Encapsulating the burden and social determinants of self-reported general health problems among a specific sub-group of transgender women in Dhaka, Bangladesh: a mixed-methods study

Abstract

Background

In Bangladesh and other resource-constrained settings, a sub-group of transgender women (predominantly known as hijra in South Asia) encounter systemic marginalization, which unfairly predisposes them to health disadvantages. Although studies are beginning to illuminate the emerging burden of various communicable and non-communicable diseases, the global scholarship has predominantly confined these marginalized people within HIV/STI research framework. Our study explored the burden of diverse self-reported health problems and their underlying contexts among hijra in Dhaka, Bangladesh.

Methods

A mixed-methods cross-sectional study was conducted among 483 hijra. The quantitative component applied systematic sampling approaches from eight drop-in centers. Moreover, in-depth interviews and focus group discussions were convened with hijra and key-informant interviews with hijra leaders known as hijra guru, DIC staff, and public health experts. Qualitative findings were manually analyzed using the social determinants of health framework and equity lenses, within the domain of thematic analysis.

Results

Hijra living in Dhaka, Bangladesh reported heightened levels of general health ailments, exacerbated by the stigma, socio-economic marginalization, and limited healthcare access. Findings reflected high health burdens (58.4% with at least one ailment in the past year); self-reported mental health concerns (61.3%), anal conditions (55.7%), cold/cough (51.1%), asthma (41.5%), hypertension (33.3%), and diabetes (24.8%). Qualitative findings linked these health ailments to various contexts underpinned by structural inequities and social determinants, e.g. mental health concerns were linked to educational and familial exclusion, infectious diseases were exacerbated by poor living conditions, and non-communicable diseases were perpetuated by food insecurities and hormone intake linked to occupational risks.

Conclusion

Findings demonstrated the burden and variegated contexts of general health problems among hijra. However, these problems are often buried beneath the HIV paradigm. Their health problems were linked to structural inequities, marginalization, and healthcare constraints, and these inequities need to be addressed to ensure their health and wellbeing. Solely biomedical and public health frameworks may not suffice for hijra, rather we need to move towards a comprehensive equity-oriented approach.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12939-026-02932-w.

Introduction

Transgender populations are disproportionately affected by socio-structural challenges, predisposing them to health inequities. Equity is defined as the absence of socially unjust or unfair health disparities [1]. These social injustices or health disparities are governed by overarching structural conditions such as poverty, discrimination, homelessness, and societal marginality [2]. Transgender populations, in particular, experience these challenges, especially in conservative, resource-constrained settings that condemn gender diversity [3–5]. In South Asia, transgender populations include hijra communities who occupy culturally specific social locations that do not neatly align with Western classifications of transgenderism, including hijra. In this paper, the term “hijra” refer to participants under the broader transgender umbrella who locally identify as part of the hijra sub-culture whose gender identities and expressions fall within broader public health understandings of transfeminine populations.

Emerging evidence suggests that transgender populations experience substantial burdens of both communicable and non-communicable diseases [6–9], though the strength and comparability of this evidence remain uneven across various geographical contexts. These include: non-communicable diseases (e.g., obesity, high blood pressure, self-reported diabetes mellitus and family history-linked heart diseases) [9–11] and, to a limited extent, non-sexually transmitted communicable diseases such as tuberculosis and viral hepatitis [12]. Existing research draws from diverse populations, geographical settings and methodological approaches, thus limiting direct compatibility. For example, a systematic review based in 45 countries identified prevalence rates of 24.7% and 73.0% for diabetes and hypertension, respectively. However, as these estimates were predominantly derived from high-income settings, with limited representation from LMICs and heterogeneous study quality [7].

Similarly, mental health concerns are more frequently documented, with studies based in USA and China reporting high prevalence rates of depression (51.4% and 32.0-54.5% respectively) and anxiety (40.4% and 28.5–51.0% respectively) among transgender women [13, 14]. However, discrepancies in sampling strategies, measurement tools, and socio-cultural contexts require careful interpretation of these findings, especially when extrapolating to LMIC settings. 36% of transgender men and women in India had weight issues, 16% had high blood pressure, and 8% had diabetes mellitus [15]. However, evidence in South Asia remains fragmented and limited, focusing on selected health outcomes as opposed to the broader spectrum of general health conditions.

General health conditions are defined as a “wide spectrum of acute and chronic conditions that affect physical, mental and functional health, which may not always be life-threatening but can significantly affect daily functioning and quality of life” [16]. These include conditions that are often deprioritized or underreported in biomedical and surveillance frameworks, especially in resource-constrained settings. Existing transgender health research generated important insights about specific domains such as NCDs and mental health. However, these bodies of work are conceptually and empirically fragmented. Most literature contains discrete conditions such as depression, hypertension, etc., without considering the broader menu of everyday health problems that influence lived experiences of wellbeing. Thus, the cumulative and co-occurring nature of health burdens, especially those that are not clinically prioritized or systematically measured, remains under-researched.

The gap particularly prevails amongst LMICs with unfavorable socio-legal climates and heightened societal marginalization towards transgender populations. In Bangladesh, despite declaring hijra as a separate gender in 2013, these populations remain marginalized [17, 18]. Hijra, a group unique to South Asia include individuals are assigned male at birth but embody feminine characteristics. While a rare subset is born intersex, some are eunuchs (i.e., removal of male genitalia) and the rest merely amplify feminine features (augmented breasts and higher pitched voice) through hormone pills [18, 19]. Hijra in Bangladesh identify as part of a certain sub-culture with their own behaviors, cultural practices, and traditional occupations such as collecting alms from families of newborns, marketplaces or other public spaces. According to recent national population size estimates in 2023, there is an estimated total of 12,629 hijra across 13 districts [20]. This differs from national census estimates in 2022 [21] which relay a total of 8,124 hijra. These discrepancies underscore the challenges of enumerating hijra populations in contexts where stigma and mobility may affect visibility in data systems. Due to inherent healthcare access challenges, hijra primarily resort to NGO-operated HIV prevention interventions [22, 23] rather than mainstream healthcare settings. However, these interventions are circumscribed to HIV and STI prevention, care and treatment.

Global and regional evidence highlights the pressing need to transcend traditional sexual health interventions and address broader general health concerns. Focusing on general health problems facilitates a deeper understanding of health that bridges conventionally siloed domains such as infectious diseases, non-communicable diseases and mental health, while also exploring how these conditions intersect and are influenced by socio-structural determinants. This exploration is particularly crucial for LMIC contexts where research priorities, health systems and service delivery models, which are predominantly HIV and STI-focused, overlook broader health concerns. Through adopting this integrative lens, this study advances existing scholarship by moving beyond condition-specific analysis to examine how diverse health concerns are collectively produced, experienced and managed among marginalized populations like hijra in Bangladesh.

Methods

Conceptual framing: Social determinants of health and equity

Equity scholars connect poorer health outcomes to unfair distribution of power, wealth and resources across society [24–26]. Keeping in mind the broader goal of achieving health equity [27], we need to understand social determinants of various illnesses for marginalized populations and how health inequities are socially produced among hijra. This analysis, thus, adopted the WHO Commission on Social Determinants of Health (CSDH) framework. This framework is particularly relevant because it shifts attention from just individual risk factors to structural conditions that pattern exposure, access to care, vulnerability, and health outcomes amongst marginalized populations. The framework allowed us to map out how structural determinants (e.g. social policies, institutional barriers, macroeconomics, societal and cultural values) intersect to shape the intermediary determinants (e.g. psychosocial stressors, risky bio-behavioral factors, unsafe neighborhood and built environments, and food insecurity). As structural challenges reverberate through intermediary determinants of health, examining only the proximal factors overlooks the root causes of health inequities. Thus, this multilayered framework could inform policies and practices which address upstream drivers and downstream expressions of ill-health among hijra [3, 28], thus advancing transgender equity.

The CSDH Framework informed both the conceptualization and operationalization of variables. In the quantitative component, key indicators were selected to reflect multiple layers of the CSDH framework, including structural determinants (socioeconomic status, education and occupation), intermediary determinants (living conditions) and health system factors (service utilization). While not all constructs could be exhaustively captured within the quantitative survey format, variable selection has been guided by the framework’s emphasis on the distribution of health and wellbeing across the social gradients. This enabled an initial mapping of how socio-structural conditions influenced the distribution of reported health problems, which was explored in greater depth in the qualitative strand. The social determinants of health framework also guided the qualitative data collection tools. For qualitative data analysis, themes were segregated into the following social determinants linked to structural inequities: poverty, education, exclusion, housing and food insecurity, and intra-community and societal challenges.

Study design

This study applied explanatory sequential mixed-methods designs which intentionally linked the quantitative and qualitative strands at various stages. While the quantitative strand identified patterns and distributions of reported health problems, the qualitative strand provided deeper explorations of lived experiences, social meanings and structural conditions underlying these patterns. This included how stigma, employment exclusion, and societal challenges created risk environments, thus cultivating health harms. The qualitative component not only explained statistical patterns but also generated deeper insight into how hijra understood, experienced and managed general health problems amidst conditions of social and institutionalized marginalization. Whilst interpreting the results, a merging strategy was adopted where findings were compared across the quantitative and qualitative strands using narrative approaches [29]. This generated meta-inferences that not only clarified the prevailing inequities, but also how and why they emerged, thus strengthening the framings of social determinants and equity in ways that each method alone could not achieve [30].

Measurement tools and strategies

General health problems denote common symptoms and health issues (i.e., headache, respiratory problems, chronic diseases etc.) that influence mental and physical well-being [31]. As this was the first general health assessment for hijra in Bangladesh, we opted for a culturally congruent approach, rather than invasive biomedical assessments, e.g. serological sampling or WHO STEPS surveys. We adopted community-based survey measures, where we asked participants to describe their own health conditions. We then verified these health conditions through other mechanisms, i.e., data collectors inquired about whether participants visited a physician in a public/private/NGO facility for the condition within the last 12 months. If so, they were asked to show their prescription or, if unavailable, their medication strip/bottle/vessel. If they were unable to provide this information, researchers asked their next of kin (e.g., family members or co-residents in the hijra residence). If none of these approaches worked, they were not counted for that specific health condition. These types of community-based survey measures were also endorsed as a default for quantifying infectious diseases for infectious and chronic diseases in resource-limited settings, by standardized behavioral survey initiatives for key populations by WHO and CDC [32, 33]. As health outcomes were primarily assessed through self-reporting mechanisms, it may be subject to recall and social desirability biases, and variations in individual health literacy. As clinical verification mechanisms are absent in community-based settings, self-reported measures for both the quantitative and qualitative components helped capture participants’ lived experiences of health problems. While this approach may limit clinical precision, it enables the documentation of health concerns that are often under-recognized within formal healthcare systems. Similarly, during the qualitative strand, when we inquired participants about their health problems, we used probes that were similar to the community-based survey measures used in the quantitative strands.

Likewise, mental health was encapsulated using single-item, community-based measures commonly applied in population-level behavioral health surveys [34, 35]. This method demonstrated acceptable validity in other vulnerable populations, endorsed by the American Journal of Public Health and CDC [36, 37]. Regional scholars also criticized mental health scales for remaining bracketed within Westernized thought processes, and overlooking regional “idioms of distress” unique to South Asian communities, e.g. “tension”, honor-shame stress (izzat), spiritual affliction, and pervasive worries (pareshani) [38–40]. In consultation with our team’s clinical psychologists, we devised culturally congruent community-based survey instruments for the quantitative and qualitative components tailored to localized issues. For the qualitative strand, similar probes were applied when inquiring about their ee mental health-related issues. While this approach limits the ability to estimate the prevalence of specific mental health disorders, it was intentionally adopted in response to concerns regarding the cultural applicability and validity of standardized Western psychometric scales in the local context. As such, these measures can be interpreted as psychological distress rather than definitive assessments of mental health conditions.

Study population and sites

The inclusion criteria for the quantitative survey and qualitative exploration comprised of hijra community members who self-identified as belonging to the hijra sub-culture and were aged 18 or above. Whereas, hijra who were visibly unable to provide informed and coherent responses at the time of data collection (e.g. due to acute intoxication or cognitive impairment) were excluded to ensure data quality and ethical participation. The study was conducted in Dhaka city, accommodating the highest proportion of hijra in Bangladesh (ASP, 2023). Hijra were selected from eight HIV prevention service centers (known as Drop-in Centers (DICs)) across Dhaka, serving as the sampling frame and randomization units (described in the Table 1). While this study provides crucial insights about health experiences of hijra engaged in community-based services, findings need to be interpreted within the context of the DIC-based sampling approach. As participants were recruited through DICs, this may not represent the full diversity of hijra, especially those out of reach of service delivery platforms. As such, findings are not intended to be statistically representative, but rather add analytically rich and contextually grounded insights into health patterns and their contextual drivers.

Table 1.

Proportionate distribution of sample size by DIC for the quantitative approach

SI	Name of DIC	# of hijra received services	Proportionate sample size targeted	Proportionate sample size achieved
	Dhaka North City Corporation
1	Badda	231	91	95
2	Uttara	345	61	67
3	Dhamrai	108	86	93
4	Darussalam	195	29	36
	Dhaka South City Corporation
5	Demra	95	33	38
6	Shyampur	126	59	67
7	Jatrabari	324	51	56
8	Lalbagh	224	25	31
Total		1,648	435	483

Sampling methods and sample size

Eight DICs in Dhaka city render HIV and STI prevention and other limited basic services such as medications for cold, fever, diarrhea, etc. To ensure representativeness estimates of the quantitative data, the target sample size (N = 435) was proportionately distributed among eight DICs (see Table 1) based on the number of hijra receiving HIV services from each DIC. After hearing about this study, more hijra participants gained motivation to participate, thus we finally included 483 participants.

Before calculating the sample size, a literature review identified estimates of indicators related to objectives in other countries (see detailed calculation in Annex-1). The sample size was calculated to estimate the prevalence of general health problems among hijra accessing community-based services in Dhaka. In the absence of reliable local prevalence estimates for the primary outcome, a conservative prevalence estimate of 50% was used to maximize sample size and account for uncertainty. Fixed precision level of 5% and 95% confidence intervals were used. Where needed, finite population correction (FPC) was considered based on the estimated service-engaged hijra available through participating DICs. FPC was applied based on programmatic estimates of active hijra registered across participating DICs during the study period. The sample size was further adjusted to account for potential non-response. Although recruitment occurred across multiple DICs, we did not adopt formal cluster sampling. A modest design effect was conservatively applied to account for potential within-site similarities in participant characteristics.

Qualitative inquiry espoused maximum variation and maximum intensity sampling. While the former ensures diverse representation by selecting various socio-demographic groups, intensity sampling selects cases providing rich, detailed insights without extreme outliers. We conducted 15 in-depth interviews (IDIs) and 5 focus group discussions (FGDs) among hijra using maximum variation sampling. The number of IDIs and FGDs was contingent on theoretical saturation [41, 42] based on the social determinants of health framework. Additionally, we conducted 7 key-informant interviews (KIIs) using maximum intensity sampling, with hijra guru, program implementers (DIC managers and peer educator), and public health researchers and clinicians working with transgender health. They were selected due to long-standing working experience and knowledge about the nuanced complexities of hijra.

Data collection

Data were collected from 1 January 2022 to 31 December 2024. The quantitative survey examined socio-demographic information, health problems, healthcare seeking experiences, and employment and financial difficulties in seeking healthcare. We also applied several qualitative data collection methods (IDIs, FGDs, and KIIs) to complement quantitative findings, and explore underlying contexts, lived experiences and perspectives. Quantitative and qualitative interviews were conducted by trained, previously sensitized social science researchers with long-standing working experience with hijra (SIK, WTS, SHK, SDI, MMR, MSAI and SH). Except WTS and SDI (both of whom are female), all authors are male. MMR and MSAI are epidemiologists with over two decades of quantitative experience, especially in handling quantitative datasets of hijra and other marginalized populations. They were responsible for handling the quantitative component of this study. They supported in developing the quantitative survey instruments, and oversaw the quantitative data collection and analysis processes. WTS and SHK are social scientists with considerable mixed methods research experience. They were responsible for conceptualizing the study, designing the data collection tools, and overseeing overall data collection and management. SDI and SH are public health and population studies experts, respectively, who have ample experience working with hijra in mixed methods research, particularly handling qualitative components. They were responsible for overseeing the qualitative strand, and drafting the stud reports and manuscripts. Moreover, SIK, a clinician by profession and medical anthropologist by academic training, has almost three decades of social and behavioral research experience with marginalized populations, including hijra. He has played a key leadership role in conceptualizing the study, designing and refining the data collection tools, and overseeing and providing strategic guidance for data analysis and the overall.

All surveys and interviews were held inside DICs, hijra or their guru’s residences (dera), depending on their preference, after being contacted over phone for a timeslot. IDI and KIIs averaged 40–45 min, while FGDs averaged 50–55 min. To protect the participants’ confidentiality, no one other than the participant and researcher(s) were in the interview room. Each interview type used separate sets of guidelines. All data collection tools were field tested beforehand. All qualitative interviews were recorded after receiving participants’ informed and understood consents.

Data analysis

We performed consistency checks both before data entry, and after entering data in Epi Info (Version 3.5.4). Descriptive statistics, such as frequency distribution, percentage values, means (if normally distributed), and medians and interquartile ranges (if not normally distributed), described populations and measurements. Categorical and numerical variables were measured by percentages and means with 95% confidence intervals (CI), respectively. To identify factors associated with general health problems during the past year, we undertook bivariate analysis utilizing univariate logistic regression analysis. All quantitative data was analyzed by SPSS (Version 27). Regression analyses were conducted as exploratory analyses to identify potential associations between socio-structural factors and reported general health problems. Since sample size was originally calculated for prevalence estimates rather than testing hypotheses, these analyses were intended to be interpretative rather than confirmatory. Formal power calculations were not conducted, and findings are intended to highlight potential associations rather than establish causal or population-level inferences.

We analyzed qualitative findings through thematic analysis in relation to the WHO Social Determinants of Health framework and equity lenses. While the CSDH framework, an iterative and reflexive approach was adopted to allow for the emergence of inductive insights. Coding processes remained open to unanticipated themes, allowing the identification of context-specific experiences extending beyond the initial theoretical framework. Immediately after data collection, we transcribed the interviews. The team searched for, reviewed and defined related themes, and then presented these themes alongside quantitative findings [43]. We followed a collective coding framework, fixed the categorization of themes and reached an iteration [44]. To ensure scientific rigor in the qualitative strand, we employed multiple approaches. We operationalized triangulation across multiple layers: (i) method triangulation through various qualitative data collection techniques, alongside quantitative surveys; (ii) setting triangulation: interviews in both hijra residences and DICs, enabling comparison of narratives in home vs. community-based settings; (iii) investigator triangulation: multiple data collectors and analysts using collaborative coding frameworks; and (iv) analytical triangulation: linking qualitative findings to predefined domains of equity and social determinants of health, and examining its convergence with quantitative trends [45]. Moreover, we convened peer debriefing sessions to share interpretations of findings, and member-checking the authenticity of the data with hijra participants. Intercoder reliability was ensured by documenting decisions in audit trails, including resolving any coding-related disputes.

Ethical considerations

This study received the ethical approval from the Ethical Review Committee of the Institutional Review Board of the host research institute (Protocol number: 22007). The study involves no more than minimal risk of hijra. Moreover, we kept participants’ personal information anonymous and confidential. Although participants had full autonomy to not participate in this study and to withdraw participation at any time during data collection, no participant refused to participate in this research.

Results

The findings revealed the burden and underlying contexts of general health ailments affecting the health equity situation of hijra. Most hijra participants (58.4%) reported health problems within the past year, whereby the most prevalent health conditions included mental health concerns (61.3%), hypertension (33.3%), diabetes (24.8%), and skin conditions (33.3%). Quantitative findings describe the distribution of these self-reported health conditions, whereas qualitative findings provide contextual insights into the participants’ lived experiences and healthcare-seeking challenges. These have collectively affected their social positioning at various spheres, including healthcare, employment, education, housing and food insecurity (see Figure 1). Qualitative findings are presented to contextualize these patterns and are not to be interpreted as establishing causal relationships between social conditions and health outcomes.

Fig. 1.

General health concerns of hijra in relation to the Social Determinants of Health framework

Socio-demographic characteristics

Table 2 demonstrates socio-demographic characteristics of survey participants (N = 483). Among the participants, majority ranged from 25 to 34 years old (37.3%, 95% CI: 33.1–41.7), followed by 20–24 years (28.2%, 95% CI: 24.3–32.4), and 34–49 years (17.2%, 95% CI: 14.1–20.8). Mean age was 28.4 years (95% CI: 27.5–29.2) and median age was 26 years (IQR: 25.0–27.0). Most participants’ schooling duration ranged from 6 to 10 years (35.0%, 95% CI: 30.8–39.4) and 27.1% had no education (95% CI: 23.3–31.3). The mean duration of schooling was 5.8 years (95% CI: 5.4–6.2) (Table 3).

Table 2.

Socioeconomic characteristics of participants

Q SL.	Variable	N=483 Unless otherwise stated n, Col% (95% CI)
Q101	Age in Category
	15–19	61, 12.6 (9.9–15.9)
	20–24	136, 28.2 (24.3–32.4)
	25–34	180, 37.3 (33.1–41.7)
	34–49	83, 17.2 (14.1–20.8)
	≥ 50	23, 4.8 (3.2–7.1)
	Mean (95% CI)	28.4 (27.5–29.2)
	Median (IQR)	26 (25.0–27.0)
q102	Years of schooling
	No Education	131, 27.1 (23.3–31.3)
	1–5	109, 22.6 (19.0-26.5)
	6–10	169, 35.0 (30.8–39.4)
	≥ 11	74, 15.3 (12.4–18.8)
	Mean (95% CI)	5.8 (5.4–6.2)
	Median (IQR)	6.0 (5.0–7.0)
q103	Duration of stay in Dhaka city (in years)
	≤ 5	93, 19.3 (16.0–23.0)
	6–10	49, 10.1 (7.7–13.2)
	≥ 11	341, 70.6 (66.4–74.5)
	Mean (95% CI)	19.2 (18.0-20.2)
	Median (IQR)	19 (18.0–20.0)
q105	Currently live with most of the time
	Alone	145, 30.0 (26.1–34.3)
	With guru	149, 30.8 (26.9–35.1)
	With family	118, 24.4 (20.8–28.5)
	With parik/friend	71, 14.7 (11.8–18.2)
q106	Main source of income in last six month*
	Business	20, 4.1 (2.7–6.3)
	Service (private/Government)	45, 9.3 (7.0-12.3)
	Tuition/teaching	6, 1.2 (0.6–2.7)
	Sex work	295, 61.1 (56.6–65.3)
	Badhai Khata/Dhol dance/Sing (Baina)	314, 65.0 (60.6–69.2)
	Cholla/begging in signal	194, 40.2 (35.9–44.6)
	Randhuni (cook)	18, 3.7 (2.4–5.8)
	Family	16, 3.3 (2.0-5.3)
	Daily basis	24, 5.0 (3.3–7.3)
q107	Income in the last month (in BDT)
	< 10,000 Tk	224, 46.4 (42.0-50.9)
	10,000–20,000 Tk	200, 41.4 (37.1–45.9)
	> 20,000 Tk	59, 12.2 (9.6–15.5)
	Mean (95% CI)	14,079 (12,577.6–15,885.3)
	Median (IQR)	10,200 (8,500 − 15,000)

IQR= Interquartile range

* Multiple responses

Table 3.

Self-reported health ailments hijra suffered within the last 12 months

Q SL.	Variable	N=483 Unless otherwise stated n, Col% (95% CI)
q122	Reported any kind of health ailments within the last 12 months
	Yes	282, 58.4 (53.9–62.7)
	No	201. 41.6 (37.3–46.1)
q123	Types of reported health ailments within the last 12 months (Denominator is who reported health ailments within the last 12 months)	N = 282
	Gastrointestinal problem*
	Digestive issues including diarrhoea	124, 44.0 (38.3–49.8)
	Venereal/sexually transmitted diseases*
	Sexually transmitted infections (STIs)1	97, 34.4 (29.1–40.2)
	HIV infection	3, 1.1 (0.3–3.3)
	Skin disease*
	Skin problems2	94, 33.3 (28.1–39.1)
	Respiratory problems*
	Tuberculosis (TB)	6, 2.1 (1.0-4.7)
	COVID-19	34, 12.1 (8.7–16.4)
	Common cold/fever with cough and sneezing	144, 51.1 (45.2–56.9)
	Asthma	117, 41.5 (35.9–47.4)
	Cardiovascular problem*
	High blood pressure	94, 33.3 (28.1–39.1)
	Low blood pressure	36, 12.8 (9.3–17.2)
	Heart problem	29, 10.3 (7.2–14.4)
	Metabolic and endocrine problems*
	Diabetes	70, 24.8 (20.1–30.2)
	Hormone related problems3	80, 28.4 (23.4–33.9)
	Other diseases/problems
	Jaundice	92, 32.6 (27.4–38.3)
	Anal pain/tear4	157, 55.7 (49.8–61.4)
	Dengue	29, 10.3 (7.2–14.4)
	Self-reported mental problem	173, 61.3 (55.5–66.9)
	Eye Problem	68, 24.1 (19.5–29.5)
	Dental problem	104, 36.9 (31.4–42.7)
	Injury (accidents/general injury for other reason)	69, 24.5 (19.8–29.8)
	Body pain	67, 23.8 (19.1–29.1)
	Physical Weakness	73, 25.9 (21.1–31.3)

*Multiple responses

¹Received syndromic treatment from DICs

²Any type of skin problems including itching, allergy, scabies, skin infection, etc

³To become feminine hijra take birth control pills and take hormones. As a result, they face various types of side effects such as, vertigo, vomiting, drowsy, loss of appetite, breast pain, etc

⁴Any type of pain or tearing in the anal area either due to constipation or sexual activity

The majority of the participants stayed in Dhaka city for over 11 years (70.6%, 95% CI: 66.4–74.5), and most were staying with hijra guru in dera (30.8%, 95% CI: 26.9–35.1). The majority of the participants engaged in Badhai/Dhol dance1 (65.0%, 95% CI: 60.6–69.2), sex work (61.1%, 95% CI: 56.6–65.3), and Cholla/begging in traffic signals (40.2%, 95% CI: 35.9–44.6). Whereas, only 9.3% (95% CI: 7.0-12.3) were engaged in private/government service job and 4.1% (95% CI: 2.7–6.3) engaged in business. Most of the hijra’s income (46.4%, 95% CI: 42.0-50.9) was less than 10,000 taka and the mean income was 14,079 taka (95% CI: 12,577.6–15,885.3).

Self-reported general health outcomes as markers of inequity

Across the sample (N = 483), 58.4% of hijra reported at least one general health problem within the past 12 months (95% CI: 53.9–62.7). Among them (N = 282), the most prevalent conditions included mental health concerns (61.3%), common cold/cough/fever (51.1%), anal pain/tear (55.7%), asthma (41.5%), skin problems (33.3%), hypertension (33.3%), diabetes (24.8%), and hormone-related problems (28.4%); STIs (34.4%) and HIV (1.1%).

Structural determinants

Structural determinants include macroeconomic, politico-legal, institutional and social contexts (Fig. 1) which could elevate their exposure to illness, and exacerbate health inequities. This section describes structural determinants in terms of housing, employment, education, poverty and societal values condemning hijra and predisposing them to ill-health. To preserve confidentiality of participants, we used pseudonyms.

Healthcare access

Participants described various barriers to accessing healthcare services in both public and private healthcare facilities. These barriers included the denial of services and lack of culturally competent care from healthcare providers, especially in public healthcare. Among the hijra participants who availed of healthcare services using their hijra identity (n = 49), 70.0% reported dissatisfactory behavior from a healthcare provider. Only 4.1% claimed that the healthcare provider adequately listened to their problems. 34.7% of participants were denied or refused services at least once during their lifetime. This was corroborated by qualitative anecdotes which revealed that doctors’ prejudices often led them to truncate their visits with hijra, by briefly prescribing medications and not attentively listening to health problems. This discourages hijra from seeking timely healthcare, thus letting their health problems worsen. As one of the participants mentioned:

Doctors do not understand whether we are a boy or girl, they don’t even take the time to know us. Without listening to the problem properly, they prescribe medicine. Because of this, we do not feel like visiting the public hospital, even if we are feeling really sick. (Shanta, 30 years old, IDI)

Several participants unfavorably compared public healthcare services to NGO-operated DICs (defined in methods) as the latter provided culturally sensitized services. However, DICs remain limited within HIV and STI management. This presents an equity gap within service design and implementation for these marginalized populations.

Poverty

Findings revealed that hijra face financial challenges in accessing healthcare services, thus widening health inequities. Quantitative findings revealed that 55.7% sometimes or regularly faced financial difficulties in accessing healthcare. Among them, the majority, 43.3% (95% CI: 37.6–49.1) needed to reduce other essential needs and 35.8% postponed healthcare treatment due to financial limitations. The ignorance and lack of empathy experienced from healthcare providers only worsened health disparities for hijra. Moreover, they lacked the financial capacity to seek private healthcare options, which may have more sensitized services in the interest of generating money. As one of the participants said, “Due to our employment and financial problems, many hijra cannot see a good doctor, cannot rent a good house, cannot eat two good grains properly, and I cannot get good service” (Hijra, 46 years old, IDI).

As formal employment avenues were inaccessible for hijra, they relied on Cholla (collecting money from bus stations, and people) and Badhai (blessing newborns or newlyweds). Although they receive limited health services from the DIC, complex health issues often warranted care from other healthcare facilities (public or private hospitals), which requires additional money and expenses.

Another hijra noted that visiting the hospital incurred financial losses as the time spent waiting in the hospital could have been invested in generating income through Cholla. Due to large patient flow, hijra wait in hospitals for prolonged periods, which means it would not be possible for them to return to cholla once done, thus relinquishing their scope of earning income that. Participants described financial constraints as an important barrier to seeking healthcare in a timely manner. As one of the participants stated her experience as:

We face financial problems while seeking healthcare. You see, a hijra has to struggle to lead a life, if I go to the hospital all day long, my income will be stopped, what will I eat? And even if I go to private hospitals, 4000–5000 taka are all gone in one blow. This is why I don’t like visiting the hospital even if I am feeling very sick (Reena, 34 years old, IDI).

Employment

Participants described limited employment opportunities and reliance on informal occupations, including sex work, badhai, and cholla. These occupations were often discussed alongside various health concerns and occupational challenges. Specifically, hijra who engaged in sex work, not only faced elevated prevalence rates of HIV and STIs at 34.4% and 1.1%, respectively, but also contracted other diseases linked to occupational risks. For example, many hijra wear chest padding under their clothes to magnify their bust. However, sweat often accumulates after wearing padding for prolonged periods. Participants described prolonged use of chest padding and hormonal tablets alongside experiences of inflicted cough, hormonal problems, heart problems, and high blood pressure which were reported by 51.1%, 28.4%, 10.3% and 33.3% of the participants, respectively. This was coupled with excessive use of hormonal tablets, which also precipitated health hazards. As one of the participants stated:

Hijra are more engaged in sex work, mostly infected with sexual diseases (jonoroug). Sometimes hijra make their breasts look bigger with cloth and it leads to sweating and cough, heart problems, and hormonal problems. Many of us take hormonal tablets which create pressure problems and weakness (Maya, 24 years old, FGD).

Our findings illuminated other occupational risks which cultivated health problems. For instance, for better income, many hijra moved to India, for which their lifestyles inadvertently contributed to UTI (urinary tract infection). Specifically, participants reported that prolonged working hours prevented them from using toilet facilities in a timely manner. Participants also mentioned that rules in the dera strictly emphasized working hours and limited rest, leaving participants with little to no scope for self-care. As Pia mentioned:

I have a urine infection, from my time in India a few years ago. At that time, there were strict house rules under our guru. When visiting someone else’s house, I didn’t have time to drink water properly. Even after doing badhai work (collecting alms) all day from 10-6pm, she would she would add on more household work. She would not even let me take a little rest after coming back from work (Pia, 46 years old, IDI).

Education

Findings revealed socio-structural challenges underlining hijra’s inability to complete their education. Participants described discrimination, harassment and neglect in educational settings, which they linked to experiences of emotional distress and school discontinuation. Participants described that they initially anticipated school as a safe learning environment but it became a hub for discrimination and bullying from fellow students and teachers. These combined experiences of verbal abuse, physical punishments, and sexual harassment cultivated feelings of fear and insecurity, exacerbating their mental distress. This aligned with the quantitative scenario, revealing that 61.3% (95% CI: 55.5–66.9) reported mental problems such as depression, anxiety and stress. As one of the participants stated:

Whenever I go to school, teachers called me names, and gave me stricter punishments than others. Teachers and other students would also sexually harass me. That’s why I stopped going to school, as it’s not possible to study in this environment. I was really hurt by these incidents, people who I trust so much do this to me, and so did by people around me. We grew up being deceived by people, which always makes us feel mentally upset (Hari, 25 years old, IDI).

Participants described these experiences as affecting their educational continuity and health-related decision-making. Thus, several participants lacked the ealth literacy needed to navigate complex health problems and internalize the gravity of their health situation. This led them to dismiss their health problems, leading to delayed or inadequate care. Although some hijra were aware of their health problems, their low-risk perception affected their capacity to prioritize their health. Specifically, they instead relied on local pharmacies for purchasing over-the-counter medicines for health problems such as fever or cold, without exhibiting concern towards adverse health consequences. As one of the participants mentioned:

I went to the pharmacy for common health problems – colds/fever, I just have to pay for medicines, I have never faced any complex problem. I am well by the grace of Allah; I am not affected by any disease (Raina, 26 years old, IDI).

Housing

Because of their gender identity, hijra were often denied housing based on landlords’ impressions that hijra would incur public nuisances. Thus, most hijra lived in slums with inadequate gas, water and electricity supplies. Participants described poor housing conditions and limited access to cooking facilities, which shaped their food practices and everyday living conditions. For example, a participant reported that she could not cook and eat by herself. Therefore, she resorted to unhealthy, unhygienic restaurant food which could perpetuate acid reflux, indigestion and diarrhea which was reported by 44.0% (95% CI: 27.4–38.3) of participants. As one participant mentioned:

As a hijra, I could live in a good rented house just like you as I earn 20,000 taka per month. I also want to live in a flat. But we are being deprived of this opportunity due to our hijra identity. House owners think of us as badly-behaved goons. That’s why I am currently living in a slum, I have no water, gas, can’t cook even if I wanted to. I have to eat from the local diners, their cooking is not hygienic. Eating outside is making me suffer from gastric problems as well (Laila, 30 years old, IDI).

Due to living in dilapidated conditions, hijra also presented heightened vulnerability to various diseases, especially infectious diseases. Participants opined that living in a good environment is a prerequisite for being healthy. However, hijra cannot exercise this right, thus entrenching them in health inequities. As Mona stated:

I live in a slum, no gas, no water here. I have to bring water from another shop or source …… If we don’t have good living conditions and our environment is bad, we will be infected with diseases. In this way we are having lots of breathing problems, colds, skin infections and everything (infectious diseases). (Mona, 30 years old, IDI).

Food insecurity

Participants also vocalized concerns about their lack of access to healthy food, as they resided in deras/slums, which constrained their scope to cook due to poor gas and water supply. Therefore, hijra often ate at roadside eateries, with unhygienic cooking environments. Participants described frequent dependence on roadside food and concerns about food quality and hygiene. Some participants perceived these food practices to be linked to their health problems, such as high blood pressure (33.3%) and diabetes (24.8%). In this case, material deprivation (i.e., food, utilities and housing) was the intermediary pathway that connected structural exclusion to observed morbidities. As Bonni mentioned:

Where do I get nutritious food? I eat at the restaurant, I must to eat to survive, so I have almost every meal there. You know that restaurants reserve 4–5 days of oil and recycle that oil (…) So, we have developed diabetes and high pressure and other diseases (Bonni, 30 years old, IDI).

Societal and cultural values

Though hijra often described psychosocial stressors shaped by overarching structural challenges, some of their everyday stresses were attributed to their immediate communities. For instance, a few participants revealed that sometimes mistrust works within the hijra community itself. When someone, for example, has a disease, they are worried about their information getting leaked if they share it with anyone. Therefore, this reduces their willingness to take a peer with them to healthcare facilities. As they are afraid to endure a hostile healthcare climate by themselves, they decided not to visit the healthcare facilities altogether, thus exacerbating their existing health conditions. As Jelena mentioned:

Now because of sex work I have anal problem and I can’t tell this to anyone. Because if I say to anyone in confidence, she might tell others in the community and everyone will know that I have disease. For this reason, I won’t take anyone with me while seeking healthcare, but I do not even want to face the hospital by myself (Jelena, 25 years old, FGD).

Moreover, societal stigmatization worsened their mental health and well-being, whereby mental ill-health was reported by 61.3% of the participants. Participants felt ashamed, exacerbated by transphobic attitudes in society which discriminated against and ridiculed hijra in public settings. Their lack of personal freedom to tread public spaces affected their state of mental wellbeing. As one of the participants described:

My mental problems are because of family torture. Sometimes I only visit my home because of my mother at night. My brother, sister and father cannot accept me. To avoid people, I do not visit during the day, otherwise people will talk a lot. When we go out on the streets, people say a lot of nasty things about us, so this gives us a lot of stress and mental problems (Uma, 26 years old, IDI).

Discussion

This study examined the distribution and lived experiences of self-reported general health problems among hijra, revealing a high burden of co-occurring health problems influenced by socio-structural vulnerabilities. Rather than aiming for statistical generalizability, this study foregrounded analytical generalization by situating observed patterns within broader social and structural contexts. Findings suggest that health problems among hijra are experienced alongside multiple socio-structural challenges, including economic precarity, stigma, and healthcare access barriers. However, the reliance on self-reported health measures may have introduced reporting biases and limit clinical interpretability. Therefore, these findings should be interpreted within the limitations of self-reported data and a cross-sectional design, which do not permit causal inference.

While previous studies in South Asia and LMICs explored single disease concerns, their upstream socio-structural determinants remained neglected. Our application of the WHO Social Determinants of Health framework enabled us to interpret hijra health outcomes as shaped by inequitable social conditions (e.g. stigma, exclusion, housing and economic precarity), rather than isolated vulnerabilities.

Our quantitative findings indicated that a considerable proportion of participants (58.4%) self-reported at least one health problem within the past year. The most prevalent conditions included: mental health concerns (61.3%), hypertension (33.3%), diabetes (24.8%), and skin conditions (33.3%). Although direct comparisons should be interpreted cautiously due to methodological differences, the prevalence estimates observed in this study appear higher than some national estimates reported for the general population. For example, the prevalence of any mental disorders (i.e., anxiety, depression, or stress) in the general population was 16.8% [46], hypertension is 26% [47], and diabetes is 11% [47]. However, these disparities need to be reported cautiously as case definitions and measurement approaches differ across sources. Notably, since screening through biomedical markers and taking anthropometric measurements were beyond the scope of this study, there might have been some previously undiagnosed, underreported cases. Similarly, a behavioral risk factor surveillance system in the US reflected lower proportions of good general health among transgender populations, ranging from 81.4 to 85.5% between 2020 and 2023, compared to a decrease from 80.9% to 63.9% within the same time period, suggesting downward trends amongst this group [48]. However, this study merely presented prevalence estimates, without delving into social determinants or qualitative explorations.

Similar patterns have been documented in other settings, although differences in context and measurements limit direct comparability [49, 50]. A recent cross-sectional study in Bangladesh revealed that NCDs affected 34% of the participants, with 12% and 8% prevalence rates of diabetes and low pressure, respectively [51]. While this study identified nutrition as a risk factor, this research overlooked upstream social determinants.

Emerging scholarship, however, indicated that structural exposures such as economic disadvantage, spatial marginality, and lack of enabling environments shaped physical and mental health outcomes [28]. While studies in India and Pakistan documented the presence of chronic diseases, e.g. diabetes (7.5%), hypertension (10.6%) [52], they merely pinpointed family history as a risk correlate [11]. Additionally, a study in India revealed that 40% of the hijra had severe depression [11]. Similarly, studies conducted in USA found that, 31.3% of the transgender people were suffering from high blood pressure, followed by 15.4% from diabetes, and 7.1% from coronary heart diseases [53].

Qualitative findings were framed in relation to Social Determinants of Health framework, which was used for the first time to analyze the socio-structural drivers of various health conditions. One book chapter has been published in the South Asian region across Bangladesh, India, Nepal and Pakistan [54], but this was limited to the social determinants of sexual health. Moreover, a US-based secondary data analysis identified risk correlates of mental ill-health amongst transgender populations, but did not explore qualitative relationships nor other health issues besides mental health concerns [55]. However, our qualitative findings provided contextual insights into how participants described the relationship between social conditions and health experiences (i.e., demonstrating how policies, economics, and socio-cultural prejudices affect intermediary environments such as living conditions and psychosocial stress). For example, participants described experiences of familial and educational exclusion alongside feelings of isolation and psychological distress. The relationship between education and minority stress among transgender women was also reflected in a scoping review analyzing the social determinants of mental ill-health and chronic diseases. A similar relationship was depicted in a qualitative study based in India [56]. While both studies identified risk correlates, it did not apply qualitative inquiry to explore how educational contexts affected their mental wellbeing [57]. Moreover, participants described unsafe and unhygienic living conditions as part of their broader health experiences, including infectious illnesses. These housing insecurities originated from the lack of viable housing options, signaling structural inequities. Similarly, a cross-sectional study on Latina gender and sexual minorities in the USA revealed that 56.9% of participants reported housing insecurities, 35.3% experienced food insecurity, and 27.8% faced employment challenges [58]. However, this study did not explain the structural mechanisms cultivating ill-health, a gap bridged by our research. Furthermore, participants frequently discussed food insecurity and occupational challenges along with chronic health conditions such as diabetes and hypertension. In essence, the application of the social determinant’s framework was not only able to link non-communicable diseases to poor dietary choices, but also revealed upstream conditions perpetuating poor diet, such as poverty and food insecurity, which are linked to structural inequities.

Our quantitative and qualitative findings also showed that over a third of the participants were denied care, and more than half experienced financial barriers that compelled them to forego treatment. Likewise, a study based in Pakistan documented that 70% of the transgender people received low quality of care in hospitals due to neglect and stigma from healthcare providers, financial problems, and legal identification barriers [59]. Our study provided contextual accounts of how participants experienced healthcare neglect along with ongoing health concerns. Our healthcare access findings aligned with global evidence transgender populations routinely faced institutional discrimination and economic marginalization [60, 61] Globally, other cross-sectional studies have linked healthcare access barriers to financial constraints and lack of social support [58, 62]. Our findings have added onto previous studies on the contexts of ill-health among transgender populations in South Asian countries and other LMICs. In India, while most transgender research was predominated by HIV, a few studies documented burdens of diabetes (7.5%) and hypertension (10.6%), which was higher than the Indian general population [63]. While the same study revealed elevated rates of severe depression, this study did not describe the contexts perpetuating these health conditions. A cross-sectional study in Nepal demonstrated that 68.8% of transgender participants had multiple NCD risk factors such as smoking and hypertension [64], however, these were not linked to upstream social determinants. Whereas, a study in Malaysia revealed that transgender women faced various non-HIV challenges including heightened rates of depression, violence and healthcare access barriers, which were all linked to structural exclusion [65].

On the global scale, a critical review indicated that stigma operates through multiple institutions, thus constraining employment, education and respectful healthcare, thus perpetuating health inequities amongst transgender populations worldwide [66]. Moreover, a global review by the Lancet reported that transgender populations in higher and lower-middle income countries, alike, experience elevated rates of HIV and other STIs, mental health distress and other chronic diseases in settings with pervasive economic marginalization and social exclusion [67]. A report based in Asia revealed that transphobia in schools, workplaces and clinics drives educational dropout, informal economies, healthcare avoidance, thus heightening infectious and chronic disease burdens [68]. However, both reports did not elaborate on the types of chronic or infectious diseases faced by these populations or the causal pathways influencing these diseases. Moreover, a recent study by Poteat and colleagues (2025) analyzed the relationship between economic disadvantage and gentrification; and self-related health and psychological distress [28]. However, this study merely established numerical associations, without examining how underlying contexts were linked with specific diseases, which was investigated in our research.

Our findings highlight that the health challenges reported by hijra are embedded within broader and institutional inequities. Moreover, these studies are largely limited to HIV and STI research. Whereas, attention is lacking in non-communicable diseases, other infectious diseases and the specific structural contexts of transgender populations in the Global South. While these findings align with broader transgender literature, they should be interpreted within the limits of the study design and study approach. Moreover, there is limited exploration of intra-community heterogeneity, which was identified by our study. In essence, our study not only illuminated the burden of their general health problems, but also illustrated how broader structural determinants create pathways for ill-health.

These findings need to be interpreted within important methodological constraints. The prevalence estimates reported in this study are based on self-reported health conditions and may be influenced by recall, reporting and diagnostic uncertainty. Likewise, mental health indicators reflect self-reported psychological distress rather than clinically validated diagnoses. Also, whilst qualitative findings provide vital contextual insights into participants’ lived experiences, the cross-sectional design does not allow causal interpretation of relationships between social conditions and health outcomes. Thus, we can best interpret these findings as contextually grounded patterns and lived experiences rather than definitive population-level estimates or causal explanations.

Implications of the findings

The findings from this study offer contextually grounded insights that may help inform future government and NGO-led health interventions for hijra. As mental health concerns demonstrated the highest prevalence, integrating mental health counselling into community-based services may be beneficial. Findings also revealed that overarching structural determinants, such as discrimination and stigma in education and employment, predisposed hijra to stress and depression. Therefore, broader interventions addressing stigma and exclusion may support improved wellbeing. For example, the Pehchan program in India yielded significant increases (p < 0.001) in the community-based demand and use of tailored health, legal, social and psychological services [69]. Although there is limited evidence on its success of alleviating mental health burdens, similar multifaceted interventions could be adapted for hijra and other marginalized populations. Moreover, as quantitative and qualitative findings both revealed healthcare access barriers amongst hijra, namely the lack of culturally competent healthcare, healthcare practitioners could benefit from training to eradicate misconceptions about hijra and their health conditions [66]. Furthermore, as hijra interventions predominantly address HIV and STI-related issues, the existing model could be expanded to screening and treating NCDs and other infectious diseases. As many hijra reported that their health problems emerged from their community-based income-generating activities and community hierarchies imposed by their guru, peer providers could convene health education sessions with hijra guru to mitigate occupational risks.

Limitations and directions for future research

This is the first study in Bangladesh and its immediate region that examines the burden and social determinants of general health problems among hijra. Although the study captured a comprehensive general health scenario amongst a service-engaged sample in Dhaka, it relied on self-reported measures which may have imbued recall and misclassification biases. Although our physician team reviewed prescriptions and medications where available, we could not clinically validate these reported conditions due to time and resource constraints. Secondly, cross-sectional designs limited the scope for drawing causal inferences between health outcomes and social determinants. Thirdly, the use of DIC-based sampling may limit the generalizability of findings of hijra not engaged with service delivery platforms, including those who remain more covert. Although the sample size was calculated to support prevalence estimation, inferential analyses need to be interpreted as exploratory and hypothesis-generating given the non-probability sampling strategy and associated limitations in external validity. Lastly, social desirability biases may have influenced responses about sensitive issues, such as mental health. Thus, future research could embed longitudinal designs, clinical assessments, and outreach-based sampling strategies across diverse geographical regions.

Notably, the absence of locally validated instruments for assessing mental health and certain health conditions among hijra represents a crucial gap. While existing measures informed item selection, their applicability remains uncertain and findings need to be cautiously interpreted.

Conclusion

Our study identified a substantial burden of self-reported general health concerns among hijra participants, many of which remain underexplored in existing research beyond HIV and STI-related health issues. Nevertheless, our findings suggest that hijra’s health challenges extend beyond individual-level factors and are experienced within broader structural and social contexts. This contributes to persisting equity gaps in understanding and addressing their unmet general health needs. Thus, existing healthcare approaches may not suffice for ill hijra, especially since they encounter considerable healthcare access barriers, especially in public health settings. Although NGO-based facilities are relatively sensitized towards hijra, due to funding constraints, they remain bracketed within HIV and STIs. These circumstances reflect the complexity of hijra health needs. Thus, these findings suggest the importance of exploring broader health systems approaches, informed by social determinants and equity frameworks, to better understand and respond to broader health needs of hijra and other marginalized populations. Responding to the needs of socially marginalized populations would, thus advance health equity, thus facilitating the achievement of Sustainable Development Goal 3 (ensuring healthy lives and promoting well-being for all).

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

SIK was key person of the study conceptualization process, supervised data collection and analysis (particularly qualitative data analysis), and wrote and reviewed the overall manuscript. WTS and SHK worked with SIK in conceptualizing the study, did the literature review, supervised quantitative collection and analysis. MMR and MSAI were both responsible for supervising the quantitative data collection and analysis, and also contributed to the writing and review of the quantitative portions of the manuscript. SDI and SH led the qualitative data collection and analysis, drafted the qualitative portions of the manuscript, and helped write the first draft of the manuscript.

Funding

This study received funding from the International Centre for Diarrhoeal Diseases Research, Bangladesh (icddr, b).

Data availability

Due to the sensitivity of the data on highly marginalized populations, we have not made it publicly available in the current anti-transgender political environment in Bangladesh. Data are available with the corresponding author Dr. Sharful Islam Khan.

Declarations

Ethics approval and consent to participate

This study has been approved by the Ethical Review Committee of the Institutional Review Board of the International Centre for Diarrhoeal Diseases Research, Bangladesh (icddr, b) (PR-22007). This study has been performed in accordance to the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study. No identifying information was included in this manuscript.

Consent for publication

Informed consent for publication has been obtained from individual participants included in the study.

Competing interests

The authors declare no competing interests.