Healthcare seeking behavior and delays in case of Drug-Resistant Tuberculosis patients in Bangladesh: Findings from a cross-sectional survey.

The emergence of Drug-Resistant Tuberculosis (DR-TB) has become a major threat globally and Bangladesh is no exception. Delays in healthcare seeking, proper diagnosis and initiation of treatment cause continuous transmission of the resistant tubercule bacilli through the communities. This study aimed to assess the different health care-seeking behaviors and delays among DR-TB patients in Bangladesh. A prospective cross-sectional study was conducted from November to December 2018, among 92 culture positive and registered DR-TB patients in four selected hospitals in Bangladesh. Data were collected through face-to-face interviews with survey questionnaire as well as record reviews. Among the 92 study participants, the median patient delay was 7 (IQR 3, 15) days, the median diagnostic delay was 88 (IQR 36.5, 210), the median treatment delay was 7 (IQR 4,12) days, and the median total delay among DR-TB patients was 108.5 (IQR 57.5, 238) days. 81.32% sought initial care from informal healthcare providers. The majority (68.48%) of the informal healthcare providers were drug sellers while 60.87% of patients sought care from more than four healthcare points before being diagnosed with DR-TB. The initial care seeking from multiple providers was associated with diagnostic and total delays. In Bangladesh, DR-TB cases usually seek care from multiple providers, particularly from informal providers, and among them, alarmingly higher healthcare-seeking related delays were noted. Immediate measures should be taken both at the health system levels and, in the community, to curb transmission and reduce the burden of the disease.

The association between body mass index and abdominal obesity with hypertension among South Asian population: findings from nationally representative surveys.

OBJECTIVE: This study aimed to determine the association between body mass index (BMI) and abdominal obesity with hypertension among the South Asian adults (18-69 years). METHODS: This study utilized the nationally representative WHO STEPwise approach to surveillance data (n = 24,413) from Afghanistan, Bangladesh, Bhutan, Nepal, and Sri Lanka. Hypertension was defined as having a systolic blood pressure of 140 mmHg or higher, a diastolic blood pressure of 90 mmHg or higher, and/or taking antihypertensive medications. A waist circumference ≥ 90 cm in men and ≥ 80 cm in women was considered as abdominal obesity. BMI was categorized according to Asia-specific cutoff and overweight was defined as BMI of 23.0-27.5 kg/m2 and obesity was defined as BMI ≥ 27.5 kg/m2. Multivariable logistic regression analyses were conducted to identify the association between BMI and abdominal obesity with hypertension. The odds ratio (OR) with a 95% confidence interval (CI) was reported. RESULTS: Abdominal obesity increased the odds of hypertension 31%-105% compared to those who did not have abdominal obesity (OR: Afghanistan: 2.05; 95% CI: 1.27-3.31; Bangladesh: 1.55; 95% CI: 1.18-2.04; Bhutan: 1.31; 95% CI: 1.03-1.66; Nepal: 1.69; 95% CI: 1.31-2.18; Sri Lanka:1.55; 95% CI: 1.23-1.95). The odds increased among participants with both overweight/obesity and abdominal obesity. In all five countries under study, participants with both overweight and abdominal obesity (OR: Afghanistan: 2.75; 95% CI: 1.75-4.34; Bangladesh: 2.53; 95% CI: 1.90-3.37; Bhutan: 2.22; 95% CI: 1.64-3.00; Nepal: 2.08; 95% CI: 1.54-2.81; Sri Lanka: 2.29; 95% CI: 1.77-2.98), as well as those with obesity and abdominal obesity (OR: Afghanistan: 6.94; 95% CI: 4.68-10.30; Bangladesh: 2.95; 95% CI: 2.19-3.97; Bhutan: 3.02; 95% CI: 2.23-4.09; Nepal: 4.40; 95% CI: 3.05-6.34; Sri Lanka: 3.96; 95% CI: 2.94-5.32), exhibited higher odds of having hypertension as compared to participants with a normal BMI and no abdominal obesity. CONCLUSION: Having both abdominal obesity and overweight/obesity increased the odds of hypertension among South Asian adults. Preventing overweight/obesity and abdominal obesity is necessary for preventing the burden of hypertension in South Asia.

Promotion of livelihood opportunities to address food insecurity in Rohingya refugee camps of Bangladesh.

The world is facing a tremendous problem in the form of food insecurity that is posing a great challenge to achieving sustainable development goal 2 of creating a hunger-free world. Refugees and displaced populations are particularly vulnerable to food insecurity and malnutrition, who lack any productive assets and depend on aid. Rohingya refugees, displaced from Myanmar and took refuge in Cox's Bazar, Bangladesh, live in a crowded unhealthy environment and are severely vulnerable to food insecurity and malnutrition. In our recent study, we found that only 21.6% of the households in Rohingya refugee camps had acceptable food security status. Interestingly, this study further revealed that acceptable food security status was significantly higher among the households that had some additional income aside from aid, compared to those relying on aid alone. This shows the importance of promoting livelihood opportunities to improve food security status among the camp dwellers. In this paper, we presented our views on promoting livelihood opportunities to address the overwhelming food insecurity crisis among the Rohingya refugees in Bangladesh.

The burden of non-disabled frailty and its associated factors among older adults in Bangladesh.

OBJECTIVE: The present study aims to measure the prevalence of non-disabled frailty and its associated factors among Bangladeshi older adults. METHODS: This cross-sectional study was conducted during September and October 2021 among 1,045 Bangladeshi older adults (≥60 years). Telephone interviews, using a semi-structured questionnaire, were undertaken to collect data on participants' characteristics and level of frailty. The non-disabled frailty was measured using the 'Frail Non-Disabled (FiND)' questionnaire. A multinomial logistic regression model assessed the factors associated with frailty among the participants. RESULTS: Around a quarter of the participants (24.8%) were frail. The multinomial regression analysis showed that older participants aged ≥80 years (RRR = 3.23, 95% CI: 1.41-7.37) were more likely to be frail compared to participants aged 60-69 years. Likewise, the participants living in a large family with ≥4 members (RRR = 1.39, 95% CI: 1.01-1.92) were more likely to be frail compared to those living in smaller families. Also, participants having memory or concentration problems (RRR = 1.56, 95% CI: 1.12-2.17) were more likely to be frail compared to those who were not suffering from these problems. Moreover, participants whose family members were non-responsive to their day-to-day assistance (RRR = 1.47, 95% CI: 1.06-2.03) were more likely to be frail compared to those whose family members were responsive. Furthermore, participants who were feeling lonely (RRR = 1.45, 95% CI: 1.07-1.98) were more likely to be frail than their counterparts who were not feeling lonely. CONCLUSIONS: The findings of the present study suggest developing tailored interventions to address the burden of frailty among the older populations in Bangladesh. In particular, providing long-term care and health promotion activities can be of value in preventing frailty and reducing adverse health outcomes among this vulnerable population group.

"We are invisible to them"-Identifying the most vulnerable groups in humanitarian crises during the COVID-19 pandemic: The case of Rohingyas and the Host communities of Cox's Bazar.

The COVID-19 pandemic has had an adverse impact on the Rohingya and the Bangladeshi host communities, which have been well documented in the literature. However, the specific groups of people rendered most vulnerable and marginalized during the pandemic have not been studied comprehensively. This paper draws on data to identify the most vulnerable groups of people within the Rohingya and the host communities of Cox's Bazar, Bangladesh, during the COVID-19 pandemic. This study employed a systematic sequential method to identify the most vulnerable groups in the context of Rohingya and Host communities of Cox's Bazar. We conducted a rapid literature review (n = 14 articles) to list down Most vulnerable groups (MVGs) in the studied contexts during the COVID-19 pandemic and conducted four (04) group sessions with humanitarian providers and relevant stakeholders in a research design workshop to refine the list. We also conducted field visits to both communities and interviewed community people using In-depth interviews (n = 16), Key-informant Interviews (n = 8), and several informal discussions to identify the most vulnerable groups within them and their social drivers of vulnerabilities. Based on the feedback received from the community, we finalized our MVGs criteria. The data collection commenced from November 2020 to March 2021. Informed consent was sought from all participants, and ethical clearance for this study was obtained from the IRB of BRAC JPGSPH. The most vulnerable groups identified in this study were: single female household heads, pregnant and lactating mothers, persons with disability, older adults, and adolescents. Our analysis also found some factors that may determine the different levels of vulnerabilities and risks faced by some groups more than others in the Rohingya and host communities during the pandemic. Some of these factors include economic constraints, gender norms, food security, social safety-security, psychosocial well-being, access to healthcare services, mobility, dependency, and a sudden halt in education. One of the most significant impacts of COVID-19 was the loss of earning sources, especially for the already economically vulnerable; this had far-reaching consequences on individuals' food security and food consumption. Across the communities, it was found that the economically most affected group was single female household heads. The elderly and pregnant and lactating mothers face challenges seeking health services due to their restricted mobility and dependency on other family members. Persons living with disabilities from both contexts reported feelings of inadequacy in their families, exacerbated during the pandemic. Additionally, the shutdown in the formal education, and informal learning centres in both communities had the most significant impact on the adolescents during the COVID-19 lockdown. This study identifies the most vulnerable groups and their vulnerabilities amid the COVID-19 pandemic in the Rohingya and Host communities of Cox's Bazar. The reasons behind their vulnerabilities are intersectional and represent deeply embedded patriarchal norms that exist in both communities. The findings are essential for the humanitarian aid agencies and policymakers for evidence-based decision-making and service provisions for addressing the vulnerabilities of the most vulnerable groups.

Exploring healthcare-seeking behavior of most vulnerable groups amid the COVID-19 pandemic in the humanitarian context in Cox's Bazar, Bangladesh: Findings from an exploratory qualitative study.

The COVID-19 pandemic has raised new concerns about healthcare service availability, accessibility, and affordability in complex humanitarian settings where heterogeneous populations reside, such as Rohingya refugees in Bangladesh. This study was conducted in ten Rohingya camps and four wards of the adjacent host communities in Cox's Bazar to understand the factors influencing healthcare-seeking behavior of the most vulnerable groups (MVGs) during COVID-19 pandemic. Data were extracted from 48 in-depth interviews (24 in each community) conducted from November 2020 to March 2021 with pregnant and lactating mothers, adolescent boys and girls, persons with disabilities, elderly people, and single female-household heads. This study adopted Andersen's behavioral model of healthcare-seeking for data analysis. Findings suggest that the healthcare-seeking behavior of the participants amid COVID-19 pandemic in the humanitarian context of Cox's Bazar was influenced by several factors ranging from socioeconomic and demographic, existing gender, cultural and social norms, health beliefs, and various institutional factors. Lack of household-level support, reduced number of healthcare providers at health facilities, and movement restrictions at community level hampered the ability of many participants to seek healthcare services in both Rohingya and host communities. Most of the female participants from both communities required permission and money from their male family members to visit healthcare facilities resulting in less access to healthcare. In both communities, the fear of contracting COVID-19 from healthcare facilities disproportionately affected pregnant mothers, elderly people, and persons with disabilities accessing health services. Additionally, the economic uncertainty had a significant impact on the host communities' ability to pay for healthcare costs. These findings have the potential to influence policies and programs that can improve pandemic preparedness and health system resilience in humanitarian contexts.

COVID-19 vaccination coverage is extremely low among older population in Bangladesh: findings from a cross-sectional study.

This cross-sectional study was conducted in September 2021 among 1,045 Bangladeshi older adults aged 60 years or above to explore the COVID-19 vaccination coverage and its associated factors. We used a semi-structured questionnaire to collect data on participants' sociodemographic and lifestyle characteristics, and COVID-19 related information (selected based on an extensive literature review). A multinomial logistic regression model was used to identify the factors independently associated with vaccine receipt. Nearly, two-thirds of the participants (64.5%) were unvaccinated and 12.5% received a single dose. Among the unvaccinated, approximately 94% reported that there was a problem in accessing the vaccine. We found that participants with formal schooling had 42% lower risk of being unvaccinated (RRR (Relative Risk Ratio) = 0.58, 95% CI 0.42-0.80) or 39% lower risk of receiving a single dose (RRR = 0.61, 95% CI 0.39-0.96) than the participants having no formal schooling. The middle family monthly income groups had 65% higher risk (RRR = 1.65, 95% CI 1.17-2.32) and rural participants had 84% higher risk (RRR = 1.84, 95% CI 1.26-2.70) of not receiving vaccines compared to their counterparts. Also, the participants with non-communicable chronic conditions had a significantly lower risk of being unvaccinated (RRR = 0.49, 95% CI 0.35-0.68) or receiving a single dose (RRR = 0.49, 95% CI 0.31-0.77) compared to their counterparts. This finding may help strengthen the existing efforts to maximize vaccine coverage among older populations in Bangladesh and reach herd immunity to break the transmission chain and gain greater overall population protection more rapidly.

Assessing gender responsiveness of COVID-19 response plans for populations in conflict-affected humanitarian emergencies.

BACKGROUND: The COVID-19 pandemic has necessitated rapid development of preparedness and response plans to quell transmission and prevent illness across the world. Increasingly, there is an appreciation of the need to consider equity issues in the development and implementation of these plans, not least with respect to gender, given the demonstrated differences in the impacts both of the disease and of control measures on men, women, and non-binary individuals. Humanitarian crises, and particularly those resulting from conflict or violence, exacerbate pre-existing gender inequality and discrimination. To this end, there is a particularly urgent need to assess the extent to which COVID-19 response plans, as developed for conflict-affected states and forcibly displaced populations, are gender responsive. METHODS: Using a multi-step selection process, we identified and analyzed 30 plans from states affected by conflict and those hosting forcibly displaced refugees and utilized an adapted version of the World Health Organization's Gender Responsive Assessment Scale (WHO-GRAS) to determine whether existing COVID-19 response plans were gender-negative, gender-blind, gender-sensitive, or gender-transformative. RESULTS: We find that although few plans were gender-blind and none were gender-negative, no plans were gender-transformative. Most gender-sensitive plans only discuss issues specifically related to women (such as gender-based violence and reproductive health) rather than mainstream gender considerations throughout all sectors of policy planning. CONCLUSIONS: Despite overwhelming evidence about the importance of intentionally embedding gender considerations into the COVID-19 planning and response, none of the plans reviewed in this study were classified as 'gender transformative.' We use these results to make specific recommendations for how infectious disease control efforts, for COVID-19 and beyond, can better integrate gender considerations in humanitarian settings, and particularly those affected by violence or conflict.

Ensuring the global COVID-19 vaccine equity: Universal vaccine access strategy in the context of low and-middle-income countries.

ABSTRACTLockdowns and other COVID-19 containment measures enforced to kerb the pandemic have had a massive impact on the overall growth of the world. Income-generating activities have been reduced, but the impact is more consequential among the low- and middle-income countries. The disproportionate access to vaccines between wealthy and poor countries has resulted in 'vaccine apartheid.' An 'every-country-for-itself' approach or 'vaccine nationalism' coupled with 'vaccine hesitancy' has contributed to disproportionate access to and uptake of the COVID-19 vaccines. This paper argues that it is time for the decision-makers to adopt a Universal Vaccine Access Strategy (UVAS). The authors argue that sharing resources by establishing local production of vaccines wherever possible, timely donation of unused COVID-19 vaccines to developing countries and addressing vaccine hesitancy have become imperative to interrupt the emergence of new variants.

"Younger women had more access to COVID-19 information": An intersectional analysis of factors influencing women and girls' access to COVID-19 information in Rohingya and host communities in Bangladesh.

The Rohingya and Bangladeshi host communities live at a heightened risk of COVID-19 impact due to their pre-existing vulnerabilities, religious beliefs, and strict socio-cultural and gender norms that render primarily women and girls vulnerable. However, the extent of this vulnerability varies within and across population groups in the host and Rohingya communities. The intersectionality lens helps identify, recognize, and understand these factors that create inequities within populations. This study explored the factors that influenced the women and girls' access to information during the COVID-19 pandemic through an intersectional lens. This paper presents partial findings from the exploratory qualitative part of mixed-method research conducted in ten Rohingya camps and four wards of the adjacent host communities in Cox's Bazar, Bangladesh. Data were extracted from 24 in-depth interviews (12 in each community) conducted from November 2020 to March 2021 with diverse participants, including adolescent girls, younger women, adult women, pregnant and lactating mothers, persons with disabilities, older adults, and single female-household heads. All participants provided verbal informed consent before the interviews. In the case of the adolescents, assent was taken from the participants, and verbal informed consent was taken from their parents/guardians. The ethical clearance of this study was sought from the institutional review board of BRAC James P Grant School of Public Health, BRAC University. We find that the women and girls living in Rohingya communities exhibit a more profound structural interplay of factors within their socio-ecological ecosystem depending on their age, power, and position in the society, physical (dis)abilities, and pre-existing vulnerabilities stemming from their exodus, making them more vulnerable to COVID-19 impact by hindering their access to information. Unlike Rohingya, the host women and girls explain the impact of the COVID-19 pandemic on their access to information through the lens of intergenerational poverty and continuous strain on existing resources, thereby highlighting shrinking opportunities due to the influx, COVID-19 infodemic and misinformation, access to digital devices amongst the adolescents, and restricted mobility mainly due to transport, school closures, and distance-related issues. Moreover, the socio-cultural beliefs and the gender norms imposed on women and adolescent girls played an essential role in accessing information regarding the COVID-19 pandemic and consequently influenced their perception of and response to the disease and its safety protocols. Socio-cultural gender norms led to mobility restrictions, which compounded by lockdowns influenced their access to information resulting in dependency on secondary sources, usually from male members of their families, which can easily mislead/provide mis/partial information. The younger age groups had more access to primary sources of information and a broader support network. In comparison, the older age groups were more dependent on secondary sources, and their social networks were limited to their family members due to their movement difficulty because of age/aging-related physical conditions. This study explored and analyzed the intersectional factors that influenced the women and girls' access to information during the COVID-19 pandemic from two contexts with varying degrees of pre-existing vulnerability and its extent. These include gender, age, state of vulnerability, power and privilege, socio-economic status, and physical (dis)ability. It is imperative that services geared towards the most vulnerable are contextualized and consider the intersectional factors that determine the communities' access to information.

Female Community Health Workers and Health System Navigation in a Conflict Zone: The Case of Afghanistan.

Afghanistan ranked 171st among 188 countries in the Gender Inequality Index of 2011 and has only 16% of its women participating in the labor force. The country has been mired in violence for decades which has resulted in the destruction of the social infrastructure including the health sector. Recently, Afghanistan has deployed community health workers (CHW) who make up majority of the health workforce in the remote areas of this country. This paper aims to bring the plight of the CHWs to the forefront of discussion and shed light on the challenges they face as they attempt to bring basic healthcare to people living in a conflict zone. The paper discusses the motivations of Afghani women to become CHWs, their status in the community and within the health system, the threatening situations under which they operate, and the challenges they face as working women in a deeply patriarchal society within a conflict zone. The paper argues that female CHWs should be provided proper accreditation for their work, should be allowed and encouraged to progress in their careers, and should be instilled at the heart of healthcare program planning because they have the field experience to make the most effective and community oriented programmatic decisions.