Gulam M. Khandaker

Access to early intervention and rehabilitation services among children with cerebral palsy (CP) remains limited in Bangladesh, which demands an innovative and sustainable service delivery model. To evaluate the effectiveness of the Sustainable Model of Early Intervention and Telerehabilitation for Children With CP (SMART-CP) model compared with usual care in improving access to and utilization of early diagnosis, early intervention, and rehabilitation services in rural Bangladesh. This was a 2-arm cluster randomized clinical trial, with 8 clusters (ie, subdistricts) randomly allocated to the intervention (SMART-CP model) or control arm. The setting was in Sirajganj, Bangladesh, and included children with CP 18 years or younger. Outcomes were measured at 0 and 12 months, and an intention-to-treat analysis was conducted. Data were analyzed from December 2023 to May 2024. The SMART-CP model comprised (1) a rural referral network involving key informants and caregiver peer groups (called mPower or mothers' power), (2) subdistrict level SMART-CP centers, and (3) telerehabilitation services. Children in the intervention arm received weekly goal-directed therapy, mPower group meetings every 2 weeks, and monthly telerehabilitation sessions. The primary outcome was whether a child with CP accessed any form of rehabilitation services, with secondary outcomes analyzed as hypothesis generating. Overall, 968 children with CP (mean [SD] age, 7.9 [4.9] years; 581 male [60.0%]) were enrolled, with 500 in the intervention arm and 468 in the control arm. Between baseline and endline, rehabilitation services uptake significantly increased in the intervention arm (70.2% [351 of 500] vs 99.4% [497 of 500]), compared with the control arm (63.9% [299 of 468] vs 68.2% [319 of 468]; P <.001). Children in the intervention arm were 1.5 times more likely to access rehabilitation than the control arm. Secondary analyses suggested that the intervention arm also facilitated early CP diagnosis (mean [SD] diagnosis time, 2.0 [2.0] years vs 3.8 [3.3] years; Cohen d = -0.7) and initiation of rehabilitation (mean [SD] rehabilitation time, 1.8 [1.8] years vs 3.6 [2.4] years; Cohen d = -0.9). Additionally, higher therapy session counts (mean [SD] session counts, 23.4 [31.7] vs 4.3 [20.8]; Cohen d = 0.7), increased assistive device utilization (20.8% [104 of 500] vs 3.0% [14 of 468]; risk ratio, 0.82; 95% CI, 0.78-0.86; P < .001), and lower out-of-pocket expenditure per month (mean [SD] expenditure, $1.5 [$1.6] vs $2.9 [$5.1]; Cohen d = -0.4) were found in the intervention arm. No significant difference in clinical outcomes and mortality rates was observed between the intervention and control groups. Results of this cluster randomized clinical trial reveal that the SMART-CP model improved access to and utilization of early diagnosis and intervention services for children with CP in rural Bangladesh. This model holds promise for global scalability. ANZCTR Trial Identifier: ACTRN12622000396729.

Objective: Diabetic foot disease (DFD) requires proactive healthcare management to minimise the risk of complications. Healthcare delivery has been shown to present significant challenges in rural and regional settings with Central Queensland being a large geographic area with limited local healthcare resources. Our objectives are to describe the distribution of DFD in a regional setting and assess the impact of remoteness on healthcare accessibility for this cohort. Methods: A retrospective analysis of hospital admissions for DFD data between January 2017 and December 2023. Methods: All recorded episodes of care for DFD patients provided by Central Queensland Hospital and Health Service (CQHHS) were included. Methods: Primary outcome was the number of DFD episodes. Secondary outcomes included the number of hospital bed days used by DFD cases, the number of lower extremity amputations and the number of interhospital transfers (IHTs) for DFD cases. Results: 1597 DFD episodes, 15 528 bed days, 340 lower extremity amputations and 452 IHTs were recorded. Population-adjusted outcomes showed 1054 DFD episodes per 100 000 males compared with 383 per 100 000 females (incidence rate ratio (IRR) 2.75, 95% CI: 2.46 to 3.07), and 1384 per 100 000 Indigenous Australians compared with 669 per 100 000 non-Indigenous Australians (IRR 2.07, 95% CI: 1.80 to 2.38). Remoteness was associated with lower DFD treatment completion rates at local hospitals, with only 9.3% of patients from the most remote regions completing treatment locally, compared with 76.3% from the least remote regions (p<0.001). The number of IHTs and amputations referred to healthcare facilities external to CQHHS increased throughout the study period. Conclusions: Males and Indigenous Australians were disproportionately affected by DFD in Central Queensland. Remoteness poses a significant risk factor to completing treatment for DFD at a local facility. Further research into key drivers leading to the disproportionate outcomes demonstrated in this study between specific cohorts of people with DFD is suggested to help design future interventions to improve accessibility and outcomes.

BackgroundHousehold food insecurity is a critical concern for ultra-poor families in low- and middle-income countries like Bangladesh, particularly those with members who have disabilities. The COVID-19 pandemic has worsened this situation.ObjectiveThis study aimed to assess the impact of microfinance-based livelihood programs on food insecurity in ultra-poor families with members affected by cerebral palsy in Bangladesh.MethodsData were extracted from the SUPPORT CP trial for 251 children with cerebral palsy. The Household Food Insecurity Access Scale score was the outcome variable. The explanatory variable was the intervention type, dividing the sample into 3 arms: Arm C (care as usual), Arm B (Community-Based Rehabilitation [CBR]), and Arm A (CBR with the integrated microfinance-based livelihood program [IMCBR]). Both linear regression and the Generalized Estimating Equations model were used to determine the association of outcome variable with explanatory variables adjusting for covariates.ResultsWe found a consistent level of household food insecurity across each time point, with a significant increase in the midline during the peak of COVID-19 pandemic in 2020. However, following the end of the COVID-19 pandemic, both Arms A and B, where interventions were provided, reported a significant decline in food insecurity. Notably, Arm A, where IMCBR was provided, exhibited the fastest decrease in food insecurity followed by Arm B, where only CBR was provided, compared to Arm C.ConclusionMicrofinance programs can reduce food insecurity among families of children with cerebral palsy in Bangladesh, especially during crises like COVID-19, underscoring the need to integrate them with tailored disability rehabilitation services.

Background: People with disabilities have the same need for contraception as the general population. However, their access to modern contraceptive methods is largely underexplored in low- and middle-income countries. Objective: This study aimed to explore the prevalence of modern contraception use among reproductive-aged (15-49 years) persons with disabilities in low- and middle-income countries and identify the key determinants. Methods: In June 2024, we conducted a systematic search across six databases including PubMed, Web of Science, Embase, Global Health, Medline and Scopus to identify studies on disability and modern contraception in low- and middle-income countries. The search terms included a combination of Medical Subject Headings (MeSH) terms and keywords related to disability, modern contraception and low- and middle-income countries integrated using the Boolean operators (AND, OR). All studies published between January 2015 and June 2024, in English, and conducted in low- and middle-income countries were included. The primary outcomes were the prevalence of modern contraception use and its determinants among persons with any disability. Summary estimates were calculated using meta-analysis with a fixed effects model for lower heterogeneity. Random effects meta-analysis was used for mid-level heterogeneity (50%-74%) and high-level heterogeneity (75%-100%). Results: A total of 18 studies from low- and middle-income countries were included, with 11 included in the meta-analysis. The pooled prevalence of modern contraception use among persons with disabilities was 31.4% (95% CI: 26.5, 36.2). Significant heterogeneity was observed across respondent characteristics (I2 = 94.55%). Five factors were significantly associated with higher contraception use: being aged over 25 years, having some level of education, being in a higher wealth quintile, having adequate knowledge of family planning and being in a formal marital relationship. Conclusions: This study reveals a significantly lower prevalence of modern contraception use among persons with disabilities in low- and middle-income countries compared to the general population. Improving access to education, addressing social norms and strengthening healthcare systems may contribute to increasing access to contraception and uptake among persons with disabilities in low- and middle-income countries.

Respiratory syncytial virus (RSV) is a leading cause of acute lower respiratory tract infections, especially in infants and young children globally. Despite its impact, RSV testing and epidemiological data remain limited, particularly in regional Australia. Central Queensland, with its subtropical climate, provides a unique setting in which to study RSV trends, testing patterns, and associated hospital burden. This study used hospital-based data to analyse RSV-related hospitalisations and testing from Central Queensland. Data were collected retrospectively between 2018 and 2021 and prospectively between 2022 and 2023. Eligible cases included individuals presenting to or admitted at any hospitals in Central Queensland with laboratory-confirmed RSV or RSV-related diagnoses based on ICD-10-AM codes. The analysis focused on RSV-related hospital admissions and hospitalisation outcomes. Incidence rate ratios (IRR) for hospitalisation rates between the two periods were calculated. Between 2018 and 2023, there were 1,279 RSV-related hospitalisations, with 53.2% of cases being male. Infants under 12 months accounted for the highest proportion of admissions (38.4%). RSV-related hospitalisations peaked during the prospective study period, rising from 123 in 2018 to 357 in 2023. The hospitalisation rate among infants was significantly higher in the prospective study period compared to the retrospective study period (IRR: 2.2; 95% confidence interval [95% CI]: 1.8-2.6; p < 0.001). The Indigenous population had a significantly higher hospitalisation rate than the non-Indigenous population over the whole study period (IRR: 3.1; 95% CI: 2.7-3.6; p < 0.001). The median length of stay was two days, with 20.6% of those hospitalised requiring ventilation, 2.2% needing intensive care unit (ICU) support, and 0.9% of hospitalisations resulting in death. Mortality was highest among those aged 60 years and above (91.7%). Although infants under 12 months had the lowest RSV testing rates (9.8%), they had the highest test positivity rate (16.4%). RSV admissions have been under-reported due to limited testing. Increased awareness and widespread testing during prospective surveillance revealed a significant rise in RSV-related admissions. These findings underscore the need for enhanced RSV testing, improved resource allocation, and expanded immunisation efforts to effectively manage the burden of RSV.