Mr Md Nuruzzaman Khan

The presence of comorbidities among individuals with disabilities worsens their already complex health and social circumstances. This study aims to explore prevalence and patterns of morbidities among persons with disabilities in Bangladesh and identify associated socio-demographic factors. Data from 4270 persons with disability was analysed extracted from the 2021 Bangladesh National Household Survey on Persons with Disability. Outcome variable considered was the occurrence of morbidity among persons with disabilities. Explanatory variables encompassed factors at the individual, household, and community levels. Adjusted and unadjusted multilevel mixed-effects logistic regression model was used to explore association of outcome variable with explanatory variables. We found that approximately half of individuals with disabilities experienced one or more morbidities, with chronic conditions being the most prevalent (44%). Around 42% of total persons with disability were unable to work. Specifically, hypertension (18.3%), diabetes (9.1%), and heart problems (17.1%) were prevalent chronic conditions. The likelihood of experiencing comorbidity was found to be higher among females (aOR 1.3, 95% CI 1.1, 1.7), increase year of education (aOR, 1.1, 95% CI 1.0¿1.2), and those from wealthier households (aOR 1.6, 95% CI 1.2, 2.2). This underscores the need for targeted policies and interventions addressing their distinct healthcare needs.

Background With the rapid increase in the number of women in their later reproductive years (aged 35 and above) in the present decade, the concern surrounding their contraceptive considerations has reached a critical point of importance. This study aims to examine the trends and determinants of modern contraceptive uptake among later reproductive-aged women in Bangladesh. Methods A total of 17,736 women aged 35 and above were included in the analysis, utilizing data from three consecutives Bangladesh Demographic and Health Surveys conducted in 2011, 2014, and 2017¿18. The outcome variable was the uptake of modern contraceptive methods (yes or no). The explanatory variables encompassed survey years, individual characteristics of the women, as well as characteristics of their partners and the community. Multilevel logistic regression model was used to explore the association of the outcome variable with explanatory variables. Results We found that approximately 54% of women aged 35 and more do not use modern contraceptive methods, and there have been no significant shifts in their usage observed over the survey years. Compared to women aged 35¿39, women aged 40¿45 (aOR = 0.53, 95% CI: 0.49¿0.57) and 45¿49 (aOR = 0.24, 0.22¿0.26) reported lower likelihoods of modern contraceptive method uptake. Higher education correlated with increased uptake of modern contraceptive methods (112%-142%), while partner¿s education showed a negative association. Later reproductive-aged women in richer (aOR = 0.83, 95% CI: 0.74¿0.94) and richest (aOR = 0.76, 95% CI: 0.66¿0.88) quintiles reported lower uptake of modern contraceptive methods compared to their counterparts in the poorest quintile. Later reproductive-aged women in Dhaka (aOR = 1.22, 95% CI: 1.07¿1.38) and Rajshahi (aOR = 1.37, 95% CI: 1.19¿1.59) regions had higher uptake of modern contraception than those residing in the Barishal division. Modern contraceptive methods uptake was 1.22 times higher among women who reported exposure to mass media and 1.19 times higher among women who reported engagement in paid work compared to among women who reported no exposure to mass media and participation in no formal work, respectively. Modern contraceptive methods uptake was 43% higher (aOR = 1.43, 95% CI: 1.32¿1.55) in women with more than 2 children compared to those with =2 children. Conclusion The study highlights no significant change in modern contraception uptake among later reproductive-aged women in Bangladesh. This raises concerns about the elevated risk of unintended pregnancies and shorter birth intervals, emphasizing the need for targeted interventions to address the specific needs and preferences of this demographic.

Objectives: To explore relationship among perceived stress regarding loneliness, interpersonal trust and institutional trust of expatriates during the early COVID-19 period (from 30th March to 30th May 2020). Methods: Data from 21,439 expatriates were extracted from COVIDiSTRESS global survey. The outcome variable was perceived stress. The explanatory variables were age, perceived loneliness, trust (interpersonal and institutional). Pairwise correlation, and structural equation modelling were used to determine relationship among outcome and explanatory variables. Results: The majority of the¿expatriates were female (73.85%), married (60.20%), had college degree (47.76%), and employed (48.72%). Over 63% of the total expatriates reported that the COVID-19 pandemic changed their lives. The¿average age of the respondents was 40.4¿years (± 13.7), and the average score of perceived stress, loneliness, interpersonal and institutional trust were 25.5, 7.4, 14.2 and 40.4, respectively. We found a moderate correlation of perceived stress with age, perceived loneliness, interpersonal trust and institutional trust (p < 0.001). They were also found moderately related to each other. Structural equation modelling evaluated that a¿lack of trust can cause loneliness among expatriates, which later lead¿to perceived stress. Interpersonal trust was more likely to be associated with stress than institutional trust, whereas perceived loneliness mediated between both trusts and perceived stress. Conclusion: Perceived stress can be reduced through trusting others and alleviating the loneliness. Making strong linkage among migrants as well as between¿migrants and local community is important to ensure proper mental wellbeing of expatriates.

Background: Health facility-level factors play a crucial role in women's access to and use of caesarean section (CS) services, but lacks relevant evidence. The study aimed to understand the effects of health facility-level factors on CS delivery in Bangladesh. Methods: The 2017¿18 Bangladesh Demographic and Health Survey (2017¿18 BDHS) and the 2017 Bangladesh Health Facility Survey (2017 BHFS) were linked and analysed in this study. The sample comprised of 4954 women gave at least one live birth within three years preceding the survey. The outcome variable was delivery through CS (yes, no) and the explanatory variables were health facility-level, individual-level, household-level, and community-level factors. Moran's I and Getis-Ord General G statistic were used to identify the hotspots of delivery through CS. Mixed-effect multilevel logistic regression was used to examine the association of the outcome variable with explanatory variables. Findings: Around 33% of women in Bangladesh underwent CS in their most recent pregnancies. The hotspots of delivery through CS are located primarily in Rajshahi, Dhaka, and Khulna divisions. The likelihood of delivered through CS increased with the rising scores of the management (Adjusted Odds Ratio (AOR), 1.83; 95% CI 1.04¿2.07) and infrastructure (AOR, 3.14; 95% CI 1.40¿5.12) of the nearest health facility. The readiness of health facilities to provide comprehensive obstetric care was significantly associated with an increased likelihood of delivery through CS (AOR, 2.18; 95% CI 1.15¿3.28). These relationships were strong for private than non-government and government health facilities. Interpretation: The proximity of comprehensive obstetric care facilities to women's residences and their readiness to provide services play critical roles in the access to and use of CS in Bangladesh. The findings highlight the importance of necessary healthcare personnel, including midwives, availability of government hospitals where undue CS are avoided, and awareness-building programmes about the adverse effects of CS delivery. Funding: None.

Background: Women's involvement in family planning decision-making is significantly low among refugee women, potentially leading to an increased unintended and short interval pregnancies. This study aims to investigate the relationship between women's decision-making in childbearing and short-interval births among Rohingya refugee women in Bangladesh. Methods: Data from 719 women residing in three Rohingya refugee camps in Ukhiya, Cox's Bazar, Bangladesh, were analyzed. The outcome variable was birth spacing, categorized as short (<33 months between the two most recent births) or normal (=33 months between the two most recent births). The primary explanatory variable was women's involvement in fertility decision-making with their partner, classified as never, sometimes, and always. Multivariate logistic regression analysis was conducted to assess the association between the outcome and explanatory variable while adjusting for potential covariates. Findings: 58% of births occurred within a short interval, while almost 48% of women reported no participation in fertility decision-making with their partner. Short interval birth was found to be increasing with decreasing women's participation in fertility decision-making with their partner. Women who sometimes or never made fertility decisions with their partner had 1.20 times (95% CI, 1.01¿1.88) and 1.69 times (95% CI, 1.06¿2.29) higher likelihood of short interval births, respectively, compared to women who always decided with their partner. Interpretation: Low women's participation in fertility decision-making with their partner among Rohingya refugees increases short interval births and adverse maternal and child health outcomes, including mortality. This highlights the need for counselling programs to educate and empower women, promoting joint fertility decision-making by couples. Funding: This research did not receive any specific funds.

Background: Maternal parity, which is usually measured as the number of children born to a mother, has a substantial impact on the social and environmental factors around children and their development. This paper estimates the Early Childhood Development Index (ECDI) of 3- and 4-year-old children in Bangladesh and examines the relationship between maternal parity and early childhood development. Methods: The study analysed nationally representative data from the Bangladesh Multiple Indicator Cluster Survey 2019. The dataset had 9453 children aged from 36 to 59 months. The ECDI was computed following the UNICEF's approach involving psychometric computation of four domains of development: physical, literacy-numeracy, learning and social¿emotional. Since the dataset has a hierarchical structure, we used multilevel logistic regression. Results: A quarter (25%) of the children were not on track in their early childhood development. Seventy-one percent were not developmentally on track in the literacy-numeracy domain, 27% were not in the social¿emotional and smaller percentages were not in learning (9%) and physical (1%) domains. There was a significant negative association between maternal parity and ECDI (adjusted odds ratio [AOR] 0.95; 95% CI: 0.91¿0.99). Attendance at early childhood education programmes was significantly associated with early childhood development (AOR 1.73; 95% CI: 1.47¿2.03). Also, female children, those who were not stunted, located in rural areas, received parental stimulation activities, lived in relatively wealthy households or had mothers who had received secondary or further education were more likely than others to be on track of early childhood development. Conclusions: Early childhood development is negatively correlated with maternal parity. The literacy-numeracy domain constitutes the major developmental delay. Programmes for parental awareness should be widely expanded.

Background In Bangladesh, as in other low- and middle-income countries, parents frequently migrate to other areas, often for employment opportunities, leaving their children behind with the hope that their earnings will contribute to securing a better future for them. However, the absence of parents due to migration can have negative implications for the well-being of these left-behind children. Despite the existence of studies investigating this phenomenon, the evidence thus far has produced inconclusive findings, with no specific data available from Bangladesh. Therefore, the objective of this study was to examine the effects of parental migration on the early childhood development of left-behind children in Bangladesh. Methods The present study utilized data from the Bangladesh Multiple Indicator Cluster Survey (MICS) conducted in 2019. A sample of 8,833 children aged 3¿4 years was included in the analysis. The Early Childhood Development Index (ECDI) and its individual domains served as the outcome variables of interest. The primary explanatory variables considered in the analysis were father migration, mother migration, migration of both parents, and migration of either parent. To assess the association between the outcomes and explanatory variables, multilevel logistic regression analysis was employed, controlling for relevant covariates. Results Approximately 29% of all children in the study were not developmentally on track, as measured by the ECDI. When examining the individual domains of the ECDI, only 9% of the total children demonstrated developmental progress in the learning domain. Regarding the association between parental migration and ECDI outcomes, we observed a 26% decrease in the likelihood of overall ECDI among children with a migrated father (OR: 0.74, 95% CI: 0.54¿0.93). This decrease became even more pronounced, reaching 37% (OR: 0.63, 95% CI: 0.48¿0.97), among children with both parents migrated, compared to children with neither parent migrated. Conclusion The findings of this study indicate that parental migration, especially when both parents are involved, has a substantial negative impact on the likelihood of achieving favourable ECDI outcomes for children in Bangladesh. To ensure the optimal development of children with migrating parents, it is crucial to strengthen early childhood development education programs and implement robust social safety nets. These efforts should specifically target the unique needs and challenges faced by children with migrated parents, providing them with the necessary support and resources for their holistic development.

Background: Early marriage is highly prevalent in Bangladesh. It is linked with a range of adverse outcomes, including maternal and child mortality. However, research on regional variations and factors associated with early marriage is scarce in Bangladesh. This study aimed to explore the geographical variations and predictors of early marriage in Bangladesh. Methods: Data of women aged 20¿24 in the Bangladesh Demographic and Health Survey¿2017¿18 were analysed. The occurrence of early marriage was the outcome variable. Explanatory variables were several individual-, household- and community-level factors. Geographical hot spots and cold spots of early marriage were first determined using Global Moran¿s I statistic. Multilevel mixed-effect Poisson regression was used to determine the association of early marriage with individual-, household-, and community-level factors. Results: Almost 59% of women aged 20¿24 reported they were married before reached 18. The hotspots of early marriage were mainly concentrated in Rajshahi, Rangpur and Barishal, and the cold spots were in Sylhet and Chattogram divisions. The prevalence of early marriage was lower among higher educated (adjusted prevalence ratio (aPR): 0.45; 95% CI: 0.40, 0.52), and non-Muslim women (aPR: 0.89; 95% CI: 0.79, 0.99) than their counterparts. Higher community-level poverty was significantly associated with early marriage (aPR, 1.16; 95% CI: 1.04, 1.29). Conclusion: The study concludes that promoting girls¿ education, awareness-building programs about the adverse effects of early marriage and proper application of the child marriage restraint act, particularly in disadvantaged communities are recommended.

This study aimed to investigate spatial variations in the non-use of modern contraception in Bangladesh and identify associated individual, household, and community-level factors. The analysis utilized data from 16,135 women, extracted from the 2017/18 Bangladesh Demographic and Health Survey. The study's main outcome was the prevalence of non-use of modern contraception (yes or no), while the explanatory variables included factors at the individual, household, and community level. To assess geographical heterogeneity in non-use of modern contraception, Moran's I statistics were applied. Additionally, the Gettis-Ord Gi* was calculated to measure spatial autocorrelation differences across various study locations. The relationship between non-use of modern contraception and location was further explored using a geographically weighted regression model at the cluster level. The results indicated that 42.8% (95% CI 41.6¿43.8) of respondents reported non-use of modern contraception in Bangladesh, with significant variation across geographical locations (p < 0.001). Hot spots of high non-use were predominantly identified in the Sylhet, Barishal, and some areas of the¿Chattogram divisions, while cold spots of low use were concentrated in the Rangpur, Mymensingh, and some areas¿Rajshahi divisions. Notably, the likelihood of non-use was highest among women and partners with low levels of education. The analysis of other risk factors, such as partner occupation, community-level illiteracy, and poverty, revealed varying effects on non-use of modern contraception across different locations (clusters) within the country. The study's findings underscore the importance of targeted, area-specific policies and programs aimed at promoting knowledge and uptake of modern contraception in Bangladesh.

Background: Diabetes, particularly type 1 diabetes, at younger ages can be a largely preventable cause of death with the correct health care and services. We aimed to evaluate diabetes mortality and trends at ages younger than 25 years globally using data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019. Methods: We used estimates of GBD 2019 to calculate international diabetes mortality at ages younger than 25 years in 1990 and 2019. Data sources for causes of death were obtained from vital registration systems, verbal autopsies, and other surveillance systems for 1990¿2019. We estimated death rates for each location using the GBD Cause of Death Ensemble model. We analysed the association of age-standardised death rates per 100 000 population with the Socio-demographic Index (SDI) and a measure of universal health coverage (UHC) and described the variability within SDI quintiles. We present estimates with their 95% uncertainty intervals. Findings: In 2019, 16 300 (95% uncertainty interval 14 200 to 18 900) global deaths due to diabetes (type 1 and 2 combined) occurred in people younger than 25 years and 73·7% (68·3 to 77·4) were classified as due to type 1 diabetes. The age-standardised death rate was 0·50 (0·44 to 0·58) per 100 000 population, and 15 900 (97·5%) of these deaths occurred in low to high-middle SDI countries. The rate was 0·13 (0·12 to 0·14) per 100 000 population in the high SDI quintile, 0·60 (0·51 to 0·70) per 100 000 population in the low-middle SDI quintile, and 0·71 (0·60 to 0·86) per 100 000 population in the low SDI quintile. Within SDI quintiles, we observed large variability in rates across countries, in part explained by the extent of UHC (r2=0·62). From 1990 to 2019, age-standardised death rates decreased globally by 17·0% (-28·4 to -2·9) for all diabetes, and by 21·0% (¿33·0 to -5·9) when considering only type 1 diabetes. However, the low SDI quintile had the lowest decline for both all diabetes (-13·6% [¿28·4 to 3·4]) and for type 1 diabetes (-13·6% [¿29·3 to 8·9]). Interpretation: Decreasing diabetes mortality at ages younger than 25 years remains an important challenge, especially in low and low-middle SDI countries. Inadequate diagnosis and treatment of diabetes is likely to be major contributor to these early deaths, highlighting the urgent need to provide better access to insulin and basic diabetes education and care. This mortality metric, derived from readily available and frequently updated GBD data, can help to monitor preventable diabetes-related deaths over time globally, aligned with the UN's Sustainable Development Targets, and serve as an indicator of the adequacy of basic diabetes care for type 1 and type 2 diabetes across nations. Funding: Bill & Melinda Gates Foundation.

Despite substantial declines since 2000, lower respiratory infections (LRIs), diarrhoeal diseases, and malaria remain among the leading causes of nonfatal and fatal disease burden for children under 5 years of age (under 5), primarily in sub-Saharan Africa (SSA). The spatial burden of each of these diseases has been estimated subnationally across SSA, yet no prior analyses have examined the pattern of their combined burden. Here we synthesise subnational estimates of the burden of LRIs, diarrhoea, and malaria in children under-5 from 2000 to 2017 for 43 sub-Saharan countries. Some units faced a relatively equal burden from each of the three diseases, while others had one or two dominant sources of unit-level burden, with no consistent pattern geographically across the entire subcontinent. Using a subnational counterfactual analysis, we show that nearly 300 million DALYs could have been averted since 2000 by raising all units to their national average. Our findings are directly relevant for decision-makers in determining which and targeting where the most appropriate interventions are for increasing child survival.

Background Maternal anemia is an ongoing public health challenge in low- and middle- income countries, including Bangladesh. The aim of this study was to explore the association of maternal anemia with a range of adverse maternal health and birth outcomes in Bangladesh. Methods A total of 2,259 maternal women data was analyzed, extracted from the 2011 Bangladesh Demographic and Health Survey. Outcome variables considered were a range of maternal health and birth outcomes. Adverse maternal health outcomes were pregnancy complications, pregnancy termination, menstrual irregularities, cesarean delivery, diabetes, and hypertension. Adverse birth outcomes considered were low birth weight, stillbirths, early neonatal deaths, perinatal deaths, preterm birth, and prolonged labor. The main exposure variable was maternal anemia status. Mixed effect multilevel logistic/poisson regression model was used to determine the association between exposure and outcome variable adjusted for individual-, household-, and community-level factors. Results The reported prevalence of anemia was 44%. A higher likelihoods pregnancy complication (AOR, 1.39, 95% CI, 1.09-2.41, p<0.05) and lower likelihoods of menstrual irregularities (AOR, 0.79, 95% CI, 0.58-0.94, p<0.05), diabetes (AOR, 0.78, 95% CI, 0.49-0.98, p<0.05) and hypertensive (AOR, 0.79, 95% CI, 0.60-0.96, p<0.05) were found among anemic maternal women as compared to the non-anemic maternal women. Adverse birth outcomes, including preterm birth (AOR, 2.03, 95% CI, 1.01-4.25, p<0.05), early neonatal mortality (AOR, 1.87, 95% CI, 1.06-5.10), and perinatal mortality (AOR, 1.54, 95% CI, 1.09- 3.52, p<0.05), were also found higher among newborn of anemic maternal women as compared to the newborn of non-anemic maternal women. Conclusion Anemia during pregnancy increases the occurrence of adverse maternal health and birth outcomes. Strategies to reduce anemia, such as iron supplementation, during pregnancy and among reproductive-aged women need to be prioritized in the policies and programs.

Background: In estimating the global burden of cancer, adolescents and young adults with cancer are often overlooked, despite being a distinct subgroup with unique epidemiology, clinical care needs, and societal impact. Comprehensive estimates of the global cancer burden in adolescents and young adults (aged 15¿39 years) are lacking. To address this gap, we analysed results from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, with a focus on the outcome of disability-adjusted life-years (DALYs), to inform global cancer control measures in adolescents and young adults. Methods: Using the GBD 2019 methodology, international mortality data were collected from vital registration systems, verbal autopsies, and population-based cancer registry inputs modelled with mortality-to-incidence ratios (MIRs). Incidence was computed with mortality estimates and corresponding MIRs. Prevalence estimates were calculated using modelled survival and multiplied by disability weights to obtain years lived with disability (YLDs). Years of life lost (YLLs) were calculated as age-specific cancer deaths multiplied by the standard life expectancy at the age of death. The main outcome was DALYs (the sum of YLLs and YLDs). Estimates were presented globally and by Socio-demographic Index (SDI) quintiles (countries ranked and divided into five equal SDI groups), and all estimates were presented with corresponding 95% uncertainty intervals (UIs). For this analysis, we used the age range of 15¿39 years to define adolescents and young adults. Findings: There were 1·19 million (95% UI 1·11¿1·28) incident cancer cases and 396 000 (370 000¿425 000) deaths due to cancer among people aged 15¿39 years worldwide in 2019. The highest age-standardised incidence rates occurred in high SDI (59·6 [54·5¿65·7] per 100 000 person-years) and high-middle SDI countries (53·2 [48·8¿57·9] per 100 000 person-years), while the highest age-standardised mortality rates were in low-middle SDI (14·2 [12·9¿15·6] per 100 000 person-years) and middle SDI (13·6 [12·6¿14·8] per 100 000 person-years) countries. In 2019, adolescent and young adult cancers contributed 23·5 million (21·9¿25·2) DALYs to the global burden of disease, of which 2·7% (1·9¿3·6) came from YLDs and 97·3% (96·4¿98·1) from YLLs. Cancer was the fourth leading cause of death and tenth leading cause of DALYs in adolescents and young adults globally. Interpretation: Adolescent and young adult cancers contributed substantially to the overall adolescent and young adult disease burden globally in 2019. These results provide new insights into the distribution and magnitude of the adolescent and young adult cancer burden around the world. With notable differences observed across SDI settings, these estimates can inform global and country-level cancer control efforts. Funding: Bill & Melinda Gates Foundation, American Lebanese Syrian Associated Charities, St Baldrick's Foundation, and the National Cancer Institute.

The objective of this study was to determine how changes in pre-pregnancy contraceptive methods used between 2011 and 2017/18 contributed to the changes in pregnancy resulting from contraceptive methods failure in Bangladesh. We used 2011 and 2017/18 Bangladesh Demographic and Health Survey data. Pre-pregnancy contraceptive methods failure was our outcome of interest, which was determined using women¿s response about whether they became pregnant while using contraceptives before the most recent pregnancy. The year of the survey was the main explanatory variable. Descriptive statistics were used to describe the characteristics of the respondents. The difference in contraceptive methods failure across the socio-demographic characteristics was assessed by Chi-squared test. Multilevel poison regressions were used to determine the changes in the prevalence ratio of contraceptive methods failure across the survey years. Contraceptive methods failure rate increased between the surveys, from 22.8% in 2011 to 27.3% in 2017/18. Also, male condom use increased by 2.8%, while withdrawal/periodic abstinence and/or other methods decreased by 2.9%. The failure rates in these two categories of contraceptive methods increased substantially by 4.0% and 9.0%, respectively. Compared to the 2011 survey, the prevalence ratio (PR) of contraceptive methods failure was 20% (PR 1.2, 95% CI 1.1¿1.3) high in the 2017/18 survey. This PR declined 13% (PR 1.1, 95% CI 1.04¿1.2) once the model was adjusted for women¿s and their partner¿s characteristics along with the last contraceptives used. This study provides evidence of increasing rates of pregnancy due to contraceptive failure in Bangladesh. Given that this type of pregnancy is known to cause adverse pregnancy outcomes, including abortion, pregnancy complications, maternal and early child morbidity and mortality, policy and programs are needed to reduce its prevalence. Effective coordination between the contraception providers at the healthcare facilities and the households and a proactive role of family planning workers to make couples aware of the effective use of contraceptives are recommended.

Currently, around a million Rohingya refugees live in Cox¿s Bazar, Bangladesh. Displacement from homelands and restrictions on movement in the refugee camps may exacerbate intimate partner abuse (IPA) against refugee women and their abilities to reject husbands¿ advances to unwanted sex. This study examines Rohingya refugee women¿s attitudes toward and experience of intimate partner abuse (IPA) and their impact on the abilities to reject husbands¿ advances to unwanted sex. A survey was conducted among Rohingya refugee women in Cox¿s Bazar, Bangladesh. Women¿s attitudes toward IPA, and experience of IPA were the exposure variables. Women¿s abilities to say ¿no¿ to husbands¿ advances to unwanted sexual intercourse was the outcome variable. Multivariable logistic regression models were used to examine the relationships. Participants¿ median age was 22 years (range: 13-41). Most women perceived hitting/beatings by their husbands in certain situations as justifiable, 72% had experienced such abuse and 56.5% had to engage in unwanted sexual intercourse with their husbands. Women with increasing leniency towards hitting/beatings and those who had experienced such abuse were less likely to be able to say ¿no¿ to husbands¿ advances to unwanted sexual intercourse. Rohingya women¿s attitudes toward and experience of IPA are associated with their abilities to say ¿no¿ to husbands¿ advances to unwanted sex. Intervention is needed to denormalize the current practice of IPA, create awareness against IPA, and ensure formal education for girls.

Background: Globally, transport and unintentional injuries persist as leading preventable causes of mortality and morbidity for adolescents. We sought to report comprehensive trends in injury-related mortality and morbidity for adolescents aged 10¿24 years during the past three decades. Methods: Using the Global Burden of Disease, Injuries, and Risk Factors 2019 Study, we analysed mortality and disability-adjusted life-years (DALYs) attributed to transport and unintentional injuries for adolescents in 204 countries. Burden is reported in absolute numbers and age-standardised rates per 100 000 population by sex, age group (10¿14, 15¿19, and 20¿24 years), and sociodemographic index (SDI) with 95% uncertainty intervals (UIs). We report percentage changes in deaths and DALYs between 1990 and 2019. Findings: In 2019, 369 061 deaths (of which 214 337 [58%] were transport related) and 31·1 million DALYs (of which 16·2 million [52%] were transport related) among adolescents aged 10¿24 years were caused by transport and unintentional injuries combined. If compared with other causes, transport and unintentional injuries combined accounted for 25% of deaths and 14% of DALYs in 2019, and showed little improvement from 1990 when such injuries accounted for 26% of adolescent deaths and 17% of adolescent DALYs. Throughout adolescence, transport and unintentional injury fatality rates increased by age group. The unintentional injury burden was higher among males than females for all injury types, except for injuries related to fire, heat, and hot substances, or to adverse effects of medical treatment. From 1990 to 2019, global mortality rates declined by 34·4% (from 17·5 to 11·5 per 100 000) for transport injuries, and by 47·7% (from 15·9 to 8·3 per 100 000) for unintentional injuries. However, in low-SDI nations the absolute number of deaths increased (by 80·5% to 42 774 for transport injuries and by 39·4% to 31 961 for unintentional injuries). In the high-SDI quintile in 2010¿19, the rate per 100 000 of transport injury DALYs was reduced by 16·7%, from 838 in 2010 to 699 in 2019. This was a substantially slower pace of reduction compared with the 48·5% reduction between 1990 and 2010, from 1626 per 100 000 in 1990 to 838 per 100 000 in 2010. Between 2010 and 2019, the rate of unintentional injury DALYs per 100 000 also remained largely unchanged in high-SDI countries (555 in 2010 vs 554 in 2019; 0·2% reduction). The number and rate of adolescent deaths and DALYs owing to environmental heat and cold exposure increased for the high-SDI quintile during 2010¿19. Interpretation: As other causes of mortality are addressed, inadequate progress in reducing transport and unintentional injury mortality as a proportion of adolescent deaths becomes apparent. The relative shift in the burden of injury from high-SDI countries to low and low¿middle-SDI countries necessitates focused action, including global donor, government, and industry investment in injury prevention. The persisting burden of DALYs related to transport and unintentional injuries indicates a need to prioritise innovative measures for the primary prevention of adolescent injury. Funding: Bill & Melinda Gates Foundation.

Background: Reducing the burden of death due to infection is an urgent global public health priority. Previous studies have estimated the number of deaths associated with drug-resistant infections and sepsis and found that infections remain a leading cause of death globally. Understanding the global burden of common bacterial pathogens (both susceptible and resistant to antimicrobials) is essential to identify the greatest threats to public health. To our knowledge, this is the first study to present global comprehensive estimates of deaths associated with 33 bacterial pathogens across 11 major infectious syndromes. Methods: We estimated deaths associated with 33 bacterial genera or species across 11 infectious syndromes in 2019 using methods from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, in addition to a subset of the input data described in the Global Burden of Antimicrobial Resistance 2019 study. This study included 343 million individual records or isolates covering 11 361 study-location-years. We used three modelling steps to estimate the number of deaths associated with each pathogen: deaths in which infection had a role, the fraction of deaths due to infection that are attributable to a given infectious syndrome, and the fraction of deaths due to an infectious syndrome that are attributable to a given pathogen. Estimates were produced for all ages and for males and females across 204 countries and territories in 2019. 95% uncertainty intervals (UIs) were calculated for final estimates of deaths and infections associated with the 33 bacterial pathogens following standard GBD methods by taking the 2·5th and 97·5th percentiles across 1000 posterior draws for each quantity of interest. Findings: From an estimated 13·7 million (95% UI 10·9¿17·1) infection-related deaths in 2019, there were 7·7 million deaths (5·7¿10·2) associated with the 33 bacterial pathogens (both resistant and susceptible to antimicrobials) across the 11 infectious syndromes estimated in this study. We estimated deaths associated with the 33 bacterial pathogens to comprise 13·6% (10·2¿18·1) of all global deaths and 56·2% (52·1¿60·1) of all sepsis-related deaths in 2019. Five leading pathogens¿Staphylococcus aureus, Escherichia coli, Streptococcus pneumoniae, Klebsiella pneumoniae, and Pseudomonas aeruginosa¿were responsible for 54·9% (52·9¿56·9) of deaths among the investigated bacteria. The deadliest infectious syndromes and pathogens varied by location and age. The age-standardised mortality rate associated with these bacterial pathogens was highest in the sub-Saharan Africa super-region, with 230 deaths (185¿285) per 100 000 population, and lowest in the high-income super-region, with 52·2 deaths (37·4¿71·5) per 100 000 population. S aureus was the leading bacterial cause of death in 135 countries and was also associated with the most deaths in individuals older than 15 years, globally. Among children younger than 5 years, S pneumoniae was the pathogen associated with the most deaths. In 2019, more than 6 million deaths occurred as a result of three bacterial infectious syndromes, with lower respiratory infections and bloodstream infections each causing more than 2 million deaths and peritoneal and intra-abdominal infections causing more than 1 million deaths. Interpretation: The 33 bacterial pathogens that we investigated in this study are a substantial source of health loss globally, with considerable variation in their distribution across infectious syndromes and locations. Compared with GBD Level 3 underlying causes of death, deaths associated with these bacteria would rank as the second leading cause of death globally in 2019; hence, they should be considered an urgent priority for intervention within the global health community. Strategies to address the burden of bacterial infections include infection prevention, optimised use of antibiotics, improved capacity for microbiological analysis, vaccine developmen...

Aim: To estimate the prevalence of undiagnosed diabetes, and to identify the relative importance of risk factors for undiagnosed diabetes among Bangladeshi adults. Method: Data from 11, 421 Bangladeshi adults aged 18 years and older available from the most recent nationally representative Bangladesh Demographic and Health Survey 2017¿18 were used. Anthropometric measurements and fasting blood glucose samples were taken as part of the survey. Prevalence estimates of undiagnosed diabetes was age-standardised with direct standarisation, and risk factors were identified using multilevel mix-effects Poisson regression models with robust variance. Results: The overall age-standardised prevalence of undiagnosed diabetes was 6.0% (95 %CI, 5.5¿6.4%) (men: 6.1%, women: 5.9%). Risk factors associated with undiagnosed diabetes were older age, elevated body mass index (BMI), highest wealth quintile, hypertension, and being male. The top two modifiable risk factors contributing over 50% to undiagnosed diabetes were BMI and wealth quintiles. Conclusion: Undiagnosed diabetes affects a substantial proportion of Bangladeshi adults. Since elevated BMI and the highest wealth quintile are strong risk factors, these offer an opportunity for early detection and screening to reduce undiagnosed diabetes in Bangladesh. In addition, wide-reaching awareness campaigns among the general public, clinicians, and policymakers are needed.

Background: The health risks associated with moderate alcohol consumption continue to be debated. Small amounts of alcohol might lower the risk of some health outcomes but increase the risk of others, suggesting that the overall risk depends, in part, on background disease rates, which vary by region, age, sex, and year. Methods: For this analysis, we constructed burden-weighted dose¿response relative risk curves across 22 health outcomes to estimate the theoretical minimum risk exposure level (TMREL) and non-drinker equivalence (NDE), the consumption level at which the health risk is equivalent to that of a non-drinker, using disease rates from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2020 for 21 regions, including 204 countries and territories, by 5-year age group, sex, and year for individuals aged 15¿95 years and older from 1990 to 2020. Based on the NDE, we quantified the population consuming harmful amounts of alcohol. Findings: The burden-weighted relative risk curves for alcohol use varied by region and age. Among individuals aged 15¿39 years in 2020, the TMREL varied between 0 (95% uncertainty interval 0¿0) and 0·603 (0·400¿1·00) standard drinks per day, and the NDE varied between 0·002 (0¿0) and 1·75 (0·698¿4·30) standard drinks per day. Among individuals aged 40 years and older, the burden-weighted relative risk curve was J-shaped for all regions, with a 2020 TMREL that ranged from 0·114 (0¿0·403) to 1·87 (0·500¿3·30) standard drinks per day and an NDE that ranged between 0·193 (0¿0·900) and 6·94 (3·40¿8·30) standard drinks per day. Among individuals consuming harmful amounts of alcohol in 2020, 59·1% (54·3¿65·4) were aged 15¿39 years and 76·9% (73·0¿81·3) were male. Interpretation: There is strong evidence to support recommendations on alcohol consumption varying by age and location. Stronger interventions, particularly those tailored towards younger individuals, are needed to reduce the substantial global health loss attributable to alcohol. Funding: Bill & Melinda Gates Foundation.

Background Under-five mortality is unacceptably high in Bangladesh instead of governmental level efforts to reduce its prevalence over the years. Increased availability and accessibility to the health care facility and its services can play a significant role to reduce its occurrence. We explored the associations of several forms of child mortality with health facility level factors. Methods The 2017-18 Bangladesh Demographic and Health Survey (BDHS) data and 2017 Bangladesh Health Facility Survey (BHFS) data were linked and analysed. The outcome variables were neonatal mortality, infant mortality, and under-five mortality. Health facility level factors were considered as major explanatory variables. They were the basic management and administrative system of the nearest health care facility where child health care services are available, degree of availability of the child health care services at the nearest health care facility, degree of readiness of the nearest health care facility (where child health care services are available) to provide child health care services and average distance of the nearest health care facility from mothers¿ homes where child health care services are available. The associations between the outcome variables and explanatory variables were determined using the multilevel mixed-effect logistic regression model. Results Reported under-five, infant and neonatal mortality were 40, 27, and 22 per 10 000 live births, respectively. The likelihood of neonatal mortality was found to be declined by 15% for every unit increase in the score of the basic management and administrative system of the mothers¿ homes nearest health care facility where child health care services are available. Similarly, degree of availability and readiness of the mothers¿ homes nearest health care facilities to provide child health care services were found to be linked with 18%-24% reduction in neonatal and infant mortality. On contrary, for every kilometre increased distance between mothers¿ homes and its nearest health care facility was found to be associated with a 15%-20% increase in the likelihoods of neonatal, infant and under-five mortality. Conclusions The availability of health facilities providing child health care services close to mothers¿ residence and its readiness to provide child health care services play a significant role in reducing under-five mortality in Bangladesh. Policies and programs should be taken to increase the availability and accessibility of health facilities that provide child health care services.

Background Short birth interval (SBI) is linked with higher rates of child mortality in low and lower-middle-income countries (LMICs). In this study, we estimated the summary effects of SBI on several forms of child mortality in LMICs. Methods Eight databases, PubMed, CINAHL, Web of Science, Embase, PsycINFO, Cochrane Library, Popline, and Maternity and Infant Care, were searched, covering the period of January 2000 to January 2022. Studies that had examined the association between SBI and any form of child mortality were included. The findings of the included studies were summarized through fixed-effects or random-effects meta-analysis and the model was selected based on the heterogeneity index. Results A total of 51 studies were included. Of them, 19 were conducted in Ethiopia, 10 in Nigeria and 7 in Bangladesh. Significant higher likelihoods of stillbirth (odds ratio (OR) = 2.11; 95% confidence interval (CI) = 1.32-3.38), early neonatal mortality (OR = 1.58; 95% CI = 1.04-2.41), perinatal mortality (OR = 1.71; 95% CI = 1.32-2.21), neonatal mortality (OR = 1.85; 95% CI = 1.68-2.04), post-neonatal mortality (OR = 3.01; 95% CI = 1.43-6.33), infant mortality (OR = 1.92; 95% CI = 1.77-2.07), child mortality (OR = 1.67; 95% CI = 1.27-2.19) and under-five mortality (OR = 1.95; 95% CI = 1.56-2.44) were found among babies born in short birth intervals than those who born in normal intervals. Conclusions SBI significantly increases the risk of child mortality in LMICs. Programmes to reduce pregnancies in short intervals need to be expanded and strengthened. Reproductive health interventions aimed at reducing child mortality should include proper counselling on family planning, distribution of appropriate contraceptives and increased awareness of the adverse effects of SBI on maternal and child health.

Background: More than 3 billion people do not have access to clean energy and primarily use solid fuels to cook. Use of solid fuels generates household air pollution, which was associated with more than 2 million deaths in 2019. Although local patterns in cooking vary systematically, subnational trends in use of solid fuels have yet to be comprehensively analysed. We estimated the prevalence of solid-fuel use with high spatial resolution to explore subnational inequalities, assess local progress, and assess the effects on health in low-income and middle-income countries (LMICs) without universal access to clean fuels. Methods: We did a geospatial modelling study to map the prevalence of solid-fuel use for cooking at a 5 km × 5 km resolution in 98 LMICs based on 2·1 million household observations of the primary cooking fuel used from 663 population-based household surveys over the years 2000 to 2018. We use observed temporal patterns to forecast household air pollution in 2030 and to assess the probability of attaining the Sustainable Development Goal (SDG) target indicator for clean cooking. We aligned our estimates of household air pollution to geospatial estimates of ambient air pollution to establish the risk transition occurring in LMICs. Finally, we quantified the effect of residual primary solid-fuel use for cooking on child health by doing a counterfactual risk assessment to estimate the proportion of deaths from lower respiratory tract infections in children younger than 5 years that could be associated with household air pollution. Findings: Although primary reliance on solid-fuel use for cooking has declined globally, it remains widespread. 593 million people live in districts where the prevalence of solid-fuel use for cooking exceeds 95%. 66% of people in LMICs live in districts that are not on track to meet the SDG target for universal access to clean energy by 2030. Household air pollution continues to be a major contributor to particulate exposure in LMICs, and rising ambient air pollution is undermining potential gains from reductions in the prevalence of solid-fuel use for cooking in many countries. We estimated that, in 2018, 205 000 (95% uncertainty interval 147 000¿257 000) children younger than 5 years died from lower respiratory tract infections that could be attributed to household air pollution. Interpretation: Efforts to accelerate the adoption of clean cooking fuels need to be substantially increased and recalibrated to account for subnational inequalities, because there are substantial opportunities to improve air quality and avert child mortality associated with household air pollution. Funding: Bill & Melinda Gates Foundation.

Pregnancy complications are the major cause of maternal and newborn deaths in low- and middle-income countries that are more frequently associated with unintended pregnancy. The World Health Organization (WHO) recommends postnatal care (PNC) for women and their newborns within 24¿hr of birth to prevent pregnancy complications and associated adverse outcomes. We, therefore, examined the relationship between unintended pregnancy and PNC use in Bangladesh. Data from 4,493 women and newborn dyads were extracted from the 2014 Bangladesh Demographic and Health Survey and analysed. PNC was classified as: no PNC; some level of PNC (either the woman or her newborn missed PNC within 24¿hr of birth but had at least one PNC visit within 42¿days of birth); and WHO¿s recommended level of PNC (at least one PNC use for both the woman and her child within 24¿hr of birth). Pregnancy intention at conception for the last live birth was categorised as wanted, mistimed or unwanted. Multilevel multinomial logistic regression modelling was used to assess the association between pregnancy intention and PNC use, adjusting for possible confounders. We found around 27% of participants had adhered to WHO¿s PNC use recommendations. Around 26% of pregnancies that resulted in live births were unintended at conception, including 15% of which were classified as mistimed and 11% as unwanted. Following adjustment of confounders, a 37% (OR¿=¿0.63, 95% CI: 0.47¿0.85) lower odds of using WHO¿s recommended level of PNC and a 33% (OR, 95% CI, 0.49¿0.93) lower odds of some level of PNC were found for pregnancies that were unwanted relative to those that were wanted. No association was found between mistimed pregnancy and PNC use. Strengthening healthcare facilities and improving the linkage between women and existing healthcare facilities are important to ensure WHO¿s PNC recommendations are met for women experiencing an unwanted pregnancy.

Background: Solid fuel use was found to be associated with under-five mortality in low- and lower-middle income countries (LMICs) though current understanding is lacking for Bangladesh. This study investigated the associations between HAP and neonatal, infant and under-five child mortality in Bangladesh. Methods: We analysed 4189 mother-child dyads data extracted from the 2017/18 Bangladesh Demographic and Health Survey data. Fuel types and levels of exposure to HAP (unexposed, moderately exposed, highly exposed) were considered as exposure variables and several forms of child mortality was considered as outcome variables. Relationships between the exposure and outcome variables were explored by using the multilevel mixed-effect logistic regression model adjusting for possible confounders. Results: Solid fuels were found to be used in nearly 80% of the total mothers analysed. A higher likelihood of mortality was found among neonates (aOR, 3.78; 95% CI, 1.14¿12.51) and infants (aOR, 2.93; 95% CI, 1.60¿6.15) of the women who used solid fuels as compared to the mothers who used clean fuel. The association was found strongest when we considered solid fuel used together with place of cooking. The likelihood of neonatal and infant mortality was found 4.33 (95% CI, 1.16¿16.23) and 2.05 (95% CI, 1.18¿7.23) times higher among mothers who were highly exposed to solid fuel used as compared to the mothers who were unexposed to solid fuel used. Conclusion: Solid fuels used is an important cause of neonatal and under-five mortality in Bangladesh. Administrative initiatives to increase clean fuel use are need to be prioritized in the national level policies and programs. Awareness building programs covering adverse effects of solid fuels used on human health, particularly child health, should also be taken to motivate mothers not to bring their under-five aged children in the cooking place.

Household air pollution (HAP) from solid fuel use (SFU) for cooking is a major public health threat for women and children in low and middle-income countries. This study investigated the associations between HAP and neonatal, infant, and under-five child mortality in Myanmar. The study consisted of¿3249 sample of under-five children in the households from the¿first Myanmar Demographic and Health Survey 2016. Fuel types and levels of exposure to SFU (no, moderate and high) were proxies for HAP. We estimated covariate-adjusted relative risks¿(aRR) of neonatal, infant, and under-five child mortality with 95% confidence intervals, accounting for the survey design. The prevalence of SFU was 79.0%. The neonatal, infant, and under-five child mortality rates were 26, 45, and 49 per 1000 live births, respectively. The risks of infant (aRR 2.02; 95% CI 1.01¿4.05; p-value = 0.048) and under-five mortality (aRR 2.16; 95% CI 1.07¿4.36; p-value = 0.031), but not neonatal mortality, were higher among children from households with SFU compared to children from households using clean fuel. Likewise, children highly exposed to HAP had higher risks of mortality than unexposed children. HAP increases the risks of infant and under-five child mortality in Myanmar, which could be reduced by increasing access to¿clean cookstoves and fuels.

Background: Documentation of patterns and long-term trends in mortality in young people, which reflect huge changes in demographic and social determinants of adolescent health, enables identification of global investment priorities for this age group. We aimed to analyse data on the number of deaths, years of life lost, and mortality rates by sex and age group in people aged 10¿24 years in 204 countries and territories from 1950 to 2019 by use of estimates from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019. Methods: We report trends in estimated total numbers of deaths and mortality rate per 100 000 population in young people aged 10¿24 years by age group (10¿14 years, 15¿19 years, and 20¿24 years) and sex in 204 countries and territories between 1950 and 2019 for all causes, and between 1980 and 2019 by cause of death. We analyse variation in outcomes by region, age group, and sex, and compare annual rate of change in mortality in young people aged 10¿24 years with that in children aged 0¿9 years from 1990 to 2019. We then analyse the association between mortality in people aged 10¿24 years and socioeconomic development using the GBD Socio-demographic Index (SDI), a composite measure based on average national educational attainment in people older than 15 years, total fertility rate in people younger than 25 years, and income per capita. We assess the association between SDI and all-cause mortality in 2019, and analyse the ratio of observed to expected mortality by SDI using the most recent available data release (2017). Findings: In 2019 there were 1·49 million deaths (95% uncertainty interval 1·39¿1·59) worldwide in people aged 10¿24 years, of which 61% occurred in males. 32·7% of all adolescent deaths were due to transport injuries, unintentional injuries, or interpersonal violence and conflict; 32·1% were due to communicable, nutritional, or maternal causes; 27·0% were due to non-communicable diseases; and 8·2% were due to self-harm. Since 1950, deaths in this age group decreased by 30·0% in females and 15·3% in males, and sex-based differences in mortality rate have widened in most regions of the world. Geographical variation has also increased, particularly in people aged 10¿14 years. Since 1980, communicable and maternal causes of death have decreased sharply as a proportion of total deaths in most GBD super-regions, but remain some of the most common causes in sub-Saharan Africa and south Asia, where more than half of all adolescent deaths occur. Annual percentage decrease in all-cause mortality rate since 1990 in adolescents aged 15¿19 years was 1·3% in males and 1·6% in females, almost half that of males aged 1¿4 years (2·4%), and around a third less than in females aged 1¿4 years (2·5%). The proportion of global deaths in people aged 0¿24 years that occurred in people aged 10¿24 years more than doubled between 1950 and 2019, from 9·5% to 21·6%. Interpretation: Variation in adolescent mortality between countries and by sex is widening, driven by poor progress in reducing deaths in males and older adolescents. Improving global adolescent mortality will require action to address the specific vulnerabilities of this age group, which are being overlooked. Furthermore, indirect effects of the COVID-19 pandemic are likely to jeopardise efforts to improve health outcomes including mortality in young people aged 10¿24 years. There is an urgent need to respond to the changing global burden of adolescent mortality, address inequities where they occur, and improve the availability and quality of primary mortality data in this age group. Funding: Bill & Melinda Gates Foundation.

Objective To determine the prevalence of the use of contraceptives among female Rohingya refugees in Bangladesh and its associated factors. Methods We conducted our cross-sectional survey at the Kutupalong refugee facility located in Cox¿s Bazar in November 2019. We used univariable and multivariable logistic regression models to determine the association between the use of contraceptives and our various predictor variables, including women¿s age, age at first marriage, education level and employment status. We also considered factors such as whether previous pregnancies were planned or unplanned, and the occurrence of non-consensual sex with husbands. Findings We found that 50.91% (251/493) of the survey participants used contraceptives, and that injection (169/251; 67.33%) and oral contraceptives (75/251; 29.88%) were the predominant modes. Of the women who did not use contraceptives, the main reasons were reported as disapproval by husbands (118/242; 48.76%), actively seeking a pregnancy (42/242; 17.36%) and religious beliefs (37/242; 15.29%). An increased likelihood of using contraceptives was found to be positively associated with women¿s employment outside their households (odds ratio, OR: 3.11; 95% confidence interval, CI: 1.69¿6.11) and the presence of a health-care centre in the camp (OR: 3.92; 95% CI: 2.01¿7.67). Women who reported an unplanned pregnancy during the previous 2 years were less likely to use contraceptives (OR: 0.02; 95% CI: 0.01¿0.05). Conclusion To increase the acceptance and use of contraceptives, we recommend programmes targeted at women of reproductive age and their husbands, religious and community leaders, and providers of family planning and child and maternal health-care services.

Background: Rohingya girls living in the refugee camps in Bangladesh are disproportionately vulnerable to child marriages and teenage pregnancies. This study examines the factors affecting child marriage and contraceptive use among Rohingya girls who have experienced child marriages. Methods: We collected and analysed quantitative and qualitative data from adolescent Rohingya girls (age 10-19 years) who experienced child marriages. The quantitative data (n=96) came from a cross-sectional survey, and the qualitative data (n=18) from in-depth interviews conducted in the world's largest refugee camp located in Cox's Bazar, Bangladesh. We also interviewed service providers (n=9) of reproductive healthcare services to gain their perspectives regarding contraceptive use among these young girls. We used descriptive statistics to characterise the girls¿ demographic profiles, ages at their first marriages, and contraceptive use. Thematic analysis was used for the qualitative data to identify key factors influencing child marriage and contraceptive use among these girls. Findings: On average, the adolescent female participants had been 15.7 years old when they were first married. Over 80% had given birth during the two years before the survey or were pregnant during time of the data collection. The main factors that influenced child marriage were found to be perceptions regarding the physical and mental maturity for marriage, social norms, insecurity, family honour, preferences for younger brides and the relaxed enforcement of the minimum legal age for marriage. A third (34%) of the girls said they were using contraceptives on the week when the study was conducted. The desire for children, religious beliefs, misapprehension about contraception and long waiting periods in facility-based health services and current service provision were the main factors influencing contraceptive use. Depo Provera injections and pills were the dominant methods of contraception. Contraceptive use during the period between marriage and the first childbirth is rare. Interpretation: Girl child marriage is common in Rohingya camps. Contraceptive use is rare among newly married girls before they give birth for the first time. The involvement of female and male Rohingya volunteers for outreach services can be catalytic in promoting contraceptive use. Funding: La Trobe Asia, La Trobe University, Melbourne, Australia. Bengali translation of the abstract in Appendix 1

COVID-19 is one of the worst pandemics in recent human history, causing huge health, economic, and psychosocial damage. Since the pandemic hit, several unsubstantiated claims regarding exposure, transmission and management have been disseminated. Misinformation and associated public confusion now extend to the COVID-19 vaccines, spanning from claims based on possible links between some vaccine types and rare blood clots, to baseless claims. As a result, the public¿s trust in COVID-19 vaccines has been eroded, fuelling an already troubling trend of vaccine hesitancy. As medication experts and the most accessible healthcare providers, pharmacists are well equipped with the required skills and knowledge to improve COVID-19 vaccine uptake by taking roles that range from dispelling myths, to providing reliable evidence-based information, through to vaccine administration. This paper discusses public hesitancy to COVID-19 vaccines, major contributing factors, and the role pharmacists can play in reducing hesitancy and increasing vaccine uptake.

Anemia is a globally widespread condition in women and is associated with reduced economic productivity and increased mortality worldwide. Here we map annual 2000¿2018 geospatial estimates of anemia prevalence in women of reproductive age (15¿49 years) across 82 low- and middle-income countries (LMICs), stratify anemia by severity and aggregate results to policy-relevant administrative and national levels. Additionally, we provide subnational disparity analyses to provide a comprehensive overview of anemia prevalence inequalities within these countries and predict progress toward the World Health Organization¿s Global Nutrition Target (WHO GNT) to reduce anemia by half by 2030. Our results demonstrate widespread moderate improvements in overall anemia prevalence but identify only three LMICs with a high probability of achieving the WHO GNT by 2030 at a national scale, and no LMIC is expected to achieve the target in all their subnational administrative units. Our maps show where large within-country disparities occur, as well as areas likely to fall short of the WHO GNT, offering precision public health tools so that adequate resource allocation and subsequent interventions can be targeted to the most vulnerable populations.

Background: Human immunodeficiency virus (HIV) remains a public health priority in Latin America. While the burden of HIV is historically concentrated in urban areas and high-risk groups, subnational estimates that cover multiple countries and years are missing. This paucity is partially due to incomplete vital registration (VR) systems and statistical challenges related to estimating mortality rates in areas with low numbers of HIV deaths. In this analysis, we address this gap and provide novel estimates of the HIV mortality rate and the number of HIV deaths by age group, sex, and municipality in Brazil, Colombia, Costa Rica, Ecuador, Guatemala, and Mexico. Methods: We performed an ecological study using VR data ranging from 2000 to 2017, dependent on individual country data availability. We modeled HIV mortality using a Bayesian spatially explicit mixed-effects regression model that incorporates prior information on VR completeness. We calibrated our results to the Global Burden of Disease Study 2017. Results: All countries displayed over a 40-fold difference in HIV mortality between municipalities with the highest and lowest age-standardized HIV mortality rate in the last year of study for men, and over a 20-fold difference for women. Despite decreases in national HIV mortality in all countries¿apart from Ecuador¿across the period of study, we found broad variation in relative changes in HIV mortality at the municipality level and increasing relative inequality over time in all countries. In all six countries included in this analysis, 50% or more HIV deaths were concentrated in fewer than 10% of municipalities in the latest year of study. In addition, national age patterns reflected shifts in mortality to older age groups¿the median age group among decedents ranged from 30 to 45 years of age at the municipality level in Brazil, Colombia, and Mexico in 2017. Conclusions: Our subnational estimates of HIV mortality revealed significant spatial variation and diverging local trends in HIV mortality over time and by age. This analysis provides a framework for incorporating data and uncertainty from incomplete VR systems and can help guide more geographically precise public health intervention to support HIV-related care and reduce HIV-related deaths.

Objective This study examines trends and puts forward projections of under-5 mortality (U5M) in Bangladesh and identifies the effects of maternal high-risk fertility behaviours and use of healthcare services. Methods Data from seven waves of the Bangladesh Demographic and Health Survey (1994 2014) were analyzed for trends and projections of U5M and a Chi-square (x2) test was used to identify if there was any association with maternal high-risk fertility behaviours and use of healthcare services. A multivariate logistic regression model was used to determine the effects of fertility behaviors and healthcare usage on the occurrence of U5M adjusting with confounders. Results U5M declined from 82.5 to 41.0 per 1000 livebirths during 1994 2014 and is projected to further reduce to 17.6 per 1000 livebirths by 2030. The study identified a noticeable regional variation in U5M with maternal high-risk fertility behaviours including age at birth <18 years (aOR: 1.84, 95% CI: 1.23 2.76) and birth interval <24 months (aOR: 1.56, 95% CI: 1.02 2.37) found to be significant determinants. There was a 39 53% decline in this rate of mortality among women that had used antenatal care services at least four times (aOR, 0.51, 95% CI: 0.27 0.97), delivery care (aOR, 0.47, 95% CI: 0.24 0.95), and had received postnatal care (aOR, 0.61, 95% CI: 0.41 0.91) in their last birth. Cesarean section was found to be associated with a 51% reduction in U5M (aOR, 0.49, 95% CI: 0.29 0.82) compared to its non-use. Conclusion The Sustainable Development Goals require a U5M rate of 25 per 1000 livebirths to be achieved by 2030. This study suggests that with the current trend of reduction, Bangladesh will achieve this target before the deadline. This study also found that maternal high-risk fertility behaviours and non-use of maternal healthcare services are very prevalent in some regions of Bangladesh and have increased the occurrence of U5M in those areas. This suggests therefore, that policies and programmes designed to reduce the pregnancy rates of women that are at risk and to encourage an increase in the use of maternal healthcare services are needed.

The purpose of this study was to estimate the age-standardised prevalence, awareness, treatment, and control of hypertension and to identify their risk factors in Bangladeshi adults. Data from 12 904 adults aged 18¿95 years, available from the most recent nationally representative 2017¿2018 Bangladesh Demographic and Health Survey were used. Hypertension was defined as having systolic blood pressure =140¿mmHg and/or a diastolic blood pressure =90¿mmHg, and/or taking anti-hypertensive drugs to control blood pressure. Age-standardized prevalence of hypertension and management were estimated with direct standardisation. A multilevel mixed-effects Poisson regression model with a robust variance was used to identify risk factors associated with hypertension and its awareness, treatment, and control. The overall age-standardized prevalence of hypertension was 26.2% (95% CI, 25.5-26.9); (men: 23.5%, women: 28.9%). Among those with hypertension (n¿=¿3531), 36.7% were aware that they had the condition, and only 31.1% received anti-hypertensive medication. The prevalence of controlled hypertension was 12.7% among those with hypertension and 43.6% among those treated for hypertension (n¿=¿1306). Factors independently associated with hypertension were increasing age, higher body mass index, being women, having diabetes, and residing in selected administrative divisions. A declining trend of hypertension control was observed with increasing age and low education. Hypertension is highly prevalent (one in four) in Bangladeshi adults, while awareness, treatment, and control are low. Irrespective of the risks associated with hypertension and its management, programs to increase its awareness, treatment, and control should be given high priority in reducing hypertension prevalence and improving hypertension control in Bangladesh.

Exclusive breastfeeding (EBF)¿giving infants only breast-milk for the first 6 months of life¿is a component of optimal breastfeeding practices effective in preventing child morbidity and mortality. EBF practices are known to vary by population and comparable subnational estimates of prevalence and progress across low- and middle-income countries (LMICs) are required for planning policy and interventions. Here we present a geospatial analysis of EBF prevalence estimates from 2000 to 2018 across 94 LMICs mapped to policy-relevant administrative units (for example, districts), quantify subnational inequalities and their changes over time, and estimate probabilities of meeting the World Health Organization¿s Global Nutrition Target (WHO GNT) of =70% EBF prevalence by 2030. While six LMICs are projected to meet the WHO GNT of =70% EBF prevalence at a national scale, only three are predicted to meet the target in all their district-level units by 2030.

A double burden of malnutrition occurs when individuals, household members or communities experience both undernutrition and overweight. Here, we show geospatial estimates of overweight and wasting prevalence among children under 5 years of age in 105 low- and middle-income countries (LMICs) from 2000 to 2017 and aggregate these to policy-relevant administrative units. Wasting decreased overall across LMICs between 2000 and 2017, from 8.4% (62.3 (55.1¿70.8) million) to 6.4% (58.3 (47.6¿70.7) million), but is predicted to remain above the World Health Organization¿s Global Nutrition Target of <5% in over half of LMICs by 2025. Prevalence of overweight increased from 5.2% (30 (22.8¿38.5) million) in 2000 to 6.0% (55.5 (44.8¿67.9) million) children aged under 5 years in 2017. Areas most affected by double burden of malnutrition were located in Indonesia, Thailand, southeastern China, Botswana, Cameroon and central Nigeria. Our estimates provide a new perspective to researchers, policy makers and public health agencies in their efforts to address this global childhood syndemic.

CONTEXT: Ineffective use or nonuse of contraceptives following an unplanned birth can contribute to the risk of a subsequent unintended pregnancy; however, the literature on the relationship between unintended pregnancy and postpartum contraceptive use is sparse, especially in low-and middle-income countries. METHODS: Data on 4,493 women from the 2014 Bangladesh Demographic and Health Survey were analyzed; the subjects of the analysis had had a live birth in the three years prior to the survey and were currently at risk of pregnancy. Multilevel logistic regression analysis was used to examine associations between the intendedness of a woman¿s last pregnancy resulting in a live birth and her current modern contraceptive use adjusting for individual, household and community-level variables. RESULTS: Twenty-six percent of women reported that their last pregnancy resulting in a live birth had been unintended (15% mistimed and 11% unwanted); 61% reported current use of a modern contraceptive method. Compared with women who reported the pregnancy as having been wanted, those who reported the pregnancy as mistimed had greater odds of current modern contraceptive use (odds ratio, 1.6); no association was found between having had an unwanted pregnancy and subsequent modern contraceptive use. Other important correlates of modern contraceptive use included women¿s autonomy and desire for children, time since last birth and community-level poverty. CONCLUSIONS: Bangladeshi women who experience an unwanted pregnancy may have an elevated risk of subsequent unintended pregnancy. Broader coverage of family planning services, and integration of family planning with maternal health care, may increase modern contraceptive use following an unplanned birth.

Skilled delivery care has been targeted in the Sustainable Development Goals to reduce preventable maternal and newborn deaths, which mostly occur because of birthing complications. Birthing complications are more frequent in women with unintended than intended pregnancies, and around 43% of total pregnancies in low-A nd middle-income countries are unintended. This study quantified the impact of unintended pregnancy on skilled birth attendance and delivery in health care facilities in Bangladesh. Data from 4493 women participating in the cross-sectional 2014 Bangladesh Demographic and Health Survey were analysed. Multilevel logistic regression models were used to assess the association of unintended pregnancy with skilled birth attendance and delivery in a health care facility through skilled providers while adjusting for individual-, household-A nd community-level factors identified using a directed acyclic graph. Around 26% of women reported that their last pregnancy (occurring within the previous 3 years) that ended with a live birth was unintended at conception. Only 42% reported having a skilled birth attendant present at their last birth and 38% gave birth in a health care facility. Significant differences were found across pregnancy intention. Lower odds of skilled birth attendance (OR, 0.70, 95% CI, 0.52-0.93) and delivery in a health care facility through skilled providers (OR, 0.65, 95% CI, 0.48-0.89) were found among women who had an unwanted pregnancy relative to women who had a wanted pregnancy. However, a mistimed pregnancy was not found to be associated with skilled birth attendance or delivery in health care facility through skilled providers. Increased availability of health care facilities at the community level is required in Bangladesh to ensure skilled delivery care for women with an unwanted pregnancy. Policies are also required to integrate women with an unwanted pregnancy into mainstream health care services through earlier detection and increased awareness in order to reduce the adverse maternal and fetal outcomes associated with lack of quality birthing care.

Background: Worldwide people in disorder of sex development (DSD) faces multiple barriers while seeking their social rights, particularly healthcare services. We aimed to explore the healthcare opportunities available to them, using patterns of healthcare utilization and difficulties faced by DSD population in accessing healthcare services in Bangladesh. Methods: Data from a total of 945 DSD population and 71 medical staff were analyzed, collected from three major divisions (Dhaka, Chittagong, and Rajshahi) in Bangladesh during the period of January to December of 2017. A structured questionnaire was used to collect data via face-to-face interviews. Descriptive statistic was used to determine the frequencies of the visit by the DSD population in healthcare facilities as well as to analyze difficulties experienced by the DSD population in getting healthcare services. Multivariate regression analysis was used to explore the association between perceived barriers in getting healthcare services and failures of the DSD population to receive the healthcare services. Results: Present data revealed that around 80% of DSD population sought healthcare services from government healthcare facilities, where the overall success rate in getting healthcare services was less than 50%. The DSD population reported a number of reasons for failures in getting healthcare services, including non-friendly interaction by non-clinical hospital's staff, non-friendly interaction by physicians, public fright as general people do not want to mingle with a DSD person, undesirable excess public interest in DSD individuals, and limitation of the treatment opportunities of hospitals to merely male or female patients. Among the stated reasons, the most frequently reported reason was non-friendly interaction by physicians (50.27%), followed by undesirable excess public interest in DSD individuals (50.16%). Conclusion: DSD population in Bangladesh have limited access to healthcare facilities and facing multiple barriers to get healthcare services. Initiatives from the government and social organizations are important to ensure their access to healthcare services.

Background: Anxiety is a common psychiatric disorder among adolescents in developing countries. This study aimed to examine the risk factors of anxiety disorder and the adverse consequences of anxiety disorder among adolescents in Bangladesh. Methods: A total of 2,989 adolescent data of the 2014 Global School-based Student Health Survey (GSHS), Bangladesh, was analyzed WHO. The prevalence of anxiety disorder across psychosocial and socio-environmental factors was calculated as descriptive statistics, whereas their effects on occurring anxiety disorder were determined using the unadjusted and adjusted multivariable binary logistic regression model. The consequences of anxiety disorder were also determined using the multivariable binary logistic regression model. Results: The prevalence of anxiety disorder was 4.7%, which was found higher among female than their male counterparts. The psychosocial factors were found associated with the anxiety disorder are loneliness (AOR: 2.26, 95% CI: 1.08¿4.72), being bullied (AOR: 6.00, 95% CI: 3.14¿11.47), and physical abuse (AOR: 2.12, 95% CI: 1.07¿4.21). Moreover, poor understandings with parents (AOR: 1.75, 95% CI: 1.02¿3.01) and lack of peer support (AOR: 2.23, 95% CI: 1.18¿4.23) were the socio-environmental factors that found associated with the anxiety disorder. Subgroup analysis across gender found these associations were consistent for adolescent male and female. Moreover, the likelihood increased with the increasing number of the adverse psychosocial, or socio-environmental factors. Conclusions: Around 5% of school-going adolescents in Bangladesh reported anxiety associated with the exposure of single or multiple adverse psychosocial and socio-environmental factors including bullying and physical abuse. Early screening and interventions are essential, targeted to adolescent at risk, which could reduce the rate of anxiety disorder among adolescent in Bangladesh.

Background Coronavirus disease 2019 (COVID-19), the most hectic pandemic of the era, is increasing exponentially and taking thousands of lives worldwide. This study aimed to assess the prevalence of pre-existing comorbidities among COVID-19 patients and their mortality risks with each category of pre-existing comorbidity. Methods To conduct this systematic review and meta-analysis, Medline, Web of Science, Scopus, and CINAHL databases were searched using pre-specified search strategies. Further searches were conducted using the reference list of the selected studies, renowned preprint servers (eg, medRxiv, bioRxiv, SSRN), and relevant journals¿ websites. Studies written in the English language included if those were conducted among COVID-19 patients with and without comorbidities and presented survivor vs non-survivor counts or hazard/odds of deaths or survivors with types of pre-existing comorbidities. Comorbidities reported in the selected studies were grouped into eight categories. The pooled likelihoods of deaths in each category were estimated using a fixed or random-effect model, based on the heterogeneity assessment. Publication bias was assessed by visual inspection of the funnel plot asymmetry and Egger¿s regression test. Trim and Fill method was used if there any publication bias was found. Results A total of 41 studies included in this study comprised of 27 670 samples. The most common pre-existing comorbidities in COVID-19 patients were hypertension (39.5%), cardiovascular disease (12.4%), and diabetes (25.2%). The higher likelihood of deaths was found among COVID-19 patients who had pre-existing cardiovascular diseases (odds ratio (OR) = 3.42, 95% confidence interval (CI) = 2.86-4.09), immune and metabolic disorders (OR = 2.46, 95% CI = 2.03-2.85), respiratory diseases (OR = 1.94, 95% CI = 1.72-2.19), cerebrovascular diseases (OR = 4.12, 95% CI = 3.04-5.58), any types of cancers (OR = 2.22, 95% CI = 1.63-3.03), renal (OR = 3.02, 95% CI = 2.60-3.51), and liver diseases (OR = 2.35, 95% CI = 1.50-3.69). Conclusions This study provides evidence that COVID-19 patients with pre-existing comorbidities had a higher likelihood of death. These findings could potentially help health care providers to sort out the most susceptible COVID-19 patients by comorbidities, take precautionary measures during hospitalization, assess susceptibility to death, and prioritize their treatment, which could potentially reduce the number of fatalities in COVID-19.

Background: Many countries have shown marked declines in diarrhoeal disease mortality among children younger than 5 years. With this analysis, we provide updated results on diarrhoeal disease mortality among children younger than 5 years from the Global Burden of Diseases, Injuries, and Risk Factors Study 2017 (GBD 2017) and use the study's comparative risk assessment to quantify trends and effects of risk factors, interventions, and broader sociodemographic development on mortality changes in 195 countries and territories from 1990 to 2017. Methods: This analysis for GBD 2017 had three main components. Diarrhoea mortality was modelled using vital registration data, demographic surveillance data, and verbal autopsy data in a predictive, Bayesian, ensemble modelling tool; and the attribution of risk factors and interventions for diarrhoea were modelled in a counterfactual framework that combines modelled population-level prevalence of the exposure to each risk or intervention with the relative risk of diarrhoea given exposure to that factor. We assessed the relative and absolute change in diarrhoea mortality rate between 1990 and 2017, and used the change in risk factor exposure and sociodemographic status to explain differences in the trends of diarrhoea mortality among children younger than 5 years. Findings: Diarrhoea was responsible for an estimated 533 768 deaths (95% uncertainty interval 477 162¿593 145) among children younger than 5 years globally in 2017, a rate of 78·4 deaths (70·1¿87·1) per 100 000 children. The diarrhoea mortality rate ranged between countries by over 685 deaths per 100 000 children. Diarrhoea mortality per 100 000 globally decreased by 69·6% (63·1¿74·6) between 1990 and 2017. Among the risk factors considered in this study, those responsible for the largest declines in the diarrhoea mortality rate were reduction in exposure to unsafe sanitation (13·3% decrease, 11·2¿15·5), childhood wasting (9·9% decrease, 9·6¿10·2), and low use of oral rehydration solution (6·9% decrease, 4·8¿8·4). Interpretation: Diarrhoea mortality has declined substantially since 1990, although there are variations by country. Improvements in sociodemographic indicators might explain some of these trends, but changes in exposure to risk factors¿particularly unsafe sanitation, childhood growth failure, and low use of oral rehydration solution¿appear to be related to the relative and absolute rates of decline in diarrhoea mortality. Although the most effective interventions might vary by country or region, identifying and scaling up the interventions aimed at preventing and protecting against diarrhoea that have already reduced diarrhoea mortality could further avert many thousands of deaths due to this illness. Funding: Bill & Melinda Gates Foundation.

Background: Despite large reductions in under-5 lower respiratory infection (LRI) mortality in many locations, the pace of progress for LRIs has generally lagged behind that of other childhood infectious diseases. To better inform programmes and policies focused on preventing and treating LRIs, we assessed the contributions and patterns of risk factor attribution, intervention coverage, and sociodemographic development in 195 countries and territories by drawing from the Global Burden of Diseases, Injuries, and Risk Factors Study 2017 (GBD 2017) LRI estimates. Methods: We used four strategies to model LRI burden: the mortality due to LRIs was modelled using vital registration data, demographic surveillance data, and verbal autopsy data in a predictive ensemble modelling tool; the incidence of LRIs was modelled using population representative surveys, health-care utilisation data, and scientific literature in a compartmental meta-regression tool; the attribution of risk factors for LRI mortality was modelled in a counterfactual framework; and trends in LRI mortality were analysed applying changes in exposure to risk factors over time. In GBD, infectious disease mortality, including that due to LRI, is among HIV-negative individuals. We categorised locations based on their burden in 1990 to make comparisons in the changing burden between 1990 and 2017 and evaluate the relative percent change in mortality rate, incidence, and risk factor exposure to explain differences in the health loss associated with LRIs among children younger than 5 years. Findings: In 2017, LRIs caused 808 920 deaths (95% uncertainty interval 747 286¿873 591) in children younger than 5 years. Since 1990, there has been a substantial decrease in the number of deaths (from 2 337 538 to 808 920 deaths; 65·4% decrease, 61·5¿68·5) and in mortality rate (from 362·7 deaths [330·1¿392·0] per 100 000 children to 118·9 deaths [109·8¿128·3] per 100 000 children; 67·2% decrease, 63·5¿70·1). LRI incidence declined globally (32·4% decrease, 27·2¿37·5). The percent change in under-5 mortality rate and incidence has varied across locations. Among the risk factors assessed in this study, those responsible for the greatest decrease in under-5 LRI mortality between 1990 and 2017 were increased coverage of vaccination against Haemophilus influenza type b (11·4% decrease, 0·0¿24·5), increased pneumococcal vaccine coverage (6·3% decrease, 6·1¿6·3), and reductions in household air pollution (8·4%, 6·8¿9·2). Interpretation: Our findings show that there have been substantial but uneven declines in LRI mortality among countries between 1990 and 2017. Although improvements in indicators of sociodemographic development could explain some of these trends, changes in exposure to modifiable risk factors are related to the rates of decline in LRI mortality. No single intervention would universally accelerate reductions in health loss associated with LRIs in all settings, but emphasising the most dominant risk factors, particularly in countries with high case fatality, can contribute to the reduction of preventable deaths. Funding: Bill & Melinda Gates Foundation.

Background: Universal access to safe drinking water and sanitation facilities is an essential human right, recognised in the Sustainable Development Goals as crucial for preventing disease and improving human wellbeing. Comprehensive, high-resolution estimates are important to inform progress towards achieving this goal. We aimed to produce high-resolution geospatial estimates of access to drinking water and sanitation facilities. Methods: We used a Bayesian geostatistical model and data from 600 sources across more than 88 low-income and middle-income countries (LMICs) to estimate access to drinking water and sanitation facilities on continuous continent-wide surfaces from 2000 to 2017, and aggregated results to policy-relevant administrative units. We estimated mutually exclusive and collectively exhaustive subcategories of facilities for drinking water (piped water on or off premises, other improved facilities, unimproved, and surface water) and sanitation facilities (septic or sewer sanitation, other improved, unimproved, and open defecation) with use of ordinal regression. We also estimated the number of diarrhoeal deaths in children younger than 5 years attributed to unsafe facilities and estimated deaths that were averted by increased access to safe facilities in 2017, and analysed geographical inequality in access within LMICs. Findings: Across LMICs, access to both piped water and improved water overall increased between 2000 and 2017, with progress varying spatially. For piped water, the safest water facility type, access increased from 40·0% (95% uncertainty interval [UI] 39·4¿40·7) to 50·3% (50·0¿50·5), but was lowest in sub-Saharan Africa, where access to piped water was mostly concentrated in urban centres. Access to both sewer or septic sanitation and improved sanitation overall also increased across all LMICs during the study period. For sewer or septic sanitation, access was 46·3% (95% UI 46·1¿46·5) in 2017, compared with 28·7% (28·5¿29·0) in 2000. Although some units improved access to the safest drinking water or sanitation facilities since 2000, a large absolute number of people continued to not have access in several units with high access to such facilities (>80%) in 2017. More than 253 000 people did not have access to sewer or septic sanitation facilities in the city of Harare, Zimbabwe, despite 88·6% (95% UI 87·2¿89·7) access overall. Many units were able to transition from the least safe facilities in 2000 to safe facilities by 2017; for units in which populations primarily practised open defecation in 2000, 686 (95% UI 664¿711) of the 1830 (1797¿1863) units transitioned to the use of improved sanitation. Geographical disparities in access to improved water across units decreased in 76·1% (95% UI 71·6¿80·7) of countries from 2000 to 2017, and in 53·9% (50·6¿59·6) of countries for access to improved sanitation, but remained evident subnationally in most countries in 2017. Interpretation: Our estimates, combined with geospatial trends in diarrhoeal burden, identify where efforts to increase access to safe drinking water and sanitation facilities are most needed. By highlighting areas with successful approaches or in need of targeted interventions, our estimates can enable precision public health to effectively progress towards universal access to safe water and sanitation. Funding: Bill & Melinda Gates Foundation.

© 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license Background: Across low-income and middle-income countries (LMICs), one in ten deaths in children younger than 5 years is attributable to diarrhoea. The substantial between-country variation in both diarrhoea incidence and mortality is attributable to interventions that protect children, prevent infection, and treat disease. Identifying subnational regions with the highest burden and mapping associated risk factors can aid in reducing preventable childhood diarrhoea. Methods: We used Bayesian model-based geostatistics and a geolocated dataset comprising 15 072 746 children younger than 5 years from 466 surveys in 94 LMICs, in combination with findings of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017, to estimate posterior distributions of diarrhoea prevalence, incidence, and mortality from 2000 to 2017. From these data, we estimated the burden of diarrhoea at varying subnational levels (termed units) by spatially aggregating draws, and we investigated the drivers of subnational patterns by creating aggregated risk factor estimates. Findings: The greatest declines in diarrhoeal mortality were seen in south and southeast Asia and South America, where 54·0% (95% uncertainty interval [UI] 38·1¿65·8), 17·4% (7·7¿28·4), and 59·5% (34·2¿86·9) of units, respectively, recorded decreases in deaths from diarrhoea greater than 10%. Although children in much of Africa remain at high risk of death due to diarrhoea, regions with the most deaths were outside Africa, with the highest mortality units located in Pakistan. Indonesia showed the greatest within-country geographical inequality; some regions had mortality rates nearly four times the average country rate. Reductions in mortality were correlated to improvements in water, sanitation, and hygiene (WASH) or reductions in child growth failure (CGF). Similarly, most high-risk areas had poor WASH, high CGF, or low oral rehydration therapy coverage. Interpretation: By co-analysing geospatial trends in diarrhoeal burden and its key risk factors, we could assess candidate drivers of subnational death reduction. Further, by doing a counterfactual analysis of the remaining disease burden using key risk factors, we identified potential intervention strategies for vulnerable populations. In view of the demands for limited resources in LMICs, accurately quantifying the burden of diarrhoea and its drivers is important for precision public health. Funding: Bill & Melinda Gates Foundation.

Background: Rigorous analysis of levels and trends in exposure to leading risk factors and quantification of their effect on human health are important to identify where public health is making progress and in which cases current efforts are inadequate. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 provides a standardised and comprehensive assessment of the magnitude of risk factor exposure, relative risk, and attributable burden of disease. Methods: GBD 2019 estimated attributable mortality, years of life lost (YLLs), years of life lived with disability (YLDs), and disability-adjusted life-years (DALYs) for 87 risk factors and combinations of risk factors, at the global level, regionally, and for 204 countries and territories. GBD uses a hierarchical list of risk factors so that specific risk factors (eg, sodium intake), and related aggregates (eg, diet quality), are both evaluated. This method has six analytical steps. (1) We included 560 risk¿outcome pairs that met criteria for convincing or probable evidence on the basis of research studies. 12 risk¿outcome pairs included in GBD 2017 no longer met inclusion criteria and 47 risk¿outcome pairs for risks already included in GBD 2017 were added based on new evidence. (2) Relative risks were estimated as a function of exposure based on published systematic reviews, 81 systematic reviews done for GBD 2019, and meta-regression. (3) Levels of exposure in each age-sex-location-year included in the study were estimated based on all available data sources using spatiotemporal Gaussian process regression, DisMod-MR 2.1, a Bayesian meta-regression method, or alternative methods. (4) We determined, from published trials or cohort studies, the level of exposure associated with minimum risk, called the theoretical minimum risk exposure level. (5) Attributable deaths, YLLs, YLDs, and DALYs were computed by multiplying population attributable fractions (PAFs) by the relevant outcome quantity for each age-sex-location-year. (6) PAFs and attributable burden for combinations of risk factors were estimated taking into account mediation of different risk factors through other risk factors. Across all six analytical steps, 30 652 distinct data sources were used in the analysis. Uncertainty in each step of the analysis was propagated into the final estimates of attributable burden. Exposure levels for dichotomous, polytomous, and continuous risk factors were summarised with use of the summary exposure value to facilitate comparisons over time, across location, and across risks. Because the entire time series from 1990 to 2019 has been re-estimated with use of consistent data and methods, these results supersede previously published GBD estimates of attributable burden. Findings: The largest declines in risk exposure from 2010 to 2019 were among a set of risks that are strongly linked to social and economic development, including household air pollution; unsafe water, sanitation, and handwashing; and child growth failure. Global declines also occurred for tobacco smoking and lead exposure. The largest increases in risk exposure were for ambient particulate matter pollution, drug use, high fasting plasma glucose, and high body-mass index. In 2019, the leading Level 2 risk factor globally for attributable deaths was high systolic blood pressure, which accounted for 10·8 million (95% uncertainty interval [UI] 9·51¿12·1) deaths (19·2% [16·9¿21·3] of all deaths in 2019), followed by tobacco (smoked, second-hand, and chewing), which accounted for 8·71 million (8·12¿9·31) deaths (15·4% [14·6¿16·2] of all deaths in 2019). The leading Level 2 risk factor for attributable DALYs globally in 2019 was child and maternal malnutrition, which largely affects health in the youngest age groups and accounted for 295 million (253¿350) DALYs (11·6% [10·3¿13·1] of all global DALYs that year). The risk factor burden varied considerably in 2019 between age groups and locations. Among childr...

Aim: Substance use is not unusual among women of childbearing age. Pregnant women who use a substance and the consequent impacts on a newborn vary across studies and settings. We reviewed New Zealand and Australian literature to examine the short-term health outcomes of newborn of substance-using mothers and their demographic characteristics. Methods: Five medical/nursing databases and google scholar were searched in April 2017. Studies were considered eligible if they described outcomes of newborn of substance-using mothers. Mixed Methods Appraisal Tool was used for quality assessment of candidate studies. Relevant data were extracted and analyzed using narrative synthesis. Based on data availability, a subset of studies was included in meta-analysis. Results: Although findings of individual studies vary, there are some evidence that the infants born to substance-using mothers were likely to have preterm birth, low birthweight, small-for-gestational age, low Apgar score, and admission to neo-natal intensive care unit. The likelihood of adverse health outcomes was much higher for newborns of polysubstance-using mothers, than newborns of mothers using a single substance. Pregnant women who use illicit substance are predominantly socially disadvantaged, in their twenties and or of Aboriginal descent. Conclusion: Infants of substance-using mothers suffer a range of adverse health outcomes. Multidisciplinary and integrated approach of services that ensure supportive social determinants of health may result in a better outcome for newborn and positive behavioral change among mothers.

Background The coexistence of overweight mother and stunted child at the same household is a type of Double Burden of Malnutrition at Household Level (DBMHL). This particular public health concern is now emerging at an alarming rate among most of the South Asian and its neighboring lower-and-middle income countries which are going through nutritional transition. This study has examined the prevalence rate and the risk factors of DBMHL along with the socio-economic inequality in DBMHL among Bangladesh, Nepal, Pakistan, and Myanmar. Methods Latest Demographic and Health Survey datasets were used in this study. To identify the significant association of DBMHL with socio-demographic characteristics, a multivariate technique named as logistic regression model, and for measuring socio-economic inequalities in DBMHL prevalence, relative index of inequality (RII) and slope index of inequality (SII) were used. Results The prevalence rates of DBMHL were 4.10% (urban: 5.57%, rural: 3.51%), 1.54% (urban: 1.63%, rural: 1.42%), 3.93% (urban: 5.62%, rural: 3.20%), and 5.54% (urban: 6.16%, rural: 5.33%) respectively in Bangladesh, Nepal, Pakistan, and Myanmar. The risk ratios (RR) obtained from RII for Bangladesh, Nepal, Pakistan and Myanmar were 1.25, 1.25, 1.14, and 1.09, respectively, and ß coefficient from SII were 0.01, 0.004, 0.005, and 0.006 unit respectively. In addition to not breastfeeding [Bangladesh (AOR: 1.55; 95% CI: 1.11¿2.15), Myanmar (AOR: 1.74; 95% CI: 1.02¿2.95)], respondent¿s older age (in Bangladesh, Nepal, and Myanmar), child¿s older age (in Pakistan and Myanmar), and middle and rich groups of wealth-index (in Bangladesh and Pakistan) were strong risk factors for DBMHL. On the other hand, female child [Nepal (AOR: 0.50; 95% CI: 0.26¿0.95), Pakistan (AOR: 0.58; 95% CI: 0.41¿0.84)], higher education [in Pakistan], respondent not participated in decision making [in Bangladesh and Nepal] and media access [Nepal (AOR: 0.44; 95% CI: 0.20¿0.98)] had negative association with DBMHL. Conclusion The DBMHL persists in all selected countries, with a higher prevalence in urban areas than in rural areas. In order to control the higher prevalence of DBMHL in urban areas, respective countries need urgent implementation of multisectoral actions through effective policies and empowering local communities.

Background: Although the burden of influenza is often discussed in the context of historical pandemics and the threat of future pandemics, every year a substantial burden of lower respiratory tract infections (LRTIs) and other respiratory conditions (like chronic obstructive pulmonary disease) are attributable to seasonal influenza. The Global Burden of Disease Study (GBD) 2017 is a systematic scientific effort to quantify the health loss associated with a comprehensive set of diseases and disabilities. In this Article, we focus on LRTIs that can be attributed to influenza. Methods: We modelled the LRTI incidence, hospitalisations, and mortality attributable to influenza for every country and selected subnational locations by age and year from 1990 to 2017 as part of GBD 2017. We used a counterfactual approach that first estimated the LRTI incidence, hospitalisations, and mortality and then attributed a fraction of those outcomes to influenza. Findings: Influenza LRTI was responsible for an estimated 145 000 (95% uncertainty interval [UI] 99 000¿200 000) deaths among all ages in 2017. The influenza LRTI mortality rate was highest among adults older than 70 years (16·4 deaths per 100 000 [95% UI 11·6¿21·9]), and the highest rate among all ages was in eastern Europe (5·2 per 100 000 population [95% UI 3·5¿7·2]). We estimated that influenza LRTIs accounted for 9 459 000 (95% UI 3 709 000¿22 935 000) hospitalisations due to LRTIs and 81 536 000 hospital days (24 330 000¿259 851 000). We estimated that 11·5% (95% UI 10·0¿12·9) of LRTI episodes were attributable to influenza, corresponding to 54 481 000 (38 465 000¿73 864 000) episodes and 8 172 000 severe episodes (5 000 000¿13 296 000). Interpretation: This comprehensive assessment of the burden of influenza LRTIs shows the substantial annual effect of influenza on global health. Although preparedness planning will be important for potential pandemics, health loss due to seasonal influenza LRTIs should not be overlooked, and vaccine use should be considered. Efforts to improve influenza prevention measures are needed. Funding: Bill & Melinda Gates Foundation.

Objectives: To examine the association between unintended pregnancy and maternal healthcare services utilization in low- and lower-middle-income countries. Methods: A systematic literature search of Medline, Cinahl, Embase, PsycINFO, Cochrane Library, Popline, Maternity and Infant Care, and Scopus databases published since the beginning of the Millennium Development Goals (i.e. January 2000) to June 2018 was performed. We estimated the pooled odds ratios using random effect models and performed subgroup analysis by participants and study characteristics. Results: A total of 38 studies were included in the meta-analysis. Our study found the occurrence of unintended pregnancy was associated with a 25¿39% reduction in the use of antenatal, delivery, and postnatal healthcare services. Stratified analysis found the differences of healthcare services utilization across types of pregnancy unintendedness (e.g. mistimed, unwanted). Conclusions: Integrating family planning and maternal healthcare services should be considered to encourage women with unintended pregnancies to access maternal healthcare services.

Objective: This study examined the inequality in cesarean section (CS) utilization and its socio-economic contributors. Study design: Retrospective two-stage stratified sample design. Methods: Data were extracted from two rounds of the Bangladesh Demographic and Health Survey conducted in 2004 and 2014. Concentration Index of CS utilization was calculated using the wealth quintile. Regression-based decomposition method was applied to assess the socio-economic contributors of inequality in CS utilization. Results: The rate of CS utilization increased from 4.98% in 2004 to 24.21% in 2014. The utilization of CS was highly concentrated among the women of higher socio-economic status (SES) in both rounds of the survey. Results of the decomposition models revealed wealth quintile, higher education, higher number of antenatal visits, and being overweight or obese as the critical factors contributing to the inequalities of CS utilization. Conclusion: Bangladesh is now observing a rapid rise in CS utilization and women with higher SES are the main client group of this life saving procedure. There may have inadequate access for those who are relatively less advantaged, even when CS is necessary. Strong initiative from the government is necessary to ensure proper access to this service regardless of women's SES.

Background A key component of achieving universal health coverage is ensuring that all populations have access to quality health care. Examining where gains have occurred or progress has faltered across and within countries is crucial to guiding decisions and strategies for future improvement. We used the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) to assess personal health-care access and quality with the Healthcare Access and Quality (HAQ) Index for 195 countries and territories, as well as subnational locations in seven countries, from 1990 to 2016. Methods Drawing from established methods and updated estimates from GBD 2016, we used 32 causes from which death should not occur in the presence of effective care to approximate personal health-care access and quality by location and over time. To better isolate potential effects of personal health-care access and quality from underlying risk factor patterns, we risk-standardised cause-specific deaths due to non-cancers by location-year, replacing the local joint exposure of environmental and behavioural risks with the global level of exposure. Supported by the expansion of cancer registry data in GBD 2016, we used mortality-to-incidence ratios for cancers instead of risk-standardised death rates to provide a stronger signal of the effects of personal health care and access on cancer survival. We transformed each cause to a scale of 0-100, with 0 as the first percentile (worst) observed between 1990 and 2016, and 100 as the 99th percentile (best); we set these thresholds at the country level, and then applied them to subnational locations. We applied a principal components analysis to construct the HAQ Index using all scaled cause values, providing an overall score of 0-100 of personal health-care access and quality by location over time. We then compared HAQ Index levels and trends by quintiles on the Socio-demographic Index (SDI), a summary measure of overall development. As derived from the broader GBD study and other data sources, we examined relationships between national HAQ Index scores and potential correlates of performance, such as total health spending per capita. Findings In 2016, HAQ Index performance spanned from a high of 97·1 (95% UI 95·8-98·1) in Iceland, followed by 96·6 (94·9-97·9) in Norway and 96·1 (94·5-97·3) in the Netherlands, to values as low as 18·6 (13·1-24·4) in the Central African Republic, 19·0 (14·3-23·7) in Somalia, and 23·4 (20·2-26·8) in Guinea-Bissau. The pace of progress achieved between 1990 and 2016 varied, with markedly faster improvements occurring between 2000 and 2016 for many countries in sub-Saharan Africa and southeast Asia, whereas several countries in Latin America and elsewhere saw progress stagnate after experiencing considerable advances in the HAQ Index between 1990 and 2000. Striking subnational disparities emerged in personal health-care access and quality, with China and India having particularly large gaps between locations with the highest and lowest scores in 2016. In China, performance ranged from 91·5 (89·1-93·6) in Beijing to 48·0 (43·4-53·2) in Tibet (a 43·5-point difference), while India saw a 30·8-point disparity, from 64·8 (59·6-68·8) in Goa to 34·0 (30·3-38·1) in Assam. Japan recorded the smallest range in subnational HAQ performance in 2016 (a 4·8-point difference), whereas differences between subnational locations with the highest and lowest HAQ Index values were more than two times as high for the USA and three times as high for England. State-level gaps in the HAQ Index in Mexico somewhat narrowed from 1990 to 2016 (from a 20·9-point to 17·0-point difference), whereas in Brazil, disparities slightly increased across states during this time (a 17·2-point to 20·4-point difference). Performance on the HAQ Index showed strong linkages to overall development, with high and high-middle SDI countries generally having higher scores and faster gains for non-communicable diseases. None...