaid crucial issue this paper intended to identify climatic and non-climatic factors for the spatial variation of malnutrition prevalence in Bangladesh. The climatic data on temperature and rainfall are obtained from the WorldClim dataset. We obtained a set of global climate layers that included monthly data on minimum temperature, maximum temperature, mean temperature, and rainfall for the period 1960-1990, at a spatial resolution up to 30 'onds (~ 1 × 1 km at the equator). The data are extracted at the district level using the zonal-statistics in QGIS. This study performed a spatial lag regression to evaluate association of malnutrition with climate characteristics and other factors. The prevalence of malnutrition exhibited substantial association with temperature and precipitation. Food production, water access, improved sanitation, literacy, road density, solvency ratio and GDP had a significant association with the spatial variation of malnutrition in Bangladesh.

Situation analysis for delivering integrated comprehensive sexual and reproductive health services in humanitarian crisis condition for Rohingya refugees in Cox's Bazar, Bangladesh: protocol for a mixed-method study.

INTRODUCTION: Rohingya diaspora are one of the most vulnerable groups seeking refuge in camps of Cox's Bazar, Bangladesh, arising an acute humanitarian crisis. More than half of the Rohingya refugees are women and adolescent girls requiring quality sexual and reproductive health (SRH) services. Minimum initial service package of SRH are being rendered in the refugee camps; however, WHO is aiming to provide integrated comprehensive SRH services to meet the unmet needs of this most vulnerable group. For sustainable and successful implementation of such comprehensive SRH service packages, a critical first step is to undertake a situation analysis and understand the current dimensions and capture the lessons learnt on their SRH-specific needs and implementation challenges. This situation analysis is pertinent in current humanitarian condition and will provide an overview of the needs, availability and delivery of SRH services for adolescent girls and women, barriers in accessing and providing those services in Rohingya refugee camps in Cox's Bazar, Bangladesh, and similar humanitarian contexts. METHODS AND ANALYSIS: A concurrent mixed-methods design will be used in this study. A community-based household survey coupled with facility assessments as well as qualitative in-depth interviews, key informant interviews and focus group discussions will be conducted with community people of Rohingya refugee camps and relevant stakeholders providing SRH services to Rohingya population in Cox's Bazar, Bangladesh. Survey data will be analysed using univariate, bivariate and multivariable regression statistics. Descriptive analysis will be done for facility assessment and thematic analysis will be conducted with qualitative data. ETHICS AND DISSEMINATION: Ethical approval from Institutional Review Board of BRAC James P Grant School of Public Health (2018-017-IR) has been obtained. Findings from this research will be disseminated through presentations in local, national and international conferences, workshops, peer-reviewed publications, policy briefs and interactive project report.

An invisible workforce: the neglected role of cleaners in patient safety on maternity units.

Hospital cleaning has been shown to impact on rates of healthcare-associated infections (HCAIs) and good environmental hygiene is critical to quality care, yet those tasked with the role of ensuring a safe and clean environment often go unrecognised as members of the healthcare workforce. Sepsis is a leading cause of maternal and newborn death, a significant proportion of these cases are estimated to be due to HCAIs. Deliveries in health institutions have now reached 75% globally, and in low and middle income countries the corresponding increased pressure on facilities  has impacted both quality of care provided and quality of the birth environment in terms of infection prevention and control (IPC) and HCAIs. The paper discusses the neglected role of health facility cleaners, providing evidence from the literature and from needs assessments conducted by The Soapbox Collaborative and partners in Bangladesh, India, The Gambia and Zanzibar. While not the primary focus of the assessments, common themes emerged consistently pointing to institutional neglect of cleaning and cleaners. The paper argues that low status within facilities, wider societal marginalisation, lack of training, and poor pay and working conditions contribute to the lack of prioritisation placed on health facility environmental hygiene. With increased international attention focused towards health facility water, sanitation and hygiene and a growing focus on IPC, now is the time to address the neglect of this frontline healthcare workforce. We propose that provision of and improved training can enable the recognition of the valuable role cleaning staff play, as well as equipping these staff with the tools required to perform their job to the highest standard. In addition to training, wider systems changes are necessary to establish improvements in environmental hygiene and the role of cleaning staff, including addressing resource availability, supportive supervision, and an increased emphasis on preventative healthcare.

Reasons for formula feeding among rural Bangladeshi mothers: A qualitative exploration.

In Bangladesh the exclusive breastfeeding rate remains low and prelacteal, formula and bottle feeding is increasing. This study aims to explore reasons behind infant formula feeding practices from mothers, caregivers, and health care provider's perspective. This was a qualitative study carried out in four sub-districts of Sylhet and Jessore of rural Bangladesh. Data were collected through focus group discussions (12), in-depth interviews (4) and key informant interviews (12) from January to February 2014. The qualitative data collected and were analyzed using thematic content analysis. This study clearly showed the factor behind formula feeding by Bangladeshi rural women. One of the major findings was that women could not differentiate between formula and other milk. Main differences between formula and powder milk were the type of consumer where formula only was taken by infant and children less than 2 years. Other major reasons include; poor breastfeeding practices, lack of appropriate breastfeeding practices, superficial knowledge on harmful effect on infant formula; perceived insufficient breast milk production, the influence of family and society and authoritarian power of hospital staff. Rural mothers have intension to feed infant formula to their infants due to various factors including individual, social, cultural and institutional. These identified factors can contribute to policy making and develop more specific interventions targeting expected mother and their family members that can contribute to stop formula feeding and increase breastfeeding practices in rural Bangladesh.