BACKGROUND
Since August 2017, approximately 960,000 Rohingya refugees have settled in Cox’s Bazar, Bangladesh. Water, sanitation, and hygiene (WASH) infrastructure and programs were implemented across the camps to address the needs of the population and reduce the burden of linked infectious diseases. However, monitoring and maintenance of this infrastructure has been inconsistent. This study aimed to assess progress in WASH in the camps of Cox’s Bazar since the early emergency phase in 2018, and to update the priorities for intervention.
METHODS
From January to March 2022, a lot quality assurance sampling (LQAS) survey was conducted across 19 camps. Nineteen households were randomly selected per camp. Data on access to and quality of WASH services, household practices, and health outcomes including skin infections among children under five years of age were collected. Crude and weighted averages with 95% confidence intervals were calculated for each indicator and compared with targets pre-defined based on Sphere guidelines and Médecins Sans Frontières WASH experts. Chi-squared tests were used to compare the results to a 2018 LQAS survey.
RESULTS
More than half of the indicators (59%; 16/27) did not meet the pre-determined targets. Performance was adequate on three of five water quality and supply indicators, with less than half of households (44%, 95% CI: 39–49%) reporting that water was continuously available in the past week. Regarding water storage, performance on three indicators was considered adequate, as the proportion of households that keep water for less than one day was 27% (95% CI: 23-32%). Of six hygiene indicators, adequate performance was identified for only one. Performance on the sanitation indicators was inadequate, with 11% (95% CI: 8-15%) of households using an improved sanitation facility. In solid waste management, two of four indicators suggested adequate performance, and for health outcomes, the proportion of children who hadn’t shown any skin infection was inadequate at 69% (95% CI: 64-73%).
CONCLUSIONS
Improvements in the WASH situation in Cox’s Bazar have been observed in 2022 compared to 2018. However, significant gaps remain in water supply, sanitation facilities, and hygiene services. LQAS can be an effective monitoring tool to support long-term multisectoral interventions in protracted emergencies.
The crowded conditions within camps for refugees and internally displaced people create risk environments for unmitigated transmission of SARS-CoV-2. Within one such setting, Cox’s Bazar, Bangladesh, MSF distributed face masks in July-August 2020 for use by people living in eight camps to reduce transmission risks. However, uptake of face masks within camp populations and the factors influencing use are not well understood.
METHODS
We conducted a multi-level triangulation mixed-methods study in March 2021 in Cox’s Bazar. Field observations were undertaken in public spaces in four camps, noting individuals’ facemask use (appropriate versus not), use of other types of face covering (e.g., headscarf), and gender. We also analysed photographs posted on Twitter during March 2021 that were geotagged in the Cox’s Bazar area, posted with a specific keyword, or posted by connected accounts and tweets. Photographs were also categorised by facemask/headscarf use and gender. Finally, we conducted 32 in-depth interviews to understand perceptions and barriers around mask use. Qualitative data were analysed thematically using NVivo.
ETHICS
This study was approved by the Office of the Civil Surgeon, Cox’s Bazar, Bangladesh and by the MSF Ethics Review Board.
RESULTS
We made 3,152 public observations. Only 190/3,152 (6%) were using a mask appropriately. Men were more likely to be seen using any visible standard facemask appropriately than women (odds ratio, OR, 1.5, 95% confidence interval 1.1-2.2, p-value 0.037). Most women were observed wearing headscarves that precluded observing if masks were worn underneath. The content of 20 tweets were analysed. One photograph showed one person wearing a mask correctly; in 17 photographs individuals wore no face covering and in 2 wore scarves. Qualitative data suggested participants were aware of the importance of mask use but highlighted several reasons for not wearing them, including the fear of being insulted for wearing a mask due to the association between mask use and having Covid-19; a view that they were unnecessary because there was little Covid-19 in the camps; experiences of physical difficulties or discomfort whilst wearing masks; and a belief that wearing facemasks was unnecessary because “life or death is up to Allah”. Participants highlighted the current shortage of masks in the camps as well as adverse consequences of insufficient masks, and requested further distribution.
CONCLUSION
These findings suggest low adherence to recommendations around mask use in this camp setting. Multiple strategies need to be considered, including better distribution strategies and improved messaging and engagement with religious and community leaders to increase facemask use in settings such as Cox’s Bazar.
CONFLICTS OF INTEREST
None declared.
Malaria is one of the major public health problems in Myanmar. Village health volunteers (VHV) are the key malaria diagnosis and treatment service provider at community level in addition to basic health staffs (BHS). This countrywide analysis aimed to assess and compare the accessibility to- and quality of malaria care (treatment initiation, treatment within 24 h and complete treatment delivery) between VHV and BHS in Myanmar.
METHODS
This was a retrospective cohort study using record review of routinely collected programme data available in electronic format. All patients with undifferentiated fever screened and diagnosed for malaria in January-December 2015 by VHV and BHS under National Malaria Control Programme in Myanmar were included in the study. Unadjusted and adjusted prevalence ratios (aPR) were calculated to assess the effect of VHV/BHS on receipt of treatment by patients.
RESULTS
Of 978,735 undifferentiated fever patients screened in 2015, 11.0% of patients were found malaria positive and the malaria positivity in VHV and BHS group were 11.1 and 10.9% respectively. Access to malaria care: higher proportion of children aged 5-14 years (21.8% vs 17.3%) and females (43.7% vs 41.8%) with fever were screened for malaria by VHV compared to BHS. However, the same for children aged < 5 years was 2.2% lower in VHV group compared to BHS. Quality of malaria care: the proportion of malaria cases that received treatment was 96.6 and 94.9; treatment initiation within 24 h of fever was 44.7 and 34.1; and, complete treatment delivery was 80.9 and 88.2, respectively, in VHV and BHS groups. After adjustment for potential confounders, patients with malaria provided care by VHV had 1.02 times higher chance of receiving treatment compared to BHS [aPR (95% confidence interval) 1.017 (1.015, 1.020)].
CONCLUSIONS
The VHV were more accessible to children and women than BHS in providing malaria screening services. The malaria treatment services provided by VHV was as good as BHS. Further qualitative research to explore and address the challenges on initiation and delivering complete treatment by VHV including inventory assessment and cost-effectiveness studies on integration of VHV in routine health system are needed.