Policy priorities for strengthening smokeless tobacco control in Bangladesh:A mixed-methods analysis

Introduction Smokeless tobacco (ST) remains poorly regulated in Bangladesh. This study describes the prevalence and trends of ST use in Bangladesh, presents ST-related disease burden, identifies relevant policy gaps, and highlights key implications for future policy and practice for effective ST control in Bangladesh. Methods We analyzed secondary data from the two rounds (2009 and 2017) of The Global Adult Tobacco Survey, estimated ST-related disease burden, and conducted a review to assess differences in combustible tobacco and ST policies. In addition, we gathered views in a workshop with key stakeholders in the country on gaps in existing tobacco control policies for ST control in Bangladesh and identified policy priorities using an online survey. Results Smokeless tobacco use, constituting more than half of all tobacco use in Bangladesh, declined from 27.2% (25.9 million) in 2009 to 20.6% (22 million) in 2017. However, in 2017, at least 16947 lives and 403460 Disability-Adjusted Life Years (DALYs) were lost across Bangladesh due to ST use compared to 12511 deaths and 324020 DALYs lost in 2010. Policy priorities identified for ST control have included: introducing specific taxes and increasing the present ad valorem tax level, increasing the health development surcharge, designing and implementing a tax tracking and tracing system, standardizing ST packaging, integrating ST cessation within existing health systems, comprehensive media campaigns, and licensing of ST manufactures. Conclusions Our analysis shows that compared to combustible tobacco, there remain gaps in implementing and compliance with ST control policies in Bangladesh. Thus, contrary to the decline in ST use and the usual time lag between tobacco exposure and the development of cancers, the ST-related disease burden is still on the rise in Bangladesh. Strengthening ST control at this stage can accelerate this decline and reduce ST related morbidity and mortality

“Everything the hujur tells is very educative but if I cannot apply those in my own life then there is no meaning”: a mixed-methods process evaluation of a smoke-free homes intervention in Bangladesh

Background Second-hand smoke exposure from tobacco significantly contributes to morbidity and mortality worldwide. A cluster RCT in Bangladesh compared a community-based smoke-free home (SFH) intervention delivered in mosques, with or without indoor air quality (IAQ) feedback to households to no intervention. Neither was effective nor cost-effective compared to no intervention using an objective measure of second-hand smoke. This paper presents the process evaluation embedded within the trial and seeks to understand this. Methods A mixed method process evaluation comprising interviews with 30 household leads and six imams (prayer leader in mosque), brief questionnaire completed by 900 household leads (75% response), fidelity assessment of intervention delivery in six (20%) mosques and research team records. Data were triangulated using meta-themes informed by three process evaluation functions: implementation, mechanisms of impact and context. Results IMPLEMENTATION: Frequency of SFH intervention delivery was judged moderate to good. However there were mixed levels of intervention fidelity and poor reach. Linked Ayahs (verses of the Qur’an) with health messages targeting SHS attitudes were most often fully implemented and had greatest reach (along with those targeting social norms). Frequency and reach of the IAQ feedback were good. MECHANISMS OF IMPACT: Both interventions had good acceptability. However, views on usefulness of the interventions in creating a SFH were mixed. Individual drivers to behaviour change were new SFH knowledge with corresponding positive attitudes, social norms and intentions. Individual barriers were a lack of self-efficacy and plans. CONTEXT: Social context drivers to SFH intervention implementation in mosques were in place and important. No context barriers to implementation were reported. Social context drivers to SHS behaviour change were children’s requests. Barriers were women’s reluctance to ask men to smoke outside alongside general reluctance to request this of visitors. (Not) having somewhere to smoke outside was a physical context (barrier) and driver. Conclusions Despite detailed development and adaption work with relevant stakeholders, the SFH intervention and IAQ feedback became educational interventions that were motivational but insufficient to overcome significant context barriers to reduce objectively measured SHS exposure in the home. Future interventions could usefully incorporate practical support for SFH behaviour change. Moreover, embedding these into community wide strategies that include practical cessation support and enforcement of SFH legislation is needed. Trial registration Current Controlled Trials ISRCTN4997545

Situational Analysis of Forensic Mental Health in Bangladesh

Abstract Forensic Mental Health in Bangladesh is an unattended domain of mental health services. With about 17% of the population suffering from mental disorders per year and more than 80 thousand prisoners in the country, there have not been any studies to look into forensic mental health situations. This research has given an overview of the health and legal systems through qualitative research focusing on a desk review and key informant interviews. Findings show that though there are guidelines in the law and regulatory codes in the judicial systems, implementing those guidelines is not seen in many cases. There are several areas in the health system in terms of capacity, service and resources which needs to be addressed by the government for supporting the healthcare providers, lawyers, judges and mentally ill or disabled people. Our study also portrayed the current referral mechanisms connecting both legal and health systems while addressing different cases of forensic mental health. Finally, discussing the implications of the findings, we presented recommendations from our study and other literature.</jats:p

Prevalence of Eye Problems among Young Infants of Rohingya Refugee Camps: Findings from a Cross-Sectional Survey

Early detection of pediatric eye problems can prevent future vision loss. This study was to estimate the prevalence of common eye problems among infants born in a resource-constrained emergency setting with a broader aim to prevent future vision loss or blindness among them through early detection and referral. We conducted a cross-sectional survey among 670 infants (0–59 days old) born in Rohingya refugee camps in Bangladesh between March and June of 2019. The most common eye problem found was watering from the eye and accumulation of discharge by which 14.8% of the children were suffering (95% CI: 12.2–17.7). More than 5% of the infants had visual inattention (95% CI: 3.5–7.0), and 4% had redness in their eyes (95% CI: 2.7–5.8). Only 1.9% of infants (95% CI: 1–3.3) had whitish or brown eyeballs, and 1.8% of children might have whitish pupillary reflex (95% CI: 0.9–3.1). None of the eye problems was associated with the gender of the infants. The prevalent eye problems demand eye care set up for the screening of eye problems in the camps with proper referral and availability of referral centres with higher service in the districts.</jats:p

How do patient feedback systems work in low- and middle-income countries? Insights from a realist evaluation in Bangladesh.

Abstract Background Well-functioning patient feedback systems can contribute to improved quality of healthcare and ultimately make health systems more accountable. We used realist evaluation to understand the functioning of patient feedback systems at frontline health facilities in Bangladesh. Methods We collected and analysed data in two stages using: document review; secondary analysis of data from publicly-available web-portals; in-depth interviews with patients, health workers and managers; non-participant observations of feedback environments; and stakeholder workshops. Stage 1 focused on identifying and articulating the initial program theory of patient feedback systems. In Stage 2, we iteratively tested and refined this initial theory, through analysing data and grounding emerging findings within substantive theories and empirical literature, to arrive at a refined program theory. Results Multiple patient feedback systems operate in Bangladesh, essentially comprising stages of collection, analysis and actions on feedback. Key contextual enablers include political commitment to accountability, whereas key constraints include limited patient awareness of feedback channels, lack of guidelines and documented processes, local political dynamics and priorities, institutional hierarchies and accountability relationships. Findings highlight that relational trust may be important for many people to exercise citizenship and providing feedback, and that appropriate policy and regulatory frameworks with clear lines of accountability are critical for ensuring effective patient feedback management within frontline healthcare facilities. Conclusion Tolib Information, Mirzoev*, Sumit Kanea, Bassey Ebenso1,b</jats:p

How do patient feedback systems work in low-income and middle-income countries? Insights from a realist evaluation in Bangladesh

BackgroundWell-functioning patient feedback systems can contribute to improved quality of healthcare and systems accountability. We used realist evaluation to examine patient feedback systems at health facilities in Bangladesh, informed by theories of citizenship and principal–agent relationships.MethodsWe collected and analysed data in two stages, using: document review; secondary analysis of data from publicly available web-portals; in-depth interviews with patients, health workers and managers; non-participant observations of feedback environments; and stakeholder workshops. Stage 1 focused on identifying and articulating the initial programme theory (PT) of patient feedback systems. In stage 2, we iteratively tested and refined this initial theory, through analysing data and grounding emerging findings within substantive theories and empirical literature, to arrive at a refined PT.ResultsMultiple patient feedback systems operate in Bangladesh, essentially comprising stages of collection, analysis and actions on feedback. Key contextual enablers include political commitment to accountability, whereas key constraints include limited patient awareness of feedback channels, lack of guidelines and documented processes, local political dynamics and priorities, institutional hierarchies and accountability relationships. Findings highlight that relational trust may be important for many people to exercise citizenship and providing feedback, and that appropriate policy and regulatory frameworks with clear lines of accountability are critical for ensuring effective patient feedback management within frontline healthcare facilities.ConclusionTheories of citizenship and principal–agent relationships can help understand how feedback systems work through spotlighting the citizenship identity and agency, shared or competing interests, and information asymmetries. We extend the understanding of these theories by highlighting how patients, health workers and managers act as both principals and agents, and how information asymmetry and possible agency loss can be addressed. We highlight the importance of awareness raising and non-threatening environment to provide feedback, adequate support to staff to document and analyse feedback and timely actions on the information.</jats:sec

Prevalence of Eye Problems among Young Infants of Rohingya Refugee Camps: Findings from a Cross-Sectional Survey

Early detection of pediatric eye problems can prevent future vision loss. This study was to estimate the prevalence of common eye problems among infants born in a resource-constrained emergency setting with a broader aim to prevent future vision loss or blindness among them through early detection and referral. We conducted a cross-sectional survey among 670 infants (0&ndash;59 days old) born in Rohingya refugee camps in Bangladesh between March and June of 2019. The most common eye problem found was watering from the eye and accumulation of discharge by which 14.8% of the children were suffering (95% CI: 12.2&ndash;17.7). More than 5% of the infants had visual inattention (95% CI: 3.5&ndash;7.0), and 4% had redness in their eyes (95% CI: 2.7&ndash;5.8). Only 1.9% of infants (95% CI: 1&ndash;3.3) had whitish or brown eyeballs, and 1.8% of children might have whitish pupillary reflex (95% CI: 0.9&ndash;3.1). None of the eye problems was associated with the gender of the infants. The prevalent eye problems demand eye care set up for the screening of eye problems in the camps with proper referral and availability of referral centres with higher service in the districts