Action monitoring for equity and gender in health.

Equity and gender, despite being universal concerns for all health programmes in Bangladesh, are often missing in many of the health agenda. The health programmes fail to address these important dimensions unless these are specifically included in the planning stage of a programme and are continually monitored for progress. This paper presents the situation of equity in health in Bangladesh, innovations in monitoring equity in the use of health services in general and by the poor in particular, and impact of targeted non-health interventions on health outcomes of the poor. It was argued that an equitable use of health services might also result in enhanced overall coverage of the services. The findings show that government services at the upazila level are used by the poor proportionately more than they are in the community, while at the private facilities, the situation is reverse. Commonly-used monitoring tools, at times, are not very useful for the programme managers to know how well they are doing in reaching the poor. Use of benefit-incidence ratio may provide a quick feedback to the health facility managers about their extent of serving the poor. Similarly, Lot Quality Assurance Sampling can be an easy-to-use tool for monitoring coverage at the community level requiring a very small sample size. Although health problems are biomedical phenomena, their solutions may include actions beyond the biomedical framework. Studies have shown that non-health interventions targeted towards the poor improve the use of health services and reduce mortality among children in poor households. The study on equity and health deals with various interlocking issues, and the examples and views presented in this paper intend to introduce their importance in designing and managing health and development programmes.

Sociodemographic characteristics of tobacco consumers in a rural area of Bangladesh.

Bangladesh typifies many developing countries experiencing an increasing trend in tobacco consumption. However, little is known about the general pattern of tobacco consumption and about population groups who are more prone to tobacco consumption. This paper aimed at generating knowledge on tobacco consumption, especially emphasizing the identification of sociodemographic groups who are more prone to tobacco consumption vis-à-vis tobacco-related health consequences in a remote rural area in Bangladesh. Information on the tobacco consumption status of 6,618 individuals (52.1% males, 47.9% females), aged over 15 years, was collected in 1994. Both univariate and multivariate analyses were done. Individuals were categorized as consumers if they consumed tobacco in any form at all, i.e. smoke or chew. The independent variables included various characteristics of individuals and households. Overall, 43.4% of the study subjects consumed tobacco. Males were 9.38 times more likely to consume tobacco than their female counterparts. Individuals with no education were 3.62 times more likely to consume tobacco than those who had completed six or more years of schooling, and the poor were almost twice as likely to consume tobacco than the rich. Tobacco consumption in both smoke and chewing form has been a part of household consumption in Bangladesh from time immemorial. Only aggressive anti-tobacco programmes on various fronts may salvage the vulnerable groups from the menace of tobacco consumption in Bangladesh.

Battered bodies & shattered minds: violence against women in Bangladesh.

Violence against women is a common and insidious phenomenon in Bangladesh. The types of violence commonly committed are domestic violence, acid throwing, rape, trafficking and forced prostitution. Domestic violence is the most common form of violence and its prevalence is higher in rural areas. A higher prevalence of verbal abuse than physical abuse by partners has been observed. The reasons mentioned for abuse were trivial and included questioning of the husband, failure to perform household work and care of children, economic problems, stealing, refusal to bring dowry, etc. The factors associated with violence were the age of women, age of husband, past exposure to familial violence, and lack of spousal communication. The majority of abused women remained silent about their experience because of the high acceptance of violence within society, fear of repercussion, tarnishing family honour and own reputation, jeopardizing children's future, and lack of an alternative place to stay. However, severely abused women, women who had frequent verbal disputes, higher level of education, and support from natal homes were more likely to disclose violence. A very small proportion of women approached institutional sources for help and only when the abuse was severe, became life threatening or children were at risk. Interestingly, violence increased with membership of women in micro-credit organizations initially but tapered off as duration of involvement increased. The high acceptability of violence within society acts as a deterrent for legal redress. Effective strategies for the prevention of violence should involve public awareness campaigns and community-based networks to support victims.

A multidimensional approach to measure poverty in rural Bangladesh.

Poverty is increasingly being understood as a multidimensional phenomenon. Other than income-consumption, which has been extensively studied in the past, health, education, shelter, and social involvement are among the most important dimensions of poverty. The present study attempts to develop a simple tool to measure poverty in its multidimensionality where it views poverty as an inadequate fulfillment of basic needs, such as food, clothing, shelter, health, education, and social involvement. The scale score ranges between 72 and 24 and is constructed in such a way that the score increases with increasing level of poverty. Using various techniques, the study evaluates the poverty-measurement tool and provides evidence for its reliability and validity by administering it in various areas of rural Bangladesh. The reliability coefficients, such as test-retest coefficient (0.85) and Cronbach's alpha (0.80) of the tool, were satisfactorily high. Based on the socioeconomic status defined by the participatory rural appraisal (PRA) exercise, the level of poverty identified by the scale was 33% in Chakaria, 26% in Matlab, and 32% in other rural areas of the country. The validity of these results was tested against some traditional methods of identifying the poor, and the association of the scores with that of the traditional indicators, such as ownership of land and occupation, asset index (r=0.72), and the wealth ranking obtained from the PRA exercise, was consistent. A statistically significant inverse relationship of the poverty scores with the socioeconomic status was observed in all cases. The scale also allowed the absolute level of poverty to be measured, and in the present study, the highest percentage of absolute poor was found in terms of health (44.2% in Chakaria, 36.4% in Matlab, and 39.1% in other rural areas), followed by social exclusion (35.7% in Chakaria, 28.5% in Matlab, and 22.3% in other rural areas), clothing (6.2% in Chakaria, 8.3% in Matlab, and 20% in other rural areas), education (14.7% in Chakaria, 8% in Matlab, and 16.8% in other rural areas), food (7.8% in Chakaria, 2.9% in Matlab and 3% in other rural areas), and shelter (0.8% in Chakaria, 1.4% in Matlab, and 3.7% in other rural areas). This instrument will also prove itself invaluable in assessing the individual effects of poverty-alleviation programmes or policies on all these different dimensions.

Performance of the lot quality assurance sampling method compared to surveillance for identifying inadequately-performing areas in Matlab, Bangladesh.

This paper compared the performance of the lot quality assurance sampling (LQAS) method in identifying inadequately-performing health work-areas with that of using health and demographic surveillance system (HDSS) data and examined the feasibility of applying the method by field-level programme supervisors. The study was carried out in Matlab, the field site of ICDDR,B, where a HDSS has been in place for over 30 years. The LQAS method was applied in 57 work-areas of community health workers in ICDDR,B-served areas in Matlab during July-September 2002. The performance of the LQAS method in identifying work-areas with adequate and inadequate coverage of various health services was compared with those of the HDSS. The health service-coverage indicators included coverage of DPT, measles, BCG vaccination, and contraceptive use. It was observed that the difference in the proportion of work-areas identified to be inadequately performing using the LQAS method with less than 30 respondents, and the HDSS was not statistically significant. The consistency between the LQAS method and the HDSS in identifying work-areas was greater for adequately-performing areas than inadequately-performing areas. It was also observed that the field managers could be trained to apply the LQAS method in monitoring their performance in reaching the target population.

'Semen contains vitality and heredity, not germs': seminal discourse in the AIDS era.

Perspectives of public health generally ignore culture-bound sexual health concerns, such as semen loss, and primarily attempt to eradicate sexually transmitted infections (STIs), including human immunodeficiency virus (HIV). Like in many other countries, sexual health concerns of men in Bangladesh have also received less attention compared to STIs in the era of AIDS. This paper describes the meanings of non-STI sexual health concerns, particularly semen loss, in the masculinity framework. In a qualitative study on male sexuality, 50 men, aged 18-55 years, from diverse sociodemographic backgrounds and 10 healthcare practitioners were interviewed. Men considered semen the most powerful and vital body fluid representing their sexual performance and reproductive ability. Rather than recognizing the vulnerability to transmission of STIs, concerns about semen were grounded in the desire of men to preserve and nourish seminal vitality. Traditional practitioners supported semen loss as a major sexual health concern where male heritage configures male sexuality in a patriarchal society. Currently, operating HIV interventions in the framework of disease and death may not ensure participation of men in reproductive and sexual health programmes and is, therefore, less likely to improve the quality of sexual life of men and women.

Marital disruption: determinants and consequences on the lives of women in a rural area of Bangladesh.

This study, carried out during the second half of 1995, investigated the predisposing factors leading to marital disruption and its consequences on the lives of women in Matlab, a rural area of Bangladesh. Both qualitative and quantitative methods were used. Data were generated from detailed case studies and quantitative surveys of a small number of maritally-disrupted women. Additional data were used from the ongoing demographic surveillance system of ICDDR,B: Centre for Health and Population Research. The findings revealed that divorced and abandoned women and their children were extremely vulnerable, both socially and economically. Various factors that influence marital disruption were identified, the most important ones being: aspects determining the process of marriage, various family problems due to non-fulfillment of demand for dowry, mutual distrust, extramarital relationships, quality of sexual life, education of women, and other behavioural characteristics of individuals. Level of education of the wife showed an inverse relationship with the risk of divorce. Women who did not have livebirths from their first pregnancy had a higher risk of divorce. The effect of pregnancy outcome was dependent on the level of education of women. Illiterate women with unsuccessful pregnancy outcomes were at the highest risk of being divorced, with the lowest risk for women with some education and a livebirth. The findings clearly indicate the need for broad-based social development programmes for women, especially to enhance their education to reduce their vulnerability to marital instability and its consequences.

Application of the capture-recapture method for estimating number of mobile male sex workers in a port city of Bangladesh.

Male sex workers (MSWs) and sex trades are not new in Bangladesh. Current HIV interventions for MSWs need to be expanded in the major cities, but the number of MSWs needs to be scientifically estimated. Although two-sample capture-recapture surveys are suitable for closed populations, this method was here applied to indirectly estimate the number of mobile MSWs in a conservative social setting, a port city of Bangladesh. Use of the method resulted in an estimation of 248 MSWs (95% confidence interval, 246-250) who picked up clients only at open and known contact venues. This estimate does not, however, reflect the total number as MSWs who worked in unknown hidden venues and could not be reached. Experience suggests that the two-sample capture-recapture method is a simple technique for reliably estimating an unrecognized population. The limitation of this method can be minimized by shortening the time gap between surveys, creating an enabling environment to encounter harassment of MSWs, and offering safety to peer-staff.

Immunization divide: who do get vaccinated in Bangladesh?

This paper examines inequalities in the use of, and access to, vaccination service in Bangladesh by analyzing national and small area-based datasets. The analysis showed that female children had a lower immunization coverage than male children--the difference persists for all antigens and widens against girls for higher doses. The immunization coverage was higher for children whose mothers were more educated. Children whose fathers had a higher-status occupation (salaried employment) were two-and-a-half times more likely to be immunized than children whose fathers held a lower-status job, e.g. day-labourer. The coverage for the poorest quintile was 70% of the well-to-do. Children residing in urban areas were more likely to be fully immunized than their rural counterparts (70% vs 59% for children aged 12-23 months). Within urban areas, the situation in slums was worse. Large differences existed among the various administrative regions of the country. Ethnic minorities in the Chittagong Hill Tracts had a lower immunization coverage than the Bangalees. In Sylhet, children of non-local workers in Bangladesh-owned tea estates had a lower coverage than their counterparts in foreign-owned tea estates. The study identifies children of various disadvantaged groups as having a lower coverage. Managers of immunization programmes must realize that only through removal of such disparities among groups will overall coverage be increased. Affirmative actions in targeting could be effective in reaching such groups.

Global Equity Gauge Alliance: reflections on early experiences.

The paper traces the evolution and working of the Global Equity Gauge Alliance (GEGA) and its efforts to promote health equity. GEGA places health equity squarely within a larger framework of social justice, linking findings on socioeconomic and health inequalities with differentials in power, wealth, and prestige in society. The Alliance's 11 country-level partners, called Equity Gauges, share a common action-based vision and framework called the Equity Gauge Strategy. An Equity Gauge seeks to reduce health inequities through three broad spheres of action, referred to as the 'pillars' of the Equity Gauge Strategy, which define a set of interconnected and overlapping actions. Measuring and tracking the inequalities and interpreting their ethical import are pursued through the Assessment and Monitoring pillar. This information provides an evidence base that can be used in strategic ways for influencing policy-makers through actions in the Advocacy pillar and for supporting grassroots groups and civil society through actions in the Community Empowerment pillar. The paper provides examples of strategies for promoting pro-equity policy and social change and reviews experiences and lessons, both in terms of technical success of interventions and in relation to the conceptual development and refinement of the Equity Gauge Strategy and overall direction of the Alliance. To become most effective in furthering health equity at both national and global levels, the Alliance must now reach out to and involve a wider range of organizations, groups, and actors at both national and international levels. Sustainability of this promising experiment depends, in part, on adequate resources but also on the ability to attract and develop talented leadership.

Nature of domestic violence against women in a rural area of Bangladesh: implication for preventive interventions.

This paper reports finding from a study carried out in a remote rural area of Bangladesh during December 2000. Nineteen key informants were interviewed for collecting data on domestic violence against women. Each key informant provided information about 10 closest neighbouring ever-married women covering a total of 190 women. The questionnaire included information about frequency of physical violence, verbal abuse, and other relevant information, including background characteristics of the women and their husbands. 50.5% of the women were reported to be battered by their husbands and 2.1% by other family members. Beating by the husband was negatively related with age of husband: the odds of beating among women with husbands aged less than 30 years were six times of those with husbands aged 50 years or more. Members of micro-credit societies also had higher odds of being beaten than non-members. The paper discusses the possibility of community-centred interventions by raising awareness about the violation of human rights issues and other legal and psychological consequences to prevent domestic violence against women.

Measuring perceived health outcomes in non-western culture: does SF-36 have a place?

This study explored the usefulness of a generic health assessment tool SF-36 in measuring perceived health outcomes in a developing-country setting. The adapted Bangla version was administered in 10 villages of Matlab sub-district in Bangladesh during second half of 1999. Respondents included currently-married males and females selected randomly from households stratified according to their association with women-focused development interventions of BRAC. Findings revealed that the respondents from BRAC households perceived their health status marginally better than the poor non-member group in most domains studied, sometimes significantly so, e.g. general and mental health (p < 0.05). The respondents from BRAC reported better 'current health' than their non-member counterparts. The gender difference in assessment of health status was noted among the groups. Age, education, and poverty were important determinants of perceived health status. SF-36 proved to be a useful tool for self-assessment of health status and group comparison when properly modified for cross-cultural adaptation.

Knowledge on, and attitude toward, HIV/AIDS among staff of an international organization in Bangladesh.

Two hundred and ninety-three randomly-selected members of the staff of ICDDR,B: Centre for Health and Population Research were surveyed anonymously in June 1998, using a pre-tested and self-administered questionnaire, to assess their knowledge on, and attitude toward, human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS). All except 4 (1.4%) heard of AIDS. Main sources of information were radio and television (93%), newspapers and magazines (84.8%), posters and leaflets (70.2%), and friends (59.2%). About 94% of the respondents believed that HIV might spread in Bangladesh. Only 61.6% knew about the causative agent for AIDS. More than 96% had knowledge that HIV could be detected through blood test. The respondents were aware that unprotected sexual intercourse (92%), transfusion of blood and blood components (93.8%), sharing unsterile needles for injections (94.1%), and delivery of babies by infected mothers (82.7%) could transmit HIV. Similarly, the respondents had the knowledge that HIV infection could be prevented by using condom during sexual intercourse (85.5%), having sex only with an HIV-negative faithful partner (87.2%), avoiding transfusion of blood not screened for HIV (88.9%), and taking injections with sterile needles (86.5%). However, only 33.0% had the knowledge that HIV-infected persons can look healthy, and 56.4% were unaware of transmission through breastmilk. Most members of the staff, particularly at lower level, had misconceptions about transmission and prevention of HIV/AIDS. More than 40% of the respondents had the attitude that HIV-infected persons should not be allowed to work, while another 10% did not have any idea about it. The findings of the study suggest that the members of the Centre's staff have a satisfactory level of essential knowledge on HIV/AIDS, although half of them have poor attitudes toward persons with HIV/AIDS. Therefore, preventive strategy for the staff should be directed toward behaviour change communication.