Household environment and behavioral determinants of respiratory tract infection in infants and young children in northern Bangladesh.

OBJECTIVES: Respiratory tract infections (RTI) are one of the leading causes of under-five mortality in Bangladesh. Solid biomass fuels are the main source of domestic fuel used for cooking across Bangladesh, leading to smoke and pollution exposure in the home. This article aims to identify risk factors for RTI among children aged under five years in Bangladesh with a particular focus on the household environment, fuel use, and cooking practices. METHODS: A cross-sectional household-health survey was carried out in 321 households in northern Bangladesh. The survey included care-giver interviews on cooking practices, child health, and household behaviors during cooking. Health status of the youngest child (under five years) from each household was recorded through maternal interviews, medical diagnosis, and assessment of biomarkers (C-reactive protein (CRP), hemoglobin) from finger-prick blood samples. Anthropometric status (weight, height) was recorded. RESULTS: Children who spent ≥30 minutes/day within 5 feet of the stove during cooking had a significantly increased risk of moderate/severe RTI compared with children spending <30 minutes/day close to the stove (OR = 2.15, 95%CI: 1.20-3.86, P = 0.01), independent of socio-economic status (SES), biomass fuel type (wood, dung, plant-derived, compressed rice husks), child age, anthropometric status, CRP and hemoglobin. CONCLUSIONS: In environments with a heavy reliance on solid biomass fuels, the amount of time a child spends near the stove during cooking may be an important risk for RTI. These novel findings from Bangladesh warrant further investigation of mother-infant behaviors during cooking in relation to child health, to ascertain whether the association is likely to be causal.

Advancing the application of systems thinking in health: sustainability evaluation as learning and sense-making in a complex urban health system in Northern Bangladesh.

BACKGROUND: Starting in 1999, Concern Worldwide Inc. (Concern) worked with two Bangladeshi municipal health departments to support delivery of maternal and child health preventive services. A mid-term evaluation identified sustainability challenges. Concern relied on systems thinking implicitly to re-prioritize sustainability, but stakeholders also required a method, an explicit set of processes, to guide their decisions and choices during and after the project. METHODS: Concern chose the Sustainability Framework method to generate creative thinking from stakeholders, create a common vision, and monitor progress. The Framework is based on participatory and iterative steps: defining (mapping) the local system and articulating a long-term vision, describing scenarios for achieving the vision, defining the elements of the model, and selecting corresponding indicators, setting and executing an assessment plan,, and repeated stakeholder engagement in analysis and decisions . Formal assessments took place up to 5 years post-project (2009). RESULTS: Strategic choices for the project were guided by articulating a collective vision for sustainable health, mapping the system of actors required to effect and sustain change, and defining different components of analysis. Municipal authorities oriented health teams toward equity-oriented service delivery efforts, strengthening of the functionality of Ward Health Committees, resource leveraging between municipalities and the Ministry of Health, and mitigation of contextual risks. Regular reference to a vision (and set of metrics (population health, organizational and community capacity) mitigated political factors. Key structures and processes were maintained following elections and political changes. Post-project achievements included the maintenance or improvement 5 years post-project (2009) in 9 of the 11 health indicator gains realized during the project (1999-2004). Some elements of performance and capacity weakened, but reductions in the equity gap achieved during the project were largely maintained post-project. CONCLUSIONS: Sustainability is dynamic and results from local systems processes, which can be strengthened through both implicit and explicit systems thinking steps applied with constancy of purpose.