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This report provides a systematic review of the evidence to date, both published and grey literature, on the relationship between water and sanitation and nutrition. We also survey the potential impact of improved water, sanitation, and hygiene (WASH) on undernutrition. This is the first report that undertakes a thorough review and discussion of WASH and nutrition in Bangladesh. The report is meant to serve two purposes. First, it synthesizes the results/evidence evolving on the pathway of WASH and undernutrition for use by practitioners working in the nutrition and water and sanitation sectors to stimulate technical discussions and effective collaboration among stakeholders. Second, this report serves as an advocacy tool, primarily for policy makers, to assist them in formulating a multisectoral approach to tackling the undernutrition problem.

National levels of personal health-care access and quality can be approximated by measuring mortality rates from causes that should not be fatal in the presence of effective medical care (ie, amenable mortality). Previous analyses of mortality amenable to health care only focused on high-income countries and faced several methodological challenges. In the present analysis, we use the highly standardised cause of death and risk factor estimates generated through the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) to improve and expand the quantification of personal health-care access and quality for 195 countries and territories from 1990 to 2015. We mapped the most widely used list of causes amenable to personal health care developed by Nolte and McKee to 32 GBD causes. We accounted for variations in cause of death certification and misclassifications through the extensive data standardisation processes and redistribution algorithms developed for GBD. To isolate the effects of personal health-care access and quality, we risk-standardised cause-specific mortality rates for each geography-year by removing the joint effects of local environmental and behavioural risks, and adding back the global levels of risk exposure as estimated for GBD 2015. We employed principal component analysis to create a single, interpretable summary measure–the Healthcare Quality and Access (HAQ) Index–on a scale of 0 to 100. The HAQ Index showed strong convergence validity as compared with other health-system indicators, including health expenditure per capita (r=0·88), an index of 11 universal health coverage interventions (r=0·83), and human resources for health per 1000 (r=0·77). We used free disposal hull analysis with bootstrapping to produce a frontier based on the relationship between the HAQ Index and the Socio-demographic Index (SDI), a measure of overall development consisting of income per capita, average years of education, and total fertility rates. This frontier allowed us to better quantify the maximum levels of personal health-care access and quality achieved across the development spectrum, and pinpoint geographies where gaps between observed and potential levels have narrowed or widened over time. Between 1990 and 2015, nearly all countries and territories saw their HAQ Index values improve; nonetheless, the difference between the highest and lowest observed HAQ Index was larger in 2015 than in 1990, ranging from 28·6 to 94·6. Of 195 geographies, 167 had statistically significant increases in HAQ Index levels since 1990, with South Korea, Turkey, Peru, China, and the Maldives recording among the largest gains by 2015. Performance on the HAQ Index and individual causes showed distinct patterns by region and level of development, yet substantial heterogeneities emerged for several causes, including cancers in highest-SDI countries; chronic kidney disease, diabetes, diarrhoeal diseases, and lower respiratory infections among middle-SDI countries; and measles and tetanus among lowest-SDI countries. While the global HAQ Index average rose from 40·7 (95% uncertainty interval, 39·0–42·8) in 1990 to 53·7 (52·2–55·4) in 2015, far less progress occurred in narrowing the gap between observed HAQ Index values and maximum levels achieved; at the global level, the difference between the observed and frontier HAQ Index only decreased from 21·2 in 1990 to 20·1 in 2015. If every country and territory had achieved the highest observed HAQ Index by their corresponding level of SDI, the global average would have been 73·8 in 2015. Several countries, particularly in eastern and western sub-Saharan Africa, reached HAQ Index values similar to or beyond their development levels, whereas others, namely in southern sub-Saharan Africa, the Middle East, and south Asia, lagged behind what geographies of similar development attained between 1990 and 2015. This novel extension of the GBD Study shows the untapped potential for personal health-care access and quality improvement across the development spectrum. Amid substantive advances in personal health care at the national level, heterogeneous patterns for individual causes in given countries or territories suggest that few places have consistently achieved optimal health-care access and quality across health-system functions and therapeutic areas. This is especially evident in middle-SDI countries, many of which have recently undergone or are currently experiencing epidemiological transitions. The HAQ Index, if paired with other measures of health-system characteristics such as intervention coverage, could provide a robust avenue for tracking progress on universal health coverage and identifying local priorities for strengthening personal health-care quality and access throughout the world. Bill & Melinda Gates Foundation.

The prevalence of stunting, wasting, and underweight are reported separately. However, the data of the multiple anthropometric failures combinations of these conventional indicators are scant. This study attempted to estimate the overall burden of undernutrition among children under 5 years old, using the composite index of anthropometric failure (CIAF), and to explore the correlates. The study used secondary data from the Bangladesh demographic and health surveys (BDHS), undertaken in 2014. CIAF provides an overall prevalence of undernutrition, which gives six mutually exclusive anthropometric measurements of height‐for‐ age, height‐for‐weight, and weight‐for‐age. Multivariable logistic regression was used to explore the correlates of CIAF. The overall prevalence of undernutrition using the CIAF was 48.3% (95% CI [47.1%, 49.5%]) among the children under 5 years old. The prevalence of anthropometric failure due to a combination of both stunting and underweight was 18.2%, wasting and underweight was 5.5%, and wasting, underweight, and stunting was 5.7%. The odds of CIAF were higher among young maternal age, having the poorest socio‐economic status, living in rural areas, higher order of birth, and received no vaccination compared with other counterparts. In Bangladesh, one out of two children has undernutrition, which is preventing the potential of the millions of children. Mothers who gave birth before age 20 living in the rural areas with belonging to lower socio‐economic status and whose children had a higher order of birth and receive no vaccination were observed as the main determinants of undernutrition. Nutrition sensitive interventions along with social protection programmes are crucial to deal the underlying causes of undernutrition.

Children are particularly vulnerable to the effects of natural disasters. This article aims to gain a deeper understanding of the specific effects of natural disasters on children and how they could better be involved in the disaster risk reduction (DRR) process. The article begins with a review of the literature published on the Child-led Disaster Risk Reduction (CLDRR) approach and describes the key issues. Then it identifies the effects of floods on children in Bangladesh and analyses the traditional coping mechanisms developed by communities, highlighting where they could be improved. Finally, it analyses how DRR stakeholders involve children in the DRR process and identifies the opportunities and gaps for the mainstreaming of a CLDRR approach in Bangladesh. This should contribute to a better understanding of how key DRR stakeholders can protect children during natural disasters. Encouraging the building of long-term, child-sensitive DRR strategies is an essential part of this process.

Although child and maternal malnutrition has been reduced in Bangladesh, the prevalence of underweight (weight-for-age z-score <-2) among children aged less than five years is still high (41%). Nearly one-third of women are undernourished with body mass index of <18.5 kg/m2. The prevalence of anaemia among young infants, adolescent girls, and pregnant women is still at unacceptable levels. Despite the successes in specific programmes, such as the Expanded Programme on Immunization and vitamin A supplementation, programmes for nutrition interventions are yet to be implemented at scale for reaching the entire population. Given the low annual rate of reduction in child undernutrition of 1.27 percentage points per year, it is unlikely that Bangladesh would be able to achieve the United Nations' Millennium Development Goal to address undernutrition. This warrants that the policy-makers and programme managers think urgently about the ways to accelerate the progress. The Government, development partners, non-government organizations, and the academia have to work in concert to improve the coverage of basic and effective nutrition interventions, including exclusive breastfeeding, appropriate complementary feeding, supplementation of micronutrients to children, adolescent girls, pregnant and lactating women, management of severe acute malnutrition and deworming, and hygiene interventions, coupled with those that address more structural causes and indirectly improve nutrition. The entire health system needs to be revitalized to overcome the constraints that exist at the levels of policy, governance, and service-delivery, and also for the creation of demand for the services at the household level. In addition, management of nutrition in the aftermath of natural disasters and stabilization of prices of foods should also be prioritized.

Background The aim of this study was to examine the effect of household food security on childhood anemia in Bangladesh while controlling for socioeconomic and demographic factors. Methods We used nationally representative Bangladesh Demographic Health Survey (BDHS) 2011 data for this study, the only existing survey including anemia information and household food security. The sample included 2171 children aged 6–59 months and their mothers. Differences between socioeconomic and demographic variables were analyzed using Chi-square test. Univariate and multivariate logistic regression analyses were performed to estimate the effects of different socioeconomic and demographic factors on childhood anemia. We also performed mediation analysis to examine the direct and indirect effect of household food security on childhood anemia. Results In Bangladesh, 53% male (95% CI: 50–56) and 51% female (95% CI: 47–54) children aged 6–59 months were anemic in 2011. The food insecure households have 1.20 times odds (95% CI: 0.97–1.48) of having anemic children comparing to food secure households in the unadjusted model. On the other hand, anemic mothers have 2 times odds (95% CI: 1.67–2.44) of having anemic children comparing to non-anemic mothers. However, household food security is no longer significantly associated with childhood anemia in the adjusted model while mothers’ anemia remained a significant factor (OR 1.87: 95% CI: 1.53–2.29). Age of children is the highest associated factor, and the odds are 4.89 (95% CI: 3.21–7.45) for 6–12 months old children comparing to 49–59 months in the adjusted model. Stunting and household wealth are also a significant factor for childhood anemia. Although food security has no significant direct effect on childhood anemia, maternal anemia and childhood stunting mediated that relationship. Conclusions Future public health policies need to focus on improving mothers’ health with focusing on household food security to eliminate childhood anemia.

This paper examines the effect of maternal education on child mortality in Bangladesh by exploiting quasi-experimental variations in the duration of exposure to a school stipend project for identification. Results from the instrumental variable estimation indicate that an additional year of maternal schooling reduces both underfive and infant mortality by about 20 percent. The findings are statistically significant and robust to a number of model specifications, including survival models controlling for right censoring of child mortality. Analysis of potential mechanisms suggests that maternal education reduces child mortality through greater wealth and literacy, positive assortative mating, lower fertility, delayed marriage and childbearing, greater health-related knowledge, better health-seeking behaviors, and female empowerment, but not through female employment.

Background The study attempts to develop an ordinal logistic regression (OLR) model to identify the determinants of child malnutrition instead of developing traditional binary logistic regression (BLR) model using the data of Bangladesh Demographic and Health Survey 2004. Methods Based on weight-for-age anthropometric index (Z-score) child nutrition status is categorized into three groups-severely undernourished (< -3.0), moderately undernourished (-3.0 to -2.01) and nourished (≥-2.0). Since nutrition status is ordinal, an OLR model-proportional odds model (POM) can be developed instead of two separate BLR models to find predictors of both malnutrition and severe malnutrition if the proportional odds assumption satisfies. The assumption is satisfied with low p-value (0.144) due to violation of the assumption for one co-variate. So partial proportional odds model (PPOM) and two BLR models have also been developed to check the applicability of the OLR model. Graphical test has also been adopted for checking the proportional odds assumption. Results All the models determine that age of child, birth interval, mothers' education, maternal nutrition, household wealth status, child feeding index, and incidence of fever, ARI & diarrhoea were the significant predictors of child malnutrition; however, results of PPOM were more precise than those of other models. Conclusion These findings clearly justify that OLR models (POM and PPOM) are appropriate to find predictors of malnutrition instead of BLR models.

Background According to the Bangladesh National Tuberculosis Control Program (NTP), the proportion of childhood tuberculosis (TB) among all reported cases is only 3%. This is considerably lower compared to other high-burden countries. One of our previous studies identified substantial gaps at the primary care level related to capacity of service providers, supply of required logistics and community awareness about childhood TB. Therefore, we conducted an implementation study with the objectives to address those gaps. Methods This implementation research was designed with pre and post-test evaluation at selected primary care facilities in urban and rural areas. Three interventions were implemented: (1) Training on childhood TB management for all categories of service providers (2) mass awareness campaign among primary and secondary school students and their teachers, mothers of <5y children, religious and community leaders and (3) facilitation of logistics supply at the study facilities. Training was conducted following the national guideline. We developed posters, leaflets, flipcharts and organized folksongs and street dramas as awareness campaign strategy. Quarterly follow up meetings were held with the facility managers of the study clinics. Cross-sectional surveys were conducted at the baseline and end line alongside review of service statistics to compare the change in community awareness and case detection of childhood TB. Results Awareness regarding childhood TB among all target audience increased significantly showing better understanding of child TB symptoms, transmission, duration and treatment option. Overall proportion of TB case detection among children increased in all three sites compared to baseline as well as NTP estimate with relatively higher proportion in urban site. Majority of the children were suffering from extra-pulmonary TB and there were more female TB cases than male. However, supply and maintenance of necessary diagnostics and child friendly TB drugs remained suboptimal. Conclusion Through implementation research, detection of childhood TB cases increased in all study facilities exceeding the NTP’s estimate. Community awareness on childhood TB improved significantly across all study sites as well. The NTP should implement strategies to raise community awareness alongside increasing the capacity of service providers and ensuring availability of diagnostics and pediatric TB drugs at the primary care level.