A community-based emergency oxygen delivery model using mosques in Bangladesh: a conceptual public health systems analysis

A community-based emergency oxygen delivery model using mosques in Bangladesh: a conceptual public health systems analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A community-based emergency oxygen delivery model using mosques in Bangladesh: a conceptual public health systems analysis Md Mahiul Bidat Chowdhury This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8624606/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Hypoxaemia is a major contributor to mortality from pneumonia, trauma, and obstetric emergencies in low- and middle-income countries (LMICs). Although hospital oxygen capacity has expanded in Bangladesh, many patients die before arrival due to prolonged pre-hospital delays, with ambulance response and transport times frequently exceeding 85–120 minutes and fewer than 15% of patients arriving by ambulance. This creates a critical “last-mile” gap in emergency oxygen access. Methods We developed a scenario-based conceptual public health systems model to assess the feasibility and potential impact of the Distributed Emergency Oxygen Network (DEON), a community-based emergency oxygen system using mosques as oxygen hubs. The model integrates Bangladesh census data on mosque density, published estimates of hypoxaemia prevalence and pre-hospital delays, UNICEF oxygen cost-effectiveness data, and WHO guidance on emergency oxygen delivery and lay responder systems. We estimated the number of patients who could receive early oxygen and potential lives saved under conservative, moderate, and high coverage scenarios. Results Bangladesh has approximately 300,000 mosques, providing near-universal geographic coverage. Scenario modelling suggests that even 1–10% participation could enable between 6,000 and 120,000 hypoxaemic patients per year to receive early oxygen during transport, potentially averting 600–24,000 deaths annually, assuming 10–20% mortality reduction from timely oxygen. Oxygen systems are highly cost-effective, with an estimated return of approximately US $ 21 in health gains for every US $ 1 invested. Conclusions A mosque-based community oxygen network represents a feasible, scalable approach to closing the pre-hospital oxygen gap in Bangladesh and similar LMIC settings. Integrating community oxygen hubs into emergency care strategies could substantially reduce avoidable deaths from hypoxaemia and should be piloted and rigorously evaluated. Introduction Hypoxaemia—dangerously low blood oxygen—is a major but often under-recognized driver of mortality from pneumonia, trauma, obstetric complications, and other acute conditions in LMICs. Pneumonia alone accounts for approximately 15% of global under-five deaths, with hypoxaemia among the strongest predictors of mortality ( 1 ). Timely oxygen therapy can prevent a large proportion of these deaths and is among the most cost-effective medical interventions available ( 5 ). In Bangladesh and similar settings, emergency care systems are characterized by severe pre-hospital limitations. In Dhaka, only about 11% of trauma and emergency patients arrive by ambulance, with most transported by rickshaw, private vehicle, or taxi without medical support ( 2 ). Even when ambulances respond, median response-to-hospital times range from 85 to 120 minutes, and only about 8% of ambulances have trained paramedics, limiting effective oxygen delivery ( 2 ). As a result, emergency oxygen remains largely hospital-confined, creating a “last-mile” gap in which patients frequently deteriorate or die before reaching care ( 10 , 2 ). Rural populations face even greater risk. Flooding, long travel distances, and poor road infrastructure further extend transport times, allowing preventable hypoxaemia to become fatal before patients reach a facility ( 35 , 36 ). Hospital-based oxygen investments alone cannot close this gap without parallel community-level emergency interventions. Community-based and faith-centered health initiatives have successfully addressed similar last-mile challenges in LMICs, including church-based malaria services and temple-based disaster response programs ( 22 , 23 ). In Bangladesh, mosques represent a uniquely dense, trusted, and community-managed infrastructure with substantial untapped potential to support emergency oxygen access. This study presents a conceptual public health systems analysis of a mosque-based Distributed Emergency Oxygen Network (DEON) and examines its feasibility, scalability, and potential impact. Methods Conceptual model We developed a deterministic, scenario-based conceptual model of DEON, a community-based emergency oxygen delivery system that uses mosques as decentralized oxygen hubs. The model links four components: (i) mosque density, (ii) case volume of hypoxaemia, (iii) probability of mortality reduction from early oxygen, and (iv) coverage levels of mosque participation. All model inputs were drawn from published sources, including Bangladesh census and mosque density data ( 3 , 13 ), emergency transport and ambulance utilization data ( 2 ), hypoxaemia prevalence and mortality relationships ( 1 , 10 ), UNICEF oxygen cost-effectiveness estimates ( 9 ), and WHO guidance on emergency oxygen and lay responder systems ( 6 , 30 – 32 ). Model structure and assumptions The model estimates the number of patients receiving early oxygen and potential lives saved under three coverage scenarios (conservative, moderate, high). Key assumptions include: 1. Mosque coverage : Bangladesh has approximately 300,000 mosques ( 3 , 13 ). We modelled participation rates of 1%, 5%, and 10%. 2. Case volume : Each participating mosque manages between 2 and 4 hypoxaemic emergencies per year, reflecting conservative assumptions based on emergency burden and volunteer capacity. 3. Effectiveness : Early oxygen delivery during transport reduces mortality by 10–20%, consistent with published estimates for pneumonia, trauma, and obstetric emergencies ( 1 , 5 , 10 ). 4. Cost-effectiveness : Oxygen systems yield approximately US $ 21 in health gains for every US $ 1 invested, with cost per DALY averted of US $ 26–US $ 59 ( 5 , 9 ). A simple sensitivity analysis was conducted by varying the assumed mortality reduction from 10% to 20%. Ethics This analysis used exclusively published, publicly available data. No human subjects or identifiable information were involved. In accordance with ICMJE recommendations, formal ethics review was not required ( 8 ). Results Estimated Reach and Potential Impact Bangladesh’s approximately 300,000 mosques provide exceptionally dense community infrastructure ( 3 , 13 ). Under DEON, each participating mosque would store oxygen cylinders and have trained volunteers capable of identifying hypoxaemia and administering WHO-recommended emergency oxygen before and during transport to hospital ( 6 , 30 – 32 ). Using published data on emergency delays, hypoxaemia burden, and mosque density ( 1 , 2 , 10 , 35 , 36 ), we estimated the potential reach of DEON under three coverage scenarios. Table 1 presents the number of patients who could receive early oxygen and the number of deaths potentially averted, assuming a conservative 10–20% reduction in mortality from timely oxygen therapy ( 5 , 10 ). Table 1 Scenario-based estimates of DEON impact in Bangladesh Scenario % of mosques participating Number of mosques Cases per mosque per year Patients receiving early oxygen Deaths averted (10–20%) Conservative 1% 3,000 2 6,000 600–1,200 Moderate 5% 15,000 3 45,000 4,500–9,000 High 10% 30,000 4 120,000 12,000–24,000 Even under conservative assumptions, a small pilot-scale implementation could deliver oxygen to thousands of hypoxaemic patients annually. At higher coverage levels, DEON could reach tens of thousands of patients per year and avert a substantial number of otherwise preventable deaths. Cost-effectiveness Oxygen therapy is among the most cost-effective health interventions in LMICs. Systematic reviews and economic analyses indicate that every US $ 1 invested in oxygen systems yields approximately US $ 21 in health gains, with costs per DALY averted between US $ 26 and US $ 59 ( 5 ). UNICEF’s 2024 guidance similarly identifies oxygen system strengthening as one of the highest-value investments for child survival in LMICs ( 9 ). DEON is expected to operate at low cost for several reasons: • It requires no new construction, as mosques already exist ( 3 , 13 ) • Trained volunteers reduce personnel costs ( 4 , 30 – 33 ) • Oxygen cylinders require no electricity and function reliably during outages (18,19,37,38) • Training and equipment can be standardized across sites ( 6 , 30 – 32 ) Training can be integrated into existing community health worker and first-responder programs using WHO training modules for lay responders ( 30 – 32 ). Cylinder refilling and maintenance can be centralized through district-level suppliers, further reducing costs. Scalability Bangladesh’s mosque network enables immediate national scalability ( 3 , 13 ). Globally, more than 1.5 million mosques exist ( 13 ). If only 30% of these participated and each managed two hypoxaemia emergencies annually, approximately 900,000 patients could receive early oxygen each year. This model is especially relevant for sub-Saharan Africa, where 28 countries report fewer than two physicians per 10,000 population ( 14 ). In such settings, volunteer-led community oxygen hubs offer a feasible mechanism for addressing pre-hospital care gaps. Although mosques are emphasized due to Bangladesh’s context, DEON is faith-neutral. Churches, temples, and community centers in LMICs have a long history of delivering health services and could serve as equivalent oxygen hubs in mixed-faith regions ( 22 , 23 ). Policy implications Three immediate actions follow from these findings: 1. Policy integration : Community-based oxygen delivery should be explicitly incorporated into emergency care strategies. Although WHA resolutions call for expanding oxygen access, current WHO toolkits do not yet include community hubs ( 11 ). 2. Pilot implementation : A pilot costing approximately US $ 100,000 to equip and train 50 mosques would allow feasibility, safety, and operational evaluation. 3. Evaluation priorities : Studies should measure mortality reduction, timeliness of oxygen delivery, equity of access, and community acceptability, with particular attention to maternal and neonatal emergencies where hypoxaemia is especially lethal ( 6 , 24 , 25 ). Discussion Operational feasibility and safety WHO and UNICEF provide detailed guidance for safe oxygen cylinder use in community and low-resource settings, including storage, ventilation, fire prevention, leak detection, and routine inspection ( 18 , 19 ). Evidence from high-income settings, such as home oxygen programs in Australia, demonstrates that community-based cylinder storage is safe when standard protocols are followed ( 20 , 21 ). Experience from LMICs further shows that oxygen is already safely administered in ambulances, community paramedic programs, and first-responder systems ( 33 , 34 ). Operational considerations for DEON include adequate storage and ventilation space within or adjacent to mosques, reliable refill logistics, theft prevention, and volunteer availability beyond prayer hours. Centralized refilling through district suppliers and routine inspection schedules are consistent with WHO and UNICEF recommendations (18,19,38). Cylinders are preferred for community deployment because they do not require electricity and are not affected by voltage instability, which is a major limitation of concentrators in many LMICs (37,38). Community engagement and equity Mosques in Bangladesh are continuously staffed by imams, muezzins, and committee members who live on or near mosque premises, making them highly accessible during emergencies ( 17 ). Faith-based institutions have repeatedly demonstrated effectiveness in mobilizing community health volunteers because of their stable leadership and deep social trust ( 12 , 15 , 16 , 29 ). Participation in DEON would be voluntary and consistent with WHO guidance endorsing trained lay responders to provide basic emergency care when professional services are delayed ( 30 – 32 ). DEON also incorporates a roster of trained area volunteers maintained by mosque committees, creating a distributed and rapidly mobilizable response network ( 32 , 33 ). The DEON model is faith-neutral. In mixed-faith regions, oxygen hubs could be located in temples, churches, or community centers to ensure equitable access for Hindu, Christian, Buddhist, and indigenous populations ( 22 , 23 ). Gender-sensitive design is essential. Women may face barriers to entering some mosque spaces despite maternal emergencies being a primary target for community oxygen systems. Equipment placement in adjacent rooms, courtyards, women’s prayer areas, or multipurpose halls is recommended to ensure safe, stigma-free access, consistent with UNFPA and WHO guidance ( 24 , 25 ). Limitations This study uses conceptual scenario-based modelling rather than empirical trial data. Assumptions about case volume and mortality reduction were derived from published literature and may vary by context. However, conservative assumptions were used, and sensitivity analysis across a 10–20% mortality reduction range demonstrates that DEON remains potentially impactful even under low-effectiveness scenarios. Conclusions Pre-hospital hypoxaemia remains a major and preventable cause of death in Bangladesh and many LMICs. Although hospital-based oxygen expansion is essential, it does not address the prolonged period when patients are most vulnerable—during transport without oxygen access. This conceptual public health systems analysis suggests that a mosque-based Distributed Emergency Oxygen Network could provide timely, low-cost oxygen support close to households. Even limited-scale implementation could avert a substantial number of pre-hospital deaths. Pilot implementation and rigorous evaluation are now warranted to determine feasibility, safety, and real-world impact. Declarations Ethics statement This analysis used exclusively published data and conceptual modelling. No human participants or identifiable information were involved. In accordance with ICMJE recommendations, formal ethics approval was not required (8). Data availability All data used in this study are publicly available and cited in the reference list. No primary data were collected. Funding The author received no specific funding for this work. Competing interests The author declares no competing interests. Author Contribution Md Mahiul Bidat Chowdhury conceived the study, developed the conceptual framework, conducted the literature review and scenario-based analysis, drafted the manuscript, and approved the final version for submission.The author’s prior experience in health systems strengthening and community-based public health programmes in Bangladesh informed the development of the conceptual framework. References Rahman AE, Hossain AT, Nair H, Chisti MJ, Dockrell D, El Arifeen S, Campbell H. The prevalence of hypoxaemia among children with pneumonia in low- and middle- income countries: a systematic review and meta-analysis. Lancet Glob Health. 2022;10(3):e348–e359. doi:10.1016/S2214-109X(21)00586-6. Hossain MM, Kroeger A, Pervin K, Norwood G, Ahmed BN, Ahmed MK, et al. Emergency medical rescue services in Dhaka City, Bangladesh: a situational analysis and needs assessment. Int J Crit Care Emerg Med. 2022;8(4):138. doi:10.23937/2474-3674/1510138. World Diabetes Foundation. Religious leaders prevent diabetes through sermons and service. 23 June 2023. https://www.worlddiabetesfoundation.org/news/religious-leaders-prevent-diabetes-through-sermons-and-service Moussally J, Saha AC, Madden S. TraumaLink: a community-based first-responder system for traffic injury victims in Bangladesh. Glob Health Sci Pract. 2022;10(4):e2100537. doi:10.9745/GHSP-D-21-00537. Lam F, Stegmuller A, Chou VB, Graham HR, et al. Oxygen systems strengthening as an intervention to prevent childhood deaths due to pneumonia in low-resource settings: systematic review, meta-analysis and cost-effectiveness. BMJ Glob Health. 2021;6(12):e007468. doi:10.1136/bmjgh-2021-007468. World Health Organization. Emergency oxygen: Emergency oxygen use in adults and children. Geneva: WHO; 2021.https://www.who.int/publications/i/item/9789240038304 World Health Organization. Essential Emergency Care Toolkit. Geneva: WHO; 2023. https://www.who.int/publications/i/item/9789240074920 International Committee of Medical Journal Editors. Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals. Updated May 2023. http://www.icmje.org/recommendations UNICEF. Oxygen cost-effectiveness analysis: LMIC contexts. New York: UNICEF; 2024. https://www.unicef.org/reports/oxygen-cost-effectiveness-analysis-lmic-contexts-2024 Graham HR, Chang H, Gohar A, Mungai R, et al. Lancet Global Health Commission on medical oxygen security. Lancet Glob Health. 2025;13(3):e528–e584. doi:10.1016/S2214-109X(24)00496-0. World Health Organization. WHA76.3 – Increasing access to medical oxygen. 2023. https://apps.who.int/gb/ebwha/pdf_files/WHA76/A76_R3-en.pdf UNICEF. Religious leaders play key role in battle against COVID-19. Kathmandu: UNICEF South Asia; 2020. https://www.unicef.org/rosa/stories/religious-leaders-play-key-role-battle-against-covid-19 ICESCO. Annual Statistical Report on Islamic Cultural Infrastructure. Rabat: ICESCO; 2020. https://www.icesco.org/en/annual-statistical-report-on-islamic-cultural-infrastructure-2020 World Health Organization. Global Health Observatory: Medical doctors per 10,000 population. 2023. https://apps.who.int/gho/data/view.main.92000 Tamura M, Kotani H, Katsura Y, Okai H. Mosque as a COVID-19 vaccination site in Osaka, Japan. Prog Disaster Sci. 2022;16:100263. Kellar I, Al Azdi Z, Jackson C, Huque R, Mdege ND, Siddiqi K, et al. Muslim communities learning about second-hand smoke in Bangladesh (MCLASS II). Pilot Feasibility Stud. 2022;8:136. Ahmad MM, Safiullah S. Historical development of Waqf governance in Bangladesh. Int J Interdiscip Discourse. 2023;10:45–60. World Health Organization. Oxygen therapy for children. 2016. UNICEF. Oxygen therapy systems: Planning and implementation tools. 2021. Australian Commission on Safety and Quality in Health Care. Oxygen safety in the home. 2021. National Asthma Council Australia. Home oxygen therapy: Safety information for patients and carers. 2020. UNICEF South Asia. Religious leaders play key role in battle against COVID-19. 2020. World Health Organization. Essential Emergency and Critical Care (EECC). 2023. UNFPA. Addressing Gender Barriers in Health Care Access. 2019. World Health Organization. Improving maternal emergency care at community level. 2021. Tamura M, Kotani H, Katsura Y, et al. Mosque as a COVID-19 vaccination site in Japan. Prog Disaster Sci. 2022. UNICEF. Faith-based engagement in health emergencies. 2021. World Health Organization. Community engagement: a cornerstone of emergency response. 2020. UNICEF. Faith-based engagement in health emergencies. 2021. World Health Organization. Essential Emergency and Critical Care (EECC). 2023. World Health Organization. Community engagement: a cornerstone of emergency response. 2020. World Health Organization. Community-based health care in the context of COVID- 19. 2020. Kobusingye O, et al. Community first responders for emergency care in LMICs. Afr J Emerg Med. 2020;10(S2):S53–S58. World Health Organization. Emergency Care Systems Framework. 2020. Mould-Millman NK, et al. Prehospital transport mortality in LMICs: a systematic review. Afr J Emerg Med. 2015. Kironji AG, et al. Identifying gaps in prehospital care in low-income settings. BMC Health Serv Res. 2018. PATH. Oxygen Concentrators for Low-Resource Settings. 2021. WHO & UNICEF. Oxygen Access Scale-Up for COVID-19 and Beyond. 2020. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 12 Feb, 2026 Reviewers agreed at journal 12 Feb, 2026 Reviewers invited by journal 12 Feb, 2026 Editor invited by journal 21 Jan, 2026 Editor assigned by journal 21 Jan, 2026 Submission checks completed at journal 21 Jan, 2026 First submitted to journal 17 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8624606","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":590697457,"identity":"4e3af5cd-adde-42d2-97e2-2c38105fe22a","order_by":0,"name":"Md Mahiul Bidat Chowdhury","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA10lEQVRIiWNgGAWjYFACHobDDAbMQAbzASAhIUO8Fh42tgSQFh6itACtAGnhMYBwCQHd9rMHDxcUWMvby/d8fnWjxoKHgf3w0Q34tJidyUs4PMMg3bCHjXebdc4xoMN40tJu4NVyIMfgMI/BYUaQFuMcNqAWCR4z/FrOvwFrse9h43lmnPOPGC03ILYkArUwP85tI0oL0BagX5J7jqWZMef2SQBDjpBfzucYfy74Y23b3nz48eecb3Vy/OyHj+HVggzYJMAkscpBgPkDKapHwSgYBaNg5AAA4alFMf0kMJMAAAAASUVORK5CYII=","orcid":"","institution":"Chattogram Maa- Shishu O General Hospital Chittagong","correspondingAuthor":true,"prefix":"","firstName":"Md","middleName":"Mahiul Bidat","lastName":"Chowdhury","suffix":""}],"badges":[],"createdAt":"2026-01-17 08:38:29","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8624606/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8624606/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102871490,"identity":"d71fe3f5-771f-4208-90ad-ff4f3b6b71a7","added_by":"auto","created_at":"2026-02-17 18:10:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":621254,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8624606/v1/3cbb9306-81bc-45f3-a0de-90f4fce936b4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A community-based emergency oxygen delivery model using mosques in Bangladesh: a conceptual public health systems analysis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHypoxaemia\u0026mdash;dangerously low blood oxygen\u0026mdash;is a major but often under-recognized driver of mortality from pneumonia, trauma, obstetric complications, and other acute conditions in LMICs. Pneumonia alone accounts for approximately 15% of global under-five deaths, with hypoxaemia among the strongest predictors of mortality (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Timely oxygen therapy can prevent a large proportion of these deaths and is among the most cost-effective medical interventions available (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn Bangladesh and similar settings, emergency care systems are characterized by severe pre-hospital limitations. In Dhaka, only about 11% of trauma and emergency patients arrive by ambulance, with most transported by rickshaw, private vehicle, or taxi without medical support (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Even when ambulances respond, median response-to-hospital times range from 85 to 120 minutes, and only about 8% of ambulances have trained paramedics, limiting effective oxygen delivery (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). As a result, emergency oxygen remains largely hospital-confined, creating a \u0026ldquo;last-mile\u0026rdquo; gap in which patients frequently deteriorate or die before reaching care (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRural populations face even greater risk. Flooding, long travel distances, and poor road infrastructure further extend transport times, allowing preventable hypoxaemia to become fatal before patients reach a facility (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Hospital-based oxygen investments alone cannot close this gap without parallel community-level emergency interventions.\u003c/p\u003e \u003cp\u003eCommunity-based and faith-centered health initiatives have successfully addressed similar last-mile challenges in LMICs, including church-based malaria services and temple-based disaster response programs (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e23\u003c/span\u003e). In Bangladesh, mosques represent a uniquely dense, trusted, and community-managed infrastructure with substantial untapped potential to support emergency oxygen access. This study presents a conceptual public health systems analysis of a mosque-based Distributed Emergency Oxygen Network (DEON) and examines its feasibility, scalability, and potential impact.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eConceptual model\u003c/h2\u003e \u003cp\u003eWe developed a deterministic, scenario-based conceptual model of DEON, a community-based emergency oxygen delivery system that uses mosques as decentralized oxygen hubs. The model links four components: (i) mosque density, (ii) case volume of hypoxaemia, (iii) probability of mortality reduction from early oxygen, and (iv) coverage levels of mosque participation.\u003c/p\u003e \u003cp\u003eAll model inputs were drawn from published sources, including Bangladesh census and mosque density data (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), emergency transport and ambulance utilization data (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e), hypoxaemia prevalence and mortality relationships (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), UNICEF oxygen cost-effectiveness estimates (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e), and WHO guidance on emergency oxygen and lay responder systems (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan additionalcitationids=\"CR31\" citationid=\"CR32\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eModel structure and assumptions\u003c/h3\u003e\n\u003cp\u003eThe model estimates the number of patients receiving early oxygen and potential lives saved under three coverage scenarios (conservative, moderate, high). Key assumptions include:\u003c/p\u003e \u003cp\u003e1. \u003cb\u003eMosque coverage\u003c/b\u003e: Bangladesh has approximately 300,000 mosques (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). We modelled participation rates of 1%, 5%, and 10%.\u003c/p\u003e \u003cp\u003e2. \u003cb\u003eCase volume\u003c/b\u003e: Each participating mosque manages between 2 and 4 hypoxaemic emergencies per year, reflecting conservative assumptions based on emergency burden and volunteer capacity.\u003c/p\u003e \u003cp\u003e3. \u003cb\u003eEffectiveness\u003c/b\u003e: Early oxygen delivery during transport reduces mortality by 10\u0026ndash;20%, consistent with published estimates for pneumonia, trauma, and obstetric emergencies (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e4. \u003cb\u003eCost-effectiveness\u003c/b\u003e: Oxygen systems yield approximately US\u003cspan\u003e$\u003c/span\u003e21 in health gains for every US\u003cspan\u003e$\u003c/span\u003e1 invested, with cost per DALY averted of US\u003cspan\u003e$\u003c/span\u003e26\u0026ndash;US\u003cspan\u003e$\u003c/span\u003e59 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA simple sensitivity analysis was conducted by varying the assumed mortality reduction from 10% to 20%.\u003c/p\u003e\n\u003ch3\u003eEthics\u003c/h3\u003e\n\u003cp\u003eThis analysis used exclusively published, publicly available data. No human subjects or identifiable information were involved. In accordance with ICMJE recommendations, formal ethics review was not required (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eEstimated Reach and Potential Impact\u003c/h2\u003e \u003cp\u003eBangladesh\u0026rsquo;s approximately 300,000 mosques provide exceptionally dense community infrastructure (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Under DEON, each participating mosque would store oxygen cylinders and have trained volunteers capable of identifying hypoxaemia and administering WHO-recommended emergency oxygen before and during transport to hospital (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan additionalcitationids=\"CR31\" citationid=\"CR32\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eUsing published data on emergency delays, hypoxaemia burden, and mosque density (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e36\u003c/span\u003e), we estimated the potential reach of DEON under three coverage scenarios. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents the number of patients who could receive early oxygen and the number of deaths potentially averted, assuming a conservative 10\u0026ndash;20% reduction in mortality from timely oxygen therapy (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eScenario-based estimates of DEON impact in Bangladesh\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScenario\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e% of mosques participating\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNumber of mosques\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCases per mosque per year\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePatients receiving early oxygen\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eDeaths averted (10\u0026ndash;20%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConservative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e600\u0026ndash;1,200\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e45,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4,500\u0026ndash;9,000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e120,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12,000\u0026ndash;24,000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eEven under conservative assumptions, a small pilot-scale implementation could deliver oxygen to thousands of hypoxaemic patients annually. At higher coverage levels, DEON could reach tens of thousands of patients per year and avert a substantial number of otherwise preventable deaths.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eCost-effectiveness\u003c/h2\u003e \u003cp\u003eOxygen therapy is among the most cost-effective health interventions in LMICs. Systematic reviews and economic analyses indicate that every US\u003cspan\u003e$\u003c/span\u003e1 invested in oxygen systems yields approximately US\u003cspan\u003e$\u003c/span\u003e21 in health gains, with costs per DALY averted between US\u003cspan\u003e$\u003c/span\u003e26 and US\u003cspan\u003e$\u003c/span\u003e59 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). UNICEF\u0026rsquo;s 2024 guidance similarly identifies oxygen system strengthening as one of the highest-value investments for child survival in LMICs (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDEON is expected to operate at low cost for several reasons:\u003c/p\u003e \u003cp\u003e\u0026bull; It requires no new construction, as mosques already exist (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e\u0026bull; Trained volunteers reduce personnel costs (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan additionalcitationids=\"CR31 CR32\" citationid=\"CR32\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e33\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e\u0026bull; Oxygen cylinders require no electricity and function reliably during outages (18,19,37,38)\u003c/p\u003e \u003cp\u003e\u0026bull; Training and equipment can be standardized across sites (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan additionalcitationids=\"CR31\" citationid=\"CR32\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e32\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eTraining can be integrated into existing community health worker and first-responder programs using WHO training modules for lay responders (\u003cspan additionalcitationids=\"CR31\" citationid=\"CR32\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Cylinder refilling and maintenance can be centralized through district-level suppliers, further reducing costs.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eScalability\u003c/h3\u003e\n\u003cp\u003eBangladesh\u0026rsquo;s mosque network enables immediate national scalability (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Globally, more than 1.5\u0026nbsp;million mosques exist (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). If only 30% of these participated and each managed two hypoxaemia emergencies annually, approximately 900,000 patients could receive early oxygen each year.\u003c/p\u003e \u003cp\u003eThis model is especially relevant for sub-Saharan Africa, where 28 countries report fewer than two physicians per 10,000 population (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). In such settings, volunteer-led community oxygen hubs offer a feasible mechanism for addressing pre-hospital care gaps.\u003c/p\u003e \u003cp\u003eAlthough mosques are emphasized due to Bangladesh\u0026rsquo;s context, DEON is faith-neutral. Churches, temples, and community centers in LMICs have a long history of delivering health services and could serve as equivalent oxygen hubs in mixed-faith regions (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003ePolicy implications\u003c/h3\u003e\n\u003cp\u003eThree immediate actions follow from these findings:\u003c/p\u003e \u003cp\u003e1. \u003cb\u003ePolicy integration\u003c/b\u003e: Community-based oxygen delivery should be explicitly incorporated into emergency care strategies. Although WHA resolutions call for expanding oxygen access, current WHO toolkits do not yet include community hubs (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e2. \u003cb\u003ePilot implementation\u003c/b\u003e: A pilot costing approximately US\u003cspan\u003e$\u003c/span\u003e100,000 to equip and train 50 mosques would allow feasibility, safety, and operational evaluation.\u003c/p\u003e \u003cp\u003e3. \u003cb\u003eEvaluation priorities\u003c/b\u003e: Studies should measure mortality reduction, timeliness of oxygen delivery, equity of access, and community acceptability, with particular attention to maternal and neonatal emergencies where hypoxaemia is especially lethal (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eOperational feasibility and safety\u003c/h2\u003e \u003cp\u003eWHO and UNICEF provide detailed guidance for safe oxygen cylinder use in community and low-resource settings, including storage, ventilation, fire prevention, leak detection, and routine inspection (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Evidence from high-income settings, such as home oxygen programs in Australia, demonstrates that community-based cylinder storage is safe when standard protocols are followed (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Experience from LMICs further shows that oxygen is already safely administered in ambulances, community paramedic programs, and first-responder systems (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e34\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOperational considerations for DEON include adequate storage and ventilation space within or adjacent to mosques, reliable refill logistics, theft prevention, and volunteer availability beyond prayer hours. Centralized refilling through district suppliers and routine inspection schedules are consistent with WHO and UNICEF recommendations (18,19,38).\u003c/p\u003e \u003cp\u003eCylinders are preferred for community deployment because they do not require electricity and are not affected by voltage instability, which is a major limitation of concentrators in many LMICs (37,38).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eCommunity engagement and equity\u003c/h2\u003e \u003cp\u003eMosques in Bangladesh are continuously staffed by imams, muezzins, and committee members who live on or near mosque premises, making them highly accessible during emergencies (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Faith-based institutions have repeatedly demonstrated effectiveness in mobilizing community health volunteers because of their stable leadership and deep social trust (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eParticipation in DEON would be voluntary and consistent with WHO guidance endorsing trained lay responders to provide basic emergency care when professional services are delayed (\u003cspan additionalcitationids=\"CR31\" citationid=\"CR32\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e32\u003c/span\u003e). DEON also incorporates a roster of trained area volunteers maintained by mosque committees, creating a distributed and rapidly mobilizable response network (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e33\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe DEON model is faith-neutral. In mixed-faith regions, oxygen hubs could be located in temples, churches, or community centers to ensure equitable access for Hindu, Christian, Buddhist, and indigenous populations (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGender-sensitive design is essential. Women may face barriers to entering some mosque spaces despite maternal emergencies being a primary target for community oxygen systems. Equipment placement in adjacent rooms, courtyards, women\u0026rsquo;s prayer areas, or multipurpose halls is recommended to ensure safe, stigma-free access, consistent with UNFPA and WHO guidance (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis study uses conceptual scenario-based modelling rather than empirical trial data. Assumptions about case volume and mortality reduction were derived from published literature and may vary by context. However, conservative assumptions were used, and sensitivity analysis across a 10\u0026ndash;20% mortality reduction range demonstrates that DEON remains potentially impactful even under low-effectiveness scenarios.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003ePre-hospital hypoxaemia remains a major and preventable cause of death in Bangladesh and many LMICs. Although hospital-based oxygen expansion is essential, it does not address the prolonged period when patients are most vulnerable—during transport without oxygen access.\u003c/p\u003e\n\u003cp\u003eThis conceptual public health systems analysis suggests that a mosque-based Distributed Emergency Oxygen Network could provide timely, low-cost oxygen support close to households. Even limited-scale implementation could avert a substantial number of pre-hospital deaths. Pilot implementation and rigorous evaluation are now warranted to determine feasibility, safety, and real-world impact.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis analysis used exclusively published data and conceptual modelling. No human participants or identifiable information were involved. In accordance with ICMJE recommendations, formal ethics approval was not required (8).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data used in this study are publicly available and cited in the reference list. No primary data were collected.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author received no specific funding for this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author declares no competing interests.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eMd Mahiul Bidat Chowdhury conceived the study, developed the conceptual framework, conducted the literature review and scenario-based analysis, drafted the manuscript, and approved the final version for submission.The author\u0026rsquo;s prior experience in health systems strengthening and community-based public health programmes in Bangladesh informed the development of the conceptual framework.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eRahman AE, Hossain AT, Nair H, Chisti MJ, Dockrell D, El Arifeen S, Campbell H. \u003cem\u003eThe prevalence of hypoxaemia among children with pneumonia in low- and middle- income countries: a systematic review and meta-analysis. \u003c/em\u003eLancet Glob Health. 2022;10(3):e348\u0026ndash;e359. doi:10.1016/S2214-109X(21)00586-6.\u003c/li\u003e\n\u003cli\u003eHossain MM, Kroeger A, Pervin K, Norwood G, Ahmed BN, Ahmed MK, et al. \u003cem\u003eEmergency medical rescue services in Dhaka City, Bangladesh: a situational analysis and needs assessment. \u003c/em\u003eInt J Crit Care Emerg Med. 2022;8(4):138. doi:10.23937/2474-3674/1510138.\u003c/li\u003e\n\u003cli\u003eWorld Diabetes Foundation. \u003cem\u003eReligious leaders prevent diabetes through sermons and service. \u003c/em\u003e23 June 2023. https://www.worlddiabetesfoundation.org/news/religious-leaders-prevent-diabetes-through-sermons-and-service\u003c/li\u003e\n\u003cli\u003eMoussally J, Saha AC, Madden S. \u003cem\u003eTraumaLink: a community-based first-responder system for traffic injury victims in Bangladesh. \u003c/em\u003eGlob Health Sci Pract. 2022;10(4):e2100537. doi:10.9745/GHSP-D-21-00537.\u003c/li\u003e\n\u003cli\u003eLam F, Stegmuller A, Chou VB, Graham HR, et al. \u003cem\u003eOxygen systems strengthening as an intervention to prevent childhood deaths due to pneumonia in low-resource settings: systematic review, meta-analysis and cost-effectiveness. \u003c/em\u003eBMJ Glob Health. 2021;6(12):e007468. doi:10.1136/bmjgh-2021-007468.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. \u003cem\u003eEmergency oxygen: Emergency oxygen use in adults and children. \u003c/em\u003eGeneva: WHO; 2021.https://www.who.int/publications/i/item/9789240038304\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. \u003cem\u003eEssential Emergency Care Toolkit. \u003c/em\u003eGeneva: WHO; 2023. https://www.who.int/publications/i/item/9789240074920\u003c/li\u003e\n\u003cli\u003eInternational Committee of Medical Journal Editors. \u003cem\u003eRecommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals. \u003c/em\u003eUpdated May 2023. http://www.icmje.org/recommendations\u003c/li\u003e\n\u003cli\u003eUNICEF. \u003cem\u003eOxygen cost-effectiveness analysis: LMIC contexts. \u003c/em\u003eNew York: UNICEF; 2024. https://www.unicef.org/reports/oxygen-cost-effectiveness-analysis-lmic-contexts-2024\u003c/li\u003e\n\u003cli\u003eGraham HR, Chang H, Gohar A, Mungai R, et al. \u003cem\u003eLancet Global Health Commission on medical oxygen security. \u003c/em\u003eLancet Glob Health. 2025;13(3):e528\u0026ndash;e584. doi:10.1016/S2214-109X(24)00496-0.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. \u003cem\u003eWHA76.3 \u0026ndash; Increasing access to medical oxygen. \u003c/em\u003e2023. https://apps.who.int/gb/ebwha/pdf_files/WHA76/A76_R3-en.pdf\u003c/li\u003e\n\u003cli\u003eUNICEF. \u003cem\u003eReligious leaders play key role in battle against COVID-19. \u003c/em\u003eKathmandu: UNICEF South Asia; 2020. https://www.unicef.org/rosa/stories/religious-leaders-play-key-role-battle-against-covid-19\u003c/li\u003e\n\u003cli\u003eICESCO. \u003cem\u003eAnnual Statistical Report on Islamic Cultural Infrastructure. \u003c/em\u003eRabat: ICESCO; 2020. https://www.icesco.org/en/annual-statistical-report-on-islamic-cultural-infrastructure-2020\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. \u003cem\u003eGlobal Health Observatory: Medical doctors per 10,000 population. \u003c/em\u003e2023. https://apps.who.int/gho/data/view.main.92000\u003c/li\u003e\n\u003cli\u003eTamura M, Kotani H, Katsura Y, Okai H. \u003cem\u003eMosque as a COVID-19 vaccination site in Osaka, Japan. \u003c/em\u003eProg Disaster Sci. 2022;16:100263.\u003c/li\u003e\n\u003cli\u003eKellar I, Al Azdi Z, Jackson C, Huque R, Mdege ND, Siddiqi K, et al. \u003cem\u003eMuslim communities learning about second-hand smoke in Bangladesh (MCLASS II). \u003c/em\u003ePilot Feasibility Stud. 2022;8:136.\u003c/li\u003e\n\u003cli\u003eAhmad MM, Safiullah S. \u003cem\u003eHistorical development of Waqf governance in Bangladesh.\u003c/em\u003eInt J Interdiscip Discourse. 2023;10:45\u0026ndash;60.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. \u003cem\u003eOxygen therapy for children. \u003c/em\u003e2016.\u003c/li\u003e\n\u003cli\u003eUNICEF. \u003cem\u003eOxygen therapy systems: Planning and implementation tools. \u003c/em\u003e2021.\u003c/li\u003e\n\u003cli\u003eAustralian Commission on Safety and Quality in Health Care. \u003cem\u003eOxygen safety in the home. \u003c/em\u003e2021.\u003c/li\u003e\n\u003cli\u003eNational Asthma Council Australia. \u003cem\u003eHome oxygen therapy: Safety information for patients and carers. \u003c/em\u003e2020.\u003c/li\u003e\n\u003cli\u003eUNICEF South Asia. \u003cem\u003eReligious leaders play key role in battle against COVID-19.\u003c/em\u003e2020.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. \u003cem\u003eEssential Emergency and Critical Care (EECC). \u003c/em\u003e2023.\u003c/li\u003e\n\u003cli\u003eUNFPA. \u003cem\u003eAddressing Gender Barriers in Health Care Access. \u003c/em\u003e2019.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. \u003cem\u003eImproving maternal emergency care at community level. \u003c/em\u003e2021.\u003c/li\u003e\n\u003cli\u003eTamura M, Kotani H, Katsura Y, et al. \u003cem\u003eMosque as a COVID-19 vaccination site in Japan. \u003c/em\u003eProg Disaster Sci. 2022.\u003c/li\u003e\n\u003cli\u003eUNICEF. \u003cem\u003eFaith-based engagement in health emergencies. \u003c/em\u003e2021.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. \u003cem\u003eCommunity engagement: a cornerstone of emergency response. \u003c/em\u003e2020.\u003c/li\u003e\n\u003cli\u003eUNICEF. \u003cem\u003eFaith-based engagement in health emergencies. \u003c/em\u003e2021.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. \u003cem\u003eEssential Emergency and Critical Care (EECC). \u003c/em\u003e2023.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. \u003cem\u003eCommunity engagement: a cornerstone of emergency response. \u003c/em\u003e2020.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. \u003cem\u003eCommunity-based health care in the context of COVID-\u003c/em\u003e\u003cem\u003e19. \u003c/em\u003e2020.\u003c/li\u003e\n\u003cli\u003eKobusingye O, et al. \u003cem\u003eCommunity first responders for emergency care in LMICs. \u003c/em\u003eAfr J Emerg Med. 2020;10(S2):S53\u0026ndash;S58.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. \u003cem\u003eEmergency Care Systems Framework. \u003c/em\u003e2020.\u003c/li\u003e\n\u003cli\u003eMould-Millman NK, et al. \u003cem\u003ePrehospital transport mortality in LMICs: a systematic review. \u003c/em\u003eAfr J Emerg Med. 2015. \u003c/li\u003e\n\u003cli\u003eKironji AG, et al. \u003cem\u003eIdentifying gaps in prehospital care in low-income settings. \u003c/em\u003eBMC Health Serv Res. 2018.\u003c/li\u003e\n\u003cli\u003ePATH. \u003cem\u003eOxygen Concentrators for Low-Resource Settings. \u003c/em\u003e2021.\u003c/li\u003e\n\u003cli\u003eWHO \u0026amp; UNICEF. \u003cem\u003eOxygen Access Scale-Up for COVID-19 and Beyond. \u003c/em\u003e2020. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8624606/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8624606/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eHypoxaemia is a major contributor to mortality from pneumonia, trauma, and obstetric emergencies in low- and middle-income countries (LMICs). Although hospital oxygen capacity has expanded in Bangladesh, many patients die before arrival due to prolonged pre-hospital delays, with ambulance response and transport times frequently exceeding 85\u0026ndash;120 minutes and fewer than 15% of patients arriving by ambulance. This creates a critical \u0026ldquo;last-mile\u0026rdquo; gap in emergency oxygen access.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe developed a scenario-based conceptual public health systems model to assess the feasibility and potential impact of the Distributed Emergency Oxygen Network (DEON), a community-based emergency oxygen system using mosques as oxygen hubs. The model integrates Bangladesh census data on mosque density, published estimates of hypoxaemia prevalence and pre-hospital delays, UNICEF oxygen cost-effectiveness data, and WHO guidance on emergency oxygen delivery and lay responder systems. We estimated the number of patients who could receive early oxygen and potential lives saved under conservative, moderate, and high coverage scenarios.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eBangladesh has approximately 300,000 mosques, providing near-universal geographic coverage. Scenario modelling suggests that even 1\u0026ndash;10% participation could enable between 6,000 and 120,000 hypoxaemic patients per year to receive early oxygen during transport, potentially averting 600\u0026ndash;24,000 deaths annually, assuming 10\u0026ndash;20% mortality reduction from timely oxygen. Oxygen systems are highly cost-effective, with an estimated return of approximately US\u003cspan\u003e$\u003c/span\u003e21 in health gains for every US\u003cspan\u003e$\u003c/span\u003e1 invested.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eA mosque-based community oxygen network represents a feasible, scalable approach to closing the pre-hospital oxygen gap in Bangladesh and similar LMIC settings. Integrating community oxygen hubs into emergency care strategies could substantially reduce avoidable deaths from hypoxaemia and should be piloted and rigorously evaluated.\u003c/p\u003e","manuscriptTitle":"A community-based emergency oxygen delivery model using mosques in Bangladesh: a conceptual public health systems analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-17 18:10:13","doi":"10.21203/rs.3.rs-8624606/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-02-12T10:43:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"158730877155753566319180179433947684115","date":"2026-02-12T10:28:29+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-12T07:35:08+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-21T07:43:15+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-21T06:30:17+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-21T06:30:11+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2026-01-17T08:32:41+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a4616281-af58-43e8-b55a-4730a7d3578b","owner":[],"postedDate":"February 17th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-17T18:10:13+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-17 18:10:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8624606","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8624606","identity":"rs-8624606","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}