Background Midwifery is a relatively new profession in Bangladesh, formally established in 2013. While emerging research has begun to document the advancements and the challenges midwives face, there remains limited understanding of the experiences of those practising in rural settings in rural Bangladesh. Aim This study aimed to explore the lived experiences of midwives working in rural Bangladesh. Method A qualitative descriptive study was used. Seventeen midwives with at least six months of rural experience participated in semi-structured interviews conducted Zoom or WhatsApp with an interpreter present when required to facilitate communication. Data was analysed inductively using Braun and Clarke’s six phase process of thematic analysis, supported by Atlas.ti software. Trustworthiness was established through member checking, reflexivity, and use of Lincoln and Guba’s criteria for rigour. Results Five overarching themes were identified including Community Perceptions and Trust in Midwifery, Climate and Environmental Pressures on Rural Midwifery Care, Infrastructure, System and Resource Constraints, Professional Identity, Motivation and Scope of Practice and Supports Needed to Strengthen the Rural Midwifery Workforce. Midwives demonstrated resilience and professional pride despite facing resource shortages, limited recognition, and cultural and structural barriers. Discussion The importance of community awareness, continued education, government investment, and system level support to enhance midwifery care in rural areas were highlighted in this study. Addressing these needs could improve both workforce strength and sustainability and health outcomes. Conclusion Midwives in rural Bangladesh demonstrate strong commitment to woman-centred care despite systemic barriers. Strengthening support, education, and policy investment is essential to sustain this vital workforce.

Polio is targeted for global eradication by 2029. Immunization campaigns face significant challenges in humanitarian emergencies due to instability, population displacement, and health infrastructure collapse. The two primary vaccines used, Inactivated Polio Vaccine (IPV) and Oral Polio Vaccine (OPV), have distinct delivery requirements. This scoping review maps key implementation barriers for each delivery mechanism in disaster settings and assesses reported coverage outcomes to inform vaccine selection in emergencies. Following the PRISMA extension for Scoping Reviews (PRISMA-ScR), we searched PubMed, EMBASE, Web of Science, and Cochrane Library (CENTRAL), supplemented by a targeted grey-literature search. Studies were included if they focused on OPV and/or IPV campaigns in humanitarian crises, provided data on coverage or logistics, and were published in English within the last 20 years. Included studies were appraised using JBI Critical Appraisal Tools. The search identified 1604 studies, of which 24 met inclusion criteria. Key IPV implementation barriers were higher operational costs, the requirement for skilled health workers, reliance on fixed-post delivery, and complex cold chain requirements. Prominent OPV barriers included bans on campaigns by armed groups, misinformation leading to vaccine refusal, and restricted access to populations due to insecurity. Three studies reported high IPV coverage (80

Introduction Accurate and timely reporting of deaths and causes of death is crucial evidence for health policy and planning. However, in practice, there is a low level of completeness of the death registration process in low-income settings such as Bangladesh and more so among females than males. An in-depth exploration of the barriers to low registration among females is needed in Bangladesh, a country bound by unequal gender norms and practices.Methods The study relied on a qualitative approach and consisted of 33 key informant interviews with field-level implementers, policymakers and 13 focus group discussions among beneficiaries in eight subdistricts with low and high sex disparity.Results The findings show that poor awareness about the registration process, inheritance-driven need and missing accurate supporting information hinder and delay death registration. Deep-rooted male-dominated inheritance practices contribute to lower registration of female deaths. This is further compounded by complex registration procedures, including the requirement for a pre-existing birth certificate and difficulties in obtaining or verifying supporting documents. In addition, awareness activities often emphasise inheritance-related benefits, unintentionally reinforcing the perception that death registration is more important for men than for women.Conclusions Policies need to be strengthened and adapted to improve death registration completeness by addressing the barriers. More gender-sensitive, stronger and context-appropriate policy reforms, along with better implementation and oversight, are needed to improve the completeness of female death registration.

The analysis of health system resilience has advanced considerably, yet a wide range of conceptual frameworks continues to be employed. The ClimHB conceptual framework, developed in 2019, combines two influential models: the Levesque model of healthcare access and the DFID’s resilience framework. It is designed to examine health system resilience in response to climate-induced events. What sets the ClimHB framework apart is its emphasis on the population as an active participant on the demand side, complementing the supply side represented by healthcare services and providers. The framework is defined by three key dimensions – exposure, sensitivity, adaptive capacity. Its dual focus on demand and supply highlights their dynamic interaction in shaping health system resilience. A workshop and the World Café method refined the ClimHB framework by incorporating empirical data from Haiti and Bangladesh with findings from a literature review. The updated framework offers a dynamic perspective on resilience, focusing on the interconnected nature of its elements to guide decision-making across all levels of health systems. Key enhancements include greater emphasis on contextual factors, highlighting the influence of socio-economic and ecological conditions. It also features strengthened connections between resilience outcomes and contextual variables, improving the understanding of how context affects results. Governance and professional awareness were highlighted as critical elements for improving health system responses, and feedback loops were integrated in the supply side to enhance adaptability and decision-making processes. Empirical studies have demonstrated the ClimHB framework’s adaptability and capacity to create synergy between theoretical concepts and practical implementation. However, challenges remain in operationalising the framework for policymakers. These challenges highlight the need for further validation of the framework, the development of standardised measures, and a deeper understanding of resilience dynamics. Future research should prioritise the framework’s implications for structural management, workforce training, and resource allocation, addressing critical gaps in resilience research.

The ‘know–do’ gap is the failure to act on evidence and knowledge from research to improve health outcomes. Considering the know–do gap as a simple linear dichotomous concept is a fallacy, because it instead represents a continuum. Five recommendations focused on this continuum can address global health challenges.

Bangladesh completed a primary series of COVID-19 vaccinations for about 86 individuals per 100 population as of 5 July 2023. However, ensuring higher coverage in vulnerable areas is challenging. We report on the COVID-19 vaccine uptake and associated factors among adults in two vulnerable areas in Bangladesh. We conducted a cross-sectional study between August and September 2022 in Duaripara, a slum in northeast Dhaka (in-migration site), and Tala, a disaster-prone sub-district in southwest Satkhira (out-migration site). We surveyed 1,239 adults in Duaripara and 1,263 adults in Tala from 625 and 596 randomly selected households, respectively. We reported coverage and examined associations between the uptake and demographic and socioeconomic characteristics using multilevel mixed-effects generalized linear regression models. We checked for spatial autocorrelation to assess geographical patterns in vaccine distribution. First- and second-dose coverage was about 91% and 80.4% in Duaripara and 96.6% and 92.2% in Tala, respectively. Individuals above 40 were more likely to be vaccinated (IRR: 1.12, p-value = 0.04 for Duaripara, and IRR: 1.14, p-value <0.01 for Tala). Professions requiring more outdoor interactions had a higher likelihood of receiving the vaccine. In Tala, television access (IRR: 2.09, p-value <0.01) and micro-credit membership (IRR: 1.50, p-value = 0.05) were positively associated with receiving a booster dose and negatively associated with smart-phone access (IRR: 0.58, p-value = 0.03). Moreover, temporarily migrated respondents were more likely to be unvaccinated (IRR: 0.87, p-value = 0.04). Income was not associated, indicating equitable distribution. Moreover, no geographical clustering was detected. The credit for high COVID-19 vaccine coverage in Bangladesh can be attributed to the country’s longstanding success in implementing immunization programs, which relied on community mobilization and effective health education to generate demand. However, to ensure comprehensive coverage in vulnerable areas, targeted interventions can help increase uptake by addressing specific sociodemographic differences.

Background:Over-the-counter antibiotic sales in community-pharmacies significantly drive antimicrobial resistance (AMR) in low- and middle-income countries (LMICs) due to inappropriate use and early treatment discontinuation. In Bangladesh, community pharmacies, which dispense 56.6 % of antibiotics without prescriptions, serve as the first health-seeking touchpoint, yet conventional stewardship strategies often overlook these informal providers, heightening AMR risks. This study examines drug-sellers' understanding and practices towards antibiotic dispensing and compares their symptomatic-treatment practices with Bangladesh's Standard Treatment Guidelines (STGs) to understand the extent of antibiotic misuse. Methods:A cross-sectional survey in two urban and two rural areas of Bangladesh involved 120 drug-sellers from 30 randomly selected pharmacies per site. Knowledge was compared between drug-sellers with pharmacy-dispensing training and those without training, and their suggested treatments for two simulated health-symptoms-upper respiratory-tract and gastrointestinal infections-were evaluated against STGs to determine the extent of misuse. Results:Most drug-sellers were aged 41-50 years (35.0 %), with 39.2 % holding a bachelor's degree or higher, and 65.8 % having pharmacy-dispensing training. The overall knowledge score on antibiotic use and AMR was moderate at 60.2 % (5-7 out of 10), with 32.5 % scoring ≤4, indicating poor knowledge; trained drug-sellers scored significantly better (p = 0.008). Over half (57.5 %) were unaware of antibiotic dispensing policies, though most (75.8 %) acknowledged the link between AMR and antibiotic use. For simulated upper respiratory-tract infections, 54.2 % recommended single antibiotic-90.8 % Watch, 9.2 % Access (per WHO-AWaRe classification)-with 66.2 % of these prescriptions deviating from guidelines due to inappropriate selection or dosage. For gastrointestinal infections, 55.8 % recommended single antibiotic (40.3 % Watch, 59.7 % Access), with 82.1 % deviated from the guidelines. Additionally, 26.7 % recommended two antibiotics (51.6 % Watch, 48.4 % Access), all of which were inconsistent with guideline recommendations. For both simulated symptoms, no significant difference was observed in drug sellers' treatment practices based on their knowledge level. Conclusion:This study highlights the need for context-specific policies and regulatory measures in informal healthcare settings. While improving drug-sellers' knowledge is vital for antimicrobial stewardship in LMICs like Bangladesh, it alone is insufficient due to market competition, weak regulation, and patient-driven demand. Thus, curbing inappropriate antibiotic use at the community level requires stronger enforcement and multifaceted, context-tailored interventions-including public awareness, targeted training, and market-responsive strategies.

Waterlogging, a type of stagnant flooding, is becoming more prevalent in southwest Bangladesh. It is expected to worsen due to the expansion of shrimp farming and climate change, which will contribute to environmental degradation. However, the impact of waterlogging on health, health service utilisation and household health expenditure remains poorly understood. We conducted a quantitative study between August and September 2022 in Tala, a disaster-prone sub-district in southwest Satkhira. Data were collected from 596 randomly selected households. A total of 1266 adults were surveyed, of whom 768 reported a recent illness. Of these adults, 213 reported seeking formal healthcare for their initial visit. Information about households' exposure to waterlogging in the past 12 months was also collected. Bivariate analyses were used to test the association between the outcome variables (reporting illness, utilisation of formal healthcare, and out-of-pocket expenditure) and the following other variables: age, gender, education, whether the respondent was the head of the household, type of illness, household wealth index, household size, and experience of waterlogging in the past 12 months. Two probit models were fitted for illness reporting and formal healthcare utilisation. Waterlogging experience was significantly associated with illness reporting [Coef: 0.47; CI 0.14,0.80], p = 0.006). However, it was not significantly associated with healthcare utilisation among the 768 adults who reported any illness [Coef: -0.11; CI -0.51,0.029], p = 0.600). Bivariate analyses of the association between healthcare expenditure and waterlogging revealed no significant association (p = 0.635). Significant associations were found between illness reporting and household wealth (wealthiest/poorest) and age (older/younger). In contrast, gender (male/female) and household size (larger/smaller) were negatively associated with illness reporting. Of the 768 adults who reported illness, a negative association was observed for education (compared to higher education) and a positive association was observed for wealth (average wealthy and poorest) and chronic illness (compared to acute illness). These findings highlight the need to consider the detrimental health impacts of waterlogging when improving Bangladesh's healthcare system.

Waterlogging, a form of stagnant flooding, is increasingly affecting southwest Bangladesh and is expected to intensify with the expansion of shrimp farming and climate change, contributing to environmental degradation. However, its impacts on health, health service utilisation and household health expenditures remain poorly understood. We conducted a quantitative study between August and September 2022 in Tala, a disaster-prone sub-district in southwest Satkhira. Data were collected from 596 randomly selected households. 1266 adults were surveyed, from which 768 reported recent illness. Of these 768 adults, 213 reported formal health care utilisation for their first visit. Information about household’s exposure to waterlogging in the past 12 months was also collected from the households. Bivariate analyses were used to test the association between the outcome variables (illness report, formal health care utilisation, and out-of-pocket expenditure) and other variables (age, gender, education, being the head of the household, type of illness, wealth index of the household, household size and experience of waterlogging in the past 12 months). Two probit models followed for illness report and formal health care utilisation. Of these 1266 adults, waterlogging experience was significantly associated with illness reporting [Coef: 0.47; CI 0.14,0.80], p=0.006). However, it was not significantly associated with health care utilisation for the 768 adults reporting any illness [Coef: -0.11; CI -0.51,0.029], p=0.600). Bivariate analyses for the association of healthcare expenditure and waterlogging present no significant association (p=0.635). Considering significant associations, household wealth (wealthiest/poorest) and age (older/younger), were positively associated with illness reporting. In contrast, gender (males/females) and household size (larger/smaller) were negatively associated with illness reporting. For formal health service utilisation, on the 768 adults reporting illness, a negative association was observed for education (compared to higher education), and a positive association for wealth (average wealthy/poorest) and for chronic illness (/acute). These findings highlight the need to account for the detrimental health impacts of waterlogging when strengthening Bangladesh's health system.

BACKGROUND:Non-prescription antibiotic use is common in low- and middle-income countries, particularly in community-settings, yet research often overlooks social and commercial drivers beyond formal-healthcare. METHODS:This qualitative study conducted 64 in-depth interviews-16 each with pharmacy drug-sellers, pharmaceutical sales-representatives, registered-physicians, and antibiotic-users-across two urban and two rural areas in Bangladesh. Using a social-ecological systems framework, it examined how social-and-commercial determinants influence perceptions and practices in antibiotic marketing, prescription, dispensing, and use. RESULTS:Public-healthcare deficiencies-long waits, medication and staff shortages, limited diagnostics, and referrals to private facilities-render services inadequate and inequitable, pushing patients toward private and informal providers. High consultation fees in private facilities and out-of-pocket costs deter low-income-groups from consulting registered-physicians for 'non-severe illnesses', driving them to seek quick recovery directly from drug-sellers and unqualified-providers. These drug-sellers and informal-providers, known as doctors for their symptomatic-treatment practices, often lead to unnecessary antibiotic use without proper assessment. Weak accountability, poor enforcement, and unregistered pharmacies staffed by untrained personnel allow unregulated sales to persist. Pharmaceutical companies heavily influence prescribing and dispensing through sales representatives, who routinely engage formal and informal providers-advising on dosages and offering financial incentives, commissions, and gifts. Companies strategically target informal-providers and drug-sellers, capitalizing on their symptomatic treatment practices to boost sales, while drug-sellers rely on physician-prescriptions and sales-representatives' guidance. To sustain business, drug-sellers often sell over-the-counter antibiotics and offer symptomatic treatments despite regulations. Patients expect fast recovery, viewing "good-doctors" as those who prescribe immediate medications empirically. Patients' prior exposure to antibiotics from informal sources influences formal providers' decisions, leading them to prescribe stronger antibiotics when first-line antibiotics or non-antibiotics would suffice. Cost barriers lead many patients to buy partial courses and stop treatment once symptoms subsite, ignoring advice to complete the regimen-further exacerbating misuse. CONCLUSION:Effective antimicrobial stewardship requires health-system strengthening, context-specific policies, and behavior-change interventions targeting supply and demand, raising awareness, enforcing regulations, and aligning with stakeholders' economic realities.

INTRODUCTION:Economic shocks, that is, events that cause a sudden loss of income for households, are common in low-income and middle-income countries (LMICs), yet their impact on mental health remains understudied. While such shocks may contribute to depression and anxiety, evidence remains limited, particularly in resource-poor settings where mental health disorders are underdiagnosed and undertreated. This study examines the causal impact of economic shocks on depression and anxiety in a low-income context. METHODS:We used nationally representative panel data over two waves from Bangladesh, applying individual fixed effects to estimate the impact of economic shocks on mental health outcomes. Economic shocks were defined as adverse events negatively affecting income, assets or production. Depression and anxiety were assessed using the validated Patient Health Questionnaire-9 and Generalised Anxiety Disorder-7 scales. RESULTS:In a two-round sample of 7090 observations, 16.3% (N=1155) experienced depression, 6.5% (N=459) experienced anxiety and 5.1% (N=361) experienced both depression and anxiety. Economic shocks significantly increased depression and anxiety. Individuals experiencing multiple types of shocks had nearly double the risk of reporting either mental health disorder compared with those facing a single shock. These impacts persisted for 6-12 months postshock. Adverse mental health effects were concentrated among individuals without coping mechanisms, such as use of savings, credit or support from friends and family, while those with access to such mechanisms showed no significant adverse outcomes. Education appeared protective, with individuals who had at least primary education exhibiting lower vulnerability to mental health issues in the face of shocks. CONCLUSIONS:Economic shocks have a substantial and lasting mental health impact, with compounding effects for those experiencing multiple shocks. Education and coping mechanisms may serve as a buffer against adverse outcomes. These findings highlight the need for targeted interventions to mitigate the mental health consequences of economic disruptions in LMICs.

Background:Antibiotic nonadherence significantly contributes to poor treatment outcomes and antimicrobial resistance. In Southeast Asia, including Bangladesh, community pharmacies are crucial in primary healthcare, and are key sources of over-the-counter antibiotics. However, understanding of adherence to the full course of community-dispensed antibiotics is limited. This study measured antibiotic adherence to Bangladesh government and WHO Standard Treatment Guidelines (STGs) among patients at community pharmacies and identifies associated factors. Methods:A cross-sectional survey was conducted via phone among 358 respondents from four urban and rural areas of Bangladesh who participated in a previous antibiotic purchasing behavior survey. Descriptive analysis identified antibiotic use patterns, and adherence to the full course of antibiotics was assessed against STGs recommendations. Poisson regression model was used to explore correlations between patients' demographic characteristics, knowledge of antibiotic dosage, dosage regimen, and type of health-symptoms and adherence to the full course of antibiotics. Results:Adherence to antibiotic dosage per STGs was 40.5 %. Patients consulting a registered medical practitioner were significantly more likely to adhere (Adj-PR: 3.81, 95 % CI: 2.82-5.14) compared to those who did not. Males were 32.0 % less likely to adhere than females (Adj-PR: 0.68, 95 % CI: 0.54-0.86). Rural residents demonstrated 37.0 % lower adherence compared to urban (Adj- PR: 0.63, 95 % CI: 0.45-0.87). Respondents who recalled the antibiotic dosage had a higher likelihood of adherence (Adj-PR: 2.04, 95 % CI: 1.06-3.93). Patients on 12-hourly regimens had higher adherence (Adj-PR: 1.55, 95 % CI: 1.03-2.33) than 6-hourly regimens. Patients with uncomplicated skin-infections had higher adherence (Adj-PR: 1.72, 95 % CI: 1.22-2.47), while other symptoms showed no significant association. Conclusion:Targeted interventions in diverse healthcare settings are essential, including user-centric research and enhancing patient knowledge and involvement. Strengthening patient-physician relationships and involving community pharmacies in antimicrobial stewardship programs can improve antibiotic dispensing and counselling practices among drug-sellers.

Introduction Presbyopia, difficulty in seeing close-ups, affects a billion people globally. Mobile financial services (MFS) have been mandated since January 2021 for Bangladesh government social safety net payments, including old age allowance (OAA) and widow allowance (WA). We report the protocol for the Transforming Households with Refraction and Innovative Financial Technology randomised trial assessing the impact on the use of online banking of providing presbyopic safety net beneficiaries with reading glasses, and brief smartphone and mobile banking app training.Methods and analyses Eligible participants (n=484) are OAA (men aged 65-70 years; women aged 62-70) or WA recipients (women aged 48-60) with presbyopia as their only vision problem, passing a smartphone-based test of numeracy, cognition and dexterity, and not currently owning a smartphone or independently using MFS. All participants receive smartphones loaded with a mobile banking app and a transaction-tracking app and are randomised 1:1 to receive immediate free near-vision glasses and half-day training for smartphone and banking app use (intervention), or glasses and training 12 months later (control). The primary outcome is the mean quarterly number of mobile bank transactions over the 12-month follow-up period, comparing study groups, with and without adjustment. Secondary outcomes include food security, healthcare access and social connectedness.Ethics and dissemination The protocol was approved by ethics committees at Queen's University Belfast (reference #MHLS22_69) and BRAC James P Grant School of Public Health (reference #IRB-21 August'22-028). The trial is conducted in accordance with the Declaration of Helsinki and national regulations in Bangladesh, and results will be published in open-access, peer-reviewed journals.Trial registration number NCT05510687; ClinicalTrials.gov.

The south Asian region (SAR) is home to 1·74 billion people, corresponding to 22% of the global population. The region faces several challenges pertaining to changing epidemiology, rapid urbanisation, and social and economic concerns, which affect health outcomes. Primary health care (PHC) is a cost-effective strategy to respond to these challenges through integrated service delivery, multi-sectoral action, and empowered communities. The PHC approach has historically been an important cornerstone of health policy in SAR countries. However, the region is yet to fully reap the benefits of PHC-oriented health systems. Our introductory paper in this Lancet Series on PHC in the SAR describes the existing PHC delivery structure in five SAR nations (ie, Bangladesh, India, Nepal, Pakistan, and Sri Lanka) and critically appraises PHC performance to identify its enablers and barriers. The paper proposes investing in a shared culture of innovation and collaboration for revitalisation of PHC in the region.

The COVID-19 pandemic extensively impacted maternal, neonatal, and child health (MNCH) in Bangladesh. Misconceptions arising from a lack of knowledge related to the virus contributed to reduced uptake of MNCH services, which eventually helped increase maternal and neonatal mortality rates during the pandemic. In this study, we assessed the knowledge and practices related to COVID-19 prevention among the mothers of under-2 children in Bangladesh. The study was conducted in May 2021 as part of a broader research project related to COVID-19 response on MNCH service utilization. We collected data from 2207 mothers in six districts of Bangladesh using a multi-stage cluster sampling technique. We constructed weighted and unweighted composite knowledge and practice scores and identified different socio-demographic characteristics associated with the scores using multilevel generalized mixed-effect linear regression models. In general, the mothers revealed poor knowledge and practices related to COVID-19. On a weighted scale of 100, the mean composite knowledge and practice scores were 32.6 (SD = 16.4) and 53.1 (SD = 13.9), respectively. The mothers presented inadequate knowledge about COVID-19 transmission, symptoms, and the recommended preventive measures. At the same time, maintaining a safe physical distance was the least practiced preventative measure (10.3%). Level of education, access to television, and the internet were significantly positively associated with their knowledge and practices related to COVID-19. Knowledge score was also positively associated with the practice score (OR = 1.26; p-value <0.001). Mothers living in islands or wetlands scored poorly compared to those living in inland. The results indicate significant gaps in knowledge and practices related to COVID-19 prevention among mothers of under-2 children. Addressing these gaps, particularly by targeting mothers with lower levels of education and residing in hard-to-reach geographic locations, could consequently help enhance MNCH service uptake during pandemics like COVID-19.

BACKGROUND:The Global Polio Eradication Initiative (GPEI) helped develop the standard acute flaccid paralysis surveillance (AFP) system worldwide, including, knowledge, expertise, technical assistance, and trained personnel. AFP surveillance can complement any disease surveillance system. OBJECTIVE:This study outlines AFP surveillance evolution in Bangladesh, its success and challenging factors, and its potential to facilitate other health goals. METHODS:This mixed-method study includes a grey literature review, survey, and key informant interviews (KIIs). We collected grey literature from online websites and paper documentation from GPEI stakeholders. Online and in-person surveys were conducted in six divisions of Bangladesh, including Dhaka, Rajshahi, Rangpur, Chittagong, Sylhet, and Khulna, to map tacit knowledge ideas, approaches, and experiences. We also conducted KIIs, and Data were then combined on focused emerging themes, including the history, challenges, and successes of AFP surveillance programme. RESULTS:According to the grey literature review, survey, and KII, AFP surveillance successfully contributed to decreasing polio in Bangladesh. The major facilitating factors were multi-sectoral collaboration, Surveillance Immunization Medical Officer (SIMO) network activities, social environment, community-based surveillance, and promising political commitment. On the other hand, high population growth, hard-to-reach areas, people residing in risky zones, and polio transition planning were significant challenges. Bangladesh is also utilizing these polio surveillance assets for other vaccine-preventable diseases. CONCLUSION:As the world is so close to eradicating polio, the knowledge, and other assets of the AFP surveillance, could be used for other health programmes. In addition, its strengths can be leveraged for combating new and emerging diseases.