Ilias Mahmud

Exploring the context in which different close-to-community sexual and reproductive health service providers operate in Bangladesh: a qualitative study.

BackgroundA range of formal and informal close-to-community (CTC) health service providers operate in an increasingly urbanized Bangladesh. Informal CTC health service providers play a key role in Bangladesh’s pluralistic health system, yet the reasons for their popularity and their interactions with formal providers and the community are poorly understood. This paper aims to understand the factors shaping poor urban and rural women’s choice of service provider for their sexual and reproductive health (SRH)-related problems and the interrelationships between these providers and communities. Building this evidence base is important, as the number and range of CTC providers continue to expand in both urban slums and rural communities in Bangladesh. This has implications for policy and future programme interventions addressing the poor women’s SRH needs.MethodsData was generated through 24 in-depth interviews with menstrual regulation clients, 12 focus group discussions with married men and women in communities and 24 semi-structured interviews with formal and informal CTC SRH service providers. Data was collected between July and September 2013 from three urban slums and one rural site in Dhaka and Sylhet, Bangladesh. Atlas.ti software was used to manage data analysis and coding, and a thematic analysis was undertaken.ResultsPoor women living in urban slums and rural areas visit a diverse range of CTC providers for SRH-related problems. Key factors influencing their choice of provider include the following: availability, accessibility, expenses and perceived quality of care, the latter being shaped by notions of trust, respect and familiarity. Informal providers are usually the first point of contact even for those clients who subsequently access SRH services from formal providers. Despite existing informal interactions between both types of providers and a shared understanding that this can be beneficial for clients, there is no effective link or partnership between these providers for referral, coordination and communication regarding SRH services.ConclusionTraining informal CTC providers and developing strategies to enable better links and coordination between this community-embedded cadre and the formal health sector has the potential to reduce service cost and improve availability of quality SRH (and other) care at the community level.

Developing the content of a locomotor disability scale for adults in Bangladesh: a qualitative study

BackgroundBangladesh has an estimated 17 million adults with disabilities. A significant proportion of them are believed to have locomotor disabilities. There are over 300 non-governmental organizations providing different types of rehabilitation services to them. However, there is no locally developed and validated locomotor disability measurement scale in Bangladesh. The purpose of this study was to develop a locomotor disability scale with disability indicators suitable for adults in Bangladesh.MethodsSemi-structured interviews were conducted with 25 purposively selected adults with locomotor disabilities to generate scale items. At the second stage, cognitive interviews were conducted with 12 purposively selected adults with locomotor disabilities in order to refine the measurement questions and response categories. Data were analysed using the framework technique- identifying, abstracting, charting and matching themes across the interviews.ResultsFor a locomotor disability scale, 70 activities (disability indicators) were identified: 37 mobility activities, 9 activities of daily living, 17 work/productivity activities and 7 leisure activities. Cognitive interviews revealed that when asking the respondents to rate their difficulty in performing the activities, instead of just mentioning the activity name, such as taking a bath or shower, a detailed description of the activity and response options were necessary to ensure consistent interpretation of the disability indicators and response options across all respondents.ConclusionsIdentifying suitable disability indicators was the first step in developing a locomotor disability scale for adults in Bangladesh. Interviewing adults with locomotor disabilities in Bangladesh ensured that the locomotor disability scale is of relevance to them and consequently it has excellent content validity. Further research is needed to evaluate the psychometric properties of this scale.

Factorial structure of the locomotor disability scale in a sample of adults with mobility impairments in Bangladesh

BackgroundDisability does not only depend on individuals’ health conditions but also the contextual factors in which individuals live. Therefore, disability measurement scales need to be developed or adapted to the context. Bangladesh lacks any locally developed or validated scales to measure disabilities in adults with mobility impairment. We developed a new Locomotor Disability Scale (LDS) in a previous qualitative study. The present study developed a shorter version of the scale and explored its factorial structure.MethodsWe administered the LDS to 316 adults with mobility impairments, selected from outpatient and community-based settings of a rehabilitation centre in Bangladesh. We did exploratory factor analysis (EFA) to determine a shorter version of the LDS and explore its factorial structure.ResultsWe retained 19 items from the original LDS following evaluation of response rate, floor/ceiling effects, inter-item correlations, and factor loadings in EFA. The Eigenvalues greater than one rule and the Scree test suggested a two-factor model of measuring locomotor disability (LD) in adults with mobility impairment. These two factors are ‘mobility activity limitations’ and ‘functional activity limitations’. We named the higher order factor as ‘locomotor disability’. This two-factor model explained over 68% of the total variance among the LD indicators. The reproduced correlation matrix indicated a good model fit with 14% non-redundant residuals with absolute values > 0.05. However, the Chi-square test indicated poor model fit (p < .001). The Bartlett’s test of Sphericity confirmed patterned relationships amongst the LD indicators (p < .001). The Kaiser-Meyer-Olkin Measure (KMO) of sampling adequacy was .94 and the individual diagonal elements in the anti-correlation matrix were > .91.Among the retained 19 items, there was no correlation coefficient > .9 or a large number of correlation coefficients < .3. The communalities were high: between .495 and .882 with a mean of 0.684. As an evidence of convergent validity, we had all loadings above .5, except one. As an evidence of discriminant validity, we had no strong (> .3) cross loadings and the correlation between the two factors was .657. The ‘mobility activity limitations’ and ‘functional activity limitations’ sub-scales demonstrated excellent internal consistency (Cronbach’s alpha were .954 and .937, respectively).ConclusionsThe 19-item LDS was found to be a reliable and valid scale to measure the latent constructs mobility activity limitations and functional activity limitations among adults with mobility impairments in outpatient and community-based settings in Bangladesh.

Utilization of mobile phones for accessing menstrual regulation services among low-income women in Bangladesh: a qualitative analysis

BackgroundAs many as one-third of all pregnancies in Bangladesh are unplanned, with nearly one-half of these pregnancies ending in either menstrual regulation (MR) or illegal clandestine abortion. Although MR is provided free of charge, or at a nominal cost, through the public sector and various non-profits organizations, many women face barriers in accessing safe, affordable MR and post-MR care. Mobile health (mHealth) services present a promising platform for increasing access to MR among low-income women at risk for clandestine abortion. We sought to investigate the knowledge, attitudes and practices regarding mHealth of both MR clients and formal and informal sexual and reproductive healthcare providers in urban and rural low-income settlements in Bangladesh.MethodsA total of 58 interviews were conducted with MR clients, formal MR providers, and informal MR providers in four low-income settlements in the Dhaka and Sylhet districts of Bangladesh. Interview data was coded and qualitatively analysed for themes using standard qualitative research practices.ResultsOur findings suggest that low-income MR clients in Bangladesh have an inadequate understanding of how to use their mobile phones to obtain health service information or counselling related to MR, and correspondingly low levels of formal or informal mHealth service utilization. Few were aware of any formal mHealth services in place in their communities, despite the fact that providers stated that hotlines were available. Overall, MR clients expressed positive opinions of mHealth services as a means of improving women’s access to affordable and timely MR. Formal and informal MR providers believed that mobile phones had benefits with respect to information dissemination and making appointments, but emphasized the necessity of in-person consultations for effective sexual and reproductive healthcare.ConclusionsWe report low utilization yet high acceptability of mHealth services among low-income MR clients in Bangladesh. Expanding formal and informal mHealth services targeted towards MR – and increasing publicity of these services in low-income communities – may help increase timely access to accurate MR information and formal providers among women at risk for clandestine abortion. While expanding formal and informal mHealth services for SRHR in Bangladesh may be useful in disseminating information about MR and connecting women with formal providers, in-person visits remain necessary for adequate treatment.

Prevalence of work related musculoskeletal disorders (WMSDs) and ergonomic risk assessment among readymade garment workers of Bangladesh: A cross sectional study

Background Work related Musculoskeletal Disorders (WMSDs) are one of the most common occupational diseases which mainly affects the lower back, neck and upper and lower extremities. The aim of this study was to determine prevalence of WMSDs in nine body regions among Ready Made Garment (RMG) workers in Bangladesh and ergonomics assessment of their exposure to risk factors for the development of WMSDs. Methods This cross-sectional study was conducted among 232 RMG employees (male: 46; female: 186; age: >18yrs) from nine RMG factories in Dhaka division during October 2015 to February 2016. Data were collected using a structured questionnaire consist of demographic questions, Nordic Musculoskeletal Questionnaire-Extended (NMQ-E) for WMSDs assessment in nine body regions and Quick Exposure Check (QEC) method for ergonomic assessment. Prevalence of WMSDs for each body region was determined. The association between WMSDs and ergonomic assessment of their exposure to risk factors were also analyzed. Results Respondents’ mean age was 31.3 years (SD = 7). Their mean Body Mass Index (BMI) was 23.51 kg/m2 (SD = 3.74). Among 186 female respondents, 46 reported lower back pain (24.7%) and 44 reported neck pain (23.7%). Among 46 male respondents, 10 reported neck pain (21.7%) while 6 reported knee pain (13%). Statistically significant relationship was found between twelve month WMSDs in anatomical region in elbows (p = 0.02), hips (p = 0.01), knees (p = 0.01) and ankle (p = 0.05) with age; upper back (p = 0.001), elbows (p = 0.001), wrists (p = 0.03), hips (p = 0.001) and ankles (p = 0.01) with job experience; hips with BMI (p = 0.03); elbows (p = 0.04) with daily working hour. QEC assessment showed that level of exposure to WMSDs risk was high among 80% of the study population (p<0.003). Conclusion The study found that lower back and neck were the most affected areas among RMG workers. Moreover, QEC findings warned the level of exposure to WMSDs risks is high and ergonomics intervention along with investigation and change to decrease exposure level is essential. Addressing musculoskeletal risk factors through ergonomic interventions in terms of working space, workers sitting/standing posture, seat and hand position during work and work-rest cycle are encouraged in RMG sector and policy makers.

A new tool to measure approaches to supervision from the perspective of community health workers: a prospective, longitudinal, validation study in seven countries

BackgroundThe global scale-up of community health workers (CHWs) depends on supportive management and supervision of this expanding cadre. Existing tools fail to incorporate the perspective of the CHW (i.e. perceived supervision) in terms of supportive experiences with their supervisor. Aligned to the WHO’s strategy on human resources for health, we developed and validated a simple tool to measure perceived supervision across seven low and middle-income countries.MethodsPhase 1 was carried out with 327 CHWs in Sierra Leone. Twelve questions, informed by the extant literature on health worker supervision, were reduced to six questions using confirmatory factor analysis. Phase 2 employed structural equation modelling with 741 CHWs in six countries (Bangladesh, Ethiopia, Indonesia, Kenya, Malawi, Mozambique), to assess the factorial validity, predictive validity, and internal reliability of the questions at three time-points, over 8-months.ResultsWe developed a robust, 6-item measure of perceived supervision (PSS), capturing regular contact, two-way communication, and joint problem-solving elements as being critical from the perspective of CHWs. When assessed across the six countries, over time, the PSS was also found to have good validity and internal reliability. PSS scores at baseline positively and significantly predicted a range of performance-related outcomes at follow-up.ConclusionThe PSS is the first validated tool that measures supervisory experience from the perspective of CHWs and is applicable across multiple, culturally-distinct global health contexts with a wide range of CHW typologies. Simple, quick to administer, and freely available in 11 languages, the PSS could assist practitioners in the management of community health programmes.

Development and validation of a structured observation scale to measure responsiveness of physicians in rural Bangladesh

BackgroundResponsiveness of physicians is the social actions that physicians do to meet the legitimate expectations of service seekers. Since there is no such scale, this study aimed at developing one for measuring responsiveness of physicians in rural Bangladesh, by structured observation method.MethodsData were collected from Khulna division of Bangladesh, through structured observation of 393 patient-consultations with physicians. The structured observation tool consisted of 64 items, with four Likert type response categories, each anchored with a defined scenario. Inter-rater reliability was assessed by same three raters observing 30 consultations. Data were analyzed by exploratory factor analysis (EFA), followed by assessment of internal consistency by ordinal alpha coefficient, inter-rater reliability by intra-class correlation coefficient (ICC), concurrent validity by correlating responsiveness score with waiting time, and known group validity by comparing public and private sector physicians.ResultsAfter removing items with more than 50% missing values, 45 items were considered for EFA. Parallel analysis suggested a 5-factor model. Nine items were removed from the list owing to < 0.50 communality, <0.32 loading in un-rotated matrix, and <0.30 on any factor in rotated matrix. Since 34 items (i.e., the number of remaining items after removing nine items by EFA) were loaded neatly under five factors, explained 61.38% of common variance, and demonstrated high internal consistency with coefficient of 0.91, this was adopted as the Responsiveness of Physicians Scale (ROP-Scale). The five factors were named as 1) Friendliness, 2) Respecting, 3) Informing and guiding, 4) Gaining trust, and 5) Financial sensitivity. Inter-rater reliability was high, with an ICC of 0.64 for individual rater’s reliability and 0.84 for average reliability scores. Positive correlation with waiting time (0.51), and higher score of private sector by 0.18 point denote concurrent, and known group validity, respectively.ConclusionsThe ROP-Scale consists of 34 items grouped under five factors. One can apply this with confidence in comparable settings, as this scale demonstrated high internal consistency and inter-rater reliability. More research is needed to test this scale in other settings and with other types of providers.