ARK Foundation

IntroductionRapid urbanisation in Bangladesh has posed significant challenges to the urban health system, particularly in the delivery of primary healthcare (PHC). The country’s PHC system is fragmented, involving public, non-government organization (NGO), private and informal providers, leading to inequitable access, high out-of-pocket expenditure and inefficiencies. Strategic purchasing, which links resource allocation to health priorities and outcomes, offers a potential pathway to strengthening urban PHC systems. This study aims to assess the current urban PHC system, examine stakeholders’ perspectives on the feasibility of strategic purchasing, understand community health needs and preferences and develop a policy framework for strategically purchasing PHC services in urban settings.Method and analysisThis study will follow a sequential mixed-methods approach, integrating qualitative and quantitative data. A scoping review will be conducted to assess the characteristics and funding modalities of the existing urban PHC purchasing mechanisms. Key informant interviews with stakeholders, including policy makers and health experts, will explore the strengths and challenges of the current urban PHC system and the feasibility of implementing strategic purchasing. Community healthcare needs and preferences will be examined through in-depth interviews (IDIs), focus group discussions (FGDs) and a discrete choice experiment (DCE) survey in urban informal settlements. Insights from IDIs and FGDs will inform the DCE survey, which will present hypothetical scenarios to participants to identify the most important attributes for improving PHC services. Qualitative data will be coded deductively and inductively, and DCE data will be analysed using latent class models, with sensitivity analyses conducted using the multinomial logit model. Findings will contribute to the development of a strategic purchasing framework, validated through consultation workshops with health system stakeholders.Ethics and disseminationEthical approval has been obtained from the ethics committees in both Bangladesh and the UK. Findings will be disseminated through workshops, peer-reviewed publications, policy briefs and conference presentations.

Arteriovenous Malformations (AVM) can present themselves in an ample clinical spectrum. They worsen over time, creating local complications such as ulceration, destruction, infection, pain, and severe bleeding. Small focal AVMs can effectively be cured by surgery and/or endovascular techniques, whereas larger ones are of difficult management. Accordingly, S3 AVMs (according to SECg staging) are particularly troublesome. Here, endovascular treatment is only episodically curative while surgery leads to significant structural and functional damage. Electrochemotherapy is an established means to manage selected neoplasms. Recently it was successfully used to treat sclerotherapy-resistant or extensive low-flow vascular malformations (electrosclerotherapy, EST). EST was only anectodically tried with AVMs. A conventional EST is unlikely to effectively have an AVM responding. We conceived the Modified EST (MEST) protocol and started a pilot study. Modification of conventional EST was done by administering bleomycin locally, under ultrasound guidance, in the tissues around the nidus. After 8min, electroporation was started and covered the entire involved area. MEST was adopted in 10 patients with S3 AVMs of the cervicofacial region. Most patients received 2 sessions of MEST. The response was significant, and the patients all had a complete or near-complete reduction in the size of the AVM. Excellent aesthetic results were achieved. On follow-up imaging the AVMs were not detectable. Side effects were minor and easily managed. Results were stable. The results of the present study suggest that MEST may be the treatment of choice in selected AVMs. However, a longer follow-up is needed to further evaluate the risk of recurrence.

Introduction: People with tuberculosis (TB) who continue to smoke are more likely to have poor health outcomes than those who quit. Established smoking cessation approaches such as mHealth may help TB patients quit smoking. This paper summarises the methodology proposed to assess the effectiveness and cost-effectiveness of mTB-Tobacco (an mHealth intervention) in helping TB patients stop smoking and have improved health outcomes. Methods and analysis: A two-arm, parallel, open-label, multi-centre, cluster randomised, two-stage adaptive design trial is proposed to first evaluate the superiority of mTB-Tobacco, compared with usual care and then the non-inferiority of mTB-tobacco compared with face-to-face behaviour support. Study settings include TB treatment centres in Bangladesh and Pakistan. The study population includes adult patients, newly diagnosed (within four weeks) with pulmonary TB disease, daily smokers, willing to quit, and have access to mobile phones. The primary outcome includes biochemically verified continuous smoking abstinence assessed at 6 months per Russell Standard. A generalised linear mixed-effects model will be used to assess the impact of mTB-Tobacco intervention on continuous outcomes, incorporating fixed effects for the intervention, random effects for clusters, and relevant covariates. Cost-effectiveness analysis will be done to estimate the cost per quitter and cost per QALY gained, calculate the incremental cost-effectiveness ratios (ICER) to establish the value for money for mTB-Tobacco. Ethics and dissemination This trial will be conducted in compliance with ICH-GCP guidelines and the Declaration of Helsinki. The study has been approved by the ethics committees of the University of Edinburgh Medical School Research Ethics Committee (EMREC) of UK, the Bangladesh Medical Research Council (BMRC) and the National Bioethics Committee (PMRC) of Pakistan. Funding: The study is funded by the National Institute of Health Research (NIHR) UK under a research award named NIHR Global Health Research Unit on Respiratory Health (RESPIRE) (Award ID: NIHR132826)

BackgroundMental disorders remain the most significant contributor to years lived with disability in South Asia, yet governmental health expenditure on mental health in South Asia remains very low with limited strategic policy development. To strengthen the case for action it is important to better understand the profound economic costs associated with poor mental health. Methods: We conducted a systematic review on the costs of all mental disorders, as well as intentional self-harm and suicide, in the World Bank South Asia Region. Ten global and South Asian databases as well as grey literature sources were searched. Results: 72 studies were identified, including 38 meeting high quality criteria for good reporting of costs. Of these, 27 covered India, five Pakistan, four Nepal and three Bangladesh and Sri Lanka. Most studies focused on depressive disorders (15), psychoses (14) and harmful alcohol use (7); knowledge of economic impacts for other conditions was limited. Profound economic impacts within and beyond health care systems were found. In 15 of 18 studies which included productivity losses to individuals and/or carers, these costs more than outweighed costs of health care. Conclusion: Mental disorders represent a considerable economic burden, but existing estimates are conservative as they do not consider long-term impacts or the full range of conditions. Modelling studies could be employed covering longer time periods and more conditions. Clear distinctions should be reported between out-of-pocket and health system costs, as well as between mental health service-specific and physical health-related costs.

IntroductionThe Illicit Tobacco Trade (ITT) subverts tobacco control efforts. Cigarette packs sold without legal health warnings undermine efforts to warn the public about the dangers of tobacco. Furthermore, cigarettes sold below minimum retail prices are indicative of tax evasion leading to revenue loss and budgetary deficits in high tobacco-burden economies. The extent of the ITT in rural areas of such countries might differ from urban. We estimated the extent of illicit cigarette sales in selected rural areas of Pakistan.Aims and MethodsWe analyzed cigarette packs collected from 85 villages in Pakistan as part of a cross-sectional consumer survey of 2550 rural households. We classified cigarette packs as noncompliant if these were missing: A text health warning, pictorial health warning (PHW), underage sale prohibition warning, retail price, or manufacturer details. To measure the extent of tax evasion, we estimated the proportion of packs purchased below the legal minimum retail price.ResultsOnly 35% (429/1228) of rural smokers were able to show their cigarette packs. Out of these, 89% (382/429) of packs were noncompliant with the cigarette packaging and labeling laws. In rural areas, 83% (357/429) of packs did not have PHW and 33.8% (145/429) did not have printed retail prices. Among all packs, 41% (177/429) were purchased below the minimum retail price of 63 Pakistani Rupees and hence highly likely to have evaded taxes.ConclusionsWe found a very high previously unreported proportion of noncompliant cigarette packs in selected rural areas of Pakistan indicating weaker implementation of tobacco control laws in rural areas.ImplicationsThis paper presents previously unreported estimates of the share of illicit cigarette sales in rural areas of Pakistan. Most packs (89%) in our sample were noncompliant with the packaging and labeling regulations and a significant proportion (41%) were purchased below the minimum price. The extent of illicit tobacco was found to be far greater in rural than in urban areas of Pakistan. Taking advantage of poor law enforcement, the tobacco industry may be complicit in flooding the rural markets with illegal and cheap cigarettes. Given this disparity, law enforcement authorities must focus on rural areas.

Exposure to secondhand smoke (SHS) risks children's health. However, biomarkers are rarely used to study SHS exposure among children in low- and middle-income countries. We analyzed cross-sectional data collected between March and November 2022 for a cluster-randomized controlled trial investigating a Smoke-Free Intervention in 2769 children aged 9-15 in 74 schools (34 in Dhaka, Bangladesh, and 40 in Karachi, Pakistan). Children's saliva was tested for the concentration of cotinine-a highly sensitive and specific biomarker for SHS exposure. Based on their reports, children's homes were categorized as Nonsmoking Homes (NSH) when residents were nonsmokers; Smoke-free Homes (SFH) when residents and visitors smoked outdoors only; and Smoke-permitted Homes (SPH) when either residents or visitors smoked indoors. We compared cotinine concentrations across these home types and the two cities using a proportional odds model. Overall, 95.7% of children (92% in Dhaka; and 99.4% in Karachi) had cotinine levels between 0.1 and 12 ng/mL, indicating SHS exposure. Median cotinine levels were higher in Karachi (0.58 ng/mL, IQR 0.37 to 0.93) than in Dhaka (0.27 ng/mL, IQR 0.16 to 0.49). Median cotinine concentration was also higher among children living in SPH than those in either NSH or SFH; with absolute differences of approximately 0.1-0.3 and 0.05 ng/mL, respectively. The level of SHS exposure in Dhaka and Karachi indicates widespread and unrestricted smoking. Smoking restrictions in households and enforcement of smoking bans are urgently needed. The high levels of SHS exposure in children living in SFH suggest parental behavior to hide their smoking and/or exposure in private vehicles or public spaces. It is important to advocate for SFH and cars to protect children from SHS exposure. However, these initiatives alone may not be enough. There is a need to enforce smoking bans in enclosed public places and transportation, as well as extend these bans to playgrounds, parks, fairgrounds, and other public spaces that children frequently visit. It is essential to complement smoking restrictions with tobacco cessation advice and support in these settings.

Fascioliasis is one of the most common foodborne zoonotic infection of ruminants in Bangladesh. To estimate the prevalence and associated risk factors of fascioliasis and extent of liver damage, 825 livers of sheep and goats were randomly inspected during onsite slaughterhouse visiting in Naogaon, Natore, Rajshahi and Joypurhat districts. The overall prevalence of fascioliasis was 25.09% and significantly (P = 0.008) higher in goats (26.11%) than sheep (24.00%). During gross inspection, Fasciola infected livers were increased in size, fibrosed, fatty, multiple white or reddish necrotic foci on the parietal surface, hard to cut, calcified, and numerous mature and immature flukes were also observed. In histoarchitecture, inflammatory cell infiltration in the hepatic parenchyma and periportal area, fibrous connective tissue proliferation around necrotic area, hyperplastic bile duct, congestion, and primary biliary cirrhosis were seen in acute and chronic fascioliasis. Epidemiological investigations revealed that fascioliasis was higher in goats than sheep. Age, sex, BCS and season were found to have statistically significant associations with fascioliasis in goats. In case of sheep, age (OR = 5.8671; 95% CI: 2.9482-11.6757, P < 0.0001), sex (OR = 3.7317; 95% CI: 1.9052-7.3094, p < 0.0001), BCS (OR = 6.0346; 95% CI: 1.7986-20.2472, p < .0001), and season (OR = 8.2308; 95% CI: 3.9922-16.9693, p = < .0001) were also found to have statistically significant associations with fascioliasis. Results of the study can help for molecular epidemiology of fascioliasis in small ruminants to plan fluke control programs for safe food production.

The Meghna River estuary (MRE) and Tetulia River estuary (TRE) are tropical estuaries on the middle coast of Bangladesh. Hilsa shad (Tenualosa ilisha), is one of the most important anadromous fish (ascending rivers from the sea for breeding), migrates into the Meghna and Tetulia River estuarine systems from the Bay of Bengal. This study assessed the spawning and nursery habitats of hilsa in the Tetulia and Meghna River estuaries by examining the environmental parameters of both estuarine ecosystems. Water samples were collected from nineteen selected sampling sites along and across the estuaries from January to December 2021 covering both the dry and wet seasons. Salinity, dissolved inorganic nitrogen (DIN), and dissolved inorganic phosphorus (DIP) concentration varied significantly (p &lt; 0.05) between the MRE and TRE during the dry season. In contrast, no significant variation (p &gt; 0.05) was observed in the salinity, DIN and DIP between the MRE and TRE during the wet season. In addition, no significant variation (p &gt; 0.05) was observed in chlorophyll-a concentration between the MRE and TRE during the dry and wet seasons. The salinity tolerance range is an important driver for the spawning (salinity &lt;0.1 psu) and nursery (salinity &lt;0~2 psu) habitat of hilsa. This study explored that the TRE is suitable for spawning and nursery habitat (salinity &lt;0.09 psu) for hilsa all year round because the TRE acts as a freshwater ecosystem (salinity &lt;0.1 psu) annually. Therefore, the government should focus on protecting and conserving juvenile hilsa (jatka) and brood hilsa in the TRE year round. Ann. Bangladesh Agric. (2023) 27 (1): 57-69

The improper handling of poultry litter and waste poses risks to humans and environment by introducing certain compounds, elements, and pathogenic microorganisms into the surrounding environment and food chain. However, understanding the farmers' knowledge, attitude, and practices (KAP) could provide insights into the constraints that hinder the appropriate adoption of waste management. Therefore, this study aimed to assess poultry farmers' KAP regarding waste management issues. A cross-sectional KAP study was conducted with native poultry keepers and small-scale commercial poultry farmers in seven districts of Bangladesh. In the survey, 385 poultry producers were interviewed using validated structured questionnaires through face-to-face interviews to collect the quantitative data in their domiciles. The overall KAP of farmers regarding poultry waste management issues demonstrated a low level of KAP (p = 0.001). The analysis shows that roughly 5% of farmers have a high level of knowledge of poultry waste management issues, followed by around one-third of respondents having a moderate level of knowledge. Considering the attitude domain, more than one-fifth of native poultry keepers and nearly two-thirds of commercial producers demonstrated a low level of attitude toward poultry waste management. Considering the overall analysis, roughly half of the respondents found a high level of attitude, and over half of the farmers showed a moderate level of attitude toward poultry waste management issues. The analysis showed that the level of good practices for native and commercial poultry production systems is estimated at 77.3% versus 45.9%, respectively, despite the farmers' lesser knowledge and attitudes toward poultry waste management systems. Overall, analysis showed that nearly 60% and 40% of poultry producers had high and moderate levels, respectively, of good practices in poultry waste management issues. Analysis of the KAP data shows that farmers had a low level of KAP toward poultry waste management. The result of this study will assist in formulating appropriate strategies and to adopt poultry waste management solutions by poultry farmers to reduce environmental degradation.

Karang Jeruk is one of the destinations for coral reef ecosystems in Tegal Regency. This study aimed to determine the growth and growth rate of branched coral Acropora transplanted using the biorock® method in Karang Jeruk Waters, Tegal Regency. The method used in this research is the method of experimentation and observation. It is then analyzed through the t-Students test using SPSS version 16. Based on the research results, the absolute growth of Acropora coral at the biorock® station was more significant than the absolute growth at the control station, both for height and diameter or significantly difference. It can be seen that the absolute height growth at the biorock® station is 44.9750 ± 15.3901 mm, while at the control station, 2.1675 ± 0.6726 mm, and the absolute diameter growth at the biorock® station is 0.8350 ± 0.2177 mm while at the control station 0 .2025 ± 0.0835 mm. The growth rate of Acropora coral at the biorock® station was faster than the growth rate at the control station, both for height and diameter. It can be seen that the high growth rate at the biorock® station is 11.2438 ± 3.8475 mm month-1, while at the control station, 0.5419 ± 0.1682 mm month-1, and the diameter growth rate at the biorock® station is 0.2088 ± 0.0544 mm month-1 while at the control station 0.0506 ± 0.0209 mm month-1.