Thesis/ Project Report, Master of Public Health (James P. Grant School of Public Health)

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Open Access
Assessment of vitality and locomotor capacity among older adults in rural Bangladesh: A cross-sectional study
(BRAC University, 2026-05) Arni, Saima Ahmed; Mridha, Malay Kanti; BRAC James P Grant School of Public Health
Background: Population ageing is accelerating in Bangladesh, with 9.5% of people now aged 60 years or above, and this proportion is expected to rise to 22% by 2050. The WHO Integrated Care for Older People (ICOPE) framework identifies vitality and locomotor capacity as two foundational domains of intrinsic capacity (IC) in older adults. Impairment in these domains leads to loss of independence, increased disability, and a heavier burden on health systems. Community-level evidence on these domains from rural Bangladesh is almost completely absent. Objectives: To assess the status of vitality and locomotor capacity among community-dwelling older adults aged ≥ 60 years in rural Bangladesh and identify associated factors with impairments. Methods: A community-based cross-sectional study was conducted from January to May 2026 among 402 older adults in Sujalpur Union, Birganj, Dinajpur, Bangladesh. Simple random sampling was employed. Vitality was assessed using the Mini Nutritional Assessment Short Form (MNA-SF); a score of ≤11 indicated impairment. Locomotor capacity was assessed using the Short Physical Performance Battery (SPPB) chair stand test; a time of ≥12 s (AWGS 2019 cut-off) indicated impairment. Data on sociodemographic, behavioral, dietary, clinical, and functional characteristics were also collected. Chi-square tests were used for bivariate analysis and binary logistic regression was used to identify associated factors. Results: The mean age of the surveyed older adults was 68.3 (±6.0) years, and 54% were male. The prevalence of impaired vitality was 75.1% (n=302), and that of impaired locomotor capacity was 35.3% (n=142). In the multivariable analysis, older age (aOR: 1.07, 95% confidence interval [CI], 1.02–1.12) and female sex (aOR, 2.60; 95% CI, 1.44–4.68) were associated with higher odds of impaired vitality, whereas food security (aOR, 0.27; 95% CI, 0.14–0.51) and highest wealth tertile (aOR, 0.50; 95% CI, 0.27–0.91) were protective. For locomotor capacity, older age (aOR: 1.08, 95% CI: 1.04–1.13), female sex (aOR: 2.40, 95% CI: 1.31–4.42), and cognitive decline (aOR: 1.89, 95% CI: 1.17–3.04) increased the odds of impairment, whereas adequate physical activity (aOR: 0.43, 95% CI: 0.26–0.73) was protective. Conclusions: Three in four rural older adults had impaired vitality, and more than one in three had impaired locomotor capacity, with older women at the greatest risk. Food insecurity, poverty, physical inactivity, and cognitive decline were the most important modifiable factors. Integrating ICOPE-based screening into primary healthcare in Bangladesh can enable early detection and targeted interventions to preserve the functional independence of older adults.
Open Access
Seasonal variation of depression among male and female adults and their mental health perception of extreme heat in Niamatpur, Naogaon: A mixed-methods study
(BRAC University, 2026-06) Masud, Sinthia; Misha, Farzana; BRAC James P Grant School of Public Health
Background: Extreme heat has an effect on mental health. However, the seasonality of depression among adults and their perceptions of mental health effects are yet to be explored in the Barind area of Bangladesh. Furthermore, targeted intervention requires exploration of mental health program implementation barriers and facilitators. Objectives: The study aims to compare the seasonality of depression by gender and occupation, explore perceptions and coping strategies of mental health effects during extreme heat, and identify barriers and facilitators of implementing the BHP mental health program in Niamatpur, Naogaon. Methods: A mixed-method study was conducted among adults in Niamatpur, Naogaon, Bangladesh. Round-wise secondary data of the BHP surveillance project was used to observe seasonal depression patterns. Qualitative exploration is based on purposive sampling of 12 In-Depth Interviews (IDIs) and 5 Key Informant Interviews (KIIs). Quantitative data was analyzed using StataNow/BE 18.5 and descriptive statistics was used to present frequency and percentage. Thematic analysis of qualitative data was done using both inductive and deductive coding. Results: Depression of adults increased from 8.1% in winter to 12.5% in summer. Females had higher prevalence in both rounds and almost doubled (16%) than males (8.3%) in summer. For all occupations depression notably increased in summer. Extreme heat is mostly normalized although it significantly affects the mental health of outdoor workers (farmers, day labourers) and women for their working environment and gendered role. Conclusions: Heat is a mental health concern for the vulnerable adults and women and outdoor workers bear the disproportionate burden. The findings have notable implications for public health policy, mental health programme design, and future research in the contexts of heat-vulnerable adult populations.
Open Access
Enhancing climate-resilient primary health care: A mixed-method implementation research on JAMUNA-supported community clinic in Bogura and Sirajganj districts, Bangladesh
(BRAC University, 2026-06) Emaa, Tamanna Munmun; Anwar, Humayra Binte; BRAC James P Grant School of Public Health
Background: Community clinics are the first point of contact for availing primary healthcare in rural Bangladesh. Every year climate stress hampers CC functionality, accessibility and often massive destruction of the CC infrastructure. To address this threat the JAMUNA project aims to make CC climate resilient. Considering the evidence gap on perceptions of implementors and providers, this study aimed to explore the perceived acceptability as well as the contextual factors influencing the implementation process in the climate vulnerable context. Objectives: This study aimed to assess and explore the acceptability of JAMUNA-supported community clinic rehabilitation among service providers and JAMUNA implementation staff, and to identify contextual barriers and facilitators influencing the implementation. Methods: This study used a mixed method implementation research design with convergent approach and was conducted in Bogura and Sirajganj, covering seven community clinics. Study participants were service providers at community clinics and JAMUNA implementation staff. Quantitative and qualitative sample size was 25 (census sampling) and 12 Key Informant Interviews using a (purposive sampling). Quantitative and Qualitative data were analyzed separately, using statistical software STATA version 17 and framework analysis method respectively. Quantitative and qualitative findings were integrated at the interpretation stage. Results: The quantitative findings reveal strong positive perceptions among both categories of stakeholders, with the mean AIM score of 19.48 out of 20. Acceptability remained high across all groups. The qualitative findings further explained the reasons for shaping this high acceptability across TFA domains. Strong satisfaction regarding the rehabilitation yielded by aesthetically pleasant, structurally improved and functionally beneficial infrastructure; clear understanding of the rehabilitation purpose prior to the initiative inauguration; consistent and nurtured mutual relationships throughout and even post rehabilitation; professionally aligned and exceeding expectations, as well as predicted long sustainability. While complete rehabilitation was perceived as highly climate responsive, participants from partially rehabilitated clinics reported persistent structural vulnerabilities, particularly flood risk at the low-lying clinic premises; with consistent need for sufficient human resources, logistics and equipment. The CFIR findings demonstrated that implementation was facilitated by flexible and context-suitable design, strong community ownership, strong commitment of the providers to continue service delivery at any situation, collaborative and well-planned implementation process, involving all stakeholders, strong co-ordination between providers and implementers and highly experienced and contextually adapted implementing staff. However, the findings also highlighted important implementation barriers, such as infrastructure gaps especially in partially rehabilitated design, capacity restriction because of resource constraints and training gaps, challenges to smooth implementation driven by local as well as environmental barriers. Conclusions: This study reveals that despite high acceptability, implementation outcome can be affected by contextual factors. Without addressing contextual vulnerability, infrastructure upgrade alone cannot be enough for continued and sustained service provision.
Open Access
Exploring newborn care practices at facility and home in urban Dhaka, Bangladesh
(BRAC University, 2026-06-02) Khatun, Azima; Afsana, Kaosar; BRAC James P Grant School of Public Health
Background: Neonatal mortality remains a major global public health concern, with approximately 2.3 million newborn deaths occurring during the first month of life in 2024, many of which were preventable through timely and appropriate Essential Newborn Care (ENC). Recommended ENC practices, including thermal care, early initiation of breastfeeding, hygienic cord care, skin-to-skin contact, and early recognition of danger signs, are crucial for reducing neonatal morbidity and mortality. Despite progress in maternal and child health in Bangladesh, neonatal morbidity and mortality remain high, particularly in urban areas where rapid urbanization, overcrowding, socio-economic disparities, and gaps in newborn care practices continue to affect newborn survival. Limited qualitative evidence exists on caregivers’ knowledge, perceptions, practices, and health system factors influencing newborn care in urban settings, highlighting the need for context-specific research to improve newborn health outcomes. Objectives: The study aimed to explore comprehensive newborn care practices from health facilities to the community level in urban Dhaka by examining community and health system factors influencing newborn care. Specifically, the study explored mothers’ knowledge, perceptions, and practices regarding essential newborn care and identified and explained the factors influencing newborn care practices in both health facility and home settings. Methods: A qualitative study using a focused ethnography design was conducted from January to April 2026 in the Maternal and Child Health Training Institute (MCHTI), Azimpur, and the Kamrangirchar urban slum area in Dhaka, Bangladesh. The study population included hospital-delivered mothers, community women, family caregivers, healthcare providers, and health managers involved in newborn care. Purposive sampling was used to recruit participants who could provide in-depth information on newborn care practices and experiences. A total of 66 participants and observations were included, comprising 20 in-depth interviews (IDIs), 2 focus group discussions (FGDs), 6 key informant interviews (KIIs), and 20 non-participant observations. Data were collected using semi-structured interview guides and observation checklists. All interviews and discussions were audio-recorded, transcribed, and translated into English, and observation notes were elaborated on the same day and finally analyzed manually using thematic analysis. Both deductive and inductive coding approaches were applied to identify key themes and patterns. Data triangulation across IDIs, FGDs, KIIs, and observations enhanced the credibility and validity of the findings. Results: Findings showed that mothers had fragmented and limited knowledge regarding cord care, thermal care, breastfeeding, immunization, and newborn danger signs, with many depending on healthcare providers and family members for guidance. Early breastfeeding, skin-to-skin contact, and recommended cord care practices were inconsistently practiced, while traditional beliefs and socio-cultural influences continued to shape newborn care behaviours, particularly in home settings. Observational findings also revealed gaps between reported guideline-based care and actual practices in health facilities, where informal staff often managed immediate newborn care. Health system barriers, including shortages of trained staff, medicines, equipment, and inadequate infrastructure, further affected the quality of newborn care services. Despite these challenges, mothers expressed positive attitudes toward facility delivery and a strong interest in receiving more counselling and guidance on newborn care. Healthcare providers also emphasised the need for improved training, adequate staffing, better logistics, and strengthened neonatal care services, including NICU support. Conclusions: Mothers valued newborn care but had limited knowledge of essential newborn care practices. Socio-cultural beliefs and health system barriers, including shortages of trained staff and resources, affected proper newborn care. Improving and strengthening neonatal healthcare services reinforced by quality and community-based care are essential to achieving better newborn health outcomes.
Open Access
Implementation fidelity of heat-mitigation infrastructure interventions in primary schools in selected climate-vulnerable districts of Bangladesh: A mixed-method study
(BRAC University, 2026-06) Adhikari, Asmita; Hasan, Md Tanvir; BRAC James P Grant School of Public Health
Background: Climate change is driving more frequent and intense heatwaves across South Asia, with children often experiencing the worst impacts. In low-income community settings of climate-vulnerable districts in Bangladesh, classrooms are often equipped with single-layer iron-tin roofs that frequently overheat, harming children's health, concentration, and learning. Passive cooling interventions such as solar-reflective paint (SRP) and bamboo ceilings with polyethylene foam (BCPF) are promising low-cost, electricity-free solutions. However, there is limited evidence regarding their effectiveness in reducing classroom temperatures and improving the health and well-being of children. Objectives: The objective of this study was to assess the implementation fidelity of SRP and BCPF interventions in 69 BRAC primary schools in the Kurigram and Gaibandha districts of Bangladesh. Specific objectives were to (i) measure fidelity levels for each intervention and (ii) identify school, implementer, and context-level factors influencing fidelity. Methods: A convergent parallel mixed-methods study was conducted nested within a pilot cluster randomised controlled trial. The pilot trial (parent study) assesses the impact of implementing the infrastructure interventions (SRP only, BCPF only, and combined) in 69 BRAC primary schools across eight sub-districts in Kurigram and Gaibandha districts of Bangladesh. The quantitative component of the study included 92 intervention-event observations (46 SRP + 46 BCPF) through structured observation checklists and a school-level questionnaire administered to monitoring officers (one per school) in 69 schools. The questionnaire and checklists were administered electronically via KoBoToolbox. Fidelity was operationalised across three dimensions, content adherence, coverage, and quality of delivery, using an adapted Carroll–Hasson fidelity framework. The qualitative component included conducting 15 key informant interviews with painters, carpenters, monitoring officers, and the project coordinator, who were purposively sampled across districts and intervention types. Quantitative analysis included descriptive statistics and hierarchical ordinary least squares (OLS) linear regression with Huber-White heteroscedasticity robust standard errors in which school readiness, implementer-level, and contextual determinants of composite fidelity were entered sequentially as nested blocks. Qualitative data were analysed thematically using a hybrid deductive–inductive approach guided by the Carroll–Hasson framework and the Theoretical Domains Framework. Integration of quantitative (fidelity dimensions and determinants) and qualitative (themes) findings followed a side-by-side joint display approach for data triangulation. Results: Mean composite fidelity was high for both interventions (SRP: 86.2%, SD = 6.4; BCPF: 88.8%, SD = 9.9). In both interventions, the fidelity dimensions ranked in the same order. Content adherence was the highest scoring dimension (SRP: 96.7%; BCPF: 92.2%); coverage was the second highest (SRP: 85.5%; BCPF: 91.3%); and quality of delivery was lowest in both interventions (SRP: 76.6%; BCPF: 82.9%). Qualitative findings showed that intensive supervision, structured training, community engagement, and adaptive responses to weather disruption helped maintain implementation fidelity for both interventions. However, inconsistent use of personal protective equipment (PPE) is identified as a major challenge affecting the quality-of-delivery dimension. This inconsistency accounted for a lower fidelity score on this dimension. Conclusions: SRP and BCPF were implemented with high implementation fidelity in tin-shed primary schools in climate-vulnerable districts of Bangladesh, showing potential as low-cost, electricity-free heat-mitigation strategies. Enhancing the use of PPE among intervention implementation workers remains the main area for strengthening fidelity. Key elements that supported successful implementation in this pilot, such as strong supervision, flexibility in managing structural repairs, and weather-adaptive practices, should be maintained during scale-up. The findings provide practical evidence for BRAC, the government of Bangladesh, and other partners scaling climate-resilient infrastructure. Additionally, it contributes a replicable three-dimensional fidelity assessment framework applicable to other physical-construction interventions.
Open Access
Entrepreneurs as health-promoting agents: Community engagement for sustaining maternal and child nutrition practices within the Healthy Village In Urban Programme
(BRAC University, 2026-06) Gurung, Rohan; Ireen, Santhia; BRAC James P Grant School of Public Health
Background: Amongst the urban poor population in Bangladesh undernutrition of children and mothers remains an important public health concern where progression of care is restricted by high mobility, fragmented health services and socioeconomic constraints. Sustaining behaviour changes in these contexts relies not just on spreading of information but also on effective community-based strategies which facilitate change in the localities. Objectives: This study aimed to understand how entrepreneurial Health-Promoting Agents engage with communities to support and sustain maternal and child nutrition practices within HVUP intervention areas. Specifically, it explored how Health Promoting Agents (HPAs) build and maintain relationships with community members and identified social, economic, and contextual factors influencing sustained engagement. Methods: An exploratory qualitative study was conducted in selected urban and peri-urban areas of Lalmonirhat district under Max Foundation’s Healthy Village in Urban Programme (HVUP). The study population included HPAs, mothers/caregivers of children under five, and ESDO program staff who are implementing the project in field. A total of 24 participants were selected using purposive sampling. In-depth interviews (IDIs) with HPAs and mothers, and key informant interviews (KIIs) were conducted with program personnel. Data were collected through semi-structured interviews, audio-recorded with consent, and complemented by a desk review of program documents. Transcripts were analysed using reflexive thematic analysis with an inductive-deductive coding approach to identify key themes related to community engagement, trust-building, and sustainability. Results: Successful HPA involvement in the community was decided by the relationship with the community was developed slowly by establishing a sense of trust with the mothers. Regular communication, positive experience and perceived good guidance from HPA was key in development of trust. Moreover, HPAs' confidence and efficacy in community interactions were improved through training, applying knowledge and skills from prior experience, and continuous supervision by programme staff. By combining localized health education, improved service delivery through system linkage, and training for entrepreneurship, HPAs played a variety of roles that enhanced their relevance and long-term involvement. Program sustainability and motivation were particularly substantiated through the incorporation of entrepreneurship. Mothers reported noticeable behavioural improvements that progressively emerged through trust and reinforcement, especially in hygiene and childcare routines. Conclusions: From this study, we can see that consistent presence, self-sustaining mechanisms, trust-building, and supporting program frameworks are key components of entrepreneurial HPAs' long-term community engagement. Their strong presence promotes behaviour change within the community, while providing better access to services. These results emphasize the benefits of establishing entrepreneurial community-based models to enhance long-term maternal and child nutrition outcomes and strengthen urban primary health care methods.
Open Access
Diagnostic delay and initial healthcare-seeking pathways in childhood cancer: A cross-sectional study at the National Institute of Cancer Research and Hospital, Dhaka, Bangladesh
(BRAC University, 2026-06) Das, Siddhartha Sankar; Ahmed, Syed Masud; BRAC James P Grant School of Public Health
Background: In Bangladesh approximate 9000 cases of childhood cancer are diagnosed each year; however, however, only 5% of them receive treatment. Over 80% of children with cancer are not diagnosed or appropriately treated in Bangladesh, highlighting the need to investigate diagnostic delays and health-seeking pathways. Objectives: To identify the factors associated with diagnostic delay among childhood cancer patients in Bangladesh and to assess how caregiver’s initial healthcare-seeking pathways influence the time to diagnosis. Methods: A cross-sectional quantitative study was conducted from January, 2026 to June, 2026. Face-to-face interviews were done with the primary caregivers of childhood cancer patients admitted at the in-patient department of the pediatric hematology and oncology, National Institute of Cancer Research and Hospital, using Kobo Toolbox and 152 data were collected. Non-parametric tests (Mann-Whitney U and Kruskal-Wallis tests) were used to test and find association between independent variables and outcome variable (total interval) while the data was summarized by descriptive statistics. Data analysis was performed using STATA version 17 software, and p-values <0.05 were considered statistically significant. Institutional Review Board of BRAC James P Grant School of Public Health, BRAC University (IRB Ref: MPH-2025-009) approved the study and written informed consent was obtained from all participants. Results: The median total interval (time from symptom recognition to confirmed diagnosis) was 91 days (IQR: 52.5-188.5 days). The diagnostic interval was the major component of delay (median: 82.5 days, IQR: 44.2-149.7), while the patient interval was short (median: 2 days, IQR:1-7 days). Significant difference in diagnostic delay was observed across cancer types, with longer intervals for retinoblastoma (234 days), CNS tumors (145 days) and bone tumors (121 days), compared to renal tumors (35 days) and leukemia (65 days). There was a significant relationship between the total interval and family income, with the lowest income group having a median interval of 105 days and the highest income group having a median interval of 23 days (p = 0.030). Longer intervals were significantly associated prolonged time interval between first and subsequent healthcare visits (p = 0.0001), multiple healthcare facility visits (p= 0.002), and higher pre-diagnostic expenditure (p=0.002) Higher proportions of delay was associated with care pathways, where informal sector providers were the first point of contact. Conclusions: Diagnostic delay in childhood cancer patients is primarily influenced by health-system barriers, alongside socio-demographic and clinical factors. The findings suggest the need to strengthen referral system across care continuum that will allow early recognition of symptoms and timely diagnosis of cancer. Integrating referral support, reducing financial obstacles, training of frontline healthcare providers, decentralizing pediatric oncology services may help to reduce the diagnostic delay.
Open Access
The role of parental communication, gender norms, and adolescent menstrual health in Bangladesh: A secondary longitudinal analysis
(BRAC University, 2026-06) Silvia, Sadia Aktar; Hasan, Md. Tanvir; BRAC James P Grant School of Public Health
Background: Adolescent girls are a vulnerable group in terms of menstrual and reproductive health information and management. Around the world, many adolescent girls face social norms or stigma, taboo, gender norms, limited access to menstrual health information and negative attitudes from their family as well as the community. It directly affects their menstrual health and overall reproductive health, which shows a public health concern. Many research studies suggested that adolescent girls pursue their menstrual health-related education and training from their parents. Depending on their (guardians') knowledge, attitudes, and norms regarding menstruation, adolescent girls' perspectives can vary. As a result, this study aims to examine the changes in gender and social norms, menstrual knowledge and attitudes among guardians over time and how it changes the perception of their adolescent girls. Objectives: The main objective of this study was to examine the changes in parental gender social norms, knowledge and attitudes about menstrual & reproductive health from 2023 to 2025 and how these changes affected girls' perceptions. The specific objectives were: 1) to assess the changes in the outcomes over the years, 2) to assess the association between the outcomes and the socio-demographic status of guardians, 3) to determine the changes in their adolescent girls' perspectives and to see whether parental communication mediates the relationship between guardians' menstrual knowledge and girls menstrual health literacy. Methods: The study was conducted using secondary analysis of the Adolescent Menstrual Experiences and Health Cohort (AMEHC) study, a longitudinal research project currently being carried out in the sub-division of Khulna, Bangladesh. The AMEHC began with 2015 adolescent girls and their guardians in 2023 and continued till now (2026). This study focused on the baseline (2023) and wave 2 (2025) datasets of both guardians and girls. A longitudinal analysis was done using GSEM to examine how parental views on menstrual knowledge influence adolescent girls' perspectives. Additionally, a mediation analysis involving 1000 times bootstrapping iterations was performed to explore the pathways through which menstrual health information is transmitted from guardians to girls. Results: The mean age of the adolescent girls was 11.95 years (± 0.0206) at baseline. The result showed positive changes over time with progressive gender norms perception, reduced negative menstrual attitudes among guardians, but over the years, menstrual knowledge shifted into a lower category and social restriction increased among guardians (from baseline to wave 2). There was a significant association observed between the socio-demographic status of guardians and reducing gender (p<0.05) and social norms restrictions (p<0.05), improving a high level of menstrual knowledge (p<0.05) and increasing positive attitudes (p<0.05) on menstruation, except for religion. The longitudinal analysis revealed that gender norms (β= -0.45, SE= 0.03, p <0.05) reduced in wave 2 by 0.45 times from baseline, menstrual knowledge (β= 1.86, SE= 0.07, p <0.05) increased by 1.86 times and social norms (restrictive) increased by 9.48 times from 2023 to 2025 among adolescent girls. The results also showed significant changes in guardians' perceptions regarding gender norms (β= 0.10, SE= 0.02, p <0.05), menstrual knowledge (β= 0.13, SE= 0.06, p <0.05) and social norms (OR= 1.37, p<0.05) in relation to their girls. Moreover, mediation analysis showed that parental communication did not function as a potential mediator (β= 0.11, SE= 0.08, p = 0.172), but also guardians' menstrual knowledge did not associate with girls' menstrual health literacy (OR= 1.11, p = 0.106). Conclusions: Guardians are key individuals for the majority of adolescents to whom they can talk about their menstruation and reproductive health. And if mother-daughter communication is strong, it can impact on gaining better menstrual knowledge, attitudes and menstrual health management (MHM). When they can talk freely, this helps to reduce the gender norms restrictions and increase social acceptance by reducing stigma related to menstruation management. Policy makers and programme implementers should design programmes that emphasise parental involvement, address the root causes of stigma and promote an equitable society.
Open Access
Assessment of vision and hearing capacity of older adults: A cross-sectional study
(BRAC University, 2026-05) Roy, Ashish; Mridha, Malay Kanti; BRAC James P Grant School of Public Health
Background: Population ageing is associated with an increased burden of vision and hearing impairments, which significantly hampers the quality of life of older adults. Despite the substantial burden, no comprehensive assessment of vision and hearing has been conducted among older adults in Bangladesh. The Integrated Care for Older People (ICOPE) approach of the World Health Organisation was found to be effective and feasible for measuring the burden of vision and hearing with all other domains of intrinsic capacity. Objectives: This study aimed to assess the status of vision and hearing capacity of older adults (aged ≥ 60 years) and identify the factors associated with their impairments. Methods: This cross-sectional study was conducted in Sujalpur Union of Birganj, a sub-district of Dinajpur, Bangladesh. The total sample size was 402, and the sampling technique was simple random sampling. Data were collected through face-to-face interviews and anthropometric and other clinical measurements. Data analysis involved descriptive, bivariate, and regression analyses. Results: The prevalence of vision impairment was 95.77% (n=385). And the prevalence of only distant vision impairment was 76.62% (n=308). Age (aOR:3.59, 95% CI: 1.89 - 6.8, p <0.001), hypertension, and fruit and vegetable consumption (aOR: 2.24, 95% CI: 1.07 - 4.7, p 0.032) were significantly associated with distant vision impairment. On the other hand, the prevalence of hearing impairment was 6.72% (n=27). And the prevalence of hearing impairment in at least one ear was 15.67% (n=63). Age (aOR: 4.73, 95% CI: 2.54 - 8.81, p <0.001) and dietary diversity (aOR: 2.07, 95% CI: 1.05 - 4.08, p = 0.035) were significantly associated with hearing impairment in at least one ear. Conclusions: A high prevalence of vision and hearing impairment was observed among older adults in rural Bangladesh. The findings of this study highlight the need to integrate vision and hearing related care services into existing primary healthcare facilities. The associated factors of vision and hearing impairment identified in this study should be considered while developing interventions for older adults.
Open Access
Influence of WASH interventions by JAMUNA project on hygiene practices: Exploration of adoption of hygiene practices, availability and accessibility to WASH facilities among climate vulnerable char communities of Bogura, Bangladesh using mixed-methods implementation research
(BRAC University, 2026-06) Oo, Ye Naing; Anwar, Humayra Binte; BRAC James P Grant School of Public Health
Background: Access to safe water, sanitation and hygiene (WASH) services is a basic human right and fundamental for improving public health. Despite improvements in WASH services in Bangladesh, consistent hygiene practices and equitable access to WASH facilities remained challenging in disaster prone char areas. The JAMUNA Project implemented by Bangladesh Red Crescent Society aimed to improve WASH conditions and hygiene practices in vulnerable populations of Sariakandi Upazila, Bogura District. Objectives: To explore accessibility, adoption and accessibility of hygiene related WASH interventions and their influences on hygiene practices at the community level. Methods: A concurrent mixed-methods implementation research study was conducted in two unions of Sariakandi Upazila covered by the JAMUNA Project using CFIR framework. The study population included adult married men and women for the quantitative survey, and adult beneficiaries who had received WASH infrastructure support or were exposed to WASH interventions for the qualitative component. The sample size for the quantitative data collection was 85 participants, while qualitative data were collected through 8 IDI and 2 FGDs. Systematic random sampling method was applied for the survey data collection while purposive sampling was used for the qualitative data collection. The analysis was conducted using STATA MP 17.0 version for the quantitative and qualitative data were analyzed using framework thematic analysis. Results: Most households had access to improved sanitation facilities and improved water sources. However, inconsistent handwashing with soap at key times was observed. Handwashing after toilet use was more commonly practiced than before food preparation and eating. Access to a tube well did not ensure the presence of a functional handwashing facility. tationted space was identified as a main barrier to establishing handwashing facilities and participants described perception of maintaining the presence of soap and water availability at the facilities. Several households reported soap inside the latrine and soap availability at the handwashing facilities which facilitated handwashing practices. Practical demonstrations during courtyard sessions were identified as a facilitator for improving handwashing behaviours. In contrast, financial constraints such as initial procurement costs for latrine construction materials and delayed reimbursement were identified as key barriers, particularly among household with poor income. Conclusions: The study found high reported access WASH facilities and variable hygiene practices in the study areas. The JAMUNA Project interventions were perceived to support hygiene related practices, although gaps in consistent handwashing practices and access to basic handwashing facilities remained limited. The provision of soap or promotion of soap availability based on the community perceptions and existing practices, should be incorporated in future implementation. The reimbursement process should be revised to better reach the households with low income.
Open Access
Evaluating tuberculosis preventive treatment (TPT) outcomes, perspectives and implementation barriers: A mixed-methods study in BRAC covered areas under the Badda TB Diagnostic Center in Dhaka, Bangladesh
(BRAC University, 2026-06) Tun, Zin Min; Rahman, Ataur; BRAC James P Grant School of Public Health
Background and objectives: Tuberculosis (TB), a major global health problem, with Bangladesh occupying for 3.6% of the world's TB burden. While active case finding is common, scaling up Tuberculosis Preventive Treatment (TPT) is essential to eliminate the reservoir of potential cases. Currently, there is a significant gap in TPT coverage in Bangladesh, with only 32% of eligible household contacts starting treatment as of 2024. This study aimed to evaluate leakages in the TPT care cascade, compare the effectiveness of weekly (3HP) versus daily (3HR) treatment regimens and identify the barriers to successful implementation in urban Dhaka. Methods: A mixed-methods study was carried out at the Badda TB Diagnostic Center, analyzing data from five branch offices in Dhaka between January 2024 and December 2025. The quantitative component used a census of 3,341 household contacts to track the TPT care cascade and a matched-pair cohort of 278 participants to compare treatment completion. The qualitative component involved 12 in-depth and key informant interviews with household contacts of TB patients and healthcare providers to explore behavioral and systemic challenges. Quantitative (bivariate and regression analysis using Stata 17.0) and qualitative (thematic analysis using ATLAS.ti 6.1) data analysis were performed to explore TPT cascade of care, attrition and treatment completion. Results: The study found that while 89% of identified household contacts underwent investigation, only 70% of those declared eligible actually initiated TPT. A major demographic gap was identified: adults (15 years and above) were more likely to register for treatment than children under 15 (aOR = 9.2, 95% CI = 7.5–11, p < 0.001). Regarding treatment success, both the weekly 3HP and daily 3HR regimens achieved an identical completion rate of 97.12%. Qualitative findings highlighted barriers such as social stigma (fear of lost marriage or business prospects), the misconception that healthy people do not need medicine and systemic issues like medicine stock-outs and high staff workloads. Conclusion: The TPT programme shows high success once treatment starts, but a critical leakage exists between being declared eligible and actually registered for preventive treatment. To meet national targets, the programme should prioritize paediatric registration, ensure stable medicine buffer stocks and utilize visual counseling tools with dedicated counsellors to address community misconceptions and lack of awareness.
Open Access
Burden, barriers, and behavioral adaptation: A mixed-method study of hypertension and diabetes management among the geriatric population in the drought-prone barind tract of Bangladesh
(BRAC University, 2026-06) Quadir, Kazi Maruf; Misha, Farzana; BRAC James P Grant School of Public Health
Background: Intense heat and extended periods of drought is a growing concern for the rural elderly in the north-western Barind tract of Bangladesh, both physiologically and economically. Bangladesh is currently experiencing an epidemiological transition, where geriatric population is suffering from non-communicable diseases such as hypertension and diabetes, and there is a need to understand the impact of environmental precarity on the management of chronic diseases. Objectives: Overall the goal was to determine the burden and climate sensitive management of HTN and DM in the geriatric population in the rural drought-prone Barind tract. Specific objectives were to establish prevalence of these conditions, exposure to predisposing risk factors and coping and challenges faced by the people in extreme climatic conditions. Methods: The study was conducted in Niamatpur Upazila, Naogaon District using mixed method study approach. The secondary data for phase 2 (quantitative) was obtained from a climate-sensitive surveillance database for 225 geriatric subjects (60 years old and above) through the two-stage stratification random sampling technique. Purposive sampling was used to select 12 in-depth interviews (IDIs) with patients and 3 key informant interviews (KIIs) with healthcare providers. Thematic analysis with a hybrid coding structure was used for the qualitative data, and descriptive statistics were used to analyze the quantitative data using Stata. Results: Diagnosed cases of hypertension presented 37.33% and diabetes 10.67%. A critical treatment gap was identified with 47.62% of hypertensive patients reporting not taking treatment medication and 41.67% of diabetic patients reported doing the same. 58.3% among the diabetic individuals and 60.7% among the hypertensive individuals are on low level of physical activity. Qualitative results emphasized a reactive care tendency whereby patients are dependent on physical signs and not routine screening. The significant obstacles to care were high carrying costs of treatment, institutional friction (long queues) and forgetfulness. The seasonal adaptation was to range across dietary behavior change to physical activity moderation to cope with seasonal extremities. Conclusions: The geriatric population in Barind tract is exposed to various risk factors due to aging, chronic metabolic diseases and environmental stress factors. The large treatment gaps stem from the lack of resources and the dysfunction of the primary health care supply chain. Public health implications include the need for climate-resilient health infrastructure, subsidized geriatric medications and seasonally focused health education to offset the cumulative effects of drought and heat on the outcomes of chronic diseases.
Open Access
A voice in the choice: Adolescent girls' participation in menstrual material decisions and its association with reduced unmet needs — evidence from the AMEHC study
(BRAC University, 2026-06) Neha, Raisa Azim; Quayyum, Zahidul; BRAC James P Grant School of Public Health
Background: Adolescent schoolgirls in low-resource settings face extensive structural and social barriers to managing menstruation with dignity. While economic constraints are frequently studied, the protective value of adolescent individual voice and household-level purchasing autonomy remains under-researched. This study evaluated the cross-sectional association between adolescent girls’ participation in menstrual material purchasing choices and their ability to meet comprehensive menstrual practice needs in the Khulna district of Bangladesh. Methods: A complete-case analysis was conducted using cross-sectional data collected in 2024 for the Adolescent Menstrual Experiences and Health Cohort (AMEHC) study. From a baseline enrollment of 2,015 Class 6 schoolgirls, the final analytical sample was restricted to n = 1,464 post-menarche students who possessed non-missing covariate responses. This stabilization followed the sequential exclusion of 385 participants who were pre-menarche at Wave 1, 95 with missing data on purchasing decisions, 70 with incomplete responses on the outcome scale, and 1 case with missing social support data. Menstrual practice needs were measured using the validated 18-item Menstrual Practice Needs Scale–Short Form (MPNS-SF). Primary exposure agency was operationalized as a binary indicator tracking independent or joint adolescent participation in purchasing choices. To account for institutional school-level clustering across 101 physical school sites, multi-level mixed-effects logistic regression models were developed to estimate adjusted odds ratios (aOR) at a 95% confidence interval (CI). Results: The mean age of the post-menarche sample was 12.4 years, and 56.4% of the cohort actively participated in material purchasing decisions. After adjusting simultaneously for age, geographic setting, household wealth quintiles, parental baseline gender norms, and individual beliefs, active adolescent purchasing participation was significantly associated with a 31% lower odds of experiencing comprehensive unmet menstrual needs (aOR = 0.69; 95% CI: [0.52, 0.93]; p = 0.014). Strong negative statistical associations with the outcome were also observed for the background adjustment covariates of higher maternal social support (aOR = 0.17; 95% CI: [0.11, 0.26]; p < 0.001) and equitable personal gender norms (aOR = 0.56; 95% CI: [0.39, 0.80]; p = 0.002). Household wealth and geographic region setting did not maintain independent statistical associations within the fully adjusted multi-level specification. Conclusions: Individual purchasing agency and supportive social networks demonstrate strong negative statistical correlations with unmet menstrual needs. Because this model adjusted for psychosocial traits and decision-making access simultaneously, the null findings for household wealth may reflect statistical mediation paths rather than a true absence of economic influence. Public health interventions should move beyond basic material aid to focus on increasing supportive household communication with the adolescent girls, shifting restrictive personal gender beliefs, and expanding girls' active participation in health-related material choices.
Open Access
Factors associated with anxiety and depression among caregivers of children with non-communicable diseases in Bangladesh: A cross-sectional study at Bangladesh Medical University
(BRAC University, 2026-06) Chowdhury, Nil Mayuri; Ahmed, Syed Masud; BRAC James P Grant School of Public Health
Background: Non-communicable diseases (NCDs) in children require long-term care that causes physical, emotional and financial burdens on families. The mental health of caregiver is still underexplored in the Bangladeshi context even though their psychological well being directly affects the quality of care a child receives as well as overall functioning of the family. Objectives: To assess the mental health status of caregivers of children with NCDs and identify the socio-demographic and disease-related factors associated with anxiety and depression. Methods: A hospital-based cross-sectional study was conducted at the Department of Paediatrics, Bangladesh Medical University, between January to June 2026. A total of 310 primary caregivers of children under 18 years diagnosed with thalassemia, congenital heart disease, nephrotic syndrome, bronchial asthma, type 1 diabetes mellitus and epilepsy were recruited through convenience sampling. Anxiety and depression were assessed using the GAD-7 and PHQ-9, with a cut-off of ≥ 10 indicating clinically significant symptoms. Data were analyzed in STATA 17.0 using chi-square tests and multivariable logistic regression (p <0 .05). Results: Most respondents were female (77%), mothers (76%), housewives (67%), and aged over 30 years (53%); 65% earned less than BDT 25,000 per month and 44% cared for children aged five years or younger. Overall, 61% of caregivers screened positive for anxiety and 60% for depression. In the multivariable analysis, financial stress was the strongest independent predictor of both anxiety (AOR = 4.94, 95% CI: 2.37–10.33) and depression (AOR = 4.67, 95% CI: 2.31–9.45). Caregivers of children aged five years or younger had over seven times higher odds of anxiety (AOR = 7.33) and over three times higher odds of depression (AOR = 3.40). Mothers had twice the odds of depression compared to fathers (AOR = 2.14), and caregivers in the lowest income group had five times higher odds of anxiety (AOR = 5.01). Conclusions: Three out of five caregivers of children with NCDs in experience clinically significant anxiety or depression. Financial stress, young child age and being the mother are key independent predictors. Routine caregiver mental health screening and combined clinical and financial support should be integrated into paediatric NCD services.
Open Access
Lived experience of occupational health and safety among street sweepers in Dhaka city: A qualitative study
(BRAC University, 2026-06) Hassan, Mahira; Quayyum, Zahidul; BRAC James P Grant School of Public Health
Background: Street sweepers play a critical role in urban waste management, but are still a marginalized occupational group in low and middle-income countries. Dhaka, being one of the most densely populated cities, generates large volumes of waste every day, putting this group of people in the front line of urban sanitation under hazardous conditions. The street sweepers are continuously exposed to various physical, chemical, biological, and ergonomic hazards due to their working conditions and poor institutional support. While existing studies have documented health hazards and disease prevalence, limited qualitative evidence exists on how street sweeper in Dhaka perceive their health risks, seek care or manage with the ongoing demand of the occupation. Objectives: To explore the lived experiences of occupational health and safety, perceived health risk, occupation-related health problems, health-seeking behaviour, and coping mechanisms among the street sweepers in Dhaka city. Methods: A qualitative study was conducted with six wards of Dhaka North City Corporation (DNCC) in Badda, Mohakhali, Rampura, and Mirpur. 22 In-depth interviews with street sweepers, 7 key informant interviews with their direct supervisors, and 4 non-participant observations were held using snowball sampling, guided by the principle of data saturation. Thematic analysis approach was used for conducting the data analysis using deductive and inductive coding. Results: Four themes emerged from the data analysis:1) Perceived health risks, 2) Health problems, 3) Health-seeking behaviour, 4) Coping and adaptation mechanisms. The perceived health risks were mixed among the street sweepers, where some could identify their workplace hazards while others underestimated the risks or perceived illness as a matter of fate. Musculoskeletal pain was the most frequently reported health concern, followed by respiratory illness, chronic disease, skin diseases, and gastrointestinal problems. The street sweepers described mental exhaustion, financial tension, restlessness, and loss of peace of mind, showing up through irritability, anger, crying, and family conflict rather than being separately named as a mental health issue. Health care seeking was consistently delayed or avoided, primarily due to low income, time constraints, and cost of care, with pharmacies serving as the first and often only point of care, followed by public and private facilities if felt necessary. Street sweepers coped through normalising hardship, self-medication, peer support, and religious faith. Conclusions: Street sweepers in Dhaka face increasing occupational health hazards and safety issues. Despite existing legal protection, there are unenforced labour laws, limited access to healthcare, and organizational support being absent in practice. Ensuring permanent employment benefits, provision of workplace facilities, enforcement of existing labour laws, and focused occupational health interventions are in urgent need to protect the safety and health of the overlooked occupational group, street sweepers.
Open Access
Assessment of cognition and psychological capacity of older adults: A cross-sectional study
(BRAC University, 2026-06) Anan, Aysha; Mridha, Malay Kanti; BRAC James P Grant School of Public Health
Background: The ageing population is increasing globally, with the number of older adults aged 60 years or more expected to reach 2.1 billion by 2050. Bangladesh is no exception, with a current older population of approximately 15.3 million, projected to double by 2050. Cognitive decline and reduced psychological capacity are two important yet under-recognised challenges of ageing. However, no assessment of these domains using the World Health Organization’s Integrated Care for Older People (ICOPE) has been conducted in Bangladesh. Objectives: To assess the status of cognition and psychological capacity in older adults in rural Bangladesh and identify factors associated with the decline of these domains. Methods: A cross-sectional study was conducted among 402 older adults aged ≥ 60 years in three wards within the Sujalpur union of Birganj subdistrict, Dinajpur, Bangladesh, from March to April 2026. A simple random sampling technique was used to select the study participants. Bangla adaptation of the Mini-Mental State Examination (BAMSE) and Patient Health Questionnaire-9 (PHQ-9) were used to assess cognitive status and depressive symptoms. A score of less than 24 on the BAMSE was considered to indicate cognitive decline, and a score of more than 10 on the PHQ-9 was considered to indicate depressive symptoms. Data were analysed using Stata V.17.0, and descriptive and multivariable logistic regression analyses were performed. Results: The prevalence of cognitive decline was 41.8 % (n=168), and the prevalence of depressive symptoms was 46.8% (n=188). Female sex (adjusted odds ratio (aOR): 2.84, 95% CI: 1.57-5.12) and adequate physical activity (aOR: 0.59, 95% CI: 0.37-0.95) were associated with cognitive decline. Socio-economic factors related to depressive symptoms were the highest household wealth tertile (aOR: 0.57, 95% CI: 0.32-0.99) and female sex (aOR: 2.14, 95% CI: 1.17-3.93), malnutrition (aOR: 3.42, 95% CI: 1.65-7.12), and adequate sleep ≥7 hours (aOR: 0.40, 95% CI: 0.24-0.66) were associated with depressive symptoms. Conclusions: A high prevalence of cognitive decline and depressive symptoms was observed among older adults in rural Bangladesh. Factors such as sex, household wealth, physical activity, sleep, and nutritional status emerged as key determinants and should be considered when developing targeted interventions for older adults. These findings underscore an urgent need to integrate cognitive and psychological care into primary healthcare using the ICOPE framework.
Open Access
Extreme heat and child health care practices in drought-prone rural Bangladesh: A mixed-method study
(BRAC University, 2026-06) Khwaja, Atiya; Misha, Farzana; BRAC James P Grant School of Public Health
Background: Extreme heat is an increasing public health concern in Bangladesh, particularly for children under 5. However, existing peer-reviewed studies have not adequately examined how caregivers in drought-prone rural settings recognise, manage, and seek care for childhood illnesses during extreme heat. Objectives: This study aimed to assess child healthcare practices during extreme heat among children under 5 in drought-prone rural Bangladesh by estimating selected illness prevalence, exploring caregivers’ perceptions and home-based coping practices, and identifying reasons influencing care-seeking. Methods: A mixed-methods study was conducted in Niamatpur Upazila, Naogaon District. The quantitative component used secondary data of 239 children under 5 from the BRAC Health Program surveillance project dataset and was analyzed descriptively using STATA/MP 17.0. The qualitative component included 12 in-depth interviews and 2 focus group discussions with total 27 primary caregivers, all mothers, selected through purposive sampling. Qualitative data were collected using semi-structured guidelines and vignette-based scenarios, and were analyzed thematically. Results: Fever was the most commonly reported illness (43.9%), followed by cold/cough (33.5%), heat-related illnesses (6.7%), diarrhea (6.3%), and acute respiratory illness (2.5%). Qualitative findings showed that caregivers understood extreme heat through bodily discomfort and recognised children’s heat-related illness through crying, irritability, sweating, thirst, reduced movement, and seasonal illness patterns. Home-based cooling and indigenous practices were the first line of care, followed by informal providers and, finally, formal facilities when illness became severe or unresolved. Financial constraints, transport difficulties, distance, uncertainty at facilities, perceived discrimination, and gendered caregiving burden shaped care-seeking decisions. Conclusions: Extreme heat affects child health as both an environmental exposure and a household caregiving stressor. Interventions should strengthen community-level heat-health messages, promote safe home-based practices, engage informal providers and household decision-makers, and improve timely access to respectful formal healthcare in heat-vulnerable rural communities.
Open Access
Utilization, acceptability, and satisfaction regarding reproductive health services at rehabilitated community clinics in climate disaster prone chars in Bogura: A mixed-method research among women of reproductive age
(BRAC University, 2026-06) Muang, Pau Sian; Barua, Mrittika; BRAC James P Grant School of Public Health
Background: Bangladesh reduced its maternal mortality ratio to 115 per 100,000 live births in 2023 but remains above SDG target. Women in char areas consistently face compound barriers to reproductive health (RH) services. Community Clinics (CCs) are the primary community-level RH service delivery, yet evidence on how rehabilitated CCs in climate-vulnerable settings particularly from women’s perspective remains limited. Objectives: This study evaluated how women of reproductive age experience RH services delivered through rehabilitated CCs under the JAMUNA Project in the char areas of Bogura District, Bangladesh. Specific objectives were to assess utilization trends, measure client satisfaction, explore acceptability of RH services and identify barriers and facilitators to service use. Methods: A convergent parallel mixed-methods design was used at two rehabilitated CCs. The quantitative part included a cross-sectional client survey (N = 101 women aged 18--49 years; simple random sampling) using 18-item Patient Satisfaction Questionnaire (PSQ-18) and a secondary trend analysis of routine RH services across 26-months period (12 months pre- and 14 months postrehabilitation). The qualitative part included ten in-depth interviews (IDIs) guided by the Theoretical Framework of Acceptability and non-participant facility observation. Quantitative data were analyzed using Stata/BE 19.5; qualitative data through Framework Analysis. Both strands were combined at interpretation. Results: The PSQ-18 overall mean satisfaction score was 3.94 (SD = 0.26, scale 1-5) with 60.4% of participants classified as satisfied (95% CI: 50.2% - 70.0%). Interpersonal Manner had the highest score (mean = 4.29) while Accessibility and Convenience had the lowest (mean = 3.71). Clinic site was the only variable significantly associated with satisfaction (χ² = 8.110, p = 0.004, Cramér's V = 0.283) while women at partially rehabilitated Tengra Kura CC reported higher satisfaction (73.6%) than those at fully rehabilitated Pakuria CC (45.8%). Age, education, and type of RH service received were not significantly associated. Utilization trends were mixed. FP volumes increased at both sites (Pakuria CC: +6.2%; Tengra Kura CC: +6.8%) while ANC volumes diverged as +11.3% at Tengra Kura CC and -12.8% at Pakuria CC. PNC showed the weakest uptake, 22.9% declined at Pakuria CC with a marginal +7.1% at Tengra Kura CC. Qualitative findings pointed provider courtesy and geographic proximity as the primary acceptability facilitators. Seasonal flooding compounded persistent infrastructure deficits, irregular provider attendance, opportunity costs and limited awareness of the full RH service package. Conclusions: Physical rehabilitation of community clinics in flood-prone char areas is meaningful as client satisfaction reached 60.4% and FP utilization grew consistently. However, PNC declined at the fully rehabilitated site and ANC trends diverged indicating structural completion alone does not reliably translate into increased utilization. The provider-client relationship, gender-responsive staffing, climate-resilient service continuity and basic diagnostic capacity were the factors most consistently associated with whether rehabilitated CCs services are acceptable and accessible. Climate-resilient CC policy should incorporate minimum quality standards with construction metrics and seasonal contingency frameworks.
Open Access
Understanding implementers’ perspectives on the barriers and facilitators of wash interventions under the JAMUNA project in climate-vulnerable char areas of Bogura, Bangladesh: A qualitative implementation research study
(BRAC University, 2026-06) Urboshi, Ismat Zaman; Barua, Mrittika; BRAC James P Grant School of Public Health
Background: Bangladesh's riverine char communities are among its most climate-vulnerable populations, where recurrent flooding and erosion repeatedly destroy water and sanitation infrastructure and raise the burden of diarrhoeal disease. The JAMUNA project, a joint venture by BDRCS and Swiss Red Cross, delivers WASH interventions here, yet implementers' experiences of delivery remain largely undocumented. Objectives: To identify the barriers and facilitators experienced by implementers of WASH interventions under the JAMUNA project, and the adaptive strategies they used to overcome challenges in the char areas of Bogura. Methods: A qualitative exploratory study was conducted in Chaluabaria and Kazla unions, Sariakandi Upazila, Bogura. Between March and April 2026, 17 key informant interviews were conducted with implementers from multiple project tiers. Participants were selected purposively until data saturation was reached, using six semi-structured guides based on the CFIR domains. Interviews were held in Bangla, transcribed verbatim, and analysed using the Framework Method in Dedoose, producing 657 coded excerpts. Results: Facilitators included dismantlable, displacement-friendly latrines and raised DRR tubewells suited to flooding; community co-financing that strengthened ownership; organisational coverage of field-staff travel costs; school-based hygiene sessions; and revitalization of the Ward Disaster Management Committee, anchoring delivery in local governance. Barriers included geographic isolation, recurrent displacement, poverty, political and kinship influence over beneficiary selection, and workforce shortages from reliance on unpaid volunteers. Adaptive strategies included multi-step beneficiary verification, engaging religious leaders, instalmentbased bKash payments, and locally tailored session delivery. Conclusions: This study demonstrates that WASH delivery in the char areas is not a discrete technical task but a continuous process of adaptation to displacement, poverty, and local power dynamics. Although portable, raised infrastructure was essential, its effectiveness depended on community co-financing, digital payment mechanisms, the engagement of trusted local leaders, and an adequately supported frontline workforce. Together, these social and organisational factors were as central to implementation as the infrastructure itself.
Open Access
Association between household food production diversity and minimum dietary diversity of women in rural Bangladesh: A secondary analysis from BIHS 2018-19
(BRAC University, 2026-06) Apu, Apurbo Aham; Ireen, Santhia; BRAC James P Grant School of Public Health
Background: Despite advances in food production in the last decade, rural Bangladeshi women of reproductive age (15-49 years) still suffer from micronutrient deficiency due to inadequate dietary diversity. A growing number of literatures suggest a positive association between production diversity and dietary diversity of women in rural Bangladesh. However, evidence from Bangladesh remains limited on the association between production diversity and dietary diversity indicators, particularly at a national scale. This knowledge gap has important implications for national nutrition and agriculture policies and programmes. Objectives: To investigate the association between household food production diversity and the dietary diversity among women of reproductive age 15-49 years in rural Bangladesh. Methods: A quantitative, cross-sectional study was done using the data from the third round of Bangladesh Integrated Household Survey (BIHS, 2018-19). Non-pregnant, non-lactating rural women of reproductive age 15-49 years were included for the analyses (n=3687) with complete dietary, production and household level data. Women’s dietary diversity was measured by Minimum Dietary Diversity of women (MDD-W) and dietary diversity score (WDDS). Production diversity was measured by Minimum Food Group Production Diversity (MFGPD) and Food Group Production Diversity Score (FGPDS) based on the same 10 food group as MDD-W. The survey weighted descriptive, bivariate and multivariate regression analyses were done to assess the association between dichotomous minimum food group production diversity with Minimum Dietary Diversity, whereas a secondary analysis using their continuous counterparts was done to assess robustness. Results: The dietary diversity was low among the women in rural Bangladesh, with only 37% women achieving minimum dietary diversity with a mean score of 4.24. However, household food group-based production diversity was positively associated with dietary diversity, though the strength of the association was modest. Factors such as gender of the household head, household size, and wealth index were significant predictors of dietary diversity in both models, with land type and women’s education emerging as additional significant predictors in secondary analysis. Conclusions: Food consumption diversity among women in rural Bangladesh is low, suggesting persistent inadequate micronutrient intake. The relationship between dietary diversity of women and household food-group production diversity was positive but modest. This suggests that household food production diversification is not enough to enhance women's nutritional status. An integrated approach is required, and nutrition-sensitive agriculture programmes should combine production diversification with efforts to improve other associated factors, including women's access to nutritious foods, household consumption of produced foods, market access, financial affordability and women's involvement in food decision making.

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