Community-based longitudinal data on factors linked to bacterial vaginosis (BV) during and after pregnancy in Bangladesh are limited. Using data from a rural randomized trial of vitamin A and β-carotene supplementation, we examined factors associated with Nugent-score–assessed BV. Self-collected vaginal swabs from 1,812 participants were obtained in early pregnancy, late pregnancy, and 3 months postpartum for Nugent scoring. We analyzed associations between participant factors and Nugent-BV (scores 7–10 vs. 0–6; 4–10 vs. 0–3) at each time point. Bivariate associations were tested using chi-square and t-tests, and multivariable log-binomial regression was used to estimate adjusted prevalence ratios with 95% confidence intervals. In early pregnancy, consistent soap use during bathing (vs. never/sometimes) was associated with a decreased risk of Nugent-BV 7–10 (adjusted prevalence ratio (aPR): 0.64, 95% CI: 0.43, 0.96). In late pregnancy, Hindu religion (vs. Muslim) (aPR: 2.68, 95% CI: 1.52, 4.72) and higher gestational age (aPR: 1.18, 95% CI: 1.04, 1.35) were associated with increased risk of Nugent-BV 7–10 and 4–10. Furthermore, maternal underweight (BMI < 18.5 kg/m² vs. ≥ 18.5) (aPR: 0.62, 95% CI: 0.44, 0.87) and having ≥1 antenatal care visit (vs. none) (aPR: 0.59, 95% CI: 0.38, 0.91) were associated with reduced risk of Nugent-BV 4–10. Among multiparous individuals, a longer pregnancy interval of ≥18 months (vs. < 18 months) was protective against Nugent-BV 7–10 (aPR: 0.34, 95% CI: 0.14, 0.81). At 3-months postpartum, vitamin A supplementation (vs. placebo) was associated with a decreased risk of Nugent-BV 7–10, consistent with prior trial findings. Our findings indicate that Nugent-BV during pregnancy and postpartum is linked to modifiable factors, including hygiene, nutrition, birth spacing, and healthcare access. Rigorous randomized trials are needed to evaluate their ability to reduce BV, promote long-term vaginal health, and lower the risk of adverse pregnancy outcomes.

Few research approaches have dominated the landscape of epidemiologic investigation as have intervention trial methods. Over the past four decades, numerous refinements have been made to the methods used to define the efficacy of public health and clinical strategies, from drugs to behavioral interventions. In contrast to observational methods, intervention studies or trials strive to demonstrate, to the extent possible, causal associations between the public health strategy and the health outcome under investigation. Community intervention trials aim to measure the feasibility, efficacy, or effectiveness of a putative public health strategy, beyond the confines of clinical facilities, in the free‐living populations where these strategies are likely to be implemented. The evidence generated by robust, rigorous, sometimes randomized, controlled community intervention trials often serves as the basis for the design and implementation of public health programs.

Background: The food environment is a driver of the double burden of malnutrition, influencing dietary intake by increasing or restricting access to foods. Objectives: The objective of this study was to assess the association between geospatial food environment indicators and the diet quality among postpartum women in rural Bangladesh. Methods: Participants were women of infants enrolled in a cluster-randomized controlled trial from 2018 to 2020. Food vendor availability was defined as the number of food vendors within a specific household radius, and proximity was defined as the distance to the nearest vendor. Dietary intake was measured using a 7-d food frequency questionnaire collected at 3 mo, 6 mo, and 12 mo postpartum. Our primary outcome was nonstarchy staple food variety scores (FVS). Secondary outcomes included dietary diversity scores and individual food group consumption. To assess the association between food environment indicators and diet quality indicators, we fit linear regression models for the FVS outcome, Poisson regression models for the dietary diversity outcome, and logistic regression models for individual food group outcomes. Results: A total of 5064 women were included in this analysis. Women reported consuming an average of 9.7 (standard deviation: 3.7) nonstarchy staple foods in the previous week. Women who lived in households with the highest market availability (≥7 markets within 1600 m) had an average of 0.84-unit (95% confidence interval: 0.53, 1.16) higher FVS compared with those in households with the lowest market availability (≤ 2 markets) (P < 0.001). Geospatial food environment indicators were not significantly associated with the odds of consuming less healthy food options. Conclusions: We found a positive relationship between market availability and diet quality for postpartum women in rural Bangladesh. However, more research is needed to understand which components of the food environment are associated with increased consumption of less healthy foods.

Few studies have examined the pandemic’s impact on both parents-to-be. Our study examined parents’-to-be pandemic-related stress, correlates of pandemic-related stress, and dyadic agreement on pandemic-related stress and its impact. Participants consisted of 74 parent-to-be dyads recruited from a larger text-messaging intervention of fathers-to-be with lower education from February 2020 to February 2022 before their partner was 25 weeks gestation from one mid-Atlantic U.S. city. Our baseline cross-sectional data assessed parents’ pandemic-related stress, perceived pandemic-related impact on infant interactions, help with infant care by caregivers, access to health care, concerns about finances, and participants’ background characteristics. We compared perceived pandemic-related stress and impact within dyads. Separate multivariate linear regressions explored factors associated with pandemic-related stress without and with adjustment for participants’ characteristics stratified by fathers- and mothers-to be. Our findings showed overall low levels of pandemic-related stress, with fathers-to-be within dyads reporting lower levels of pandemic-related stress than reported by mothers-to-be. We found differential factors were associated with greater pandemic-related stress for fathers- than mothers-to-be, except that for both parents greater pandemic-related stress was associated with greater concerns about being able to interact with their own infant and getting infant care help from the mothers’ parents. Whereas greater pandemic-related stress for mothers-to-be was associated with only concerns about getting infant care help, greater stress for fathers-to-be was associated with concerns about getting infant care help and accessing health care. Findings have implications for better understanding expectant parents’ differential response to stressful events that may be informed by gender role expectations during pregnancy and the postpartum period. Clinical Trial Registry and Registration number. Not applicable for the current data presented.

Escherichia coli (E. coli) is a commensal organism in humans and animals. It can serve as a reservoir for antibiotic resistance, thus providing an indicator of drug resistance patterns in a community. We investigated antibiotic resistance in E. coli isolated from nondiarrheal stool samples of 6-month-old infants (n = 110) from northwest Bangladesh. We conducted susceptibility testing using a disc diffusion assay against 20 antibiotics. Resistance was most pronounced for macrolides (98.2% resistant), whereas the most sensitive antibiotics were fosfomycin (100%), gentamicin (99.1%), meropenem (98.2%), mecillinam (97.3%), tigecycline (97.3%), and imipenem (87.3%). Excluding erythromycin, roughly 55% of isolates were multidrug-resistant. Our results likely reflect the burden of drug-resistant E. coli in the guts of infants in rural Bangladesh and the prevailing drug resistance patterns in this community.

BACKGROUND:Protein requirements established for healthy populations may be insufficient to support healthy growth in infants consuming largely cereal-based complementary foods and frequently exposed to enteric pathogens. OBJECTIVES:This study aimed to assess independent and combined effects of protein supplementation and antibiotic treatment on linear growth of infants aged 6-12 mo. METHODS:We conducted a 2 × 4 factorial cluster-randomized trial in northwestern Bangladesh, allocating 566 clusters to masked azithromycin (10 mg/kg × 3 d) or placebo at 6 and 9 mo of age and unmasked delivery of an egg white protein-rich blended food supplement (250 kcal; 10 g added protein), a rice-based isocaloric supplement, egg, or nutrition education from 6 to 12 mo. We measured length at 6 and 12 mo. For this cluster-level intention-to-treat analysis of the 2 × 2 antibiotic and protein interventions, we used multiple linear or log-binomial regression with generalized estimating equations to assess changes in length-for-age z (LAZ) score and stunting (LAZ < -2), respectively. RESULTS:We enrolled 2055 infants (283 clusters) and included 1821 infants (281 clusters) with complete anthropometry data at 6 and 12 mo in our analysis. There were no significant interactions between the protein and antibiotic interventions for any outcomes. Independently, protein supplement did not improve LAZ (β: 0.05; 95% CI: 0.00, 0.11; P = 0.07) or reduce stunting (prevalence ratio: 1.12; 95% CI: 0.85, 1.49; P = 0.41) compared with the isocaloric supplement. The antibiotic intervention had no effect on LAZ (β: -0.05; 95% CI: -0.11, 0.01; P = 0.09) or stunting (prevalence ratio: 0.99; 95% CI: 0.75, 1.31; P = 0.96), relative to the placebo. CONCLUSIONS:Supplementation to increase intakes of high-quality protein, provided with or without presumptive treatment for enteric pathogens, did not improve linear growth from 6 to 12 mo of age. This trial was registered at clinicaltrials.gov as NCT03683667.

Background: Evidence-based decision-making is essential to improve public health benefits and resources, especially in low-and middle-income countries (LMICs), but the mechanisms of its implementation remain less straightforward. The availabilityof high-quality, reliable, and sufficient data in LMICs can be challenging due to issues such as a lack of human resource capacityand weak digital infrastructure, among others. Health information systems (HISs) have been critical for aggregating and integratinghealth-related data from different sources to support evidence-based decision-making. Nutrition information systems (NISs),which are nutrition-focused HISs, collect and report on nutrition-related indicators to improve issues related to malnutrition andfood security-and can assist in improving populations'nutritional statuses and the integration of nutrition programming intoroutine health services. Data visualization tools (DVTs) such as dashboards have been recommended to support evidence-baseddecision-making, leveraging data from HISs or NISs. The use of such DVTs to support decision-making has largely been unexploredwithin LMIC contexts. In Bangladesh, the Mukto dashboard was developed to display and visualize nutrition-related performanceindicators at the national and subnational levels. However, despite this effort, the current use of nutrition data to guide prioritiesand decisions remains relatively nascent and underused. Objective: The goal of this study is to better understand how Bangladesh's NIS, including the Mukto dashboard, has been usedand areas for improvement to facilitate its use for evidence-based decision-making toward ameliorating nutrition-related servicedelivery and the health status of communities in Bangladesh. Methods: Primary data collection was conducted through qualitative semistructured interviews with key policy-level stakeholders(n=24). Key informants were identified through purposive sampling and were asked questions about the experiences and challengeswith the NIS and related nutrition dashboards. Results: Main themes such as trust, data usability, personal power, and data use for decision-making emerged from the data.Trust in both data collection and quality was lacking among many stakeholders. Poor data usability stemmed from unstandardizedindicators, irregular data collection, and differences between rural and urban data. Insufficient personal power and staff trainingcoupled with infrastructural challenges can negatively affect data at the input stage. While stakeholders understood and expressed he importance of evidence-based decision-making, ultimately, they noted that the data were not being used to their maximumpotential. Conclusions: Leveraging DVTs can improve the use of data for evidence-based decision-making, but decision makers musttrust that the data are believable, credible, timely, and responsive. The results support the significance of a tailored data ecosystem,which has not reached its full potential in Bangladesh. Recommendations to reach this potential include ensuring a clear intendeduser base and accountable stakeholders are present. Systems should also have the capacity to ensure data credibility and supportongoing personal power requirements

Objective We investigated whether a zip code's location or demographics are most predictive of changes in daily mobility throughout the course of the COVID-19 pandemic.Design We used a population-level study to examine the predictability of daily mobility during the COVID-19 pandemic using a two-stage regression approach, where generalised additive models (GAM) predicted mobility trends over time at a large spatial level, then the residuals were used to determine which factors (location, zip code-level features or number of non-pharmaceutical interventions (NPIs) in place) best predict the difference between a zip code's measured mobility and the average trend on a given date.Setting We analyse zip code-level mobile phone records from 26 metropolitan areas in the USA on 15 March-31 September 2020, relative to October 2020.Results While relative mobility had a general trend, a zip code's city-level location significantly helped to predict its daily mobility patterns. This effect was time-dependent, with a city's deviation from general mobility trends differing in both direction and magnitude throughout the course of 2020. The characteristics of a zip code further increased predictive power, with the densest zip codes closest to a city centre tended to have the largest decrease in mobility. However, the effect on mobility change varied by city and became less important over the course of the pandemic.Conclusions The location and characteristics of a zip code are important for determining changes in daily mobility patterns throughout the course of the COVID-19 pandemic. These results can determine the efficacy of NPI implementation on multiple spatial scales and inform policy makers on whether certain NPIs should be implemented or lifted during the ongoing COVID-19 pandemic and when preparing for future public health emergencies.

Background: Animal source foods are rich in multiple nutrients. Regular egg consumption may improve infant growth in low- and middleincome countries. Objectives: To assess the impact of daily egg consumption on linear growth among 6 - 12-mo olds in rural Bangladesh. Methods: We conducted a 2 x 4 factorial cluster-randomized controlled trial allocating clusters ( n = 566) to treatment for enteric pathogens or placebo and a daily egg, protein supplement, isocaloric supplement, or control. All arms received nutrition education. Here, we compare the effect of the egg intervention versus control on linear growth, a prespeci fi ed aim of the trial. Infants were enrolled at 3 mo. We measured length and weight at 6 and 12 mo and visited households weekly to distribute eggs and monitor compliance. We used linear regression models to compare 12-mo mean length, weight, and z-scores for length-for-age (LAZ), weight-for-length, and weight-for-age (WAZ), and logbinomial or robust Poisson regression to compare prevalence of stunting, wasting, and underweight between arms. We used generalized estimating equations to account for clustering and adjusted models for baseline measures of outcomes. Results: We enrolled 3051 infants ( n = 283 clusters) across arms, with complete 6 and 12 mo anthropometry data from 1228 infants ( n = 142 clusters) in the egg arm and 1109 infants ( n = 141 clusters) in the control. At baseline, 18.5%, 6.0%, and 16.4% were stunted, wasted, and underweight, respectively. The intervention did not have a statistically signi fi cant effect on mean LAZ ( ss : 0.05, 95% con fi dence interval [CI]:- 0.01, 0.10) or stunting prevalence ( ss : 0.98, 95% CI: 0.89, 1.13) at 12 mo. Mean weight ( ss : 0.07 kg, 95% CI: 0.02, 0.11) and WAZ ( ss : 0.06, 95% CI: 0.02, 0.11) were signi fi cantly higher in the egg compared with control arms. Conclusions: Provision of a daily egg for 6 mo to infants in rural Bangladesh improved ponderal but not linear growth. Trial registration number: NCT03683667, https://clinicaltrials.gov/ct2/show/NCT03683667.

Objective: Online communities promote social connection and can be used for formal peer support and crisis intervention. Although some communities have programs to support their members' mental health, few programs have been formally evaluated. The authors present findings from a mixed-methods evaluation of the Stack Up Overwatch Program (StOP), a digital peersupport intervention delivered in an online gaming community. Methods: Data were collected from members of the Stack Up Discord server between June and October 2020 and included chat messages, survey responses, encounter forms (documenting information from private interactions between users and peer supporters), and interviews with peer support team members. The authors analyzed data on demographic characteristics, mental health and crises, use of and experiences with StOP, and chat posts. Thematic analysis and descriptive statistics were combined in a joint display table, with mixed-methods findings explained in narrative form. Results: The findings show that StOP provides users in crisis with a source of mental health support when other options have been exhausted and that military and veteran users valued the connections and friendships they formed while using it. Participants reported that StOP met needs for support and connection when formal services were inaccessible or did not meet their needs, and volunteer peer supporters detailed how StOP's design facilitates use of the intervention. Volunteering offered members of the peer support team a "family feeling" facilitated by the unique chat room structure. Conclusions: Community-based crisis prevention programs administered through chat rooms may provide valuable support to both users and peer support providers.

BACKGROUND:Community-based health information systems (CBISs) can provide critical insights into how community health systems function, and digitized CBISs may improve the quality of community-level data and facilitate integration and use of CBISs within the broader health system. This scoping review aims to understand how CBISs have been implemented, integrated, and used to support community health outcomes in low- and middle-income countries (LMICs). METHODS:Both peer-reviewed and gray literature were included; relevant articles were identified using key terms and controlled vocabulary related to community/primary health care, health information systems, digital health, and LMICs. A total of 11,611 total records were identified from 5 databases and the gray literature. After deduplication, 6,985 peer-reviewed/gray literature were screened, and 95 articles/reports were included, reporting on 105 CBIS implementations across 38 countries. RESULTS:Findings show that 55% of CBISs included some level of digitization, with just 28% being fully digitized (for data collection and reporting). Data flow from the community level into the health system varied, with digitized CBISs more likely to reach national-level integration. National-level integration was primarily seen among vertical CBISs. Data quality challenges were present in both paper-based and digitized CBISs, exacerbated by fragmentation of the community health landscape with often parallel reporting systems. CBIS data use was constrained to mostly vertical and digitized (partially or fully) CBISs at national/subnational levels. CONCLUSION:Digitization can play a pivotal role in strengthening CBIS use, but findings demonstrate that CBISs are only as effective as the community health systems they are embedded within. Community-level data are often not being integrated into national/subnational health information systems, undermining the ability to understand what the community health needs are. Furthermore, stronger investments within community health systems need to be in place broadly to reduce fragmentation and provide stronger infrastructural and systemic support to the community health workforce.

Background The nutrition transition underway in South Asia is likely mediated by changes to the food environment. Yet, few studies have been conducted in rural areas of South Asia to describe how the food environment has changed. Objective This analysis assessed changes in household availability of and proximity to markets, grocery shops, and tea shops over a 16-year time period in Gaibandha, Bangladesh. Methods We analyzed household demographic and geospatial data collected at 3 time points from 2004 to 2020 in a contiguous rural area (435 km2). We defined availability as number of food vendors within 400- and 1600-m radius of households and proximity as distance to nearest vendor. We used linear and Poisson models to estimate associations between household socioeconomic status (SES) and food vendor availability and proximity. We used multi-level models to conduct similar analyses for community-level urbanicity. Results From 2004 to 2020, the numbers of markets, grocery shops and tea shops increased by 21%, 66% and 270%, respectively. Food vendor proximity did not change by household SES, but less urban households witnessed larger increases in proximity to markets (p for interaction<0.001) and tea shops (p for interaction<0.001) over time. Grocery shop and tea shop availability was initially higher and increased more over time for households in higher urbanicity areas (p for interaction<0.001). Conclusion Over a 16-year period, this rural area of Bangladesh became more urbanized, increasing the availability of and proximity to markets, grocery shops, and tea shops. Further research is needed to see how these changes impact rural residents’ intake and nutritional status.

The COVID-19 pandemic has forced a reflection on the origins of supplies in African healthcare market and underscored the need for an increase in local manufacturing of medical supplies. Several African countries' health markets have been heavily reliant on imports. First, this article demonstrates how the African healthcare market has had a high import dependency and the role that the African Continental Free Trade Area (AfCFTA) could play to reverse this. It is estimated that African countries import between 80% and 94% of medical supplies, 75% of testing kits, between 70% and 95% of pharmaceuticals, and 99% of vaccines. Second, during the COVID-19 pandemic, countries imposed export restrictions which impacted the flow of medical supplies to African countries. This finding highlighted the limited production capabilities on the African continent and reiterated the need to strengthen continental value chains and local manufacturing capacity to establish the continent's New Public Health Order. Third, there was the emergence of local innovations seeking to minimize the impact of these supply chain disruptions. Using case studies on the local production of COVID-19 testing kits and personal protective equipment, the article highlights progress made toward health market reform. It calls attention to the implementation of the AfCFTA to strengthen the supply, manufacturing, and trade of medical resources. Fourth, this article highlights countries that have African-made pharmaceuticals and vaccinations and the importance of regional hubs to expand these products in African healthcare markets. It concludes by discussing investments made to expand local manufacturing of health products.

Background: The rise of virtual healthcare underscores the transformative influence of digital technologies in reshaping the healthcare landscape. As technology advances and the global demand for accessible and convenient healthcare services escalates, the virtual healthcare sector is gaining unprecedented momentum. Saudi Arabia, with its ambitious Vision 2030 initiative, is actively embracing digital innovation in the healthcare sector. Methods: In this narrative review, we discussed the key drivers and prospects of virtual healthcare in Saudi Arabia, highlighting its potential to enhance healthcare accessibility, quality, and patient outcomes. We also summarized the role of the COVID-19 pandemic in the digital transformation of healthcare in the country. Healthcare services provided by Seha Virtual Hospital in Saudi Arabia, the world's largest and Middle East's first virtual hospital, were also described. Finally, we proposed a roadmap for the future development of virtual health in the country. Results and conclusions: The integration of virtual healthcare into the existing healthcare system can enhance patient experiences, improve outcomes, and contribute to the overall well-being of the population. However, careful planning, collaboration, and investment are essential to overcome the challenges and ensure the successful implementation and sustainability of virtual healthcare in the country.

Background Early and exclusive breastfeeding may reduce neonatal and post-neonatal mortality in low-resource settings. However, prelacteal feeding (PLF), the practice of giving food or liquid before breastfeeding is established, is still a barrier to optimal breastfeeding practices in many South Asian countries. We used a prospective cohort study to assess the association between feeding non-breastmilk food or liquid in the first three days of life and infant size at 3–5 months of age. Methods The analysis used data from 3,332 mother-infant pairs enrolled in a randomized controlled trial in northwestern rural Bangladesh conducted from 2018 to 2019. Trained interviewers visited women in their households during pregnancy to collect sociodemographic data. Project staff were notified of a birth by telephone and interviewers visited the home within approximately three days and three months post-partum. At each visit, interviewers collected data on breastfeeding practices and anthropometric measures. Infant length and weight measurements were used to produce length-for-age (LAZ), weight-for-age (WAZ), and weight-for-length (WLZ) Z-scores. We used multiple linear regression to assess the association between anthropometric indices and PLF practices, controlling for household wealth, maternal age, weight, education, occupation, and infant age, sex, and neonatal sizes. Results The prevalence of PLF was 23%. Compared to infants who did not receive PLF, infants who received PLF may have a higher LAZ (Mean difference (MD) = 0.02 [95% CI: -0.04, 0.08]) score, a lower WLZ (MD=-0.06 [95% CI: -0.15, 0.03]) score, and a lower WAZ (MD=-0.02 [95% CI: -0.08, 0.05]) score at 3–5 months of age, but none of the differences were statistically significant. In the adjusted model, female sex, larger size during the neonatal period, higher maternal education, and wealthier households were associated with larger infant size. Conclusion PLF was a common practice in this setting. Although no association between PLF and infant growth was identified, we cannot ignore the potential harm posed by PLF. Future studies could assess infant size at an earlier time point, such as 1-month postpartum, or use longitudinal data to assess more subtle differences in growth trajectories with PLF. Trial registration ClinicalTrials.gov: NCT03683667 and NCT02909179.

BackgroundEvidence-based decision-making is essential to improve public health benefits and resources, especially in low- and middle-income countries (LMICs), but the mechanisms of its implementation remain less straightforward. The availability of high-quality, reliable, and sufficient data in LMICs can be challenging due to issues such as a lack of human resource capacity and weak digital infrastructure, among others. Health information systems (HISs) have been critical for aggregating and integrating health-related data from different sources to support evidence-based decision-making. Nutrition information systems (NISs), which are nutrition-focused HISs, collect and report on nutrition-related indicators to improve issues related to malnutrition and food security—and can assist in improving populations’ nutritional statuses and the integration of nutrition programming into routine health services. Data visualization tools (DVTs) such as dashboards have been recommended to support evidence-based decision-making, leveraging data from HISs or NISs. The use of such DVTs to support decision-making has largely been unexplored within LMIC contexts. In Bangladesh, the Mukto dashboard was developed to display and visualize nutrition-related performance indicators at the national and subnational levels. However, despite this effort, the current use of nutrition data to guide priorities and decisions remains relatively nascent and underused. ObjectiveThe goal of this study is to better understand how Bangladesh’s NIS, including the Mukto dashboard, has been used and areas for improvement to facilitate its use for evidence-based decision-making toward ameliorating nutrition-related service delivery and the health status of communities in Bangladesh. MethodsPrimary data collection was conducted through qualitative semistructured interviews with key policy-level stakeholders (n=24). Key informants were identified through purposive sampling and were asked questions about the experiences and challenges with the NIS and related nutrition dashboards. ResultsMain themes such as trust, data usability, personal power, and data use for decision-making emerged from the data. Trust in both data collection and quality was lacking among many stakeholders. Poor data usability stemmed from unstandardized indicators, irregular data collection, and differences between rural and urban data. Insufficient personal power and staff training coupled with infrastructural challenges can negatively affect data at the input stage. While stakeholders understood and expressed the importance of evidence-based decision-making, ultimately, they noted that the data were not being used to their maximum potential. ConclusionsLeveraging DVTs can improve the use of data for evidence-based decision-making, but decision makers must trust that the data are believable, credible, timely, and responsive. The results support the significance of a tailored data ecosystem, which has not reached its full potential in Bangladesh. Recommendations to reach this potential include ensuring a clear intended user base and accountable stakeholders are present. Systems should also have the capacity to ensure data credibility and support ongoing personal power requirements.