Demographic and Health Analysis: Country Report & Analysis Overview

[606.601.86] Fundamentals in Global Health Practice

AY 2018-2019

Country Analysis and Report

Country:	Bangladesh
Topic:	Diabetes
Name:

Part 1: Demographic, Epidemiologic and Economic Transition (Modules 1 & 2)

Figure 1: Population pyramid – should be the most recent (Drag your picture file and drop it into the center of this box. These can be found at https://www.populationpyramid.net/

The 2018 Population Pyramid of Bangladesh with Population of 164,827,717

Source: PopulationPyramid.net (2018)

Table 1: Demographic and economic indicators. Don’t forget to report at least 2 subgroup (disaggregated) indicators!
Indicators	Value	Year	Reference[footnoteRef:1] [1: Number corresponding to the list of sources on the last page.]
Demographic Indicators (select at least 5)
1. Fertility rate	2.4 children born per woman	2018	Bangladesh Bureau of Statistics
2. Life expectancy at birth	70.90 Years	2015	PopulationPyramid.net
3. Death rate	5.4 deaths/1000 population	2017	The World Bank Group
4. Indicator by subgroup
a. Life Expectancy Male	69.4 Years	2017	Bangladesh Bureau of Statistics
b. Life Expectancy Female	72.0 Years	2017	Bangladesh Bureau of Statistics
5. Indicator by subgroup
a. Birth Rate	18.80 Births/1000	2017	Bangladesh Bureau of Statistics
b. Infant Mortality Rate	31.70 deaths/1,000 live births	2017	Bangladesh Bureau of Statistics
c. Growth rate	1.04%	2017	Bangladesh Bureau of Statistics
Economic Indicators (select at least 2):
1. Inflation rate [CPI]	5.78%	2018	CPD
2. GDP per capita	$1,211.7	2017	World Health Organization
3. Education Expenditure	18.1% of GDP	2016	The World Bank Group
4. Health expenditure	2.8% of GDP	2015	World Health Organization

Table 2: Burden of disease indicators (Select at least 5). Don’t forget to report at least 2 subgroup (disaggregated) indicators.
Indicators	Value	Year	Reference
1. Cardio-vascular disease	30.0%	2016	World Health Organization
2. Diabetes	3.0%	2016	World Health Organization
3. Cancer	12.0%	2016	World Health Organization
4. Indicator by subgroup
a. Obesity adults [18 + yrs.]	3.0 %	2016	World Health Organization
b. Low level of physical activity	27.0%	2016	World Health Organization
5. Indicator by subgroup
a. Diarrhea [DALYs/1000 capital]	16	2016	Public Health and the Environment Geneva 2009
b. Malaria [1000 Population at risk]	2.4	2015	World Health Organization
6. Indicators for Disability-Adjusted Life Years (DALYs)
i. DALYs loss to communicable, maternal, perinatal & nutritional[footnoteRef:2] [2: Note regarding DALY indicators: In the WHO DALY report, DALYs are reported at different sub-levels within the disease/condition categories. Report data for the top 3 DALY causes at the level that you feel is most appropriate/informative. Also, please pay attention to DALY units. They should be reported in thousands.]	39.0 %	2010	The World Bank, South Asia Human Development, Health Nutrition, and Population
Top three causes of DALY loss for this category a. Preterm birth complications	15 DALYs	2010	IHME-GBD
b. Lower respiratory infections	2 DALYs	2010	IHME-GBD
c. Neonatal encephalopathy	15 DALYs	2010	IHME-GBD
ii. DALYs lost to non-communicable diseases	61 %	2010	IHME-GBD
Top three causes of DALY loss for this category a. Stroke b. Depressive disorder c. Ischemic heart disease	1 DALYs 12 DALYs 3 DALYs	2010	IHME-GBD
iii. DALYs lost to injuries	18 %	2010	IHME-GBD
Top three causes of DALY loss for this category a. Drowning	15 DALYs	2010	IHME-GBD
b. Self-harm	9 DALYs	2010	IHME-GBD
c. Transport injuries	1 DALYs	2010	IHME-GBD

Demographic and epidemiologic transition questions:

Answer the following questions based on figure 1, tables 1 and 2, and your own review of the relevant literature.

1. Provide an explanation for why you chose the indicators reported in Table 1 (200 words)

Population growth is associated with fertility rate. Bangladesh has witnessed increasing fertility rate and at the same time decline in mortality rate. Population pressure was the leading problem in Bangladesh since 1978. The government of Bangladesh with help from non-governmental organizations and international organizations worked towards solving the problem. Some successes were achieved in different areas as decline of fertility was witnessed. Life expectancy is a measure of overall quality of life in a country. It explains mortality rate in a country. It also shows potential yield on investment in human capital. Life expectancy has been progressing over the past several years. Death rate is the average annual number of deaths per 1000 population at midyear during a year. It is also known as crude death rate. It generally shows the mortality situation of a country. It therefore shows the impact of mortality on population growth. Death rate in Bangladesh is at 5.4 deaths/1000 population in the year 2017. In early years like 1920s, mortality trends have been uneven due to historical events such as independence war and partition. There has been decline in mortality rate to a lower level. There is possibility of increase in mortality rate due to ageing of the population (Bairagi, & Datta, 2001). These indicators reflect the population health status overtime, as well as between populations at a single point of time. Hence they permit the health system comparison, besides highlighting populations in need of particular healthcare services.

2. At what stage (or stages) is your country in the demographic transition? Provide evidence from the data to support your answer. (200 words)

Bangladesh is at early stages of demographic transition. It has achieved significant progress in both mortality and fertility decline. Bangladesh is a traditional agricultural society with poor infrastructure and limited resource base. There has been occurrence of demographic changes despite slow economic progress. It is among the densely populated countries. According to United Nations 2014, about 156 million people reside within a small area of about 147,570 square kilometers. The density of population in Bangladesh is five times that of any other super country. It is nearly five times that of Pakistan and three times that of India. The country has escaped Malthusian trap by speeding up food productions, employing female labor in productive sectors and exporting human capital. It also has steady industrialization especially in garment industry. This has improved child survival and reduced fertility. Since independence, population growth was identified as national problem and strong population control policy was adopted. At now, fertility rate is at 2.4 children per woman. This is not far from replacement-fertility of level of 2.1. Regions like Khuna and Rajshahi have achieved replacement fertility level. The life expectancy at birth has also improved to 73.4 years in 2017. Therefore, demographic transition in Bangladesh has followed a typical pattern of decline in mortality rate followed by decline in fertility rate (Hayes & Jones, 2015).

3. Describe and explain any significant variation in the stage of demographic transition within the country by region, social class, or ethnic group. (hint: report on data over time) (200 words)

The demographic transition has not occurred uniformly geographically, because some areas are in the fifth stage and some are in the second stage. These could be due to industrialization prospects such as technology diffusion from developed world that champion’s reduction in death rates in some regions. UNFPA (2015) points out that the fertility rate in Bangladesh can be characterized based of different groups such as wealthiest and most educated women with low fertility rate while poor women and least educated women have highest fertility rate. There are huge regional differences like Chittagong division in the East having higher fertility rate compared to Khulna in the West. Rural fertility is also higher than urban. Furthermore, disproportional planning and investment for the regions in terms of special populations such as persons with disabilities, the elderly, indigenous people, besides youth and adolescents (UNFPA, 2015), leads to variations in fertility rate that makes the non-uniformity of the demographic transition. Likewise, internal and international migration infiltration, unplanned urbanization, human lifestyle changes, education and health investments affects the uniformity. Moreover, the UNFPA (2015) urges that the lack of addressing gender inequality and gender based violence in some regions worsens the girls and women potential towards increasing regional and national productivity, yet they constitute 50 percent of the population.

4. Is the concept of “epidemiologic transition” applicable to your country and, if so, at what stage is your country in the epidemiologic transition? (150 words)

Bangladesh is developing country which is faced by high inequalities and rampant poverty. There is still increasing burden of non-communicable diseases. Non-communicable diseases cause two thirds of all deaths. This indicates that Bangladesh is under rapid epidemiologic transition. Over the recent years, there has been changing patterns of diseases. Some diseases are disappearing while others are appearing and disappearing (Islam, Rahman & Siddiqui, 2014). UNFPA (2015) emphasizes that the demographic transition with unplanned urbanization besides human lifestyle changes are championing the burden of non-communicable diseases. Epidemiologic transition is therefore between the age of degenerative and manmade diseases. Increased urbanization has contributed to the rise of chronic disease burden. Rapid urbanization leads to reduced physical activity, change in food habits and increased access to processed food. Therefore, change of life style has contributed to this transition. The age pattern mortality has changed from young to old ages.

5. Using your topic as a guide, describe direct or indirect evidence that different groups within your country (by region, social, or ethnic group) have distinct patterns of disease burden? (350 words)

Bangladesh has been undergoing rapid epidemiologic transition with non-communicable diseases occupying two-thirds of all deaths. In 2004, non-communicable diseases occupied 61% with the remaining percentage being occupied by communicable diseases, and maternal and child health issues. According to US Census Bureau (2013), cardiovascular diseases occupy 13.4% of the total burden, mental health 11.2%, injuries 10.7%, respiratory diseases 4.0%, cancer 3.9% and diabetes 1.2%. Some years back about 70 years ago, infectious diseases were the leading cause of death. The country has now shifted to non-communicable diseases. This situation has imposed pressure on the country in solving the double burden.

It is true that different groups have different patterns of disease burden. Diabetes affects mostly rural people. Smoking is mostly the cause of chronic respiratory diseases and is therefore more prevalent in men than females. It also affects mostly youths. Smokeless tobacco is leveling tobacco consumption among men and women. This is supported by the culture of Bangladesh due to minimal public health consequence. Most people who are affected by injuries like road traffic injuries are men while those affected by drowning injuries are children. There are also other different disease burdens based on age such as degenerative and manmade diseases. Non-communicable diseases are mostly affecting the aging population. Chronic disease burden is increasing in urban areas due to reduced physical activity, increased access to processed food and change in food habits. The use of tobacco, inadequate intake of fruit and vegetables, abdominal obesity, hypertension and low-level of physical activity are prevalent in Bangladesh adults. Smoking is one of risk factors of non-communicable diseases which bring difference in prevalence of burden of disease. Tobacco use is more in rural areas than in urban areas. The issue of obesity also differs between rural and urban areas where it is high in urban areas than rural areas. This means that unplanned urbanization is the cause of this obesity (Mahmood, Ali & Islam, 2013).

Chronic non-communicable diseases are mostly caused by low physical activity. Special attention need to be put on rich people and urban women. Level of physical activity is affected by poor urban planning. These differences call for prevention and control measures to be designed with their consideration.

References:

Bairagi, R., & Datta, A. K. (2001). Demographic transition in Bangladesh: what happened in the twentieth century and what will happen next?. Asia-Pacific Population Journal, 16(4), 3-16.

CPD (2017): State of the Bangladesh Economy in FY2017 (First Reading). https://cpd.org.bd/wp-content/uploads/2017/01/state-of-the-bangladesh-economy-in-fy2016-17-first-reading.pdf

Hayes, G. R., & Jones, G. (2015). The Impact of Demographic Transition on Socio-economic Development in Bangladesh: Future Prospects and Implications for Public Policy Fund, Bangladesh County office.

IHME-GBD. (2010). Bangladesh: Global burden of diseases, injuries, and risk Factors Study 2010 https://www.healthdata.org/sites/default/files/files/country_profiles/GBD/ihme_gbd_country_report_bangladesh.pdf

Islam, S. R. U., Rahman , F., & Siddiqui, M. M. R. (2014). Bangladesh is Experiencing Double Burden with Infectious Diseases and Non-Communicable Diseases (NCD’s): An Issue of Emerging Epidemics. Answer Khan Modern Medical College Journal, 5(1), 46-50.

Mahmood, S. A. I., Ali, S., & Islam, R. (2013). Shifting from infectious diseases to non-communicable diseases: A double burden of diseases in Bangladesh. Journal of Public Health and Epidemiology. 5(11), 424-434.

PopulationPyramid.net. (2018). Bangladesh: 2015 life expectancy at birth, total years. https://www.populationpyramid.net/hnp/life-expectancy-at-birth-total-years/2015/bangladesh/

PopulationPyramid.net. (2018). Population pyramid of Bangladesh: 2018. https://www.populationpyramid.net/bangladesh/2018/

The World Bank Group. (2018). Bangladesh: Current health expenditure (% of GDP). https://data.worldbank.org/indicator/SH.XPD.CHEX.GD.ZS

The World Bank Group. (2018). Bangladesh: Government expenditure on education, total (% of government expenditure). https://data.worldbank.org/indicator/SE.XPD.TOTL.GB.ZS

UNFPA. (2015). The impact of the demographic transition on socioeconomic development in Bangladesh: future prospects and implications for public policy. https://bangladesh.unfpa.org/sites/default/files/pub-pdf/4.%20Demographic%20Impact%20Study.pdf

World Health Organization. (2017). 2017 Health SDG Profile: Bangladesh. http://www.searo.who.int/entity/health_situation_trends/countryprofile_ban.pdf?ua=1

World Health Organization.(2018). Bangladesh: Non-communicable diseases [NCD] profile. http://www.who.int/nmh/countries/bgd_en.pdf?ua=1

Part 2: Family Health & Social Determinants (Module 3) Comment by Toun Olateju: Note a general comment about references: The referencing style you are using is not Vancouver as required. Though we are not deducting points for using a wrong referencing style in Parts 1 and 2, we will deduct points for a wrong referencing style in Part 3. Recommend reviewing the referencing document on Courseplus to modify your style before Assignment 3. Also, ALL references used should be compiled to one location at the end of the document, not different references for each part of the assignment in different places.

Total grade: 32.5/40 pts

See the Courseplus Schedule for Due Date. All assignments are due at 11:59 PM EST on the due date.

Table 3. Health and Nutrition through the Life Cycle. Don’t forget to report at least 2 subgroup (disaggregated) indicators! Comment by Toun Olateju: 12/16 pts.Some of the indicators selected are not in the correct groups- please see comments below.
Indicators	Value	Year	Reference
3A. Maternal: (select at least 5)
1. Prevalence of anemia in women aged 15-49	40%	2016	UNICEF
1. Minimum dietary diversity Comment by Toun Olateju: Applicable to children, not mothers.-1 pt	28%	2014	Countdown to 2030
1. Women of reproductive age, short stature	13%	2014	Countdown to 2030
1. Indicator by subgroup Comment by Toun Olateju: A and b are not subgroup of the same indicator
3. Low birth weight prevalence	22%	2016	UNICEF
3. Vitamin A, supplementation, full coverage	99%	2015	UNICEF
1. Indicator by subgroup
4. Women [20+ yrs.]: BMI˂18.5 kg/m2	23%	2016	Countdown to 2030
4. BMI: 25-30 kg/m2 [Overweight]	18%	2016	UNICEF
4. BMI: ˃30 kg/m2 [Obese]	5%	2016	UNICEF
3B. Neonatal/Perinatal: (select at least 3)
1. Pregnant women living with HIV receiving ART Comment by Toun Olateju: This is not a neonatal/perinatal indicator-1 pt	17%	2016	UNICEF
1. Antenatal care [4+ visits] Comment by Toun Olateju: This is not a neonatal/perinatal indicator-1pt	31%	2014	UNICEF
1. Institutional delivery	37%	2014	UNICEF
3C. Post-neonatal/Infant/Child: (select at least 5)
1. Immunization: Measles	94%	2016	UNICEF
1. Immunization:DPT3	97%	2016	Countdown to 2030
1. Early initiation of breastfeeding Comment by Toun Olateju: This is a perinatal/neonatal indicator-1 pt	51%	2016	UNICEF
1. Continued breastfeeding [1 yr.]	96%	2016	UNICEF
1. Exclusive breastfeeding	55%	2016	Countdown to 2030
1. Diarrhea treatment with ORS	77%	2016	UNICEF

Table 4: Indicators of social determinants of health Comment by Toun Olateju: Excellent choices! 11/11 pts Based on the global health topic you are addressing in this assignment, report at least 8 indicators total for this table. You may want to consider the following categories though some will be more relevant than others: Education, Status of Women, Water & Sanitation, Household Characteristics. Don’t forget to report at least 2 subgroup (disaggregated) indicators!
Indicators	Value	Year	Reference
Indicators of Social Determinants of Health
1. Safely Managed Drinking Water	44.62%	2015	WHO/UNICEF JMP
1. Sanitation [Basic]	53.67%	2015	WHO/UNICEF JMP
1. Hygiene [Basic]	40.33%	2015	WHO/UNICEF JMP
1. National Literacy rate [15 Years +]	72.3%	2016	BBS
1. Full time female workers	74.06%	2016	BBS
1. Poverty rate	24.3%	2016	BBS
1. Indicator by subgroup
6. Male National Literacy rate [15 Years +]	75.2%	2016	BBS
6. Female National Literacy rate [15 Years +]	69.5%	2016	BBS
1. Indicator by subgroup
7. Agriculture: major source of household income	63%	2016	BBS
7. Agriculture: Major occupation of the household head	65%	2016	BBS
7. 5 + hours per week: Labor invested for home gardening	63%	2016	BBS

Health and nutrition through the life cycle questions:

Answer the following questions based on tables 3 and 4 and your own review of the relevant literature. Consider your selected topic and the country’s context!

1. Describe the maternal health and nutrition situation. (200 words) Comment by Toun Olateju: Claims were made without the evidence to back them up. There was a mix-up of maternal health and child health issues.2.5/3 pts

Bangladesh’s maternal health and nutrition situation has achieved significant progress so far in terms of reducing low birth weight prevalence, reducing prevalence of anemia in pregnant women aged 15-49 years-old, and increasing full coverage Vitamin A supplementation. It has registered positive results with post-neonatal infant and child DPT3 and measles immunization, as well as continued breastfeeding up to one year. The increase in supplement feeding besides breastfeeding, could be as a result of increase in female literacy level, in addition to employment status that positively fosters education for mothers on significance of maternal health and nutrition such as immunization, prescription medication, sanitation and safe drinking water (Countdownto2030, 2018). The increase in female literacy level has also fostered increase in antenatal as well as postnatal care by means of medically trained providers. Additionally, diarrhea treatment through oral dehydration therapy administration has increased. Moreover, there has been moderate increase in the rate of pregnant women delivering from institutions that have medically trained attendants. As a consequence, family members and communities have become aware and careful about the hygiene, as well as the importance of breastfeeding; which has seen a positive increase in hygiene, sanitation, and safe drinking water (WHO, 2015). In addition, the percentage of obese pregnant women as well as overweight ones, is decreasing. Comment by Toun Olateju: Evidence/reference source? Comment by Toun Olateju: How is this relevant in maternal health situation? Comment by Toun Olateju: Is diarrhea a public health issue for adult women? Comment by Toun Olateju: It’s not clear if you are linking breastfeeding as being responsible for increasing hygiene and sanitation.

1. Describe the neonatal/perinatal health and nutrition situation. (200 words) Comment by Toun Olateju: The responses in Q2 and Q3 show you are mixing up neonatal interventions with post-neonatal and under5 interventions. I suggest revising the lecture modules and reach out to your TA for further clarification.2/3 pts

The Bangladesh’s neonatal/perinatal health and nutrition situation has had increased immunization coverage, antibiotics for pneumonia, oral rehydration therapy for diarrhea, and supplementations such as Vitamins A. Therefore, neonatal health and nutrition care has significantly improved. Furthermore, the combination of these and facility deliveries as well as skilled birth attendance, have subsidized the reduction of neonatal and perinatal infections plus deaths (Countdownto2030, 2018). The remarkable improvements registered include within one hour early initiation of breastfeeding, continued breastfeeding, exclusive breastfeeding for children under the age six months, immunization of infants and children between 12 and 23 months with measles and DPT3 prevalent. Similarly, percentage of children having diarrhea under five years receiving oral rehydration therapy for diarrhea, and those above five years receiving the same plus zinc ; which have significantly registered positive rates. As well, increase in percentage of children under five years receiving vitamin A supplement in the previous six months. In addition, the percentage of pregnant women who are HIV-positive and on antiretroviral medication, although being low still, but has increased from 13% in 2013 to 17% in 2016 (WHO, 2015); which has reduced mother-to-child HIV transmission. The percentage of postnatal care for newborns within two days of birth by a medically trained provider also increased. Comment by Toun Olateju: Are these interventions in the first 28 days of life?

1. Describe the post-neonatal (1-11 months) and child (12-59 months) health and nutrition situation. (200 words) Comment by Toun Olateju: See comment in Q2 above.2/3 pts

Bangladesh’s post-neonatal [1-11 months] health and nutrition situation has registered positive results, since essential newborn care practices have remarkably increased, including percentage of newborns being breastfed within one hour of birth, newborns being dried and wrapped within five minutes of birth, and newborns being bathed after seventy-two hours of delivery. Furthermore, the percentage of post-neonatal [1-11 months] newborns and their mothers receiving care within two days of birth and delivery respectively from a medically trained provider (Countdownto2030, 2018). Likewise, there has been a positive increase in percentage of newborns receiving exclusive breastfeeding under six months. On the other hand, child [12-59 month’s] health and nutrition situation includes, increase in percentage of immunization of infants and children between 12 and 23 months with measles and DPT3 prevalent (WHO, 2015). Similarly, increase in percentage of children having diarrhea under five years receiving oral rehydration therapy for diarrhea, and those above five years receiving the same plus zinc, have significantly registered positive rates. Moreover, increase in percentage of children under five years receiving vitamin A supplement in the previous six months (Countdownto2030, 2018). As a consequence, both have contributed to decrease in in infant and child mortality, with the latter’s rate reducing considerably as compared to the former.

1. Using the indicators reported in Tables 3 and 4, how might these data affect the health and social situation for school-aged children and adolescents? (250 words) Comment by Toun Olateju: This response does not answer the question sufficiently.3/4 pts

These indicates a positive influence in the health and social situation for school-aged children besides adolescents. This is for the reason that mortality declines are significantly positively correlated with enhanced coverage of appropriate interventions to curb as well as treat the most significant causative factors of child mortality in addition with enhancements in socio-economic environments (WHO, 2015). Furthermore, increment in the coverage of immunization towards preventing diseases, diarrhea treatment, and PMTC HIV infection and other maternal health and nutrition interventions, will significantly reduce disparities that can hamper school-aged children and adolescents from attending school at the early age of school-going. Comment by Toun Olateju: How is this relevant to school-aged children and adolescents?

The data will also ensure that they acquire effective preventive amenities such as physical and psychosocial growth besides development monitoring, with particular responsiveness to delicate periods in which effective healthcare is substantial for comprehensive progress and development (Abel, 1993). These will ascertain that they are not limited by chronic conditions towards their capacity of realizing performance of regular activities, cognitive development, as well as playing and attending school. Moreover, this will ensure that any problems experienced during their significant stages of development are identified and that proper interventions are made to reverse the consequences, before they go well beyond out of hand (WHO, 2015). Furthermore, it allow for adolescents with an opportunity of preventing the onset of health-destructive behavior at the same time as introducing and establishing healthy behavioral patterns that might span over generations. As a consequence, the health and social situation for school-aged children besides adolescents will be positively influenced.

References:

Abel, H.C. ed. (1993). Paying attention to children in a changing health care system: Summaries of workshops. Washington (DC): National Academies Press

Bangladesh Bureau of Statistics [BBS]. (2017). Bangladesh Statistics 2017. http://bbs.portal.gov.bd/sites/default/files/files/bbs.portal.gov.bd/page/a1d32f13_8553_44f1_92e6_8ff80a4ff82e/Bangladesh%20%20Statistics-2017.pdf

Countdown to 2030 (2018). Bangladesh: Demography. http://profiles.countdown2030.org/#/cp/BGD

WHO/UNICEF JMP. (2017). Bangladesh: Water, sanitation and Hygiene. https://washdata.org/data#!/bgd

World Health Organization. (2015). Success factors for women’s and children’s health: Bangladesh. http://www.who.int/pmnch/knowledge/publications/bangladesh_country_report.pdf

Page 11 of 13