Relationships of Exclusion and Cohesion with Health: The Case of Bangladesh

The concept of social exclusion, applied widely in the European Union, has in recent years been gaining use in Bangladesh, mostly by international development agencies. Does this discourse of deprivation, developed in the welfare states of northern Europe, have salience in its application to deprivation in countries like Bangladesh where, for example, 31% of the rural population lives in chronic poverty? The concept of social exclusion has three principal components: a dynamic and relational perspective which requires the identification of who or what causes exclusion; an explicit recognition of multiple dimensions of deprivation; and a longitudinal perspective, recognizing that individuals and groups are dynamic intra- and intergenerationally. The Social Exclusion Knowledge Network of the World Health Organization Commission on Social Determinants of Health expanded the concept to include health status as a contributor to and an outcome of exclusion and to show that actors beyond the state or public sector can critically impact exclusionary processes. In the Bangladesh application, the relevance of the modified model was explored to find that while there are negative associations between social exclusion and health status, much stronger documentation is needed of the relationship. The modification of including multiple sectors, such as private enterprise and civil society, in addition to the state, as having potential to impact exclusionary processes is fundamental to the application of the social exclusion model in Bangladesh

Spousal Violence in Bangladesh: A Call for a Public-health Response

Spousal violence against women is a serious public-health issue. Although there is a growing body of literature on this subject, there are still many unanswered questions regarding the prevalence of this violence, the risk factors, the consequences, and how to address the issue. The purpose of this literature review is to organize and synthesize the empirical evidence on spousal violence against women in Bangladesh and to provide direction for both researchers and practitioners for future work in this area. The review suggests that spousal violence against women is high in Bangladesh. The list of correlates is long and inconclusive. Although there is evidence on adverse consequences of this violence on health of women and their children, more research is needed to explore the multifaceted consequences of violence for women, children, families, and communities. Action research is needed to develop and test preventive and curative interventions

Relationships of Exclusion and Cohesion with Health: The Case of Bangladesh

The concept of social exclusion, applied widely in the European Union, has in recent years been gaining use in Bangladesh, mostly by international development agencies. Does this discourse of deprivation, developed in the welfare states of northern Europe, have salience in its application to deprivation in countries like Bangladesh where, for example, 31% of the rural population lives in chronic poverty? The concept of social exclusion has three principal components: a dynamic and relational perspective which requires the identification of who or what causes exclusion; an explicit recognition of multiple dimensions of deprivation; and a longitudinal perspective, recognizing that individuals and groups are dynamic intra- and intergenerationally. The Social Exclusion Knowledge Network of the World Health Organization Commission on Social Determinants of Health expanded the concept to include health status as a contributor to and an outcome of exclusion and to show that actors beyond the state or public sector can critically impact exclusionary processes. In the Bangladesh application, the relevance of the modified model was explored to find that while there are negative associations between social exclusion and health status, much stronger documentation is needed of the relationship. The modification of including multiple sectors, such as private enterprise and civil society, in addition to the state, as having potential to impact exclusionary processes is fundamental to the application of the social exclusion model in Bangladesh

Spousal Violence in Bangladesh: A Call for a Public-health Response

Spousal violence against women is a serious public-health issue. Although there is a growing body of literature on this subject, there are still many unanswered questions regarding the prevalence of this violence, the risk factors, the consequences, and how to address the issue. The purpose of this literature review is to organize and synthesize the empirical evidence on spousal violence against women in Bangladesh and to provide direction for both researchers and practitioners for future work in this area. The review suggests that spousal violence against women is high in Bangladesh. The list of correlates is long and inconclusive. Although there is evidence on adverse consequences of this violence on health of women and their children, more research is needed to explore the multifaceted consequences of violence for women, children, families, and communities. Action research is needed to develop and test preventive and curative interventions

The Group-lending Model and Social Closure: Microcredit, Exclusion, and Health in Bangladesh

According to social exclusion theory, health risks are positively associated with involuntary social, economic, political and cultural exclusion from society. In this paper, a social exclusion framework has been used, and available literature on microcredit in Bangladesh has been reviewed to explore the available evidence on associations among microcredit, exclusion, and health outcomes. The paper addresses the question of whether participation in group-lending reduces health inequities through promoting social inclusion. The group-lending model of microcredit is a development intervention in which small-scale credit for income-generation activities is provided to groups of individuals who do not have material collateral. The paper outlines four pathways through which microcredit can affect health status: financing care in the event of health emergencies; financing health inputs such as improved nutrition; as a platform for health education; and by increasing social capital through group meetings and mutual support. For many participants, the group-lending model of microcredit can mitigate exclusionary processes and lead to improvements in health for some; for others, it can worsen exclusionary processes which contribute to health disadvantage

Can community health workers play a greater role in increasing access to medical abortion services? A qualitative study

Despite being legally available in India since 1971, barriers to safe and legal abortion remain, and unsafe and/or illegal abortion continues to be a problem. Community health workers have been involved in improving access to health information and care for maternal and child health in resource poor settings, but their role in facilitating accurate information about and access to safe abortion has been relatively unexplored. A qualitative study was conducted in Rajasthan, India to study acceptability, perspectives and preferences of women and community health workers, regarding the involvement of community health workers in medical abortion referrals.; In-depth interviews were conducted with 24 women seeking early medical abortion at legal abortion facilities or presenting at these facilities for a follow-up assessment after medical abortion. Ten community health workers who were trained to assess eligibility for early medical abortion and/or to assess whether women needed a follow-up visit after early medical abortion were also interviewed. The transcripts were coded using ATLAS-ti 7 (version 7.1.4) in the local language and reports were generated for all the codes, emerging themes were identified and the findings were analysed.; Community health workers (CHWs) were willing to play a role in assessing eligibility for medical abortion and in identifying women who are in need of follow-up care after early medical abortion, when provided with appropriate training, regular supplies and job aids. Women however had apprehensions about contacting CHWs in relation to abortions. Important barriers that prevented women from seeking information and assistance from community health workers were fear of breach of confidentiality and a perception that they would be pressurised to undergo sterilisation.; Our findings support a potential for greater role of CHWs in making safe abortion information and services accessible to women, while highlighting the need to address women's concerns about approaching CHWs in case of unwanted pregnancy. Further intervention research would be needed to shed light on the effectiveness of role of CHWs in facilitating access to safe abortion and to outline specific components in a programme setting.; Not applicable

Accuracy of assessment of eligibility for early medical abortion by community health workers in Ethiopia, India and South Africa

Objective To assess the accuracy of assessment of eligibility for early medical abortion by community health workers using a simple checklist toolkit. Design Diagnostic accuracy study. Setting Ethiopia, India and South Africa. METHODS: Two hundred seventeen women in Ethiopia, 258 in India and 236 in South Africa were enrolled into the study. A checklist toolkit to determine eligibility for early medical abortion was validated by comparing results of clinician and community health worker assessment of eligibility using the checklist toolkit with the reference standard exam. RESULTS: Accuracy was over 90% and the negative likelihood ratio <0.1 at all three sites when used by clinician assessors. Positive likelihood ratios were 4.3 in Ethiopia, 5.8 in India and 6.3 in South Africa. When used by community health workers the overall accuracy of the toolkit was 92% in Ethiopia, 80% in India and 77% in South Africa negative likelihood ratios were 0.08 in Ethiopia, 0.25 in India and 0.22 in South Africa and positive likelihood ratios were 5.9 in Ethiopia and 2.0 in India and South Africa. CONCLUSION: The checklist toolkit, as used by clinicians, was excellent at ruling out participants who were not eligible, and moderately effective at ruling in participants who were eligible for medical abortion. Results were promising when used by community health workers particularly in Ethiopia where they had more prior experience with use of diagnostic aids and longer professional training. The checklist toolkit assessments resulted in some participants being wrongly assessed as eligible for medical abortion which is an area of concern. Further research is needed to streamline the components of the tool, explore optimal duration and content of training for community health workers, and test feasibility and acceptability

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570