Rumana Huque

Smokeless tobacco control policies in South Asia: a gap analysis and recommendations.

INTRODUCTION Almost a fifth of the worlds tobacco is consumed in smokeless form. Its consumption is particularly common in South Asia, where an increasing array of smokeless tobacco (SLT) products is widely available. Mindful of the growing public health threat from SLT, a group of international academics and policy makers recently gathered to identify policy and knowledge gaps and proposed strategies to address these. METHODS We reviewed key policy documents and interviewed policy makers and representatives of civil society organizations in 4 South Asian countries: Bangladesh, India, Nepal, and Pakistan. We explored if SLT features in existing tobacco control policies and, if so, the extent to which these are implemented and enforced. We also investigated barriers to effective policy formulation and implementation. The findings were presented at an international meeting of experts and were refined in the light of the ensuing discussion in order to inform policy and research recommendations. RESULTS We found that the existing SLT control policies in these 4 South Asian countries were either inadequate or poorly implemented. Taxes were low and easily evaded; regulatory mechanisms, such as licensing and trading standards, either did not exist or were inadequately enforced to regulate the composition and sales of such products; and there was little or no cessation support for those who wanted to quit. CONCLUSIONS Limited progress has been made so far to address the emerging public health threat posed by SLT consumption in South Asia. International and regional cooperation is required to advocate for effective policy and to address knowledge gaps.

Effectiveness of involving the private medical sector in the National TB Control Programme in Bangladesh: evidence from mixed methods

Objectives In Bangladesh, private healthcare is common and popular, regardless of income or area of residence, making the private sector an important player in health service provision. Although the private sector offers a good range of health services, tuberculosis (TB) care in the private sector is poor. We conducted research in Dhaka, between 2004 and 2008, to develop and evaluate a public–private partnership (PPP) model to involve private medical practitioners (PMPs) within the National TB Control Programme (NTP)s activities. Since 2008, this PPP model has been scaled up in two other big cities, Chittagong and Sylhet. This paper reports the results of this development, evaluation and scale-up. Design Mixed method, observational study design. We used NTP service statistics to compare the TB control outcomes between intervention and control areas. To capture detailed insights of PMPs and TB managers about the process and outcomes of the study, we conducted in-depth interviews, focus group discussions and workshops. Setting Urban setting, piloted in four areas in Dhaka city; later scaled up in other areas of Dhaka and in two major cities. Findings The partnership with PMPs yielded significantly increased case finding of sputum smear-positive TB cases. Between 2004 and 2010, 703 participating PMPs referred 3959 sputum smear-positive TB cases to the designated Directly Observed Treatment, Short-course (DOTS) centres, contributing about 36% of all TB cases in the project areas. There was a steady increase in case notification rates in the project areas following implementation of the partnership. Conclusions The PPP model was highly effective in improving access and quality of TB care in urban settings.

Tuberculosis in the workplace: developing partnerships with the garment industries in Bangladesh

OBJECTIVES To implement and evaluate a public-private partnership model involving garment factories to reduce the tuberculosis (TB) burden in this workforce. DESIGN We used operational research to develop and evaluate a mechanism for effective and sustainable TB control in workplaces in three areas of Dhaka, Bangladesh. Strategies, protocols, guides and tools were developed with stakeholders. We assessed the impact of the project using quantitative and qualitative measures: changes in TB outcomes were calculated using standard indicators based on factory and DOTS centre records; changes in TB care-seeking behaviour were assessed using qualitative in-depth interviews with factory managers and medical personnel, and focus group discussions with factory workers, including TB patients. FINDINGS The project brought positive changes in knowledge, attitudes and practices of managers, workers and health care providers on TB care and control. During 2008-2010, a total of 3372 workers from a workforce of 69,000 were referred for sputum microscopy and 598 were diagnosed with smear-positive TB, 145 of whom received care at their workplace. The overall treatment success rate was 100%. CONCLUSION It is feasible to engage factories in TB control activities in Bangladesh, and thereby increase case notifications and improve treatment outcomes.

Is health care a necessary or luxury product for Asian countries? An answer using panel approach

A number of studies have estimated the income elasticity of health care expenditure to identify whether health care is a necessary or luxury product. However, the issue has received less attention in developing countries, especially in Asian economies. The current study for the first time has used the panel data covering 36 Asian countries for the period 1995–2013 for revealing the nature of health care as a product. Along with conventional econometric techniques we have addressed the issue of cross section dependence and used Westerlund (2007) panel cointegration test which is robust against cross section dependence and heterogeneity for detecting the presence of panel cointegration. By applying Fully Modified OLS (FMOLS) and Dynamic OLS (DOLS) it was found that the long run elasticity of Health Care Expenditure (HCE) with Gross Domestic Product (GDP) is less than unit implying that the health care can be regarded as necessary in nature for these countries.

Determinants of Salivary Cotinine among Smokeless Tobacco Users: A Cross-Sectional Survey in Bangladesh.

Introduction More than 80% of all smokeless tobacco (ST) products in the world are consumed in South Asia; yet little is known about their consumption behaviour, addictiveness, and toxic properties. This paper, for the first time, describes associations between salivary cotinine concentrations among ST users in Bangladesh and their socio-demographic characteristics and tobacco use behaviours. Methods In a survey of ST users in Dhaka, Bangladesh, we purposively recruited 200 adults who were non-smokers but consumed ST on a regular basis. In-person interviews were conducted to obtain information about socio-demographic and ST use behaviours, and saliva samples were collected to measure cotinine concentration. Simple and multiple linear regression analyses were conducted to test associations between the log transformed salivary cotinine concentration and other study variables. Results The geometric mean of cotinine concentration among ST users was 380ng/ml (GSD:2). Total duration of daily ST use in months had a statistically significant association with cotinine concentration. Other ST use characteristics including type and quantity of ST use, swallowing of tobacco juice, urges and strength of urges and attempts to cut down on tobacco use were not found to be associated with cotinine concentration in a multivariable model. Conclusion This is the first report from Bangladesh studying cotinine concentration among ST users and it points towards high levels of addiction. This warrants effective tobacco control policies to help ST cessation and prevention.

Children's exposure to second-hand smoke at home in Bangladesh: a community survey

Objectives In Bangladesh, second-hand smoke (SHS) is recognised as a principal source of indoor air pollution and a major public health problem. However, we know little about the extent to which people are aware of the risks of second-hand smoking, or restrict smoking indoors or in the presence of children. We report findings of a community survey exploring these questions. Design and setting A total of 722 households were surveyed in urban and rural settings, using a multistage cluster random sampling approach and a semistructured questionnaire. In addition, we used qualitative methods to further explore the determinants of smoking-related behaviours inside homes. Findings 55% of households in our sample had at least one regular smoker. Smoking indoors was common. In 30% of households, smoking occurred in the presence of children, exposing nearly 40% of children to SHS. Overall, we found a lack of awareness about the harms associated with second-hand smoking. Conclusions Our study highlights that a sizeable proportion of children and non-smokers are exposed to SHS at homes in Bangladesh, posing a significant and grave public health problem. In the absence of any impetus to legislate against smoking in private places, an educational approach is recommended to change smoking practices at home. Such a shift toward voluntary smoking restrictions at home would require behaviour change among smokers and support from non-smoking family members.

Public-Private Partnership for TB Control in Bangladesh: Role of Private Medical Practitioners in the Management of TB patients

Background: Despite enormous efforts, Bangladesh has one of the highest burdens of tuberculosis (TB) in the world. Treatment in the private sector is common and popular among TB patients in South Asian countries, including Bangladesh, even though the quality of diagnosis and treatment of TB patients has been shown to be poor in several such countries. The Bangladesh National Tuberculosis Programme (NTP) has recently shown considerable interest in exploring policy options to address this problem. Consequently, the NTP and non-governmental organization (NGO) partners planned to develop a public-private partnership (PPP) model for effective involvement of private medical practitioners (PMPs) in TB control. However, there was a lack of solid data on TB case management practice by PMPs, which was needed to appraise the potential role and contribution of PMPs in TB control. The purpose of the study is therefore to assess the knowledge, attitudes, and practices of PMPs on TB control in an urban setting in Bangladesh in order to inform development of a public-private collaboration model.

Protocol for a mixed-methods realist evaluation of a health service user feedback system in Bangladesh

Introduction Responsiveness to service users’ views is a widely recognised objective of health systems. A key component of responsive health systems is effective interaction between users and service providers. Despite a growing literature on patient feedback from high-income settings, less is known about effectiveness of such systems in low-income and middle-income countries. Methodology and analysis This paper disseminates the protocol for an 18-month ‘RESPOND’ project that aims to evaluate the system of collecting and responding to user feedback in Bangladesh. This mixed-method study uses a realist evaluation approach to examine user feedback systems at two Upazila health complexes in Comilla District of Bangladesh, and comprises three steps: (1) initial theory development; (2) theory validation; and (3) theory refinement and development of lessons learnt. The project also uses (1) process evaluation to understand causal mechanisms and contexts of implementation; (2) statistical analysis of patient feedback to clarify the nature of issues reported; (3) social science methods to illuminate feedback processes and user and provider experiences; and (4) health policy and systems research to clarify issues related to integration of feedback systems with quality assurance and human resource management. During data analysis, qualitative and quantitative findings will be integrated throughout to help achieve study objectives. Analysis of qualitative and quantitative data will be done using a convergent mixed-methods model, involving continuous triangulation of multiple data sets to facilitate greater understanding of the context of user feedback systems including the links with relevant policies, practices and programmes. Ethics and dissemination Ethics approvals were obtained from the University of Leeds and the Bangladesh Medical Research Council. All data collected for this study will be anonymised, and identifying characteristics of respondents will not appear in a final manuscript or reports. The study findings will be presented at scientific conferences and published in peer-reviewed journals.

Smokeless tobacco and public health in Bangladesh

Despite the high prevalence of smokeless tobacco (SLT) use among adults in Bangladesh, SLT was not included in the Tobacco Control Law till 2013. Information on SLT use among Bangladeshi people is inadequate for policymaking and implementing effective control measures. With the aim to identify the prevalence and trends of different SLT products, health and economic impacts, manufacture, and sale of and policies related to SLT in Bangladesh, we carried out a literature review, which involved literature search, data extraction, and synthesis. Evidence suggests that in Bangladesh, SLTs range from unprocessed to processed or manufactured products including Sada Pata, Zarda, Gul, and Khoinee. Over 27% of Bangladeshi adults aged 15 years and older use SLT in one form or other. SLT use is associated with age, sex, education, and socioeconomic status. SLT consumption has reportedly been associated with increased prevalence of heart diseases, stroke, and oral cancer and led to around 320,000 disability adjusted life years lost in Bangladesh in 2010. No cessation service is available for SLT users in public facilities. Compared to cigarettes, taxation on SLT remains low in Bangladesh. The amendment made in Tobacco Control Law in 2013 requires graphic health warnings to cover 50% of SLT packaging, ban on advertisement of SLT products, and restriction to sale to minors. However, implementation of the law is weak. As the use of SLT is culturally accepted in Bangladesh, culturally appropriate public awareness program is required to curb SLT use along with increased tax and cessation services.

Behaviour change interventions to reduce second-hand smoke exposure at home in pregnant women – a systematic review and intervention appraisal

BackgroundSecond-hand smoke (SHS) exposure during pregnancy is associated with poor pregnancy and foetal outcomes. Theory-based behaviour change interventions (BCI) have been used successfully to change smoking related behaviours and offer the potential to reduce exposure of SHS in pregnant women. Systematic reviews conducted so far do not evaluate the generalisability and scalability of interventions. The objectives of this review were to (1) report the BCIs for reduction in home exposure to SHS for pregnant women; and (2) critically appraise intervention-reporting, generalisability, feasibility and scalability of the BCIs employed.MethodsStandard methods following PRISMA guidelines were employed. Eight databases were searched from 2000 to 2015 in English. The studies included used BCIs on pregnant women to reduce their home SHS exposure by targeting husbands/partners. The Workgroup for Intervention Development and Evaluation Research (WIDER) guidelines were used to assess intervention reporting. Generalisability, feasibility and scalability were assessed against criteria described by Bonell and Milat.ResultsOf 3479 papers identified, six studies met the inclusion criteria. These studies found that BCIs led to increased knowledge about SHS harms, reduction or husbands quitting smoking, and increased susceptibility and change in level of actions to reduce SHS at home. Two studies reported objective exposure measures, and one reported objective health outcomes. The studies partially followed WIDER guidelines for reporting, and none met all generalisability, feasibility and scalability criteria.ConclusionsThere is a dearth of literature in this area and the quality of studies reviewed was moderate to low. The BCIs appear effective in reducing SHS, however, weak study methodology (self-reported exposure, lack of objective outcome assessment, short follow-up, absence of control group) preclude firm conclusion. Some components of the WIDER checklist were followed for BCI reporting, scalability and feasibility of the studies were not described. More rigorous studies using biochemical and clinical measures for exposures and health outcomes in varied study settings are required. Studies should report interventions in detail using WIDER checklist and assess them for generalisability, feasibility and scalability.Trial registrationCRD40125026666.