Search

Objective: This paper reflected on the prevalence of hypertension and diabetes in Bangladesh, which is spreading rapidly in low-income countries. The rationale of constructing more health centers for addressing NCDs was assessed in this paper by determining the relationship between prevalence of NCDs, particularly hypertension and diabetes, and distance to health facilities. Methods: From BDHS (Bangladesh Health and Demographic Survey) 2011 data set, 7544 samples were analyzed to demonstrate association between Non-communicable diseases (NCD) and distance from respondents’ home to health facilities like hospitals, community clinics, pharmacies or doctors’ chambers, and community facilities like market, post office or cinema hall. Bivariate analysis was conducted between accessibility to health facilities and prevalence of the diseases. The causal relationship between the spatial effects and the prevalence of the diseases were analyzed by applying Generalized Linear Mixed Model (GLMM) was fitted. Results: Fitting linear mixed effect models, we found that hypertension and diabetes react differently with various spatial effects. Distance from home to hospital had significant effect (P < 0.001) on hypertension showing people living further from the facilities or town centers seemed to be less hypertensive, whereas diabetes showed no such affiliation. Conclusion: Higher prevalence of diabetes (40.9%) over hypertension (26.5%) in people aging 35 or higher, have appeared to have caused the difference, which concluded that each non-communicable disease should be dealt to its own merit for policy making instead considering as a group of diseases. [ABSTRACT FROM AUTHOR]

Motivation: Proper management of fecal sludge has significant positive health and environmental externalities. Most research on managing onsite sanitation so far either simulates the costs of, or the welfare effects from, managing sludge in situ in pit latrines. Thus, designing management strategies for onsite rural sanitation is challenging, because the actual costs of transporting sludge for treatment, and sources for financing these transport costs, are not well understood. Methods: In this paper we calculate the actual cost of sludge management from onsite latrines, and identify the contributions that latrine owners are willing to make to finance the costs. A spreadsheet-based model is used to identify a cost-effective transport option, and to calculate the cost per household. Then a double-bound contingent valuation method is used to elicit from pit-latrine owners their willingness-to-pay to have sludge transported away. This methodology is employed for the case of a rural subdistrict in Bangladesh called Bhaluka, a unit of administration at which sludge management services are being piloted by the Government of Bangladesh. Results: The typical sludge accumulation rate in Bhaluka is calculated at 0.11 liters/person/day and a typical latrine will need to be emptied approximately once every 3 to 4 years. The costs of emptying and transport are high; approximately USD 13 per emptying event (circa 14% of average monthly income); household contributions could cover around 47% of this cost. However, if costs were spread over time, the service would cost USD 4 per year per household, or USD 0.31 per month per household—comparable to current expenditures of rural households on telecommunications. Conclusion: This is one of few research papers that brings the costs of waste management together with financing of that cost, to provide evidence for an implementable solution. This framework can be used to identify cost effective sludge management options and private contributions towards that cost in other (context-specific) administrative areas where onsite sanitation is widespread. [ABSTRACT FROM AUTHOR]

The demand for district level statistics has increased tremendously in Bangladesh due to existence of decentralised approach to governance and service provision. The Bangladesh Demographic Health Surveys (BDHS) provide a wide range of invaluable data at the national and divisional level but they cannot be used directly to produce reliable district-level estimates due to insufficient sample sizes. The small area estimation (SAE) technique overcomes the sample size challenges and can produce reliable estimates at the district level. This paper uses SAE approach to generate model-based district-level estimates of diarrhoea prevalence among under-5 children in Bangladesh by linking data from the 2014 BDHS and the 2011 Population Census. The diagnostics measures show that the model-based estimates are precise and representative when compared to the direct survey estimates. Spatial distribution of the precise estimates of diarrhoea prevalence reveals significant inequality at district-level (ranged 1.1–13.4%) with particular emphasis in the coastal and north-eastern districts. Findings of the study might be useful for designing effective policies, interventions and strengthening local-level governance. [ABSTRACT FROM AUTHOR]

Background: Around 63% of total health care expenditure in Bangladesh is mitigated through out of pocket payment (OOP). Heavy reliance on OOP at the time of care seeking poses great threat for financial impoverishment of the households. Households employ different strategies to cope with the associated financial hardship. Objective: The aim of this paper is to understand the determinants of hardship financing in coping with OOP adopted for health care seeking of under five childhood illnesses in rural setting of Bangladesh. Methods: A community based cross sectional survey was conducted during August to October, 2014 in 15 low performing sub-districts of northern and north-east regions of Bangladesh. Of the 7039 mothers of under five children surveyed, 1895 children who suffered from illness and sought care for their illness episodes were reported in this study. Descriptive statistics and ordinal regression analysis were conducted. Results: A total number of 7,039 under five children reported to have suffered illness by their mothers. Among these children 37% suffered from priority illness. Care was sought for 88% children suffering from illnesses. Among them 26% went to a public or private sector medically trained provider. 5% of households incurred illness cost more than 10% of the household’s monthly expenditure. The need for assistance was higher among those compared to others (31% vs 13%). Different financing mechanisms adopted to meet OOP are loan with interest (6%), loan without interest (9%) and financial help from relatives (6%) Need for financial assistance varied from 19% among households in the lowest quintile to 9% in the highest wealth. Ordinal regression analysis revealed that burden of hardship financing increases by 2.17 times when care is sought from a private trained provider compared to care seeking from untrained provider (CI: 1.49, 3.17). Similarly, for families that incur a health care expenditure that is more than 10% of their total monthly expenditure (CI:1.46, 3.88), the probability of falling into more severe financial burden increases by 2.4 times. We also found severity of the hardship financing to be around half for households with monthly income of more than BDT 7500 (OR = 0.56, CI: 0.37, 0.86). The burden increased by 2.10 times for households with a deficit (CI: 1.53, 2.88) between their monthly income and expenditure. The interaction between family income and severity of illness showed to significantly affect the scale of hardship financing. Children suffering from priority illness belonging to poor households were found have two times (CI: 1.09, 3.47) higher risks of suffering from hardship financing. Conclusion and policy implications: Findings from this study will help the policy makers to identify the target groups and thereby design effective health financing programs. [ABSTRACT FROM AUTHOR]

Bangladesh has made significant progress towards elimination of visceral leishmaniasis, and is on track to achieve its target of less than one case per 10,000 inhabitants in each subdistrict in 2017. As the incidence of disease falls, it is likely that the political capital and financial resources dedicated towards the elimination of visceral leishmaniasis may decrease, raising the prospect of disease resurgence. Policy memos may play a crucial role during the transition of the elimination plan from the ‘attack’ to the ‘consolidation’ and ‘maintenance’ phases, highlighting key stakeholders and areas where ongoing investment is crucial. An example of a policy brief is outlined in this paper. The background to the current elimination efforts is highlighted, with emphasis on remaining uncertainties including the impact of disease reservoirs and sustainable surveillance strategies. A stakeholder map is provided outlining the current and projected future activities of key bodies. Identification of key stakeholders subsequently frames the discussion of three key policy recommendations in the Bangladeshi context for the transition to the consolidation and maintenance phases of the elimination program. Recommendations include determining optimal vector control and surveillance strategies, shifting the emphasis towards horizontal integration of disease programs, and prioritising remaining research questions with a focus on operational and technical capacity. Achieving elimination is as much a political as a scientific question. Integrating the discussion of key stakeholders with policy priorities and the research agenda provides a novel insight into potential pathways forwards in the elimination of visceral leishmaniasis in Bangladesh and in the rest of the Indian subcontinent. [ABSTRACT FROM AUTHOR]

Bangladesh is a culturally conservative nation with limited freedom for women. A number of studies have evaluated intimate partner violence (IPV) and spousal physical violence in Bangladesh; however, the views of women have been rarely discussed in a quantitative manner. Three nationwide surveys in Bangladesh (2007, 2011, and 2014) were analyzed in this study to characterize the most vulnerable households, where women themselves accepted spousal physical violence as a general norm. 31.3%, 31.9% and 28.7% women in the surveys found justification for physical violence in household in 2007, 2011 and 2014 respectively. The binary logistic model showed wealth index, education of both women and their partner, religion, geographical division, decision making freedom and marital age as significant household contributors for women’s perspective in all the three years. Women in rich households and the highly educated were found to be 40% and 50% less likely to accept domestic physical violence compared to the poorest and illiterate women. Similarly, women who got married before 18 years were 20% more likely accept physical violence in the family as a norm. Apart from these particular groups (richest, highly educated and married after 18 years), other groups had around 30% acceptance rate of household violence. For any successful attempt to reduce spousal physical violence in the traditional patriarchal society of Bangladesh, interventions must target the most vulnerable households and the geographical areas where women experience spousal violence. Although this paper focuses on women’s attitudes, it is important that any intervention scheme should be devised to target both men and women. [ABSTRACT FROM AUTHOR]

Background: Despite remarkable progress in maternal and child health, inequity persists in maternal care utilization in Bangladesh. Government of Bangladesh (GOB) with technical assistance from United Nation Population Fund (UNFPA), United Nation Children’s Fund (UNICEF) and World Health Organization (WHO) started implementing Maternal and Neonatal Health Initiatives in selected districts of Bangladesh (MNHIB) in 2007 with an aim to reduce inequity in healthcare utilization. This study examines the effect of MNHIB on inequity in maternal care utilization. Method: Two surveys were carried out in four districts in Bangladesh- baseline in 2008 and end-line in 2013. The baseline survey collected data from 13,206 women giving birth in the preceding year and in end-line 7,177 women were interviewed. Inequity in maternal healthcare utilization was calculated pre and post-MNHIB using rich-to-poor ratio and concentration index. Results: Mean age of respondents were 23.9 and 24.6 years in 2008 and 2013 respectively. Utilization of pregnancy-related care increased for all socioeconomic strata between these two surveys. The concentration indices (CI) for various maternal health service utilization in 2013 were found to be lower than the indices in 2008. However, in comparison to contemporary BDHS data in nearby districts, MNHIB was successful in reducing inequity in receiving ANC from a trained provider (CI: 0.337 and 0.272), institutional delivery (CI: 0.435 in 2008 to 0.362 in 2013), and delivery by skilled personnel (CI: 0.396 and 0.370). Conclusions: Overall use of maternal health care services increased in post-MNHIB year compared to pre-MNHIB year and inequity in maternal service utilization declined for three indicators out of six considered in the paper. The reductions in CI values for select maternal care indicators imply that the program has been successful not only in improving utilization of maternal health services but also in lowering inequality of service utilization across socioeconomic groups. Maternal health programs, if properly designed and implemented, can improve access, partially overcoming the negative effects of socioeconomic disparities. [ABSTRACT FROM AUTHOR]

Background: Bangladesh had one of the highest burdens of lymphatic filariasis (LF) at the start of the Global Programme to Eliminate Lymphatic Filariasis (GPELF) with an estimated 70 million people at risk of infection across 34 districts. In total 19 districts required mass drug administration (MDA) to interrupt transmission, and 15 districts were considered low endemic. Since 2001, the National LF Programme has implemented MDA, reduced prevalence, and been able to scale up the WHO standard Transmission Assessment Survey (TAS) across all endemic districts as part of its endgame surveillance strategy. This paper presents TAS results, highlighting the momentous geographical reduction in risk of LF and its contribution to the global elimination target of 2020. Methodology/Principal findings: The TAS assessed primary school children for the presence of LF antigenaemia in each district (known as an evaluation unit—EU), using a defined critical cut-off threshold (or ‘pass’) that indicates interruption of transmission. Since 2011, a total of 59 TAS have been conducted in 26 EUs across the 19 endemic MDA districts (99,148 students tested from 1,801 schools), and 22 TAS in the 15 low endemic non-MDA districts (36,932 students tested from 663 schools). All endemic MDA districts passed TAS, except in Rangpur which required two further rounds of MDA. In total 112 students (male n = 59; female n = 53), predominately from the northern region of the country were found to be antigenaemia positive, indicating a recent or current infection. However, the distribution was geographically sparse, with only two small focal areas showing potential evidence of persistent transmission. Conclusions/Significance: This is the largest scale up of TAS surveillance activities reported in any of the 73 LF endemic countries in the world. Bangladesh is now considered to have very low or no risk of LF infection after 15 years of programmatic activities, and is on track to meet elimination targets. However, it will be essential that the LF Programme continues to develop and maintain a comprehensive surveillance strategy that is integrated into the health infrastructure and ongoing programmes to ensure cost-effectiveness and sustainability. [ABSTRACT FROM AUTHOR]

Introduction: Tobacco smoking is often more prevalent among those with lower socio-economic status (SES) in high-income countries, which can be driven by the inequalities in initiation and cessation of smoking. Smoking is a leading contributor to socio-economic disparities in health. To date, the evidence for any socio-economic inequality in smoking cessation is lacking, especially in low- and middle-income countries (LMICs). This study examined the association between cessation behaviours and SES of smokers from eight LMICs. Methods: Data among former and current adult smokers aged 18 and older came from contemporaneous Global Adult Tobacco Surveys (2008–2011) and the International Tobacco Control Surveys (2009–2013) conducted in eight LMICs (Bangladesh, Brazil, China, India, Mexico, Malaysia, Thailand and Uruguay). Adjusted odds ratios (AORs) of successful quitting in the past year by SES indicators (household income/wealth, education, employment status, and rural-urban residence) were estimated using multivariable logistic regression controlling for socio-demographics and average tobacco product prices. A random effects meta-analysis was used to combine the estimates of AORs pooled across countries and two concurrent surveys for each country. Results: Estimated quit rates among smokers (both daily and occasional) varied widely across countries. Meta-analysis of pooled AORs across countries and data sources indicated that there was no clear evidence of an association between SES indicators and successful quitting. The only exception was employed smokers, who were less likely to quit than their non-employed counterparts, which included students, homemakers, retirees, and the unemployed (pooled AOR≈0.8, p<0.10). Conclusion: Lack of clear evidence of the impact of lower SES on adult cessation behaviour in LMICs suggests that lower-SES smokers are not less successful in their attempts to quit than their higher-SES counterparts. Specifically, lack of employment, which is indicative of younger age and lower nicotine dependence for students, or lower personal disposable income and lower affordability for the unemployed and the retirees, may be associated with quitting. Raising taxes and prices of tobacco products that lowers affordability of tobacco products might be a key strategy for inducing cessation behaviour among current smokers and reducing overall tobacco consumption. Because low-SES smokers are more sensitive to price increases, tobacco taxation policy can induce disproportionately larger decreases in tobacco consumption among them and help reduce socio-economic disparities in smoking and consequent health outcomes. [ABSTRACT FROM AUTHOR]

Background: Millions of children and others across the world are being dangerously exposed to tobacco smoke and toxins in their own homes. Whilst there is limited interest in laws and interventions controlling tobacco use in public places in Bangladesh, no attention has been given to preventing tobacco-use inside homes. This study explores the familial and socio-cultural factors that provide obstacles for ensuring tobacco-free homes in Bangladesh. Materials and methods: A mixed-method design was adopted and from among the 1,436 tobacco users identified in a population of 11,853, 400 (tobacco users) were selected for cross-sectional survey. This survey involved a probability proportional sampling procedure, and 24 In-Depth Interviews. Multivariate logistic regression was performed to explore the association of familial and socio-cultural factors with tobacco-use at home adjusted by other demographic characteristics. Thematic content analysis was done on the qualitative data, and then inferences were drawn out collectively. Results: This study revealed that the prevalence of tobacco-use in the home was 25.7% in urban residential areas in Bangladesh. Multivariate logistic regression analysis identified that familial and socio-cultural factors were significantly associated with tobacco-use at home: marital status (OR 3.23, 95% CI: 1.37–6.61), education (OR 2.14, 95% CI: 1.15–3.99), smoking habits of older family members (OR 1.81 95% CI: 0.91–2.89), tobacco being offered as hospitality and for entertainment (OR 1.85, 95% CI: .94–2.95) and lack of religiosity practice (OR 2.39, 95% CI: 1.27–4.54). Qualitative findings indicated that social customs, lack of religious practice, tobacco-use of older family members, and lack of family guidance were key obstacles for enabling tobacco-free homes in urban areas. Conclusion: Use of tobacco at home is continuing as part of established familial and socio-cultural traditions. If tobacco-use at home is not addressed seriously by the authorities then the emerging threat of second-hand smoke exposure and harmful consequences of tobacco- use will be exacerbated. [ABSTRACT FROM AUTHOR]

Background: Undernutrition, an important indicator for monitoring progress of development goals, is a matter of concern in many developing countries, including Bangladesh. Despite regional differences in chronic undernutrition in Bangladesh, regional determinants among children under the age of five were not extensively explored. Data and methods: Using combined repeated cross-sectional nationwide Bangladesh Demographic and Health Surveys (BDHS 2011 and 2014) and employing bivariate and logistic regression analyses, we estimated prevalence, changes and variations in regional determinants of stunting among children aged 6–59 months over two time periods 2011 and 2014. Results: Our benchmark results suggested that the children from Rajshahi, Khulna, Rangpur, Chittagong and Dhaka tend to be significantly less stunted by 51% (p = 0.000; CI = [0.38, 0.63]), 44% (p = 0.000; CI = [0.44, 0.71]), 26% (p = 0.012; CI = [0.58, 0.93]), 23% (p = 0.012; CI = [0.62, 0.95]) and 22% (p = 0.033; [0.63, 0.97]) respectively, against Sylhet in 2011. With the exception of Dhaka, no region showed significant differences in the odds of stunting over two time periods 2011 and 2014, i.e. only Dhaka revealed significant difference by 30% reductions in the odds of stunting in 2014. Also, rural children were less likely to be stunted (by 19%) of the urban counterparts. Regional covariates of stunting differ. However, children’s age, household wealth, mother’s height, and parental education were important determinants of stunting in Bangladesh. Conclusion: Dhaka made an impressive improvement in child nutrition, thus contributed largely to the reduction of stunting levels in Bangladesh for 2014 over 2011. Sylhet and Barisal require strong push to improve nutritional status of children. Further decline is possible through region-specific multipronged interventions that can address area-specific covariates to break the cycle of undernutrition like strengthening economic and educational status, emphasizing the role of father to augment their knowledge in varying aspects like family planning, reduction of fertility and by improving mother’s health. [ABSTRACT FROM AUTHOR]

Background: The prevalence of overweightness in Bangladesh is increasing, while underweightness also continues to persist. A better understanding of the patterns and socioeconomic risk factors of both conditions, particularly among women, is critical in order to promote the development of interventions to improve maternal health in Bangladesh. This study therefore sought to assess the patterns of under- and overweightness between 2004 and 2014 and to examine the predictors of individual and community-level inequalities of under- and overnutrition in Bangladesh. Methods: Cross-sectional data of 10, 431, and 16,478 ever-married nonpregnant women aged between 15 and 49 years who did not give birth in the two months preceding the survey were extracted from the 2004 and 2014 Bangladesh Demographic and Health Surveys, respectively. Body mass index was used to measure weight status, and underweightness, at-risk for overweightness, overweightness, and obesity were the main outcome variables. Patterns of nutritional change over time was examined by considering the annual average rate of change. Multilevel multinomial logistic regression and quantile regression were used to identify the inequalities. Results: In 2014, the age-adjusted prevalence values of underweightness, at-risk for overweightness, overweightness, and obesity were 19.7%, 14.9%, 18.1% and 4.0%, respectively. A higher average annual rate of reduction of underweightness was found among wealthier, highly educated, and wealthier community–living women, while a rate of increase of overweightness was found among poorer, uneducated, and poor community–living women. Individual and community-level inequalities of malnutrition were observed among these populations. In comparison with women living in low wealth communities, women from wealthier communities were at an increased risk of being at-risk for overweightness [adjusted odds ratio (AOR): 1.53, 95% confidence interval (CI): 1.23–1.91], overweight (AOR: 1.60, 95% CI: 1.27–2.00), and obese (AOR: 2.12, 95% CI: 1.42–3.18). Conclusions: This study suggests the coexistence of a double burden of under- and overnutrition in Bangladesh and that the prevalence of overweightness surpasses that of underweightness. The burdens of under- and overnutrition are strongly associated with women’s individual socioeconomic positions and the nature of the community in which they live. [ABSTRACT FROM AUTHOR]

Postpartum depression (PPD) is a serious pubic health concern and known to have the adverse effects on mother’s perinatal wellbeing; and child’s physical and cognitive development. There were limited literatures on PPD in Bangladesh, especially in urban slum context. The aim of this study was to assess the burden and risk factors of PPD among the urban slum women. A cross-sectional study was conducted between November-December 2017 in three urban slums on 376 women within first 12 months of postpartum. A validated Bangla version of Edinburgh Postnatal Depression Scale was used to measure the depression status. Respondent’s socio-economic characteristics and other risk factors were collected with structured validated questionaire by trained interviewers. Unadjusted Prevalence Ratio (PR) and Adjusted Prevalence Ratio (APR) were estimated with Generalized Linear Model (GLM) and Generalized Estimating Equation (GEE) respectively to identify the risk factors of PPD. The prevalence of PPD was 39.4% within first 12 months following the child birth. Job involvement after child delivery (APR = 1.9, 95% CI = 1.1, 3.3), job loss due to pregnancy (APR = 1.5, 95% CI = 1.0, 2.1), history of miscarriage or still birth or child death (APR = 1.4, 95% CI = 1.0, 2.0), unintended pregnancy (APR = 1.8, 95% CI = 1.3, 2.5), management of delivery cost by borrowing, selling or mortgaging assets (APR = 1.3, 95% CI = 0.9, 1.9), depressive symptom during pregnancy (APR = 2.5, 95% CI = 1.7, 3.8) and intimate partner violence (APR = 2.0, 95% CI = 1.2, 3.3), were identified as risk factors. PPD was not associated with poverty, mother in law and any child related factors. The burden of postpartum depression was high in the urban slum of Bangladesh. Maternal mental health services should be integrated with existing maternal health services. Research is required for the innovation of effective, low cost and culturally appropriate PPD case management and preventive intervention in urban slum of Bangladesh. [ABSTRACT FROM AUTHOR]

Background: Incidence of community acquired pneumonia is high globally. In Bangladesh, more male children than female children are brought to hospitals for pneumonia. We examined if there was disparities in the severity of illness and outcome by sex among children who were admitted with pneumonia to hospitals in Bangladesh. Methods: Hospitalized children, aged 2 to 59 months, meeting a case definition of pneumonia were recruited in seven hospitals following parental consent. At baseline, study doctors obtained socio-demographic characteristics and care seeking behaviors for pneumonia, and then clinical data were collected throughout the hospital stay. Multivariate analysis was performed to determine if the sex of the child had a relationship with either illness severity on admission or outcome in the hospital. Results: Between May 2004 and December 2008, 6,856 children, including 35% females, were recruited. A total of 1,371 (19.9%) children had non-severe pneumonia, 4,118 (60.0%) had severe pneumonia, and 1,367 (19.9%) had very severe pneumonia. A higher proportion of hospitalized females had very severe pneumonia as compared to males (21.5% versus 19.1%; P = 0.01), but there was no difference by sex in the proportion of children with severe or non-severe pneumonia. There was no difference by sex observed in the clinical management provided in the hospital, but a greater proportion of females (4.7%) as compared to males (3.6%) died in hospitals (P = 0.04). In multivariate analyses, female sex was associated with very severe pneumonia on admission (OR: 1.26, 95% CI: 1.09–1.47) and fatal outcome in the hospitals (OR: 1.31, 95% CI: 1.01–1.71). Death in female children admitted with very severe pneumonia was 4 times higher than that reported in males (OR: 4.37, 95% CI: 3.24–5.89). Conclusion: Our data demonstrates a sex-based disparity in the severity of pneumonia and deaths among children admitted to hospitals in Bangladesh, despite no existing disparity by sex in hospital treatment. These findings call for further investigations to explore the determinants of health seeking behavior by parents with children with pneumonia in a community that favors males to females, and to understand the role of differences by sex in childhood pneumonia outcomes in Bangladesh. [ABSTRACT FROM AUTHOR]

The economic burden of noncommunicable diseases (NCDs), including treatment costs and income and productivity losses, is a growing concern in developing countries, where NCD medical expenditure may offset consumption of other essential commodities. This study examines the role of NCDs in household resource allocation in Bangladesh. We use the Bangladesh Household Income and Expenditure Survey (HIES) 2010 to obtain expenditure data on 11 household expenditure categories and 12 food expenditure sub-categories for 12,240 households. Household NCD status was determined through self-report of at least one of the six major NCDs within the household–heart disease, hypertension, diabetes, kidney diseases, asthma, and cancer. We estimated unadjusted and regression-adjusted differences in household expenditure shares between NCD and non-NCD households. We further investigated how consumption of different food sub-categories is related to NCD status, distinguishing between household economic levels. The medical expenditure share was estimated to be 59% higher for NCD households than non-NCD households, and NCD households had lower expenditure shares on food, clothing, hygiene, and energy. Regression results indicated that presence of NCDs was associated with lower relative expenditure on clothing and housing in all economic subgroups, and with lower expenditure on food among marginally poor households. Having an NCD was significantly associated with higher household spending on tobacco and higher-calorie foods such as sugar, beverages, meat, dairy, and fruit, and with lower spending on fish, vegetables, and legumes. The findings indicate a link between NCDs and the possibility of adverse economic effects on the household by highlighting the potential displacement effect on household consumption that might occur through higher medical expenditure and lower spending on essentials. The findings might also point to a need for raising awareness about the link between NCDs and diet in Bangladesh. [ABSTRACT FROM AUTHOR]

We aimed to estimate the impact of a Community-Based Health Insurance (CBHI) scheme on utilization of healthcare from medically trained providers (MTP) by informal workers. A quasi-experimental study was conducted where insured households were included in the intervention group and uninsured households in comparison group. In total 1,292 (646 insured and 646 uninsured) households were surveyed from Chandpur district comprising urban and rural areas after 1 year period of CBHI introduction. Matching of the characteristics of insured and uninsured groups was performed using a propensity score matching approach to minimize the observed baseline differences among the groups. Multilevel logistic regression model, with adjustment for individual and household characteristics was used for estimating association between healthcare utilization from the MTP and insurance enrolment. The utilization of healthcare from MTP was significantly higher in the insured group (50.7%) compared to the uninsured group (39.4%). The regression analysis demonstrated that the CBHI beneficiaries were 2.111 (95% CI: 1.458–3.079) times more likely to utilize healthcare from MTP.CBHI scheme increases the utilization of MTP among informal workers. Ensuring such healthcare for these workers and their dependents is a challenge in many low and middle income countries. The implementation and scale-up of CBHI schemes have the potential to address this challenge of universal health coverage. [ABSTRACT FROM AUTHOR]

There is a paucity in current literature about the level of patients’ satisfaction and factors influencing it in Bangladesh health system. We aimed to measure the level of patients’ satisfaction across different types and levels of healthcare facilities and to determine which factors influence this satisfaction level. A patient exit interview was carried out among 2207 patients attending selected health facilities in two administrative divisions of Bangladesh, namely Rajshahi and Sylhet. Information on healthcare experience and satisfaction with received care was collected through an electronic structured questionnaire. Information about ‘overall satisfaction with healthcare’ was collected on a 10-point scale and then dichotomized based on the median-split. Binomial logistic regressions, both simple and multivariable, were conducted to identify which factors contribute significantly to patients’ satisfaction. We found that 63.2% of the participants were satisfied with the healthcare service they received. Patients attending the private facilities had the highest level of satisfaction (i.e. 73%) and patients attending the primary care facilities had the lowest level of satisfaction (i.e. 52%). Factors like convenient opening hours, asking related questions to the providers, facility cleanliness and privacy settings were significantly associated with patients’ satisfaction. Being satisfied with facility cleanliness (multivariable OR 4.30; 95% CI: 3.29–5.62) and privacy settings (multivariable OR 1.68; 95% CI: 1.28–2.21) were the strongest predictors of patients’ satisfaction. In conclusion, a significant portion of the patients in Bangladesh are not satisfied with their received care. Patients’ satisfaction can be increased by focusing on improving facility cleanliness, privacy settings and providers’ interpersonal skills. [ABSTRACT FROM AUTHOR]

Background: Young children frequently defecate in the living environment in low-income countries. Unsafe child feces disposal has been associated with risk of diarrhea. Additionally, reported practices can underestimate socially undesirable unhygienic behaviors. This analysis aimed to assess (1) the sensitivity of reported child feces disposal practices as an indicator for observed presence of human feces in the domestic environment, (2) household characteristics associated with reported unsafe feces disposal and (3) whether unsafe feces disposal is associated with fly presence and diarrhea among children <3 years. Methods: We recorded caregiver-reported feces disposal practices for children <3 years; unsafe disposal was defined as feces put/rinsed into a drain, ditch, bush or garbage heap or left on the ground and safe disposal as feces put/rinsed into latrine or specific pit or buried. We conducted spot checks for human feces, counted flies in the compound and recorded caregiver-reported child diarrhea prevalence among 803 rural Bangladeshi households. We assessed associations using generalized estimating equations (GEE) and generalized linear models (GLM) with robust standard errors. Results: Unsafe disposal of child feces was reported by 80% of households. Reported disposal practices had high sensitivity (91%) but low positive predictive value (15%) as an indicator of observed feces in the compound. Unsafe disposal was more common among households that reported daily adult open defecation (PR: 1.13, 1.02–1.24) and had children defecating in a nappy or on the ground versus in a potty (PR: 2.92, 1.98–4.32), and less common in households where adults reported always defecating in latrines (PR: 0.91, 0.84–0.98). The presence of observed human feces was similarly associated with these household characteristics. Reported unsafe feces disposal or observed human feces were not associated with fly detection or child diarrhea. Conclusion: Despite access to on-site sanitation, unsafe child feces disposal was reported by the majority of households. However, this practices was not associated with diarrhea; suggesting that child feces may not be the most important fecal exposure. Before resources are invested to improve child feces management practices, studies should explore whether these contribute meaningfully to risk of enteric disease. [ABSTRACT FROM AUTHOR]

Recent advances in statistical methods enable the study of correlation among outcomes through joint modeling, thereby addressing spillover effects. By joint modeling, we refer to simultaneously analyzing two or more different response variables emanating from the same individual. Using the 2011 Bangladesh Demographic and Health Survey, we jointly address spillover effects between contraceptive use (CUC) and knowledge of HIV and other sexually transmitted diseases. Jointly modeling these two outcomes is appropriate because certain types of contraceptive use contribute to the prevention of HIV and STDs and the knowledge and awareness of HIV and STDs typically lead to protection during sexual intercourse. In particular, we compared the differences as they pertained to the interpretive advantage of modeling the spillover effects of joint modeling HIV and CUC as opposed to addressing them separately. We also identified risk factors that determine contraceptive use and knowledge of HIV and STDs among women in Bangladesh. We found that by jointly modeling the correlation between HIV knowledge and contraceptive use, the importance of education decreased. The HIV prevention program had a spillover effect on CUC: what seemed to be impacted by education can be partially contributed to one’s exposure to HIV knowledge. The joint model revealed a less significant impact of covariates as opposed to both separate models and standard models. Additionally, we found a spillover effect that would have otherwise been undiscovered if we did not jointly model. These findings further suggested that the simultaneous impact of correlated outcomes can be adequately addressed for the commonality between different responses and deflate, which is otherwise overestimated when examined separately. [ABSTRACT FROM AUTHOR]

Background: In recent years, Bangladesh government has accomplished the ambitious project of establishing hospitals 18,000 Community Health Clinics in sub-districts across the country. Operating under the affiliation of the government hospitals, these community health clinics aim to provide free healthcare services and to increase health-awareness among the extreme poor communities in the rural areas. However, a great proportion of the people are still not well aware of the services offered by the community health clinics. Thus, it is imperative to identify the factors of awareness regarding the community clinics. Research-based evidence is necessary to improve the efficacy and service coverage of community clinics among key population. Methods: Cross-sectional data of size 11,673 women aged 15 to 49 years living in rural settings across seven divisions were extracted from the latest Bangladesh Demographic and Health Survey 2014. The main outcome measures of our study were awareness and utilization of Community Clinic Services (CCs). Descriptive statistics were used to present the baseline socio-demographic and economic characteristics; Chi-square test and logistic regression were performed to identify the factors associated with awareness of community clinics. Results: About one-third (36.7%) of the women were aware of community clinics. Geographical location, level of education, household wealth status and frequency of reading newspaper were found to be significantly associated with awareness about community clinic services. Services reported to be obtained in the community clinics include family planning, immunization, tetanus, antenatal care, vitamin A, and health care for children and child growth monitoring. In the multivariate logistic regression, the odds of awareness among participants with primary education [p<0.001, AOR = 1.255, 95%CI = 1.107–1.357], secondary qualification [p<0.001, AOR = 1.370, 95%CI = 1.242–1.510] and tertiary [p<0.001, AOR = 1.526, 95%CI = 1.286–1.809] had approximately 23%, 37% and 53% respectively higher odds of awareness when compared to those with no formal education. Compared to the women living in richest households, odds of awareness were approximately 12.5%, 12.8%, 4.5% and 22.4% respectively higher among women reported in poorer, middle, richer and richest household wealth status when compared to poorest wealth status. Conclusion: Our findings suggested that policies enhancing improved education could benefit health awareness. Poverty elimination and income generation programs among women are also likely to improve awareness about community health clinics in the target population. Special policy attention is required to address the regional variation of awareness about Community clinics. [ABSTRACT FROM AUTHOR]

Background: Providing access to affordable health care for the informal sector remains a considerable challenge for low income countries striving to make progress towards universal health coverage. The objective of the study is to identify the factors shaping the decision to enroll in a cooperative based health scheme for informal workers in Bangladesh and also help to identify the features of informal workers without health schemes and their likelihood of being insured. Methods: Data were derived from a cross-sectional in-house survey within the catchment area of a cooperative based health scheme in Bangladesh during April–June 2014, covering a total of 784 households (458 members and 326 non-members). Multivariate logistic regression model was used to identify factors associated with cooperative based health scheme and explanatory variables. Findings: This study found that a number of factors were significant determinants of health scheme participation including sex of household head, household composition, occupational category as well as involvement social financial safety net programs. Conclusion: Findings from this study can be suggestive for policy-makers interested in scaling up health insurance for informal workers in Bangladesh. Shared funding from this large informal sector can generate new resources for healthcare, which is in line with the healthcare financing strategy of Bangladesh as well as the recommendation of the World Health Organization for developing social health insurance as part of the path to Universal Health Coverage. [ABSTRACT FROM AUTHOR]

Background: In 2007, the Government of Bangladesh incorporated a chapter on HIV/AIDS into the national curriculum for an HIV-prevention program for school students. For the efficient dissemination of knowledge, an intervention was designed to train the teachers and equip them to educate on the topic of HIV/AIDS. The present study intended to understand the impact of this intervention by assessing the knowledge, attitudes and behaviours related to HIV/AIDS, among the targeted students. Methods: A cross-sectional survey was conducted with the students at randomly selected schools from two adjacent districts. Considering exposure to intervention, one district was assigned for intervention and the other as a control. In total, 1,381 students, aged 13–18 years (or above) were interviewed, 675 from the control areas and 706 from the intervention areas. Univariate and bivariate analyses were performed on the collected data. Results: A significantly higher proportion (p<0.001) of students in the intervention areas attended HIV/AIDS classes, demonstrated better knowledge and fewer misconceptions regarding the transmission and prevention of HIV. The same was derived regarding their attitude towards people living with HIV, as a higher proportion (p<0.001) responded positively, compared to the control groups of the study. Additionally, multinomial logistic regression analysis showed that students in intervention area were more likely to have good knowledge on HIV transmission (OR 2.71, 95% CI 1.74–4.22) and prevention (OR 2.15, 95% CI 1.41–3.26) compared to the students in the control areas. Conclusions: The training programme needs to be scaled up, since it is likely to have an impact among students; we have witnessed that the interventions particularly helped increase HIV/AIDS knowledge among students and positively change the students’ attitudes towards HIV/AIDS. [ABSTRACT FROM AUTHOR]

Background: Rotavirus vaccines are now globally recommended by the World Health Organization (WHO), but in early 2009 WHO's Strategic Advisory Group of Experts on Immunization reviewed available data and concluded that there was no evidence for the efficacy or effectiveness of a two-dose schedule of the human rotavirus vaccine (HRV; Rotarix) given early at 6 and 10 wk of age. Additionally, the effectiveness of programmatic rotavirus vaccination, including possible indirect effects, has not been assessed in low-resource populations in Asia.Methods and Findings: In Bangladesh, we cluster-randomized (1:1) 142 villages of the Matlab Health and Demographic Surveillance System to include two doses of HRV with the standard infant vaccines at 6 and 10 wk of age or to provide standard infant vaccines without HRV. The study was initiated November 1, 2008, and surveillance was conducted concurrently at Matlab Diarrhoea Hospital and two community treatment centers to identify children less than 2 y of age presenting with acute rotavirus diarrhea (ARD) through March 31, 2011. Laboratory confirmation was made by enzyme immunoassay detection of rotavirus antigen in stool specimens. Overall effectiveness of the HRV vaccination program (primary objective) was measured by comparing the incidence rate of ARD among all children age-eligible for vaccination in villages where HRV was introduced to that among such children in villages where HRV was not introduced. Total effectiveness among vaccinees and indirect effectiveness were also evaluated. In all, 6,527 infants were age-eligible for vaccination in 71 HRV villages, and 5,791 in 71 non-HRV villages. In HRV villages, 4,808 (73.7%) infants received at least one dose of HRV. The incidence rate of ARD was 4.10 cases per 100 person-years in non-HRV villages compared to 2.8 per 100 person-years in HRV villages, indicating an overall effectiveness of 29.0% (95% CI, 11.3% to 43.1%). The total effectiveness of HRV against ARD among vaccinees was 41.4% (95% CI, 23.2% to 55.2%). The point estimate for total effectiveness was higher against ARD during the first year of life than during the second (45.2% versus 28.9%), but estimates for the second year of life lacked precision and did not reach statistical significance. Indirect effects were not detected. To check for bias in presentation to treatment facilities, we evaluated the effectiveness of HRV against acute diarrhea associated with enterotoxigenic Escherichia coli; it was 4.0% (95% CI, -46.5% to 37.1%), indicating that bias likely was not introduced. Thirteen serious adverse events were identified among recipients of HRV, but none were considered related to receipt of study vaccine. The main limitation of this study is that it was an open-label study with an observed-only control group (no placebo).Conclusions: The two-dose HRV rotavirus vaccination program significantly reduced medically attended ARD in this low-resource population in Asia. Protection among vaccinees was similar to that in other low-resource settings. In low-resource populations with high rotavirus incidence, large-scale vaccination across a wide population may be required to obtain the full benefit of rotavirus vaccination, including indirect effects.Trial Registration: ClinicalTrials.gov NCT00737503. [ABSTRACT FROM AUTHOR]

Childhood wasting is a global problem and is significantly more pronounced in low and middle income countries like Bangladesh. Socio Economic Status (SES) and Water, Sanitation and Hygiene (WASH) practices may be significantly associated with wasting. Most previous research is consistent about the role of SES, but the significance of WASH in the context of wasting remains ambiguous. The effect of SES and WASH on weight for length (WHZ) is examined using a Structural Equation Model (SEM) to explicitly describe the direct and indirect role of WASH in the context of SES.A nationally representative survey of 10,478 Bangladeshi children under 5 were examined. An expert defined SEM was used to construct latent variables for SES and WASH. The SEM included a direct pathway from SES to WHZ and an indirect pathway from SES to WHZ via WASH along with regression of relevant covariates on the outcome WHZ and the latent variables. Both SES (p<0.01) and WASH (p<0.05) significantly affect WHZ. SES (p<0.01) also significantly affects WASH. Other structural components showed that child’s age (p<0.01) affects WHZ and types of residence (p<0.01) affects SES. WASH practices at least partially mediate the association between SES and wasting status. WASH and SES are both significantly associated with WHZ. [ABSTRACT FROM AUTHOR]

Background: To assess factors associated with disability in a rural district of Bangladesh. Methods: Using a population-based systematic sampling technique, data were collected from 3104 adults aged ≥ 30 years from the Banshgram union of Narail district. Data collected included an interviewer administered questionnaire to report physical disabilities including impairment that prevents engagement with paid work, visual, hearing, and mobility as well as mental disabilities. Socio-demographic and anthropometric factors including educational attainment and body mass index, as well as clinical factors such as blood pressure, and fasting blood glucose were also collected. Binary and multinomial logistic regression techniques were used to explore the association of various socio-demographic and clinical factors with disability. Results: The mean (SD), minimum and maximum ages of the participants were 51 (12), 30 and 89 years. Of total participants, 65% were female. The prevalence of disability varied from 29.1% for visual impairment (highest) to 16.5% for hearing, 14.7% for movement difficulties and 1.6% (lowest) for any other disability that prevented engagement with paid work. Overall, the prevalence of a single disability was 28.6% and that of two or more disabilities was 14.7%. Older age, gender (female), lower socio-economic status (SES), and hypertension were associated with a higher prevalence of most of the disability components. The prevalence of hearing problems (24.5% vs. 13.3%, p<0.001) and movement difficulties (24.9% vs. 13.0%, p<0.001) was significantly higher among lower-income participants than their higher-income counterparts after controlling for age. Prevalence of visual impairment (54.6% vs. 9.2%, p<0.001), hearing (32.2% vs. 6.7%, p<0.001) and movement difficulties (29.2% vs. 5.5%, p<0.001) were significantly higher in people of aged 60 years or older than those aged 30–34 years. After multivariate adjustment, the prevalence of single disability (prevalence risk ratio [PRR] 1.25, 95% CI: 1.09–1.42, p<0.001), and multiple disabilities (PRR 1.41, 95% CI 1.14–1.73, p<0.001) was higher among females than males. The prevalence of single disability and multiple disabilities was respectively 21% (PRR 1.21, 95% CI: 1.02–1.42, p<0.001) and 88% (PRR 1.88, 95% CI: 1.38–2.54, p<0.001) higher among participants with low educational attainment (primary level or less) than those with at least a secondary level of education. Conclusions: In rural Bangladesh, the prevalence of disability is high. Public health programs should target those of low SES, older age, and female participants and aim to provide necessary supports in order to bridge disability-related inequities. [ABSTRACT FROM AUTHOR]

Introduction: Chronic non-communicable diseases (NCDs) are a major public health challenge, and undermine social and economic development in much of the developing world, including Bangladesh. Epidemiologic evidence on the socioeconomic status (SES)-related pattern of NCDs remains limited in Bangladesh. This study assessed the relationship between three chronic NCDs and SES among the Bangladeshi population, paying particular attention to the differences between urban and rural areas. Materials and Method: Data from the 2011 Bangladesh Demographic and Health Survey were used for this study. Using a concentration index (CI), we measured relative inequality across pre-diabetes, diabetes, pre-hypertension, hypertension, and BMI (underweight, normal weight, and overweight/obese) in urban and rural areas in Bangladesh. A CI and its associated curve can be used to identify whether socioeconomic inequality exists for a given health variable. In addition, we estimated the health achievement index, integrating mean coverage and the distribution of coverage by rural and urban populations. Results: Socioeconomic inequalities were observed across diseases and risk factors. Using CI, significant inequalities observed for pre-hypertension (CI = 0.09, p = 0.001), hypertension (CI = 0.10, p = 0.001), pre-diabetes (CI = -0.01, p = 0.005), diabetes (CI = 0.19, p<0.001), and overweight/obesity (CI = 0.45, p<0.001). In contrast to the high prevalence of the chronic health conditions among the urban richest, a significant difference in CI was observed for pre-hypertension (CI = -0.20, p = 0.001), hypertension (CI = -0.20, p = 0.005), pre-diabetes (CI = -0.15, p = 0.005), diabetes (CI = -0.26, p = 0.004) and overweight/obesity (CI = 0.25, p = 0.004) were observed more among the low wealth quintiles of rural population. In the same vein, the poorest rural households had more co-morbidities compared to the richest rural households (p = 0.003), and prevalence of co-morbidities was much higher for the richest urban households compared to the poorest urban households. On the other hand in rural the “disachievement” of health indicators is more noticeable than the urban ones. Conclusion: The findings indicate the high burden of selected NCDs among the low wealth quintile populations in rural areas and wealthy populations in urban areas. Particular attentions may be necessary to address the problem of NCDs among these groups. [ABSTRACT FROM AUTHOR]

Background: Malnutrition in children under five years remains a significant problem in Bangladesh, despite substantial socio-economic progress and a decade of interventions aimed at improving it. Although several studies have been conducted to identify the important risk factors of malnutrition, none of them assess the role of low birth weight (LBW) despite its high prevalence (36%). This study examines the association between LBW and malnutrition using data from the Bangladesh Demographic and Health Survey (BDHS) 2011 and provides practical guidelines for improving nutritional status of children. Methods: Malnutrition in children is measured in terms of their height-for-age, weight-for-height, and weight-for-age. Children whose Z-scores for either of these indices are below two standard deviations (–2SD) from median of WHO’s reference population are considered as stunted, wasted or underweight, respectively. The association between malnutrition and LBW was investigated by calculating adjusted risk-ratio (RR), which controls for potential confounders such as child’s age and sex, mother’s education and height, length of preceding-birth-interval, access to food, area of residence, household socio-economic status. Adjusted RR was calculated using both Cochran-Mantel-Haenszel approach and multivariable logistic regression models controlling for confounder. Results: The prevalence of malnutrition was markedly higher in children with LBW than those with normal birth-weights (stunting: 51% vs 39%; wasting: 25% vs 14% and underweight: 52% vs 33%). While controlling for the known risk factors, children with LBW had significantly increased risk of becoming malnourished compared to their counter part with RR 1.23 (95% CI:1.16–1.30), 1.71 (95% CI:1.53–1.92) and 1.47 (95% CI: 1.38–1.56) for stunting, wasting and underweight, respectively. The observed associations were not modified by factors known to reduce the prevalence of malnutrition, such as higher education of mother, better household socio-economic conditions and longer birth-interval. Conclusions: Higher education of mother, better household socio-economic conditions and prolonged birth intervals alone are not sufficient in bringing about substantial reductions in prevalence of child malnutrition in Bangladesh. Targeted interventions should be designed to reduce prevalence of LBW in addition to improving mother’s education and other socio-demographic conditions. [ABSTRACT FROM AUTHOR]

The World Health Organization (WHO) currently coordinates rotavirus diarrhea and invasive bacterial disease (IBD) surveillance at 178 sentinel sites in 60 countries. However, only 78 sites participate in both surveillance systems using a common sentinel site. Here, we explored the feasibility of extending a WHO-IBD surveillance platform to generate data on the burden of rotaviral diarrhea and its epidemiological characteristics to prepare the countries to measure the impact of rotaviral vaccine. A six-month (July to December, 2012) surveillance, managed by IBD team, collected stool samples and clinical data from under-five children with acute watery diarrhea at an IBD sentinel site. Samples were tested for rotavirus antigen by ELISA and genotyped by PCR at the regional reference laboratory (RRL). Specimens were collected from 79% (n = 297) of eligible cases (n = 375); 100% of which were tested for rotavirus by ELISA and 54% (159/297) of them were positive. At RRL, all the cases were confirmed by PCR and genotyped (99%; 158/159). The typing results revealed the predominance of G12 (40%; 64/159) genotype, followed by G1 (31%; 50/159) and G9 (19%; 31/159). All in all, this exploratory surveillance collected the desired demographic and epidemiological data and achieved almost all the benchmark indicators of WHO, starting from enrollment number to quality assurance through a number of case detection, collection, and testing of specimens and genotyping of strains at RRL. The success of this WHO-IBD site in achieving these benchmark indicators of WHO can be used by WHO as a proof-of-concept for considering integration of rotavirus surveillance with WHO-IBD platforms, specifically in countries with well performing IBD site and no ongoing rotavirus surveillance. [ABSTRACT FROM AUTHOR]

Close interpersonal contact likely drives spatial clustering of cases of cholera and diarrhea, but spatial clustering of risk factors may also drive this pattern. Few studies have focused specifically on how exposures for disease cluster at small spatial scales. Improving our understanding of the micro-scale clustering of risk factors for cholera may help to target interventions and power studies with cluster designs. We selected sets of spatially matched households (matched-sets) near cholera case households between April and October 2013 in a cholera endemic urban neighborhood of Tongi Township in Bangladesh. We collected data on exposures to suspected cholera risk factors at the household and individual level. We used intra-class correlation coefficients (ICCs) to characterize clustering of exposures within matched-sets and households, and assessed if clustering depended on the geographical extent of the matched-sets. Clustering over larger spatial scales was explored by assessing the relationship between matched-sets. We also explored whether different exposures tended to appear together in individuals, households, and matched-sets. Household level exposures, including: drinking municipal supplied water (ICC = 0.97, 95%CI = 0.96, 0.98), type of latrine (ICC = 0.88, 95%CI = 0.71, 1.00), and intermittent access to drinking water (ICC = 0.96, 95%CI = 0.87, 1.00) exhibited strong clustering within matched-sets. As the geographic extent of matched-sets increased, the concordance of exposures within matched-sets decreased. Concordance between matched-sets of exposures related to water supply was elevated at distances of up to approximately 400 meters. Household level hygiene practices were correlated with infrastructure shown to increase cholera risk. Co-occurrence of different individual level exposures appeared to mostly reflect the differing domestic roles of study participants. Strong spatial clustering of exposures at a small spatial scale in a cholera endemic population suggests a possible role for highly targeted interventions. Studies with cluster designs in areas with strong spatial clustering of exposures should increase sample size to account for the correlation of these exposures. [ABSTRACT FROM AUTHOR]

Introduction: Reliance on out-of-pocket payment for healthcare may lead poor households to undertake catastrophic health expenditure, and risk-pooling mechanisms have been recommended to mitigate such burdens for households in Bangladesh. About 88% of the population of Bangladesh depends on work in the informal sector. We aimed to estimate willingness-to-pay (WTP) for CBHI and identify its determinants among three categories of urban informal workers rickshaw-pullers, shopkeepers and restaurant workers. Methods: The bidding game version of contingent valuation method was used to estimate weekly WTP. In three urban locations 557 workers were interviewed using a structured questionnaire during 2010 and 2011. Multiple-regression analysis was used to predict WTP by demographic and household characteristics, occupation, education level and past illness. Results: WTP for a CBHI scheme was expressed by 86.7% of informal workers. Weekly average WTP was 22.8 BDT [Bangladeshi Taka; 95% confidence interval (CI) 20.9–24.8] or 0.32 USD and varied significantly across occupational groups (p = 0.000) and locations (p = 0.003). WTP was highest among rickshaw-pullers (28.2 BDT or 0.40 USD; 95% CI: 24.7–31.7), followed by restaurant workers (20.4 BDT 0.29 USD; 95% CI: 17.0–23.8) and shopkeepers (19.2 BDT or 0.27 USD; 95% CI: 16.1–22.4). Multiple regression analysis identified monthly income, occupation, geographical location and educational level as the key determinants of WTP. WTP increased 0.196% with each 1% increase in monthly income, and was 26.9% lower among workers with up to a primary level of education versus those with higher than primary, but less than one year of education. Conclusion: Informal workers in urban areas thus are willing to pay for CBHI and socioeconomic differences explain the magnitude of WTP. The policy maker might think introducing community-based model including public-community partnership model for healthcare financing of informal workers. Decision making regarding the implementation of such schemes should consider worker location and occupation. [ABSTRACT FROM AUTHOR]