Journal Articles (2019)

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Determinants of health seeking behavior for chronic non-communicable diseases and related out-of-pocket expenditure: results from a cross-sectional survey in northern Bangladesh
(BMC, 12/23/2019) Binte Rasul, Fatema; Kalmus, Olivier; Sarker, Malabika; Adib, Hossain Ishrath; Hossain, Md Shahadath; Hasan, Md Zabir; Brenner, Stephan; Nazneen, Shaila; Islam, Muhammed Nazmul; De Allegri, Manuela
Background: In spite of high prevalence rates, little is known about health seeking and related expenditure for chronic non-communicable diseases in low-income countries. We assessed relevant patterns of health seeking and related out-of-pocket expenditure in Bangladesh. Methods: We used data from a household survey of 2500 households conducted in 2013 in Rangpur district. We employed multinomial logistic regression to assess factors associated with health seeking choices (no care or selfcare, semi-qualified professional care, and qualified professional care). We used descriptive statistics (5% trimmed mean and range, median) to assess related patterns of out-of-pocket expenditure (including only direct costs). Results: Eight hundred sixty-six (12.5%) out of 6958 individuals reported at least one chronic non-communicable disease. Of these 866 individuals, 139 (16%) sought no care or self-care, 364 (42%) sought semi-qualified care, and 363 (42%) sought qualified care. Multivariate analysis confirmed that the following factors increased the likelihood of seeking qualified care: a higher education, a major chronic non-communicable disease, a higher socio-economic status, a lower proportion of chronic household patients, and a shorter distance between a household and a subdistrict public referral health facility. Seven hundred fifty-four (87 %) individuals reported out-of-pocket expenditure, with drugs absorbing the largest portion (85%) of total expenditure. On average, qualified care seekers encountered the highest out-of-pocket expenditure, followed by those who sought semi-qualified care and no care, or self-care. Conclusion: Our study reveals insufficiencies in health provision for chronic conditions, with more than half of all affected people still not seeking qualified care, and the majority still encountering considerable out-of-pocket expenditure. This calls for urgent measures to secure better access to care and financial protection.
Association between height and hypertension in the adult Nepalese population: Findings from a nationally representative survey
(Wiley, 11/7/2019) Gupta, Rajat Das; Haider, Shams Shabab; Hashan, Mohammad Rashidul; Rahman, Muhammad Aziz; Sarker, Malabika
Background and aims The burden of hypertension is increasing in Nepal. Different studies have evaluated the relationship between height and blood pressure in different regions, with mixed results. The relationship between height and hypertension has not yet been explored in the Nepalese context. Given this knowledge gap, this study aims to determine the relationship between height and hypertension among Nepalese adults (aged ≥18 years). Methods This study utilized the dataset from the Nepal Demographic and Health Survey (NDHS) 2016. Hypertension was defined as systolic blood pressure ≥ 140 mmHg and/or a diastolic blood pressure ≥ 90 mmHg. Height, measured in centimeters (cm), was analyzed as a continuous variable. Based on previous evidence, the following covariates were considered: age, sex, presence of overweight or obesity, educational status, household wealth status, and place, province, and ecological zone of residence. Multilevel multivariable logistic regression was done to evaluate the association between height and hypertension. Both crude odds ratio (COR) and adjusted odds ratio (AOR) are reported, along with a 95% confidence interval (CI). Sample weight of NDHS was adjusted during analysis. Results Among 13 393 weighted individuals over the age of 18 years, the prevalence of hypertension in Nepal was found to be 21.1% (95% CI, 19.9%‐22.4%). In the final multivariable model, after adjusting for relevant covariates, it was found that height was inversely associated with hypertension. For a Nepalese adult, the odds of hypertension decreased by 10% with each 10‐cm increase in height (AOR 0.9; 95% CI 0.8‐0.9; P = 0.003). Conclusion Awareness should be raised among people with low stature for prevention of hypertension. Longitudinal studies are recommended to include genetic and social/environmental determinants of stature in the analyses.
Health shock and preference instability: Assessing health-state dependency of willingness-to-pay for corrective eyeglasses
(BMC, 11/7/2019) Islam, Muhammed Nazmul; Rabbani, Atonu; Sarker, Malabika
Background: Differences in contingent valuation (CV) estimates for identical healthcare goods can cast considerable doubt on the true economic measures of consumer preferences. Hypothetical nature of CV methods can potentially depend on the salience, context and perceived relevance of the good or service under consideration. Thus, the high demand elasticity for healthcare goods warrants careful selection of study population as the contexts of valuation significantly changes after experiencing health shock. Methods: In this study, using triple-bounded dichotomous choice (TBDC) experiments, we test how negative health shock (namely, being diagnosed with refractive errors), can alter preference over a common health good (namely, corrective eyeglasses). We compared elicited WTP of diagnosed patients with a synthetically constructed comparable cohort without the same health shock, controlling for the possible self-selection using a number of matching techniques based on the observable socio-demographic characteristics. Results: The consumers diagnosed with vision problems exhibit a rightward shift in their demand curve compared to observationally identical consumers without such problems resulting in about 17% higher consumer surplus. The consumers without the health shock are willing to pay about BDT 762.4 [95% CI: BDT 709.9 - BDT 814.9] for corrective eyeglasses, which gets 15–30% higher for the matched with-health-shock consumers. Multivariable analyses suggest more educated and wealthier individuals are willing to pay respectively BDT 208 and BDT 119 more for corrective eyeglasses. We have tested the models for different matching protocols. Our results are fairly robust to alternate specifications and various matching techniques. Conclusion: The preferences for healthcare goods, such as eyeglasses, can significantly depend upon the respondent being diagnosed with refractive errors. Our findings have implications for general cost-benefit analyses often relying on WTP, which can vary depending on the contexts. There are also increasing interests in cost recovery models, which require understanding the demand for healthcare goods and services. We find eliciting the demand needs to consider the health status of the population from which the respondents are sampled.
Developing a framework of core competencies in implementation research for low/middle-income countries
(BMJ Journals, 2019-09) Alonge, Olakunle; Rao, Aditi; Kalbarczyk, Anna; Maher, Dermot; Gonzalez Marulanda, Edwin Rolando; Sarker, Malabika; Ibisomi, Latifat; Dako-Gyeke, Phyllis; Mahendradhata, Yodi; Launois, Pascal; Vahedi, Mahnaz
The field of implementation research (IR) is growing. However, there are no recognised IR core competencies in low/middle-income countries (LMICs), nor consistent curriculum across IR training programs globally. The goal of this effort is to develop a framework of IR core competencies for training programs in LMICs. The framework was developed using a mixed-methods approach consisting of two online surveys with IR training coordinators (n = 16) and academics (n = 89) affiliated with seven LMIC institutions, and a modified-Delphi process to evaluate the domains, competencies and proficiency levels included in the framework. The final framework comprised of 11 domains, 59 competencies and 52 sub-competencies, and emphasised competencies for modifying contexts, strengthening health systems, addressing ethical concerns, engaging stakeholders and communication especially for LMIC settings, in addition to competencies on IR theories, methods and designs. The framework highlights the interconnectedness of domains and competencies for IR and practice, and training in IR following the outlined competencies is not a linear process but circular and iterative, and starting points for training may vary widely by the project, institution and challenge being addressed. The framework established the need for a theory-based approach to identifying proficiency levels for IR competencies (ie, to determine proficiency levels for IR based on generalisable educational theories for competency-based education), and the relevance of various IR competencies for LMICs compared with highincome settings. This framework is useful for identifying and evaluating competencies and trainings, and providing direction and support for professional development in IR.
Gender differences in hypertension awareness, antihypertensive use and blood pressure control in Nepalese adults: Findings from a nationwide cross-sectional survey
(Cambridge University Press, 8/30/2019) Gupta, Rajat Das; Haider, Shams Shabab; Sutradhar, Ipsita; Hasan, Mehedi; Joshi, Hemraj; Haider, Mohammad Rifat; Sarker, Malabika
The objective of this cross-sectional study was to determine the gender differences in hypertension awareness, antihypertensive use and blood pressure (BP) control among the adult Nepalese population (≥18 years) using data from the nationally representative Nepal Demographic and Health Survey 2016. A weighted sample of 13,393 adults (5620 males and 7773 females) was included in the final analysis. After conducting descriptive analyses with the selective explanatory variable, multivariable logistic regression analysis was performed to assess the association between the outcome variable and the explanatory variables. The strength of the association was expressed in adjusted odds with 95% confidence intervals. A higher proportion of women had their BP checked (87.7% females vs 73.0% males, p<0.001) and were aware of their raised BP (43.9% females vs 37.1% males, p<0.001) compared with men. Although female hypertensive individuals had a higher prevalence of antihypertensive medication use than their male counterparts (50.1% females vs 47.5% males), a higher proportion of male hypertensive participants had their BP controlled (49.2% females vs 53.5% males). Women with the poorest wealth index had a lower prevalence of antihypertensive use than their male counterparts. The odds of having their own BP measured increased with age among men but decreased with age among women. The household wealth index was positively associated with the odds of BP measurement, awareness of own BP and antihypertensive use. This study revealed that although women had a higher prevalence of hypertension awareness and antihypertensive medication use, the practice did not translate into better BP control. Inequality in antihypertensive medication use was observed among the poorest wealth quintiles. Public health programmes in Nepal should focus on reducing these inequalities. Further research is needed to learn why females have poorer control of BP, despite having higher antihypertensive medication use.
Association of frequency of television watching with overweight and obesity among women of reproductive age in India: Evidence from a nationally representative study
(PLOS ONE, 8/29/2019) Gupta, Rajat Das; Haider, Shams Shabab; Sutradhar, Ipsita; Hashan, Mohammad Rashidul; Sajal, Ibrahim Hossain; Hasan, Mehedi; Haider, Mohammad Rifat; Sarker, Malabika
Background For women of reproductive age, overweight and obesity are an established risk factor for several medical complications. To address the increasing rate of obesity in India through public health awareness programs, the association between common behaviors and overweight and obesity needs to be investigated. This study aims to determine whether there is any association between the frequency of television watching and overweight and obesity among women of reproductive age (15–49 years) in India. Methods This is a cross-sectional study that utilized data from the National Family Health Survey (NFHS-4), which utilized a nationally representative sample from all 29 states and 7 union territories of India. The survey itself followed a two-staged stratified random sampling technique. The primary outcome of interest was overweight (23.0 kg/m2 to <27.5 kg/m2) and obesity (≥27.5 kg/m2), measured by using the Asian body mass index cut-off. The major explanatory variable was the frequency of television watching, measured in days per week. Sample weight of NFHS-4 was adjusted during the analysis. Multilevel ordered logistic regression was conducted to identify the factors associated with overweight and obesity. To show the strength of association, both the unadjusted Crude Odds Ratio (COR) and the Adjusted Odds Ratio (AOR) were reported with a 95% confidence interval (CI). A p-value<0.05 was considered statistically significant. Results The analysis included weighted data from 644,006 Indian women of reproductive age (15–49 years). Among the respondents, 33.5% were overweight or obese (BMI ≥23.0 kg/m2). The prevalence of overweight and obesity increased with age (p-value <0.0001) and almost half of the women aged 35–49 years were either overweight or obese (48.6%). The prevalence was significantly higher among those living in an urban area compared to a rural area (urban 46.5% vs. rural 26.5%; p-value <0.001). The prevalence of overweight and obesity increased with the frequency of watching television and was the highest among the individuals who reported watching television almost every day (p-value <0.0001). Women watching television almost every day had 24% (AOR: 1.24, 95% CI: 1.21–1.26; p-value <0.001) increased odds of being overweight and obese compared to their counterparts who never watched television. Conclusions This study found that the likelihood of being overweight and obese significantly increased with the frequency of watching television; likely due to physical inactivity during leisure time. Further studies should examine the physical activity and food habits of this target group. Public health promotion programs in India should raise awareness regarding the harmful effects of the sedentary lifestyle associated with watching television.
Knowledge, attitudes, and practices regarding malaria control among the slash and burn cultivators in Rangamati Hill tracts of Bangladesh
(BMC, 6/25/2019) Saha, Avijit; Sarker, Malabika; Kabir, Moktadir; Lu, Guangyu; Müller, Olaf
Abstract Background: Slash and burn cultivators are a signifcant risk group for malaria in South-East Asia. As envisaged in the National Strategic Plan for Malaria Elimination, Bangladesh aims to achieve zero indigenous malaria transmission by 2030. For the national plan to move from malaria control to malaria elimination, targeting the population of slash and burn cultivators is of overriding importance. Methods: The study used an explorative mixed method design to investigate the knowledge, attitudes, and practices (KAP) regarding malaria prevention and treatment in an endemic area of Bangladesh. Adult slash and burn cultivators in two sub-districts of the Rangamati District were selected and interviewed. Four focus group discussions were conducted, and this was followed by a cross-sectional quantitative survey with 200 participants. Results: The respondents’ general knowledge about malaria transmission and modes of prevention and treatment was good. However, there were some gaps regarding knowledge about specifc aspects of malaria transmission and in particular about the increased risk associated with their occupation. Despite a much-reduced incidence of malaria in the study area, the respondents perceived the disease as life-threatening and knew that it needs rapid attention from a health worker. Moreover, the specifc services ofered by the local community health workers for malaria diagnosis and treatment were highly appreciated. Finally, the use of insecticide-treated mosquito nets (ITN) was considered as important and this intervention was uniformly stated as the main malaria prevention method. Conclusions: The fndings from this study on promising KAP characteristics in the slash and burn cultivator population are reassuring that the goal of malaria elimination by the year 2030 can be achieved in Bangladesh.
Experience and perceived quality of care of patients and their attendants in a specialized mental hospital in Bangladesh
(BMC, 6/22/2019) Nuri, Nazmun Nahar; Sarker, Malabika; Ahmed, Helal Uddin; Hossain, Mohammad Didar; Beiersmann, Claudia; Jahn, Albrecht
Abstract Background: A person’s perception of health service quality depends on his or her expectations and priorities. If the perception of care is good, then it eventually enhances future health service utilization, adherence to treatment and desired outcomes. Understanding a patient’s perspective is key for delivering a better quality patient-centred health care service. This study explored experience and perception of patients and their attendants of mental health care services at the National Institute of Mental Health (NIMH) which is the only national level mental health institute in Bangladesh. NIMH is located in the capital city and provides specialized mental health care services for the whole population. Methods: A facility-based cross-sectional study was conducted using a mixed-method design at the NIMH. A total of 40 respondents (patients, or their attendants if the patient was minor or unable to respond due to lack of mental stability) visiting the outpatient department (OPD) of NIMH were selected by purposive sampling. For each of the ten ICD 10 categories (10th revision of International Classifcation of Diseases by the World Health Organization [WHO]) for mental disorders, four patients were chosen. Finally, 13 patients and 27 attendants (on behalf of 17 minor patients and 10 adult patients unable to respond) participated in the interview. Results: The respondents rated 34 short statements clustered around four dimensions of care (accessibility, interpersonal communications, condition of the waiting and consultation rooms, and general quality of OPD services) and we interpreted those scores as follows: 7.6–10 very satisfed/very good quality, 5.1–7.5 satisfed/good quality, 2.6–5.0 dissatisfed/poor quality and 1.0–2.5 completely dissatisfed/very poor quality. For accessibility and interpersonal communications, the patients perceived care as very good (average scores on a Likert scale of 1–10 were 8.3 and 7.6, respectively). The respondents considered the condition of the waiting and consultation rooms and general quality of OPD care as good (average scores 5.8 and 7.1, respectively). NIMH had serious lack of resources in terms of functional medical equipment and physicians appointed, which negatively impacted on the service quality. Conclusions: Patients receiving services from the NIMH OPD had a positive perception of the quality of care in general. But, at an individual level, some respondents expressed dissatisfaction. Our fndings are informative for quality improvement and client-oriented care service planning at NIMH, Bangladesh.
Willingness to pay for cataract surgeries among patients visiting eye care facilities in Dhaka, Bangladesh
(Springer Link, 5/7/2019) Islam, Muhammed Nazmul; Engels, Thomas; Hossain, Shafayet; Sarker, Malabika; Rabbani, Atonu
Background Cataract is the leading cause of avoidable blindness globally. It is estimated that 89% of people with visual impairment live in low- and middle-income countries where the cost of cataract surgery represents a major barrier for accessing these services. Developing self-sustaining healthcare programs to cater the unmet demands warrants a better understanding of patients’ willingness to pay (WTP) for their services. Objectives Using a sample of patients visiting eye care facilities in Dhaka, Bangladesh, we estimate WTP for two diferent cataract extraction techniques, namely small incision cataract surgery (SICS) and phacoemulsifcation. Methods We used contingent valuation (CV) approach and elicited WTP through double-bounded dichotomous choice experiments. We interviewed 556 randomly selected patients (283 for SICS and 273 for phacoemulsifcation) from fve diferent eye care hospitals of Dhaka. In this paper, we estimated the mean and marginal WTP using interval regression models. We also compared the estimated WTP and stated demand for cataract surgeries against the prevailing market prices of SICS and phacoemulsifcation. Results We found the mean WTP of BDT 7579 (US$93) for SICS and BDT 10,208 (US$126) for phacoemulsifcation are equivalent to 12 and 16 days of household income, respectively. Household income and assets appeared as the major determinants of WTP for cataract surgeries. However, we did not fnd any signifcant association with gender, occupation, and household size among other socioeconomic characteristics. Comparisons between market prices and average WTP suggest it is possible to have a viable market for SICS, but a subsidy-based model for phacoemulsifcation will be fnancially challenging because of low WTP and high costs. Conclusion Our fndings suggest lower-cost SICS can potentially provide patients access to surgeries to treat cataract conditions. Moreover, price discrimination and cross-subsidization could be a viable strategy to increase the service-uptake as well as ensure fnancial sustainability
Overall care-seeking pattern and gender disparity at a specialized mental hospital in Bangladesh
(Materia socio-medica, 3/31/2019) Nuri, Nazmun Nahar; Sarker, Malabika; Ahmed, Helal Uddin; Hossain, Mohammad Didar; Dureab, Fekri; Agbozo, Faith; Jahn, Albrecht
Introduction: The National Institute of Mental Health (NIMH) is the only national level mental health institution in Bangladesh, with both academic and clinical functions, thus playing a crucial role in delivering specialized mental health care for the entire population. Aim: This study examined the overall pattern of mental health care seeking, age and sex distribution of patients and mental health problems diagnosed in the facility. Methods: Using a facility-based cross-sectional study design, secondary data was collected from various hospital records and reports from April 2001 to June 2016, and quantitatively analyzed. Results: There has been a steady increase in the number of patients at NIMH over the years. Typically, female patients were about half in number compared to male patients and fewer in each age group and all disease categories except inpatients with neurotic, stress-related and somatoform disorders. The highest number of inpatients and outpatients were 15-30 years old and those with schizophrenia, schizotypal and delusional disorders. Conclusion: Minors and females seeking care at NIMH were underrepresented, thus highlighting the need for interventions to improve access for these patients.

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