Psychosocial factors related to the health care behavior of the rural people under Rajshahi Division

Chapter –I: Introduction

a) Statement of the problem

i) Psychosocial factors:

Meaning of factor (noun forms plural: factors), cause; agent; broker; financier; money lender; number which is multiplied with another to produce a given result (Ref: TOEIC Vocab -- TOEIC Vocabulary -- 684 TOEIC Word Lists Online, http://www.english-test.net/toeic/vocabulary/ meanings/173/toeic-words).

Definition of factor (FACT) noun [C], a fact or situation which influences the result of something: People's voting habits are influenced by political, social and economic factors. Heavy snow was a contributing factor in the accident. Price will be a major/crucial factor in the success of this new product. The economy is regarded as the decisive/key factor which will determine the outcome of the general election. INFORMAL The film's success is largely due to its feel-good factor (= its ability to make people feel happy). (Ref: Cambridge Advanced Learner's Dictionary, © Cambridge University Press 2004.)

Health practices are the manifestations of health care behavior. It is usual that there are many health practices existing among the rural inhabitants of Bangladesh. As a part of Bangladesh, rural people under Rajshahi Division also have them. As per the existing knowledge, a number of factors including traditional beliefs, economic condition and education etc. are related to the health care behavior.

As a public health researcher having experiences of the rural contexts in Bangladesh since decade, the researcher assumes some of the practices now existing among the rural population under Rajshahi Division are injurious to health. They are related with different social factors in one hand; again they are based on the superstitions, prejudices and misconceptions. As it is a matter of public health importance that the rural population under Rajshahi Division (as well those of Bangladesh) possesses so many practices injurious to the health.

The researcher thought health behaviors injurious to the health should be stopped immediately as it poses threats to the public health. But, first of all, it would be of value to investigate the existing health care behaviors among the rural population under Rajshahi Division from the knowledge, attitudes and practices of the population in the contexts of health to asses the nature and the magnitude of such malpractices and to understand their relation with the associated social factors.

This is the situation under which the study surfaced.

Psychological Factors are the factor generating or modifying one’s or group’s behavior. Psychological Factors are responsible for forming psychological getup of an individual or community for the response or behavior towards a specific stimulus. When these factors emerge from social contexts, they are called psychosocial factors.

Many factors prevailing in a community/society form the basis of the health care behavior of the people in that community. Basis of a behavior or response of the mass in a community to a stimulus depends on the psychological status (preparedness to combat, degree of the problem caused etc.) of the mass, which is in turn formed/controlled by the multiple interactions of different factors prevailing in the society or community. In plain, these are the Psycho-social factors related to the mass behavior.

A fruitful starting point might be the Oxford English Dictionary’s first brief definition of ‘psychosocial’ as ‘pertaining to the influence of social factors on an individual’s mind or behavior, and to the interrelation of behavioral and social factors’.¹ This definition is likely to have important implications for social epidemiologists and other health researchers, because it implies that psychosocial factors, at least in the context of health research, can be seen as: (1) mediating the effects of social structural factors on individual health outcomes, or (2) conditioned and modified by the social structures and contexts in which they exist. The definition thus raises the question of what the relevant broader social structural forces are, and how such forces might influence health through their effects on individual characteristics. To our mind this is a useful working definition of ‘psychosocial determinants of health’. In fact, it would imply that psychosocial explanations of health might be more accurately referred to as ‘social-psychological’ explanations of health.

A direct corollary of this is that psychosocial factors can be best seen as and operationalized in terms of influences acting primarily between the fully social and the fully individual level—that is being neither one nor the other. We think psychosocial factors should not be equated with structural characteristics of societies or psychological characteristics of individuals. Hence, it is important to recognize the independence of both of these concepts from the ‘psychosocial context’ and the ‘psychosocial environment’.

The term ‘psychosocial’ is also quite widely used in the literature in connection with health outcome. The roots of ‘psychosocial health’ lie in the World Health Organization’s (WHO) definition of health as ‘a state of complete physical mental and social well-being, and not merely the absence of disease and infirmity’. This WHO definition of health has been criticized on several grounds, but for us its main danger is one of confusing cause and effect. From an explanatory point of view the concept of ‘psychosocial health’, in some cases, may combine traditional medical definitions of disease and infirmity with measures that reflect individual responses to disease and even in some cases indicators of the social context itself. Such measures have merit in recognizing individuals’ experiences and quality of life, a dimension that is becoming increasingly recognized for example, in clinical trials. But researchers using health outcomes based on such definitions need to guard carefully against circular arguments.

i.i) What are psychosocial processes and how do they influence health?

To further elucidate the role of psychosocial factors in health research it can be suggested a distinction between macro-, meso- and micro-levels^2,3 as a useful sociological framework (Figure-1). We regard psychosocial as a meso-level concept, just as religious institutions, the family, the firm, and the club are meso-level social formations. These exist at a level below and are modified by macro-social structures that relate to ownership and control of land and businesses, legal and welfare structures, as well as distribution of income and other resources between groups and individuals.

Fig 1. A tentative schematic representation of psychosocial pathways

In the context of health research meso-level psychosocial concepts, such as social networks and supports, work control, effort/ reward balance, security and autonomy, home control, and work-family conflict are all produced within meso-level social formations. All these are manifested in interpersonal relationships. Thus, psychosocial explanations of health are essentially viewed here as processes that cannot be fully captured by single measures at one level, but require due attention to macro and micro (individual) level factors as well. However, not all processes from macro through meso to the individual micro level are psychosocial.

To our mind a central constituent of a psychosocial explanation of health is that macro- and meso-level social processes lead to perceptions and psychological processes at the individual level. These psychological changes can influence health through direct psychobiological processes or through modified behaviors and lifestyles (Figure 1). However, many psychosocial exposures such as unemployment (so called ‘stressful life-event’) and social networks/supports need not necessarily invoke psychosocial processes or require psychosocial explanations. Thus, unemployment that leads to loss of income and an inability to buy material necessities of life does not constitute a psychosocial explanation of health. However, a psychosocial process is operating when unemployment leads to loss of self-esteem and feelings of worthlessness that affect health via direct psychobiological processes or through modified behaviors and lifestyles.⁴ Similarly, social networks may provide instrumental and material benefits and opportunities as well as close person-to-person social contacts and emotional support; yet only the latter path seems to qualify as a psychosocial process.

The researchers are not entirely certain whether psychosocial processes can be evoked in the absence of conscious individual level changes, such as perceptions of stress or social isolation (dashed lines in Figure 1). Research into the effects of working conditions on health, where control at work has been measured using self-reports and independent assessments, provides an interesting illustration of this issue. Both measures of control have been associated with health outcomes, although these associations are independent of one another and differ in magnitude somewhat.⁵ While this might be interpreted as evidence that including both measures provides a more accurate assessment of control at work, it also suggests that these measures influence health through different pathways.

⁽References

¹ Oxford English Dictionary. http://dictionary.oed.com/.

² Coleman JS. Foundations of Social Theory. Cambridge, MA: The Belknap Press of Harvard University Press, 1990.

³ Hertzman C, Power C, Matthews S, Manor O. Using an interactive framework of society and lifecourse to explain self-rated health in early adulthood. Soc Sci Med 2001;53:1575–85.[CrossRef][ISI][Medline]

⁴ Martikainen P, Valkonen T. Excess mortality of unemployed men and women during a period of rapidly increasing unemployment. Lancet 1996;348:909–12.[CrossRef][ISI][Medline]

⁵ Bosma H, Marmot MG, Hemingway H, Nicholson AC, Brunner E, Stansfeld SA. Low job control and risk of coronary heart disease in Whitehall II (prospective cohort) study. BMJ 1997;314:558–65.[Abstract/Free Full Text]

⁶ Ben-Shlomo Y, Kuh D. A life course approach to chronic disease epidemiology: conceptual models, empirical challenges and interdisciplinary perspectives. Int J Epidemiol 2002;31:285–93.

⁷ Pekka Martikainen^a,b, Mel Bartley^b and Eero Lahelma^c Psychosocial determinants of health in social epidemiology . Int J Epidemiol

i.ii). Health care behavior and psychosocial factors:

Behavior: 1. The manner in which a person acts or performs. 2. Any or all of the activities of a person, including physical and mental activity. Kinds of behavior include abnormal behavior, automatic behavior, invariable behavior, and variable behavior.

Health Care Behavior:

Health behavior denotes an action taken by a person to maintain, attain, or regain good health and to prevent illness. Health behavior comes from a person's health beliefs. Some common health behaviors are regular exercise, eating a balanced diet, and getting vaccinations on schedule.

Health care consumer: any actual or potential receiver of health care, as a patient in a hospital, a client in a community mental health center, or a member of a prepaid health-maintenance organization.

Health behavior of a person can be defined as an action taken by a person to maintain, attain, or regain good health and to prevent illness. Health behavior comes from a person's health beliefs. Some common health behaviors are regular exercise, eating a balanced diet, and getting vaccinations on schedule

Health care behavior forms the crucial link between the emergence of illness, on one hand, and the health service facilities available at hand on the other. People perceive the emergence and continuation of diseases in their own manner i.e. to be cured from disease, to be in good health or the want to cure the person, whom they love, graveness of the disease causing financial damage to the family and the emerged necessity to cure those. They define symptoms and graveness of the illness or their health necessity in varying ways and use different health care services in response to their health conditions and according to their perception. A major part of the health care behavior is the treatment seeking behavior when a person is ill. The capacity of the patients to access the health services in turn influences their health-seeking attitude, i.e. psychological basis to seek remedy. Many social factors prevailing in a community form the basis of the health care behavior of the people in that community. Basis of a behavior or response of the mass in a community to a definite stimulus depends on the psychological status (preparedness to combat, degree of the problem caused etc.) of the mass, which is in turn formed/controlled by the myriad interactions of different factors prevailing in the society or community. In plain, these are the Psycho-social factors related to the mass behavior. Psychological and behavioral factors are important predictors of well-being, vulnerability to disease, and disease outcomes. These factors play a vital role in determining a person’s health, including risk reduction, coping behavior, self-efficacy, perceptions of control, social support, and depression.

i.iii) Population of Bangladesh:

Bangladesh: "Melting pot of Races"

Maps:

Map No -1

The leading British geographer of his time, Jammes Rennell constructed the first nearly accurate map of India and published A Bengal Atlas (1779) accompanied the Scottish geographer Alexander…

Map No-2

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Bangladeshi population, rural population of Bangladesh, historical background, contribution of the incoming population groups and the diversities in culture, beliefs and tradition:

In Bangladesh, we do posses an old and glorious civilization since thousands of years as per the history. In past, this country had been ruled and inhabited by the population groups of different races coming from different parts of the world one after another. Still today, people belonging to various ethnic diversity have been residing in Bangladesh besides the majority Bengali populations (Bengali= about 98% and others =about 2%). In the northwest and northern hilly areas, there are Garo, Santal, Oraon, Ho, Munda, Rajbangsi, Manipuri, Lushai and Kashia etc. predominantly Proto-austroloid-Dravidians. In the southeastern borders’ hilly peaks and in the banks of the forest rivers, there inhabit the Chakma, Rakhain or Marma, Mro, Lushai, Kuki, Khumi, Tipr, Tangchayanga, Bom etc. all represent the Mongoloid races.

Their beliefs, traditions, and health care practices contributed to the health care behavior of present Bangladeshi population.

In ancient times the warrior nations from the remote regions of the world like the Aryans and Greeks from the Europe and Asia minor, the Huns and others, Arabs, Turks, Pathans, Afghans, Moguls etc. in the last thousand years with the English in the recent past ruled the sub-continent, some ruled the subcontinent for hundreds of years. In times the geographical entity, which is now Bangladesh, were under their powerful administrations. Also some times, the invaders were in distant countries, but population continued to receive their culture and social norms in variable extents from remote. Thus, all the invading races and nations contributed to the social, religious and cultural contexts of Bangladeshi population in their capacities.

Present Bangladeshi people inherited the social, cultural and religious practices, norms, customs and manners from their ancestors. Therefore, the present practice or behavior has very deeply embedded root in the pasts.

Therefore, for the reasons mentioned, the present inhabitants of Bangladesh inherited wide range of practices and behaviors prevailing among them. In time, many of them have been modified or abolished by the new knowledge and ever-changing social, cultural and economical scenarios.

Importance of health care behavior study for Bangladesh and the rural contexts: unveiling the issues to be addressed for appropriate, sustainable and cost-effective health policy for the citizens

Like any other civilized population inhabiting in a geographical area, there are many practices; behaviors or habits are present amongst the population groups of Bangladesh as stated earlier. Among them, health care behavior, food behavior, reproductive behavior (behavior relating to sex, marriage, contraception, pregnancy etc.), income earning behavior etc. are important and existing in considerable variations among the population groups in Bangladesh as a result of influencing factors present related to their traditional beliefs, behaviors and practices in terms of religion, race and ethnicity. Differences also are seen in economical, educational and sex variations.

Among these mass habits, practices or behaviors, health care behavior is one of the most important behaviors for variations among the population groups in Bangladesh depending on the social factors including income earning, educational status, habitat and religion, social and cultural beliefs, norms, customs and manners etc. Factors like age, sex, knowledge etc. also influences the behaviors and the health seeking practices. There are many practices among the population those are not modern and scientific and in many case, injurious to the individuals who practices those.

Studying the health care behavior of population groups through their existing health knowledge, attitudes and practices and through other means would unveil many of the real situations, truths, problems and the scenarios that can guide us to effective planning in the health sectors, especially in the strategic health service delivery system for the nation. Such study also can enable us to take care of the associated social factors those influencing the population to adopt harmful attitudes and practices.. A poor country like Bangladesh cannot spend hard-earned money for under-performing health services organization and delivery systems for the people. Bangladesh’s capacity for spending money is much lower than the rich countries (has the capacity of $ 4 to $ 7 per capita to spend for health according to "The fifth five year plan: 1997-2002" by planning commission, ministry of planning, government of people’s republic of Bangladesh"). So, effective planning and execution in the organization and service delivery in the minimal costs to ensure efficient health service is vital. To achieve such goal, we need to design health programs coherent with the traditional thinking, practice and behavior of the common people and to consider them in the process for community-based actions. A (health) program would have its intrinsic pacemaker (community initiative) in the community if it enjoys the popular support and the popular support is again the result of the involvement of the people in the planning and implementation of their own health system organization and delivery. When the process is participatory and community based, the result becomes sustainable.

For establishing such participatory and community based sustainable efficient health service organization, studying the health care behavior is a must. The information, truth, situations, problems etc. revealed in such behavior study can contribute significantly in the process of establishing a cost-effective health service delivery system for Bangladesh and they are more likely to accept it as it they participated in the process and it is planned considering their indigenous traditions and beliefs.

Now days, study of the behavioral study and programs became popular through out the world for development of the people, also Behavior Change Communication (BCC) programs became an emerging vital concept in the different development for bringing positive changes in the practice levels in many sectors including the health. Study of the health behavior would enable the high-level policy makers, managers and the related quarters to use the lessons learnt for their initiatives in the future.

Population facts and figures of Bangladesh at a glance:

People Population 133,376,680 (2002 estimate)

Population growth Population growth rate 1.59 percent (2002 estimate)

Projected population in 2025 177,499,122 (2000 estimate)

Projected population in 2050 205,093,861 (2000 estimate)

Population density 904 persons per sq km (2002 estimate) 2,341 persons per sq mi (2002 estimate)

Urban/rural distribution Share: urban 25 percent (2000 estimate) Share rural 75 percent (2000 estimate)

(Ref: Microsoft® Encarta® Reference Library 2003. © 1993-2002 Microsoft Corporation)

Bangladesh is the most densely populated country in the world and only seconded to City-State Singapore. Out of Bangladesh’s population of 133,376,680, only about 25% reside in the urban areas. The rest 75%, a vast number of people (over 10 million or about 100032510) live in rural areas, in the villages.

In general, the urban people have access to many of the modern facilities including those of the health services; also they are more educated and enlightened, living in the limelights of the state. Therefore, they are more flexible to adopt recent scientific breakthroughs available in their hands. They are also more solvent financially and more income earning in general. In addition, the Government and NGOs usually become as they can work in an easier way there than the rural.

Although majority of the population in Bangladesh live in the rural area, but unfortunately, problems of these rural populations were not adequately addressed by the state or other actors in the contexts. Hence, a study of the health care behavior of the rural population of Bangladesh is capable of conducting a scan of the health care practices of the rural population and can reveal their relation with different social, cultural and religious contexts. It can also explore the potentialities for future intervention. Revealing the factors related with such variations in health behavior among the rural Bangladeshi people can also enable the interested quarters to understand their problems well and find the ways to involve them in designing and implementing future programs in the health sectors.

Social experiences that are significantly related to health outcomes are important components of any health care behavior research. The interactions between health conditions and socio-cultural factors forming the mental basis for health care behavior and the service seeking options are the central concerns of health-care behavior studies.

Psychosocial factors have the capacity to influence individuals’ decision to utilize health services as they include socio-cultural norms, economic condition, and awareness about health and options of health care facilities.

Predisposing conditions are themselves generally shaped by the prevailing psychosocial factors in the community and organization of the health care system to an extent. The availability and type of health care services, the motivation and professional commitment of the health personnel, and financial ability of the people to afford medical management and health financing facilities influence the extent and nature of psychological preparedness and getups for health care behaviors of the individuals or communities. These institutional influences and predisposing conditions together shape health care process and in turn service selection process. So the challenge for health care behavior research is to discern whether health service systems adequately provide health care for the people who need services or whether there could yet be a better match between clients’ need and service provision as well as to identify clients’ conditions including their psychological formations that facilitate or hinder their health care behavior.

Traditional beliefs and many other factors account for the mental basis of the individual and the community why some diseased people choose modern medical treatment, and why some seek alternative traditional sources of help, and why others resist receiving any assistance from any source. We are especially interested in how different cultural definitions of personal health problems; attitudes toward health care services. We are also interested in the role of the health professionals, in the availability of social support in the community facilitate or impede health care efforts from professionals and health care system. How these factors vary across divergent social class, age and relational status is another interest of this research as well as to specify the factors that lead an individual to deal with alternative choices for treatment of his or her diseases.

Rajshahi Division:

As the title indicates, the study "Psychosocial Factors related to the Health Care Behavior of the Rural People under Rajshahi Division" was conducted in two Districts under Rajshaihi Division, i.e. in Rangpur and Kurigram Districts. Following is a brief discussion of some relevant and important issues in context of psychosocial factors of the population groups, the inhabitants and the history the concerned areas of Rajshahi Division for the present study:

Rajshahi and Dhaka Divisions – A Closer Look

Rajshahi and Dhaka administrative divisions represent two contrasting examples of Bangladesh’s development challenges and opportunities. The Rajshahi region had been relatively isolated from the rest of the country for a long time. Dhaka, in contrast, has always been the political and economic heart of Bangladesh. Dhaka division is highly urbanized (about 64 percent of the urban population live in the division, mainly in the Dhaka metropolitan area), while Rajshahi is predominantly rural and with a lower population density. Per capita income in Rajshahi (Tk.4,525) is lower than in Dhaka (Tk.5,130). In absolute terms, while Dhaka division has the largest number of the urban poor and very poor, Rajshahi has the largest number of the rural poor and very poor. Both divisions have about the same number of municipalities.

Dhaka division captured a larger share of development efforts and investments. This is evident in the levels of physical and social infrastructure available to the population on each division. Dhaka division is more industrialized than the division of Rajshahi and the rest of Bangladesh. The industrial base in Rajshahi is rather small and weak, with agriculture still central to its economy. Average cropping intensity and rice yield are, however, higher in Dhaka than in Rajshahi. At an aggregate level, within the divisions, the urban areas have better infrastructure and services than the rural areas.

Tremendous development opportunities for both the Rajshahi and Dhaka divisions to stimulate their economies through economic integration exist. The completion of the Jamuna bridge and the facilitated communication is one of the most recent developments contributing to these opportunities. Because of its strategic geographic location, the Rajshahi region can also become a major trading center as inter-regional trade among Bangladesh, India, Nepal, Bhutan and Southern China takes off in the future. Moreover, the recent water accord with India may stimulate new irrigation farming in Rajshahi region, which will have a spill over effect on non-farm activities.

(Ref: Bangladesh: A Note prepared as a background material for a brainstorming discussion of the South Asia Regional Management Team http://www.livelihoods.org/hot_topics/docs/UR_synergiesnote.doc.):

Geographical location, boundary and area and facts/figures:

Rajshahi Division is one of the 6 administrative Divisions of Bangladesh and stands in the north of the country. It is a very old habitat.

It has to its north India's west Bengal & Kuchbihar states, The Padma River and Dhaka & Khulna Divisions in the south, Dhaka Division and the Indian State of Meghalaya in the east, & west Bengal state of India in the west. The area of division is about 34,971 square Kilometers.

Population: The population of the Rajshahi Division is nearly 2,66,68,000 About 99.5 % of the population is typical Bengali, the rests comprises of Rajbangshi, Koch, Santals and Oraon etc. (Proto-austroloid, Monogloid and their cross).

The vast majority of Bangladesh’s inhabitants are Bengalis, who are largely descendants of Indo-Aryans who began to migrate into the country from the west thousands of years ago and who mixed within Bengal with indigenous groups of various racial stocks. Ethnic minorities include the Chakma and Mogh, Mongoloid peoples who live in the Chittagong Hill Tracts District: the Santal, mainly descended from migrants from present-day India; and the Biharis, non-Bengali Muslims who migrated from India after the partition of 1947.

Apart from mainstream Indo-Aryan population comprising Muslims and Hindus, Rajshahi Division has its peculiarity in context of indigenous population: from the ancient period of the history, present greater Rangpur and Dinajpur Districts were largely inhabited by Mongoloid Rajbanshi, Koch, Proto Austroloid Santals, Oraons etc.

(Ref. Microsoft® Encarta® Reference Library 2003)

Districts: The Rajshahi division consists of 16 districts. These are Rajshahi, Nawabganj, Natore, Naogaon, Pabna, Sirajgiong, Bogra, Jaipurhat, Rangpur, Kurigram, Gaibanda, Lalmonirhat, Nilphamari, Dinajpur, Thakurgaon, & Panchagarh.

Greater Rangpur: Greater Rangpur consist of Districts of Rangpur, Kurigram, Gaibanda, Lalmonirhat and Nilphamari were once under the greater Rangpur District.

Rangpur is located about 160 km (about 100 mi) north of the city of Rājshāhi. Rangpur is a market center for jute, rice, potatoes, fine tobacco, and animal hides produced in the region. Roads and railways connect the city to Dinājpur and Rājshāhi. Several colleges affiliated with Rājshāhi University are in Rangpur. The city is also the site of Rangpur Medical College Hospital, one outdoor and two indoor stadiums, and a public library. Rangpur was designated a municipality in 1869.

Population 2527060 (Ref: Population Census 2001, Bangladesh bureu of Statistics July 2003, Zilla Tables, p-442).

Rangpur District:

Rangpur is a very ancient state. Before it contained Jalpaiguri and Dhubri Districts of West Bengal within its area and was under "Pragjotish" or "Kamrup" state ruled by the kings who were definitely not Aryans. First indigenous king of the Pragjotish or Kamrup kingdom so far we know was "Narak". As per the legend, King "Bhagodutt" mentioned in "Mahabharata" was his son and took part in the battle of "Kurukkhettra" in the side of "Kourabs" who was then fighting "Pandabs".

According to the Hindu mythology, king "Bhagodutt" was killed in hat mythological war but his descendants ruled the kingdom till 300 AD, but the history of that period is yet to be clarified. But two other kings were mentioned in the old scriptures as " Brozadutt" and Puspadutt". From Ain-e- Akbari", we see that the kingdom of "Kamrup" had been ruled by next 23 descendant kings from the King "Bhagodutt" dynasty, although the information was not anonymously supported by the historians. It is postulated from north India’s Ashoka pillar that, the kingdom of Kamrup came under the rule of Mauryan (Samudra Gupta) dynasty (up to 380 A.D.). After that period, we found king "Puspa Barma" as the ruler of Kamup. He was a friend of the Mauryan emperor, but obliged to pay taxes. At least 12 kings ruled from that dynasty.

Bhaskar Burma was the last king of this dynasty. With collaboration of the famous Emperor Harsa Bardhana, he defeated king Shashanka of Gouda dynasty.

The other dynasties ruled the Kamrup successively were Pal, king Prithhu, Khen, Chkkra dhaj, Nilamber etc. Koch tribal chief Bishu Koch who took the name as King Biswa Singh (1496-1533) and got hold of the crown of Kamrup after the death of the famous Bengal king Allauddin Hosain Shah, announced Hindu religion as the state religion. Then most of the tribal Rajbanshi and Koch left their tribal identities and became Hindu by religion and started to demand their religious identity as Hindus.

The kingdom was situated from the river Karotoa in the west and the Bora river of Assam in the east. His descendants ruled the kingdom of Kuchbihar till 1952. At that time, Rangpur was the part of that kingdom of Kuch Bihar and it continued up to the Mughal dynasty.

After the conquer of Bengal in the time of Akbar the great, Kuch Bihar king Nara Narayan became a friend of the Mughal by paying taxes (1576).

The great Mughal warlord Raja Mansinha left the area for Delhi in 1605 AD and the relation of the Mughal deteriorated with the Koch King Laxkmi Narayan.

The Mughal Subadar Mirjumla attacked the Kingdom of Kuch Bihar and Assam, defeated the opponents, but couldn’t stay there for long.

According to Ain- e- Akbari, the Mughal Rangpur contained three types of administrative areas.

Till 1765 AD, the area was ruled by the Kuch kings under the Mughals, but then took over by the East India Company. Later the Rangpur collector was established in 1769.

Till 1875, Kurigram was administratively under Rangpur Jilla sadar. In 1881, new Thana Kurigram was established.

So, apart from the majority Indo-Aryan population, Rajbanshi, Koch and the Khens are the main population groups in Rangpur, although traces of migrated Santals, Oraons and other Austric populations are still found in Rangpur District.

River Tista is streaming in to the Rangpur districts headquarters. It is famous for Tobacco industry. Eminent educationist Begum Rokeya was born in this District. It is not found anywhere wherefrom and how this district got its name. But according to the local people the name Rangpur comes from the name "RANGAPUR". Rangapur originates from "RANGA" means joy, and "PUR" means places that means "joyful places".

Boundary: Present Rangpur is much reduced in size. Lalmonirhat and river Tista to its north part Gaibandha and Dinajpur districts to its southern part. Gaibhandha, Kurigram and Lalmonirhat districts to its eastern part and Nilfamari district in the west Part.

Area: Total area of Rangpur District is 2320 square kilometer (Approximately).

Thana: This District comprises Eight Thana. These are Rangpur sadar, Gangachorra, Kawnia, Pirgacha, Mithapuker, Badargong, Taragagn and Pirgang.

Educational Institute: Total number of government and private Educational Institute is 1214
Number of Union: 83

Kurigram District:

Kurigram is one of the districts of Northern Region with a rich history and cultural heritage. There are different hearsay for the nomenclature of this districts. The district headquarters is on the bank of Dharla River. It is a place of jute and fish trade.

Population: The population of the districts is 1762920 (Ref: Population Census 2001, Bangladesh bureu of Statistics July 2003, Zilla Tables, p-436).

Number of Thana: Kurigram district consist of nine Thana. The names of the Thana are Kurigram Sadar, Ulipur, Chillmari, Nagashwari, Bhurangamari, Charrazibpur, Razarhat, Phool Bari and Raw Mari.

Number of Union: 74

Number of Mouza: 394

Rivers: Jamuna, Brammaputra, Dharla etc.

Educational Institute: There are 3 government colleges and 11 non government colleges, 5 government schools, 123 private schools and different vocational institutes provide education to the local people.

Area: The area of this District is nearly 2296 square Kilometer.

(Ref. Microsoft® Encarta® Reference Library 2003)

i.iv) Urban Vs Rural:

The Government of Bangladesh, since independence in 1971, is investing substantially in the institution building and strengthening of health and family planning services in the country, giving special attention to the vast population living in the rural areas. The main thrust of the health programmes has been in the provision of primary health care (PHC) services. The Government has already initiated the institutionalisation of maternal and child health care and family planning activities through a phased program on Maternal and Child Health and Family Planning (MCH-FP) services. In order to provide MCH-FP services, a wide range of service infrastructure and outlets such as Health and Family Welfare Centre (H&FWC), Rural Dispensary (RD), and Satellite Clinic (SC) at Union level and Thana Health Complex (THC) at Thana level have been established throughout the country. These focal points provide health and family planning services in both rural and urban areas. Moreover, the Government is implementing an integrated health and FP service delivery through static centres called Community Clinics (CCs) for 6,000 people at village level. However, the Government's efforts to provide health facilities at various levels, though free of cost and managed by trained professionals, has not lead to the desired level of use of the services. Reports from the government as well as private sources indicate that primary health care facilities are greatly under-utilised, despite the tremendous health needs and repeated efforts by the government to improve these services. Most of the people in rural areas still remain outside the reach of the government health system. On the other hand, a great majority of the people are found to use private facilities and traditional faith healers.

(Ref. Mazharul Islam, "Under-utilisation of Healthcare Services in Bangladesh: An Emerging Issue", Centre for Policy Dialogue, http://www.cpd-bangladesh.org/publications/cunfpa.html)

The Ministry of Health and Family Planning was responsible for developing, coordinating, and implementing the national health and mother-and-child health care programs. Population control also was within the purview of the ministry. The government's policy objectives in the health care sector were to provide a minimum level of health care services for all, primarily through the construction of health facilities in rural areas and the training of health care workers. The strategy of universal health care by the year 2000 had become accepted, and government efforts toward infrastructure development included the widespread construction of rural hospitals, dispensaries, and clinics for outpatient care. Program implementation, however, was limited by severe financial constraints, insufficient program management and supervision, personnel shortages, inadequate staff performance, and insufficient numbers of buildings, equipment, and supplies.

In the late 1980s, government health care facilities in rural areas consisted of subdistrict health centers, union-level health and family welfare centers, and rural dispensaries. A subdistrict health center in the mid-1980s typically had a thirty-one-bed hospital, an outpatient service, and a home-service unit staffed with field workers. Some of the services, however, were largely nonoperative because of staffing problems and a lack of support services. Health services in urban areas also were inadequate, and their coverage seemed to be deteriorating. In many urban areas, nongovernment organizations provide the bulk of urban health care services. Programming and priorities of the nongovernment organizations were at best loosely coordinated.

A union-level health and family welfare center provided the first contact between the people and the health care system and was the nucleus of primary health care delivery. As of 1985 there were 341 functional subdistrict health centers, 1,275 rural dispensaries (to be converted to union-level health and family welfare centers), and 1,054 union-level health and family welfare centers. The total number of hospital beds at the subdistrict level and below was 8,100.

District hospitals and some infectious-disease and specialized hospitals constituted the second level of referral for health care. In the mid-1980s, there were 14 general hospitals (with capacities ranging from 100 to 150 beds), 43 general district hospitals (50 beds each), 12 tuberculosis hospitals (20 to 120 beds each), and 1 mental hospital (400 beds). Besides these, there were thirty-eight urban outpatient clinics, forty-four tuberculosis clinics, and twenty-three school health clinics. Ten medical college hospitals and eight postgraduate specialized institutes with attached hospitals constituted the third level of health care.

In the mid-1980s, of the country's 21,637 hospital beds, about 85 percent belonged to the government health services. There was only about one hospital bed for every 3,600 people. In spite of government plans, the gap between rural and urban areas in the availability of medical facilities and personnel remained wide. During the monsoon season and other recurrent natural disasters, the already meager services for the rural population were severely disrupted.

(Source: U.S. Library of Congress, ttp://countrystudies.us/bangladesh/50.htm )

Clients’ Perspective

As discussed earlier, the general people’s health care behavior in the rural areas of Bangladesh depends upon varieties of factors ranging from very important and influential "traditional beliefs" to the "poverty" and to even the "personal psychological builds" of the patients and their relatives. When a person of the community is diseased, there starts a long and continued battle for a decision whether the patient should be treated in traditional way or he/she should be submitted to modern medicine? Generally both sides have many enthusiastic supporters and patrons. Usually most of them submit their opinions enough strongly in favor of their suggestions to choose the treatment outlets or the methods. If adult, patients’ opinions also have value, but merely seconded to the man or the person spending money for the illness. Usually, a cheap, easily available, thought of sufficiently effective and most importantly, supported by their traditions and customs is finally accepted by the patient and his/her family members irrespective of its nature (modern or traditional). So, many propellant factors are present in the rural community those can modify the health seeking behaviors in any moment as we already discussed. Besides the important traditional beliefs and other related factors those propel the direction of a mass behavior, the availabilities of the options for actual need i.e. health service delivery outlets for treatment facilities for the patients are very important. Sometimes it is seen that the patient being finally sent to the district hospital in the decision of the junior family members instead of sending him/her to a reputed religious healer of the area where the patient might go for treatment if the head of the family would be present in the time of decision-making. So, what is the way to have a win for the modern medicine? Most accepted answer would be to make it available and of reasonable cost and it should be blended with the flavor of the traditional beliefs, customs and manners etc.-i.e. to present it in the people’s language with honor to their values. For the purpose, what is the scenario in Bangladesh? Here, we discuss some of the issues regarding the matter. In fact, situation in a poor, populous and underdeveloped country like Bangladesh is not encouraging. Despite renewed government propaganda in the mass media, the situation probably is one of the worst even in south Asian standard.

The problems associated with health have received little attention in many developing countries. According to Bangladesh Health and Demographic Survey on Morbidity, Health, Social, and Household Environment Statistics 1997, infant mortality rate per 1000 live births is 76.79, percent received treatment for last pregnancy problems is 16.9, prevalence of morbidity per thousand population is 159.5. Still 88.3 percent delivery cases occur within the household rather than in any kind of health care centers and 59.8 percent birth attendants are untrained e.g. untrained TBAs, relatives, neighbors, others etc. The research findings also showed that 73.2 percent of treatment recipient is receiving treatment from the doctors without degree or undergo self treatment or treatment prescribed by family members for their own diseases. Lack of proper facilities have negative influences on the health care behavior of the people, as this frequently gives them chances not to decide on the modern medicine. Traditional or folk medicines practiced by the untrained quacks remains their only source for remedy. Basic information on the organization and delivery of the health care along with some necessary information in health sector is compiled in the following sections of appendix.

One of the aim of the this study became to look into the root of the health care behavior of the Bangladeshi rural people to see, explore, perceive and understand the turning factors in evoking the variations in behavior and to fill up the existing knowledge gap regarding the point of intervention on which emphasis should be given in future health programs. Through witnessing and documenting their specific knowledge, perception and activities in response to different disease conditions would appraise the benchmark situations prevailing in the community and can act as the steppingstone to the success of the future programs in the field.

Health Care Providers’ Perspective

Health care providers need to understand the existing social factors influencing the health care behavior of the people. For the sake of best management, they must be aware of and concerned with related traditional beliefs and different socio-economic factors those affect the health care behavior of the population. The blend of folk medicine beliefs and philosophical ideas usually generate the health care expectations of the rural population. Such an understanding will help them render both sensitive, acceptable and appropriate care and service to clients. Sensitive and acceptable health care refers to a care, which is consistent with the cultural, religious, traditional beliefs, values and norms.

The women are the initial primary health care providers for the family. Medical information is communicated from mother to daughter, and mostly the women decide when an illness is beyond their ability to treat and requires help of the medical professionals. If she decides that she needs others help, she usually discusses the symptoms first with family members and friends, then she may utilize the nearby medicine practitioner (including folk healers), and finally she may consult a physician. Utilization of services of both traditional and modern health care providers is also not rare.

If the service providers have a working knowledge of the culture and psychological getup of an ethnic group, they can more accurately interpret, influence and modify patients’ behavior, and can earn their confidence. Psycho-cultural sensitivity usually evolves from teach about the values, beliefs and attitudes of the population groups from which behavior arises as opposed to esoteric cultural patterns of behavior.

The most important tools that the health care providers can develop to ensure successful interactions with clients of different cultural backgrounds are good communication skills and an understanding of their cultural beliefs, values and psychological getups. The clients’ definition of their illness will directly affect their willingness to accept treatment, if the service providers consult them in the same spirit/direction.

Although not all-rural people believe in the full range of folk medicine practice or utilize the services of folk healers, it is important for health care practitioners to understand traditional beliefs regarding the etiology of health problems, which contribute largely in their psychological preparedness for health or remedy seeking. Whenever possible, medical treatment should adopt these cultural beliefs for the best utilization of their psychological build for the treatments. By developing and inculcating psycho-cultural sensitivity, health care practitioners can provide a humane, holistic and noble form of effective health care.

In comparison to the urban communities, the rural communities generally are slower to change/modify their psychological getups associated with traditional, cultural values and norms and are comparatively reluctant to adopt external influences to modify their psychological getups. Cultural values are determinants of a rural population's health perception, which in turn influences their psychologyl getups associated with health care-seeking behaviors.

People tend to maintain traditional values, which ultimately affect the health status of different communities having strong affiliation to such values. For example, rural women describe the ideal life style as being married and having children but without any involvement with income earning activities out of their homestead. Furthermore, in different small communities, the identity of a woman viewed as the wife, mother, daughter, or sister of a man, which contributes to low self-esteem and a self-defying status. For example, even in a high profile community of Armed Forces officers in Bangladesh, ladies are called as the "x bhabi", "y bahbi" etc. irrespective of their educational or job status, it is the traditional practice (x., y etc. are the names of the male officers!). This is the resultant of a woman’s psychological getup formed by the traditions within the community since hundreds of years in our country. Ultimately, this also influences a rural woman's health-promoting behaviors.

A psychological formation resulting in attitude of self-reliance and the work ethics may also deter some families from seeking health care. An inherent belief in these two long-standing values is that those who are unable to support themselves are morally deficient or undeserving. For some families, going on welfare may be so unpalatable that they choose to live without any assistance. Thus, the health practitioners need to know about the above issues relating to the self-esteem and cultural values of the rural population emerged as the social factors for better rendering of their services to this target group.

Through this study, attempt was made to explore the diversified world of health care behaviour of the Bangladeshi rural people where there exist in the human mind many characters supernatural, heavenly, medieval even prehistoric in origin. There live the mythical giants, carnivorous, cast and scheduled god/goddess and many other influencing objects in ever mystery. Their world is the nature, there influences are the natural disasters and their frequent appearances are in the night or in dark. They all are predominantly the nocturnal activists and all of them are believed to have some influence on the origin or aetiology of a diseased condition. Healing process is dependent on their defeat by the "God" or "good" power, which requires the support of many magic and counter magic arranged by the patient or family members. Even the exorcism and witchcrafts are being still believed influencing in rural Bangladesh in the aetiologies and remedies of some of the psychological ailments and diseases.

Thus, the roots of the health care behavior of the Bangladeshi rural people frequently enter to a strange world, sometime considerably different from our known world in the mega cities having science, technologies and discoveries of the 21^st century, all for the welfare of the human beings, including easy remedies of their once deadly diseases.

b) Review of Literature

Health care behavior or health behavior is defined as an action taken by a person to maintain, attain, or regain good health and to prevent illness. Health behavior comes from a person's health beliefs and surrounding influencing factors. Certain social factors affecting the mind of an individual are related to his health care behavior. Some common health behaviors are regular exercise, eating a balanced diet, getting vaccinations on schedule and taking advice for remedy if sick from a service provider. Not only the human beings, most of the other creatures including many primates have their evident natural capacity of health care, health seeking behavior or health behavior, which is one of the characteristic of life. For the human beings, this behavior depends upon the psychology of the population groups and individuals. This also differs in line with geographical and anthropological variations as per their psychology related to the phenomenon of health care. In turn, it is dependent on several related social factors those varies with the culture, social traditional beliefs, history, nature, economical chronology and religious belief etc. of the population groups. It also varies with sexual, religious, economical differences among the same population groups. Again, the phenomenon displays considerable inter-individual variations, i.e. it varies from person to person with personality, gender, education, religion, race, build, appearance and other personal features,

As the thinking, decision and execution capacities vary from one individual to another, accordingly the resultant health care behavior is also different in each individual, however narrow the range may be.

Health care behavior includes everything that human beings usually do while not in health. This also refers to the acts for avoiding diseases while not diseased. In that way, it ranges in the human beings from the try for the divine solution to the discovery of the essential life saving drugs with unprecedented efforts for the years.

Health seeking behavior or health care behavior is an inherent characteristic of a human being. Some people may be very much conscious; some may be a little bit careless. However, it is very important and perennial that they all individually and socially do everything possible on their part that they believe to be done towards cure from diseases or for maintaining their health.

Bangladesh is a densely populated country with remarkable social, religious and ethnic variations. Those gave rise to a wide range of factors for the development of health care behavior. Thus without hesitation it can be told that this population contains varieties of group and individual variations in the health care behavior due to their relations with different social factors.

These should be revealed and taken in to account to understand them better in order to compile and setup a welfare health delivery system for them, especially for the deprived millions in the rural and interior Bangladesh that suffers from the burden of ill health and disease. Their indigenous knowledge and traditional belief evoked health care behavior is still mostly medieval and is inappropriate and unsuitable. So, it is the demand of the time that it should be explored.

Unfortunately, only a handful of studies were known to be attempted in the context and no specific study was done in the present topics of "Psychological Factors related to Health Care Behaviour of the Rural Bangladeshi people."

With effort, the researcher collected several study reports. Following is the review of some of the related research works/ literatures in home and aboard.

1. FOLK DIETARY PRACTICES AND ETHNOPHYSIOLOGY OF PREGNANT WOMEN IN RURAL BANGLADESH (Ref. Zakir Hossain & Ahmed F.H. Choudhury, Working Paper 137, January 1987, http://www.isp.msu.edu/WID/papers/subject/health-abstracts.html)

In this study, it is shown that how a factor like traditional belief can modify one’s/community’s health care behavior. It is widely assumed that the improvement of nutrition is determined by economic factors alone. Yet such a perspective fails to explain why pregnant women, regardless of their socioeconomic status, consume less food. In view of the inadequacy of economic models, we propose a culture analysis of the dietary beliefs and behavior of pregnant women of rural Bangladesh. The notion of humoral disposition has been found to be practiced in dietary and health values among rural women. The common referent of the humoral properties lies in the cognition of a "hot" and "cold" dichotomy in relation to the properties of food and body-state. The transition from puberty to pregnancy signifies changes from a relative "cold" body condition to a "hot" state. Pregnant women are viewed as particularly susceptible to variation in hot/cold disposition in body-state. In order to neutralize the undesirable heat and to attain equilibrium, women prefer diets containing elements of coolness. Health is believed to depend upon the careful maintenance of this balance in food habits. The practices originating from this belief system are the delimiting factors of rural women's dietary habits, and therefore should be reckoned with in any effort of directed nutritional change in Bangladesh.

2. Socioeconomic status overrides age and gender in determining health-seeking behaviour in rural Bangladesh.

(Ref. Ahmed SM, Tomson G, Petzold M, Kabir ZN, BRAC Research and Evaluation Division, Bull World Health Organ. 2005 Feb;83(2):109-17. Epub 2005 Feb 24, http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=15744403)

OBJECTIVE: To study the health-seeking behavior of elderly members (aged > 60 years) of households in rural Bangladesh, to ascertain how their behavior differs from that of younger people (aged 20-59 years) living in the same household and to explore the determinants of health-seeking behavior. METHODS: Structured interviews were conducted to elicit information on the health-seeking behavior of household members aged > 20 years. Respondents were asked about major illnesses occurring within 15 days prior to the interview. The sample consisted of 966 households that had at least one resident who was aged > 60 (32% of 3031 households). FINDINGS: The researchers found no major differences in health-seeking behavior between elderly people and younger adults. On average about 35% (405/1169) of those who reported having been ill during the previous 15 days in both age groups chose self-care/self-treatment; for both age groups the most commonly consulted type of provider was a paraprofessional such as a village doctor, a medical assistant or a community health worker. A household's poverty status emerged as a major determinant of health-seeking behavior. The odds ratio (OR) that individuals from poor households would seek treatment from unqualified allopathic practitioners was 0.6 (95% confidence interval (CI) = 0.40-0.78); the odds ratio that individuals from poor households would seek treatment from qualified allopathic practitioners was 0.7 (95% CI = 0.60-0.95). For self-care or self-treatment it was 1.8 (95% CI = 1.43-2.36). Patients' level of education affected whether they avoided self-care/self-treatment and drugstore salespeople (who are usually unlicensed and untrained but who diagnose illnesses and sell medicine) and instead chose a formal allopathic practitioner (OR = 1.5; 95% CI = 1.15-1.96). When a household's poverty status was controlled for, there were no differences in age or gender in terms of health-care expenditure. CONCLUSION: The researcher found that socioeconomic indicators were the single most pervasive determinant of health-seeking behavior among the study population, overriding age and sex, and in case of health-care expenditure, types of illness as well.

3. Changing health-seeking behaviour in Matlab, Bangladesh: do development interventions matter?

Syed Masud Ahmed¹, Alayne M Adams², Mushtaque Chowdhury¹ and Abbas Bhuiya³

It is generally assumed that socioeconomic development interventions for the poor will enhance their material and social capacities to prevent ill health and to seek appropriate and timely care. Using cross-sectional data from surveys undertaken in 1995 and 1999 as part of the BRAC-ICDDR,B Joint Research Project in Matlab, Bangladesh, this paper explores patterns of health-seeking behavior over time, with the hypothesis that exposure to integrated socioeconomic development activities will enhance gender equity in care-seeking and the use of qualified medical care. While there is tentative evidence of greater gender equity in treatment choice among households benefiting from development interventions, a preference for qualified medical care is not apparent. Findings reveal a striking and generalized rise in self-treatment over the 4-year period that is attributed to the economic repercussions of a major flood in 1998, and greater heath awareness due to the density of community health workers in Matlab. Also noteworthy is the substantial reliance on informal and often unqualified practitioners (over 20%) such as pharmacists and itinerant drug sellers. Factors associated with the type of health care sought were identified using logistic regression. Self-care is associated with female gender, the absence of low cost health services and illnesses of relatively short duration. Medical care, on the other hand, is positively predicted by male gender, geographic location, greater socioeconomic status and serious illness of long duration. The paper concludes by emphasizing the importance of enhancing local capacities to determine whether self-treatment is indicated, to self-treat appropriately, or in cases where health care is sought, to judge provider competence and evaluate whether treatment costs are justified. The provision of pharmaceutical training to the full spectrum of health care providers is also recommended.

¹ Research and Evaluation Division, BRAC, Dhaka, Bangladesh
² Department of Population and Family Health, Columbia School of Public Health, New York, USA
³ International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh

(Ref: Health Policy and Planning; 18(3): 306-315, © Oxford University Press 2003, http://heapol.oupjournals.org/cgi/content/abstract/18/3/306)

4. Utilisation of postnatal care in Bangladesh: evidence from a longitudinal study

Nitai Chakraborty¹, M. Ataharul Islam¹, Rafiqul Islam Chowdhury² and Wasimul Bari¹

(Ref. Health & Social Care in the Community, Volume 10 Issue 6 Page 492 - November 2002
doi:10.1046/j.1365-2524.2002.00389.x, http://www.blackwell-synergy.com/links/doi/10.1046/j.1365-2524.2002.00389.x/abs/)

Utilization of health services is a complex behavioral phenomenon. Empirical studies of preventive and curative services in Bangladesh have often showed that the use of health services is related to the availability, quality and cost of services, as well as to social structure, health beliefs and personal characteristics of the users. The present paper attempts to examine factors associated with the utilization of healthcare services during the postnatal period in Bangladesh by using prospective data from a survey on maternal morbidity in Bangladesh, conducted by the Bangladesh Institute of Research for Promotion of Essential and Reproductive Health and Technologies (BIRPERT). Both bivariate and multivariate analyses of the data confirmed that the mother's age at marriage had a significant and positive impact on the utilization of quality healthcare services. The husband's occupation also showed a strong impact on healthcare utilization, indicating higher use of quality care for postpartum morbidity by wives of business and service workers. The bivariate analysis showed that the number of pregnancies prior to the index pregnancy and desired pregnancies are significantly associated with the utilization of postpartum healthcare. However, the results of this study were inconclusive on the influence of other predisposing and enabling factors, such as maternal education, the number of previous pregnancies, the occupation of the husband, antenatal care visits during pregnancy and access to health facilities. Multivariate logistic regression estimates did not show any significant impact of these factors on the use of maternal healthcare.

5. Client satisfaction and quality of health care in rural Bangladesh

Objective: To assess user expectations and degree of client satisfaction and quality of health care provided in rural Bangladesh. Methods: A total of 1913 persons chosen by systematic random sampling were successfully interviewed immediately after having received care in government health facilities. Findings: The most powerful predictor for client satisfaction with the government services was provider behaviour, especially respect and politeness. For patients this aspect was much more important than the technical competence of the provider. Furthermore, a reduction in waiting time (on average to 30 min) was more important to clients than a prolongation of the quite short (from a medical standpoint) consultation time (on average 2 min, 22 sec), with 75% of clients being satisfied. Waiting time, which was about double at outreach services than that at fixed services, was the only element with which users of outreach services were dissatisfied. Conclusions: This study underscores that client satisfaction is determined by the cultural background of the people. It shows the dilemma that, though optimally care should be capable of meeting both medical and psychosocial needs, in reality care that meets all medical needs may fail to meet the client’s emotional or social needs. Conversely, care that meets psychosocial needs may leave the clients medically at risk. It seems important that developing countries promoting client-oriented health services should carry out more in-depth research on the determinants of client satisfaction in the respective culture.

(Ref: ALDANA, Jorge Mendoza, PIECHULEK, Helga and AL-SABIR, Ahmed. Client satisfaction and quality of health care in rural Bangladesh. Bull World Health Organ, 2001, vol.79, no.6, p.512-517. ISSN 0042-9686.)

6. Health seeking behaviour literature review

Project Title: Health seeking behavior literature review
Project Investigators: Sara MacKian

Summary: This review of health seeking behavior outlines the main approaches within the field, and summarizes some of the key findings from recent work. However, it also suggests that health seeking behavior is a somewhat over-utilized and under-theorized tool. Although it remains a valid tool for rapid appraisal of a particular issue at a particular time, it is of little use as it stands to explore the wider relationship between populations and health systems development. If we wish to move the debate into new and more fruitful arenas, this review reaches the conclusion that we need to develop a tool for understanding how populations engage with health systems, rather than using health seeking behavior as a tool for describing how individuals engage with services. This opens up into the broader arena of community organization, social capital and citizenship; of political and non-political pressure points on the system. One way in which we might start to frame the debate is by using social capital and reflexive communities as key theoretical and analytical concepts.

(Ref: Publications: MacKian S, Bedri N and Lovel H. Up the garden path, and over the edge: where might health-seeking behaviour take us?. Health Policy and Planning 19(3): 137-146. 2004)

7. Ethnographic study to explore provider practices in labour wards

Project Title: Ethnographic study to explore provider practices in labour wards
Project Investigators: Loveday Penn-Kekana, Duane Blaauw and Sarah Atkinson.

Summary: This project is the second phase in the programme of work using maternal health services as a health systems probe in South Africa. It follows on from the situational analysis of maternal health services which identified the behavior and practices of front-line providers as a key health systems issue in South Africa. However, this study aims to move beyond the prevailing negative discourses regarding maternal health nurses and recognizes that broader systems and dynamics are important in influencing nursing behavior and practice. The main objective is to understand the reality of everyday nursing practice in a labor ward in a district level hospital. The study will utilize an ethnographic, participant-observation methodology, supported by a detailed literature review, in order to develop a deeper contextual and theoretical understanding of the complex interactions, relationships and organizational dynamics that influence nursing practice in labor wards in South Africa.

(Ref: Penn-Kekana L, Blaauw D and Schneider H. 'It makes me want to run away to Saudi Arabia': management and implementation challenges for public financing reforms from a maternity ward perspective.. Health Policy and Planning 19(1): 171-177. 2004)

Penn-Kekana L. The Case of the HIV Baby with HIV Negative Parents. How nurses in maternity wards deal with HIV/AIDS. In, Afflictions. L'Afrique du sud, de l'apartheid au sida CRESP, Paris.

8. Medical Belief and Village Behavior: Health Seeking Behavior

In Bangladesh, Bhardwaj and Paul (1986) had interviewed families of deceased infants from three rural districts between 1976 and 1983. Over 40% of 375 families did not seek any help to save the lives of their children despite a diversity of medical options with indigenous healers existing parallel to Western allopathic doctors. Many parents did not think their babies were seriously ill even as they were slowly dying from dysentery. Dehydration, the most dangerous sequel of diarrhea was not considered to be associated with diarrhoea nor was it treated as life threatening. Villagers tended to avoid seeking treatment until their children were very ill or had developed a physical disability. At the same time, they were reluctant to expose a very sick child to the outside elements and greatly preferred house calls. Sudden death occurred in 23% of the deaths studied before the families had time to get help. Another 15% considered them too poor to even consult local healers. No help was locally available for 11%. For mild and chronic illness, traditional healers were used and Western medical care was reserved for acute conditions. Treatment was sought earlier when sons became ill rather than daughters. Many of the 375 babies (64%) died from tetanus, followed by death from diarrhoea (15%), respiratory infections (5%), febrile illness (5%) and other causes such as measles. When newborns developed tetanus, most mothers consulted midwives first. So high priority should be given to teaching village "Dais" not to smear the umbilical cord with dung and instructing them regarding the importance of cutting the cord with sterile tools.

(Ref. siteresources.worldbank.org/.../Data%20and%20Reference/ 20206318/Bangladesh_PSA_for_HNP-Full%20report.p)

9. Village Beliefs and Oral Rehydration Programs

Aga Khan University carried out a study on health beliefs and diarrhoea. In 1986, 57 women with small children were interviewed from 35 villages near Vur (a part of the Sind, near the Western tip of India). Out of all these village mothers, only 32 had used oral rehydration mixtures. Unfortunately they had little understanding of how ORT works. The concept of fluid replacement was still unknown. They confused oral rehydration drink with medicine and gave only a few teaspoons a day like they did with tonics and other over-the counter-medications. Childhood diarrhoea was regarded as a part of growing up rather than as an illness to be prevented or cured. Symptoms of dehydration such as "sutt" or shrunken fontanel were not associated with a diarrhoeal illness. As in India and Sri Lanka, 96% of the informants considered diarrhoea as a "hot" condition in the Ayurvedic tradition.

In Northern India more than 50% of 600 mothers interviewed by Gupte and Sasan (1983) associated diarrhoea with teething. In Nepal 75% of the 320 mothers surveyed by Stapleton (1989), blamed infant diarrhoea on teething. During the teething stage of development, babies are entering a high-risk period for enteric diseases because they are more mobile and more likely to be given contaminated food and water. About a third of mothers in both studies also attributed diarrhoea to supernatural causes and included magic in their cure program.

Of course oral rehydration therapy can be used along with mantras, amulets and other folk remedies and ORT is not going to interfere with teething.

(Ref: www.lifescapes.org/Papers/ TechnKnowledge-Coreil%2090.htm)

10. Morbidity and Health-seeking Behavior by Syed Masud Ahmed

The health component of the survey on Socioeconomic and Health profile of Chittagong Hill tracts (CHT) (May-July 1998) solicited information, among others, on household illness occurring within the past 15 days and related health-seeking behavior. About 14% of the sick population did not seek any treatment, the proportion being highest among the Mros (58%). Of those who sought care, majority was treated by the ‘unqualified allopaths’ (40%). The qualified allopaths were consulted in most cases by the Bengalis (27%) and home-remedies by the Mros (64%). The Mros are the most disadvantaged both in terms of access to static health facilities within five kilometers of their house-holds and availability of practitioners of ‘modern’ medicine within their villages.

(Ref: www.phs.ki.se/ihcar/research_ training/seminars_previous.html)

11. Health-seeking Behavior of Mothers and Factors Affecting Infant and Child Mortality of their Children: Evidence from the Bangladesh Demographic and Health Survey 1996-1997 (M. Kabir and Ali Ahmed Howlader)

The birth-history data from the Bangladesh demographic and health survey (BDHS) 1996-1997 were used for this study. In total, 9,127 ever-married women were interviewed to collect complete birth-history data. A logistic regression analysis was done to identify the significant factors that influenced the health-seeking behavior of mothers.

Ninety-five percent of the births were delivered at home, and 57% of these births were attended by the untrained traditional birth attendants, followed by relatives/others (25%). Professional doctors attended only 5% of the births. Less than half of the children were fully immunized. Survivorship was higher among the children born in the proper health facilities and attended by doctors than those born at home attended by untrained dais.

(Ref: Journal 14(1) - Demographers' Notebook: Mothers' Health-Seeking ...www.unescap.org/esid/psis/ population/journal/1999/v14n1dn.htm)

12. Traditional Health Beliefs and Health Seeking Behavior of the People in Huay-Sapad Village Chom-Thong District, Chiang Mai Province

Reported by Prayong Limtragool and another, Department of Public Health Nursing, Faculty of Nursing, Chiang Mai University.

The purposes of this descriptive study were to explore the traditional health beliefs health seeking behaviors, taboos, and ritual of the people in Huay-Sapad village, Chom-thong district, Chiang Mai province.

Samples were the heads of the Karen households and their wives and were obtained by purposive sampling.

The samples believed that spiritual ceremony could relieve bad fortune or abnormal events. Spiritual ceremony and ritual were believed to increase agricultural products and happiness among the family members. There were taboos and rituals to prevent illness for women during pregnancy, labor and delivery, postpartum period and for the newborn babies. They had a cohesive social network for health seeking behavior. Family, relatives and community, all were involved in decision-making regarding the treatment. Methods of treatment for all kinds of sickness were similar. The most common method practiced was spiritual ceremony.

(Ref: http://search.lib.cmu.ac.th/search*tha/d%)

13. Mothers' Health-Seeking Behavior and Infant and Child Mortality in Bangladesh

Mothers' Behavior in seeking health care services, for either preventive or curative purposes, is an important factor in determining child survival through the child's health and nutritional status, as well as through her own health status. The purpose of this paper was to investigate the level of health-seeking Behavior of mothers and to assess how their health-seeking Behavior affected infant and child mortality in Bangladesh. The study also attempted to identify important factors that influence mothers' health-seeking Behavior. The primary aim was to enable the findings to be put to use in helping policy makers in planning appropriate strategies so as to improve the health of this highly vulnerable population group.

(Ref: By Ali Ahmed Howlader and Monir Uddin Bhuiyan^* Asia-Pacific Population Journal, Vol. 14 No. 1 (1999, pp. 59-75)

14. Determining the knowledge and perceptions and health-seeking Behavior of the tribal communities of Keonjhar, Mayurbhanj and Sundargarh regarding chest symptoms (TB), and their sources of information on health and disease

The article has been compiled by Sonal Bhugalia, Tara Kelly, Stephanie Van De Keift, Maragaret Young and edited by Charles Kemp

Tuberculosis claims one life per minute in India. The Revised National Tuberculosis Control Program (RNTCP), based on the five-point Directly Observed Treatment, Short-course (DOTS) strategy, is being implemented in India since 1993 to combat this disease.

In Orissa, the Program has been supported by DANTB since the end of 1996, and with an aim to cover 14 tribal districts within a five-year period. Project support includes the development of infrastructure, ensuring regular drug supply, development of effective communication tools, supervised treatment by trained personnel, strengthening the review and monitoring mechanism and health systems research.

While working on ways to strengthen the service aspects of the Program, DANTB found that there is little documentation of tribal people's knowledge and perceptions of tuberculosis and their health-seeking Behavior. This is compounded by the fact that a variety of private practitioners of different systems of medicines (allopathic, homeopathic and ayurvedic), traditional healers and NGOs are also providing health care to large segments of the population. DANTB commissioned AIMS Research to conduct a study in the three districts of Keonjhar, Mayurbhanj and Sundargarh, with a view to using the information obtained in planning IEC (information, education and communication) activities, and to provide a clear focus to Program activities to meet the needs of the tribal population.

The overall objective of the study was to determine the knowledge and perceptions and health-seeking Behavior of the tribal communities of Keonjhar, Mayurbhanj and Sundargarh regarding chest symptoms (TB), and their sources of information on health and disease and preference of treatment.

(Ref: www.dantb.org/publictn/puhsbtes.html)

15. Indian Health Care Beliefs and Practices (Traditional Beliefs and Natural Remedies)

The report has been compiled by Sonal Bhugalia, Tara Kelly, Stephanie Van De Keift, Margaret Young and edited by Charles Kemp.

The Indian system of medicine is known as Ayurveda, which means "knowledge of life". Indian medicine mixes religion with secular medicine, and involves observation of the patient as well as the patient’s natural environment. More than eighty-percent of people in India rely on herbal remedies as the principal means of preventing and curing illnesses.

According to Charka, a noted practitioner of Ayurveda in ancient India, "A physician who fails to enter the body of a patient with the lamp of knowledge and understanding cannot treat diseases. He should first study all the factors, including the environment, which influences a patient’s disease, and then prescribe treatment. It is more important to prevent the occurrence of disease than to seek a cure."

According to Ayurveda, the body is comprised of three primary forces, termed dosha. The state of equilibrium between the dosha is perceived as a state of health; the state of imbalance is disease. Upon examination, the Ayurvedic physician finds out the position of the three dosha (Tridosha). Once the aggravated or unbalanced dosha is known, it is brought into balance by using different kinds of therapies. The three dosha are called Vata, Pitta, and Kapha. Each dosha represents characteristics derived from the five elements of space, air, fire, water, and earth and represents certain bodily activities. Vata is responsible for breathing, brain activity, circulation, and excretion. People whose constitution is predominantly Vata , tend to be thin, quick thinking, with swift action. In imbalance state they become nervous, anxious, constipated, and insomniac. Pitta is responsible for vision, digestion, hunger, thirst, and regulation of body heat and temperature. When in balance, people whose constitution is predominantly Pitta are intelligent, disciplined, sharp, and contented. When in imbalance they are intolerant to heat, become bald, show short temper, anger and lust; and are prone to heartburn and ulcers. Kapha represents solid structure of the body and lubricating mucous. Kapha types have strong, well-developed bodies, with the tendency not to gain weight, and are mentally cool. When in imbalance they are obese, disorganized, and sloppy; and develop allergies with dull activity, speech, and behavior.

(Ref: www3.baylor.edu/~Charles_Kemp/indian_health.htm)

16. Women's Beliefs about Disease and Health

Gupta, A., Choudhury, B.R., Balachandran, I., et al

Kali for Women. 1997. P. 66-91. ISBN: 81-85107-85-8

In a vast, multi-ethnic, multi-religious country like India, it is to be expected to have several world-views operating at the same time in people's search for health and healing. The perspectives that have dominated and permeated countrywide have been, of course, Ayurveda, Siddha, Unani and Tibetan medical systems. Modern medicine has been a late entrant, and primarily because of colonial patronage, and now state patronage, it appears to be edging out other indigenous traditions. For the common people in India, each local health tradition is a strategy of making sense out of illness 'disease and life in the context of a given social heritage. For a woman, especially, the act of giving meaning to episodes of illness and disease is part of her essential strategy for survival. These meanings have taken shape as folkore and myths, as beliefs and rituals, and as stories and local history. The sheer variety of these meanings and meaning-imbuing exercises is mind-boggling. This study was attempted towards giving a flavor of the cultural abundance of India. The study mostly explored the situation of women's health in the communities namely:

Dalits, Shaiva Reddys, Lambadis, Kaka Muslims in Chick-maglur, Karnataka

Dalit Christians, other backward communities and Muslims in Zaheerabad, Medak district, Andhra Pradesh

Bhil tribals and other backward castes in Panchmahals, Gujarat

Khol tribals of Banda and Dalits and Gujjars of Saharanpur, Uttar Pradesh

Balais, Nais, Muslims and other communities from Dewas district, Madhya Pradesh,

The research also unveiled various kinds of treatment modes as well as healers who practiced either medicinal healing or spiritual healing or a mixture of both.

In almost every village of the regions where the study was done, there were local gods and goddesses who would reward, punish, and cause floods, droughts, chicken pox, measles and other human misery. Most local people of either gender are beholden to their local gods and goddesses for both their prosperity and adversity. Common diseases are thought to be the wrath of certain gods. The healers of Panchmahals believe that gods can obstruct a person's health with their wrath, while goddesses heal and protect the village and the community; Shakambari is their goddess of healing. For example, in Andhra Pradesh., Poshama and Yellema are local goddesses who protect the village from infectious diseases like chickenpox, measles, etc., but these goddesses are worshipped only by the Dalits and lower castes.

The relationship between physical and mental health is extended to account for gynecological problems. Women feel that problems like white discharge, infertility, low back pain, headache, weakness, heavy menstrual bleeding etc., are more likely to occur among women who are unhappy in their marriage due to ill- treatment or lack of affection on the part of the husband. However, a chronic problem is usually attributed to the evil eye, or evil spirit.

To drive away the evil eye, dishti (Telugu) or nazar utarna (Hindi, Urdu), varying rites are performed in different regions. For instance, in South India and parts of Uttar.Pradesh., red chilies, mustard seeds, salt and a piece of a broomstick are rotated 21 times around the 'afflicted' woman, passed under her left leg and thrown into the fire. If there is no burning smell then it is confirmed that she was affected by the evil eye. In Kerala too, tantric-mantric healers are quite popular. They are known by different names. Velicchapadu, a man representing the local deity, treats disease as well as removes evil curses that befall a family. Flowers offered to the deity are thrown on the afflicted as a remedy. Use is also made of talismans made of copper, silver or gold foil inscribed with tantric drawings and mantras, sanctified by poojas and worn around the arm or waist. To heal a person suffering from disease or mental imbalance, a length of thread consecrated by mantras is worn by the afflicted person. Drinking water sanctified by mantras spoken into it, burning palm leaves on which mantras are inscribed, application of oil sanctified by mantras or blowing over the affected part after reciting mantras are some of the methods used to treat physical and mental afflictions. Sometimes these practices are reinforced by chewing particular herbs.

To exorcise evil spirits a more elaborate process may be required, such as visiting a shrine of a Sufi or Muslim saint, going on a jatra (religious travel or pilgrimage) to visit a baba or maharaj possessed by a devi or pari (spirit of a good person), performing ritual baths (nahni) or visiting a tantric. These shrines are usually secular and reflect how secular traditions have existed all along and how people entrusted their bodies to saints and sufis for healing and curing. The healing work of the traditional healers is a part of this belief system and consists of appeasing and befriending the evil spirit. In a sense, this approach is essentially Jungian-individuation, through acceptance of the shadow self.

17. Reproductive Health Behavior of the Nocte Women in Arunachal Pradesh

(Ref: R. K. Kar, Social Change. December, l993. 23(4).p.40-52.)

Tribal populations have distinctive problems, not because they have special kind of health, but because of special placement in difficult areas and the circumstances in which they live. This study was a qualitative appraisal of some relevant aspects of reproductive health behavior of Nocte women through a look at their social structure, culture, food habit, morbidity and traditional health-seeking behavior. Data were collected from Deomali, Namsang and Soha areas in the Changland district in Arunachal Pradesh during 1991-92. While accumulating the data standard anthropological methods were used in the field. Qualitative aspects have been relatively more emphasized as compared to the quantitative ones.

The Noctes are an important tribe of Arunachal Pradesh. According to 1991 census their total population is 22483 (Men-11177, Women11306). The people are distributed over the Tirap river valley, which includes the Tirap and Changlang districts of the State. The Noctes are considered as a branch of the Naga groups, and in racial features they belong to the mongoloid stock.

They are patrilineal, patriarchal and patrilocal. The society is organized under Chiefs, each controlling a number of villages, and their major chief receives tributes from the subordinate villages. The main source of livelihood of the people is cultivation. They practice shifting as well as wet cultivation

'Health' and 'disease' seem to be considered as Polar words by these People. Disease refers to "a departure from the state of health" and health is the 'absence' of disease. For most of the diseases, the people generally avail of the traditional medicare system. Majority of the sickness and ailments are considered to be caused by the influences of evil spirits. It is also believed that almost all sorts of sickness can be averted and all diseases can be cured by appeasing the relevant spirits responsible for causing them. For most of the ailments recovery depends upon finding out the cause of illness, which generally is done by divination by the priest/medicine man. If it is not caused by supernatural forces then herbal, animal or mineral, medicines are given.

With regard to their awareness and receiving modern medical facilities, it was found that the elderly people by and large are averse to modern medical treatment. This is however, a ground reality that in certain areas, the facilities for modem medical treatment are not available in the neighborhood of 15 to 20 km. But, even in the areas where these are available, it has been found that only the educated youths, particularly the girls take relatively more initiative to take the patients to the centers of treatment.

Further, it has been observed and also corroborated by the medical practitioners in the area that the living conditions of the people are responsible for the majority of the diseases. Thus, for example, gross lack of personal cleanliness, sanitation, potable water, provision of minimum light and ventilation in the house are responsible for the occurrence of a number of diseases. Thus, for example, there seem to be positive correlations between respiratory problems and conjunctivitis and lack of light and ventilation in the houses; diarrhea and impurity of water and lack of cleanliness; skin disease and lack of personal cleanliness; and unsanitary habits and occurrence of worms. Similarly, correlations may be drawn between excessive intake of liquor and gastritis, and repeated pregnancy and anemia in women.

A Nocte woman is believed to be healthy (sukasasen) if she has the ability of bearing a healthy and normal child. A woman is considered to be a healthy one when she can give birth to five to six children. A child is considered by the people to be the gift of God (Jauban). They believe that a woman conceives only by the blessings of God. But, a male child is preferred to a girl as it increases the manpower. During the period of pregnancy, an expectant mother observes certain taboos relating to food and movements.

From conception to delivery the people by and large do not have any idea of medical check-up. They do not seem to be very much concerned about the necessity of some special care of the mother's health. Pregnancy is considered as a natural phenomenon. An expectant Nocte mother is not given any special food. It is the same as the other members of the family. But, she is generally given whatever she wants to eat. However, she has to observe certain taboos relating to food. She should not take the meat of eel (gnapo), tortoise (Khokhap), and crab (chan) etc. They believe that if a pregnant mother eats these items, she may suffer from severe pain during the time of delivery. She is also not allowed to take kham (home brewed liquor) because it may cause miscarriage. They further believe that if expectant mother takes egg, the baby shows a delayed lisping. Meat of the sacrificed animals is taboo. Meat of a deer carrying a baby is also not taken. Though the people could not report anything explicit as to the logic of cultural prohibition and prescription of food during pregnancy, it seems, the food that are believed to be hot are avoided. Intake of these items is supposed to affect both the mother and the unborn child in different ways and degrees.

(Ref: http://www.gendwaar.gen.in/sawsg/text/articles/List%20of%20Bibliography/healthBehavior-list.htm)

18. Cultural Beliefs and Practices Affecting the Utilisation of Health Services During Pregnancy

Sarita Manocha, CTC (ICDS) R.K. Puram, New Delhi , Aneeta A. Manocha Department of Sociology, Delhi University, Delhi , Dharam Vir, Meerut University, Meerut

The present study was carried out to study the beliefs, actual dietary intake of pregnant women and ante-natal care in three villages of Haryana in India. Dietary intake was found to be maximum in village covered by ICDS. Utilisation of health services was affected by availability of health centres in the premises of village, availability of staff, awareness about the existing health services and patient's satisfaction.

In India, girls are married off at a young age, sometimes as low as 9-11 years. It is note-worthy that about 43% of all female deaths are of girls between fifteen and twenty years of age and the causes of maternal mortality are pregnancy complications, early pregnancy, abortion, deaths due to bleeding anaemia etc. Early marriage, early conception, negligible antenatal care, general negligence of women and low social status, all lead to increased mortality rates.

The study was designed with following objectives:

To find out the age at marriage and age at first conception.

To study the dietary practices prevailing in the area.

To calculate the dietary intake during pregnancy.

To study the kind of antenatal care the pregnant woman is getting and

To explore the rituals taking place during this period.

Information on the age at first conception was collected from the respondents by asking them when they conceived first after Gauna. Local language was used to draw this information 24 hours recall method was used to collect the information on dietary intake

The study was was carried out in three villages of Haryana, namely Aurangabad, Mitrol Kalsara. Village Aurgangabad is vested with a PHC (Primary Health Centre) and caters health services to village Mitrol too. In village Kalsara, there is a subcentre and it is covered by ICDS (Integrated Child Development Services) block Hathin. Lactating women with second pregnancy were taken as the subjects of the study. Primipara women were not included in the study. In village Kalsara and Mitrol all houses were visited to get the subjects, whereas in village Aurangabad, which is a big one, every alternate house was visited. In village Aurangabad and Kaisara 50 each and in village Mitrol, 52 subjects were selected. A detailed pretested schedule was prepared to get the information.

Women were found to be very casual about their food intakes. They were not conscious about eating additional food during pregnancy. Jat women in three villages have been observed drinking milk varying between 250-750 gms/day which is an adequate amount during pregnancy. The same amount is taken when they are not pregnant. The main reason behind the milk consumption is that Jats own cattle and milk is generally not sold. Intentionally reduced dietary intake during pregnancy was observed in some households, the reason for less food intake being ascribed to the fear of big fetus, causing obstruction and pain during delivery.

All the ante-natal care in these villages is in the form of rituals directed towards a handsome, healthy male child. Care of the ante-natal women has medical implications e.g. restrictions regarding eating certain foods and avoiding others, have medical implications. Medical care during childbirth is obtained from the traditional dai or ANM or doctor. In village Aurangabad, where there is a PHC, nearly 50% women had gone for ante- natal checkup, whereas in village Mitrol, 27% had gone. In village Kalsara, where there is 84% had gone for ante-natal checkup.

There is a general practice that immediately after the delivery some doctor (as named by the villagers) is called at home and both the mother and child are given Tetanus Toxoid (TT). Even if the mother has taken complete dose of TT, she may be given another shot after delivery. Though ANM may advise them not to go for third shot yet they wont follow her advice. All the elderly ladies have been found to believe that tetanus toxoid given just after delivery is more effective, otherwise child may get tetanus. In village Mitrol , it is customary to get tetanus toxoid immunization just after delivery and not before. This is the reason that neonatal mortality due to tetanus is significantly high as compared to village Aurangabad and Kalsara.

There is a need to ante-natal care and immunization against tetanus. Ante-natal check up coverage was maximum in village Kalsara because of constant motivation by AWW (anaganwadi worker)s and ANMs (auxillry nurse midwife) which highlights the importance of grassroots level health workers in promoting health.

(Ref: Journal of the Indian Anthropological Society. July 1992. 27(2).p.181-185)

19. Beliefs and Practices of Antenatal Mothers in a Rural Setting

Every society has its own traditional beliefs and practices related to health care. Beliefs in supernatural powers, i.e. God, beliefs in holy rituals, salvation, offerings and sacrifices are applied at different stages of life from birth to death. Pregnancy in the case of a woman is a very vital event. Therefore, there are many such practices; rituals, beliefs and offerings which are meant to protect a mother from influences of evil spirits and supernatural powers. People have taken pleasure in using traditional beliefs and practices for a long time and got used to it. Thus it can be made easily acceptable something that has been given by the faith healer to the community. Few practices are effective whereas others may be harmful or ineffective. These beliefs and practices are linked to culture, environment and education. Health workers must have concern for the community's cultural values and beliefs so that they can utilize the harmless practices for effective use as well as eliminate harmful practices.

This study was conducted among mothers who had children from birth to three years or were currently pregnant. This village is very small with a population of only 212. For the survey 12 mothers were selected from that village. The study was aimed:

To know the utilization of health care facilities during antenatal period, specially health check-up, immunization and diet.

To find out the prevalence of performance of religious ceremonies during pregnancy

To find out beliefs and practices and superstitions related to pregnancy.

Twelve mothers were interviewed with respect to antenatal care, diet during pregnancy, socio-religious functions, beliefs and practices during antenatal period by a door-to-door survey. This survey revealed that in this rural community most of the mothers had a low educational standard and belonged to low socioeconomic groups. The maximum number of mothers got married in early age and many mothers had got more than three pregnancies. Six mothers recognised that addition of foodstuff was required in this period but six mothers did not recognise that. Co-existence between traditional beliefs and dependency on health services were found in that community. Mothers utilized sub-centre services like check-up and immunization. Gradually, their attention has to be diverted towards scientific practices.

Saddah ceremony can be utilized for introduction of additional food throughout the pregnancy and this practice should be the focus of the health education on antenatal diet. If various types of food are continued for the whole pregnancy period it will give a significant value to the health of the mother and baby.

(Ref: A survey by students of Diploma in Community Health Nursing, The Nursing Journal of India. Jan 1995. 86(1).p.4-6)

20. Breast-Feeding and Weaning Practices - A Rural Study in Uttar Pradesh

Ms. N. Bhardwaj, MR S. Badrul Hasan, and MR Mohammad Zaheer

Breast-feeding is an unequalled way of providing ideal food for the healthy growth and development of all normal infants. This shows the importance of good nutrition during lactation. The first milk or colostrums is of particular value to the infant given its high content of proteins and fat-soluble vitamins, and its anti-infective properties. It is the infant's first immunizations. However, many rural folk discard this precious material. Ideally, exclusive breast-feeding should be the norm for the first 4-6 months of life and homemade soft foods should then be added to the infant's diet. This study was undertaken to explore breast-feeding and weaning practices in a rural setting in north India with a view to strengthen breast-feeding and infant feeding practices for improving the health of infants.

The study was conducted in four randomly selected villages of Jawan Block, District Aligarh in Western Uttar Pradesh from May 1987 to April 1989. From these villages, a total of 212 pregnant women in the last trimester were registered for the study. The women were contacted at their respective homes, and advice regarding breast-feeding practices and the benefits of colostrum feeding was given during the first contact. The importance of weaning after four to six months of breast-feeding was also explained to all the women.

They were subsequently followed up at monthly intervals for a period of two years. Two visits in the week immediately after the delivery of the newborn were mandatory so as to record the right time for the commencement of breast feeding and to know whether the colostrums was being fed to the newborn or not.

The majority of the 212 women (96.7 per cent) were Hindu; the rest (3.3 per cent) being Muslim. They were almost equally distributed among the three caste groups namely, high caste-33.5 percent, backward caste-30.2 per cent, and schedule caste-36.3 per cent. Significantly, approximately 93 per cent were illiterate. The literacy rate of 7.1 per cent found in the present study was much lower than the national average for females (17.9 per cent) in rural areas and 14 per cent in Uttar Pradesh. All the women were housewives. Going out to the fields for work was their only outdoor activity.

The study recommended the need for efforts to protect, promote and support the already existing practice of breast-feeding specially through the health services in rural areas. Improvement in nutrition during pregnancy and during lactation should be one of the aims of the services offered at the village level. Nutrition education to help mothers to wean their children at the proper time with locally available cheap foods should be encouraged. The cornerstone of any public health nutrition program for the prevention of childhood malnutrition must be the need to promote an optimal lactation pattern in the community.

(Ref: Bhardwaj, N.; Hasan, Badrul S.; Zaheer, Mohammad.: Breast-Feeding and Weaning Practices- A Rural Study in Uttar Pradesh. The Journal of Family Welfare. March 1991. 39(1).p.23-29.)

21. Beliefs And Practices about Food During Pregnancy: Implications for Maternal Nutrition

(Ref: Moni Nag, Economic and Political Weekly. Sept 10, 1994. P.2427-2438).

The present study was carried out to study the beliefs, actual dietary intake of pregnant women and ante-natal care in three villages of Haryana in India. Dietary intake was found to be better in village covered by ICDS (integrated child development service) than those not having ICDS facility. Utilisation of health services was affected by availability of health centres in the premises of village, availability of staff, awareness about the existing health services and patient's satisfaction.

As in many other countries, there are traditional beliefs in India regarding specific food items a pregnant woman should or should not eat during pregnancy and about the proper amount of food desirable for a pregnant woman for successful reproductive outcome.

The mentioned study conducted a review of the evidence available from community or hospital studies regarding these beliefs as well as the reasons reported for these beliefs and the extent to which these are reflected in their food behavior. Programmatic implications of the findings were also discussed.

(Ref: Economic and Political Weekly. Sept 10, 1994. P.2427-2438)

c) Summary of the literature review:

"A physician who fails to enter the body of a patient with the lamp of knowledge and understanding cannot treat diseases. He should first study all the factors, including the environment, which influences a patient’s disease, and then prescribe treatment. It is more important to prevent the occurrence of disease than to seek a cure."-Charka, noted practitioner of Ayurveda in ancient India

In the literature review, it was found that socioeconomic status overrides age and gender in determining health-seeking behavior in rural Bangladesh and may be many countries. So, factors associated with socioeconomic status have proven influences on the health care behaviors. Health care behavior like self-care was seen associated with female gender, the absence of low cost health services and illnesses of relatively short duration. Medical care, on the other hand, was positively predicted by male gender, geographic location, greater socioeconomic status and serious illness of long duration as was seen in BRAC-ICDDR, B intervention in Matlab. Utilization of health services is a complex behavioral phenomenon. Empirical studies of preventive and curative services in Bangladesh have often showed that the use of health services is related to the availability, quality and cost of services, as well as to social structure, health beliefs and personal characteristics of the users as seen in the study, conducted by the Bangladesh Institute of Research for Promotion of Essential and Reproductive Health and Technologies (BIRPERT).

These were found to be the plain truths behind the health care behaviors of a population and came out with the review of the literatures.

The studies also underscored that client satisfaction was determined by the cultural background of the people at least to some extents. It shows the dilemma that, though optimally care should be capable of meeting both medical and psychosocial needs, in reality care that meets all medical needs may fail to meet the client’s emotional or social needs. Conversely, care that meets psychosocial needs may leave the clients medically at risk. It seems important that developing countries promoting client-oriented health services should carry out more in-depth research on the determinants of client satisfaction in the respective culture.

Also it could be understood that the review of health seeking behavior outlines the main approaches within the field, and summarizes some of the key findings from recent works. However, it also suggests that health seeking behavior is a somewhat over-utilized and under-theorized tool. Although it remains a valid tool for rapid appraisal of a particular issue at a particular time, it is of little use as it stands to explore the wider relationship between populations and health systems development. If we wish to move the debate into new and more fruitful arenas, this review reaches the conclusion that we need to develop a tool for understanding how populations engage with health systems, rather than using health seeking behavior as a tool for describing how individuals engage with services. This opens up into the broader arena of community organization, social capital and citizenship; of political and non-political pressure points on the system. One way in which we might start to frame the debate is by using social capital and reflexive communities as key theoretical and analytical concepts ( MacKian S, Bedri N and Lovel H. Up the garden path, and over the edge: where might health-seeking behaviour take us?.).

In the South African study, we see the factors influencing the caretaker behaviors (Nurses).

In the study in Bangladesh by Bhardwaj and Paul (1986) showed over 40% of 375 families did not seek any help to save the lives of their children despite a diversity of medical options with indigenous healers existing parallel to Western allopathic doctors. How it happened? Lack of knowledge and cultural barriers were influencing their health seeking behaviors!

Aga Khan University carried out a study on health beliefs and diarrhoea in 1986 where we saw how the traditional beliefs were influencing the Oral Re-hydration Therapy (ORT). We found there that they blamed Oral Re-hydration Salt Solution for the delaying in teething!

The health component of the survey on Socioeconomic and Health profile of Chittagong Hill tracts (CHT) in Bangladesh (May-July 1998) solicited information, among others, on household illness occurring within the past 15 days and related health-seeking behavior. About 14% of the sick population did not seek any treatment, the proportion being highest among the Mros (58%).

The reasons found here are the traditional beliefs, culture, economic condition and the education. Also the information lack is the salient feature for their non-seeking of health care.

According to Charka, a noted practitioner of Ayurveda in ancient India, "A physician who fails to enter the body of a patient with the lamp of knowledge and understanding cannot treat diseases. He should first study all the factors, including the environment, which influences a patient’s disease, and then prescribe treatment. It is more important to prevent the occurrence of disease than to seek a cure."

In the study of traditional health beliefs and health seeking behavior of the people in Huay-Sapad Village Chom-Thong District, Chiang Mai Province of Thailand it is evident that among the Karen population (the population groups in the northern Burma and Thailand) there are traditional beliefs that spiritual ceremonies can protect one from the misfortunes and troubles. This finding again recalls the importance of the traditional beliefs influencing the health care behaviors as they perceive etiologies according to the beliefs and seek health as per the etiologies.

In the study titled "Mothers' Health-Seeking Behavior and Infant and Child Mortality in Bangladesh", we see that mothers’ health care behavior affect the children and thus very important factor determining children health. In the Indian study regarding the Ayurveda, related factors were emphasized. In the study "Women's Beliefs about Disease and Health" it is evident that folklore and myths, as beliefs and rituals, and as stories and local history were derived from the "meanings" and became factors for the health care behavior" of the women. In almost every village of the regions where the study was done, there were local gods and goddesses who would reward, punish, and cause floods, droughts, chicken pox, measles and other human misery. Most local people of either gender are beholden to their local gods and goddesses for both their prosperity and adversity. Common diseases are thought to be the wrath of certain gods. The healers of Panchmahals believe that gods can obstruct a person's health with their wrath, while goddesses heal and protect the village and the community; Shakambari is their goddess of healing. For example, in Andhra Pradesh., Poshama and Yellema are local goddesses who protect the village from infectious diseases like chickenpox, measles, etc., but these goddesses are worshipped only by the Dalits and lower castes.

In the study "Reproductive Health Behavior of the Nocte Women in Arunachal Pradesh", it is seen that social structure, culture, food habit, morbidity and traditional health-seeking behavior are all interrelated. Majority of the sickness and ailments are considered to be caused by the influences of evil spirits. It is also believed that almost all sorts of sickness can be averted and all diseases can be cured by appeasing the relevant spirits responsible for causing them. For most of the ailments recovery depends upon finding out the cause of illness, which generally is done by divination by the priest/medicine man. If it is not caused by supernatural forces then herbal, animal or mineral, medicines are given.

In the study "Beliefs and Practices of Antenatal Mothers in a Rural Setting" what we saw, every society has its own traditional beliefs and practices related to health care. Beliefs in supernatural powers, i.e. God, beliefs in holy rituals, salvation, offerings and sacrifices are applied at different stages of life from birth to death. Pregnancy in the case of a woman is a very vital event. Therefore, there are many such practices; rituals, beliefs and offerings which are meant to protect a mother from influences of evil spirits and supernatural powers. People have taken pleasure in using traditional beliefs and practices for a long time and got used to it.

In the way, we can conclude the followings from the literature reviews:

i) There are certain factors (socioeconomic and cultural) related to the health care behavior of an individual as they influence the mind and generate the attitude (psychosocial factors)

ii) Health care behavior can be investigated to understand the relation with the existing factors

iii) The factors have variable influences on the health care behaviors of an individual and not all the factors have influences on every individual.

d) Objectives of the study:

The objectives of the study were:

1. To explore the health care behavior of the rural people under Rajshahi Division through investigation of their existing knowledge, attitude and practices in the health context and understanding their relations with different social, cultural and economic factors, values, beliefs and practices etc. prevailing among the rural population under Rajshahi Division those influence the individual’s mind for shaping the health care behavior.

2. To investigate the disease trends, home management, extents of traditional and home management, source of information, traditional remedies and their relation with different social, economic and cultural factors etc. among the rural population under Rajshahi Division.

3. To understand the extents to which different social factors like economic status, literacy rate, religion, profession, health status, and distances from hospitals, gender, associated stigma etc. affect individual’s health seeking towards the health service providers.

4. To assess the knowledge, attitude, perception and practice levels of rural population under Rajshahi Division towards etiology, course and management of common diseases. To assess their preferences, satisfactions and role of the different service providers and their service extents.

5. To have an understanding of the social cohesiveness and emotional environment existing between the service providers and the recipients.

e) Rationale of the study:

i) Despite increased focus on medical and epidemiological aspects of health and disease, researches on psychosocial and behavioral factors were not adequately addressed.

ii) Findings of the study are expected to help health service planners for their designing of appropriate service delivery system for the rural population. Social, cultural, economic and other factors revealed in the study may be of help for the policy makers and NGOs for advocacy.

The information revealed by the study would help us to design a cost effective welfare health service for rural Bangladesh by valuing their indigenous and traditional beliefs and values.

iii) The study would fill up the knowledge gaps regarding the views from the communities, so that the knowledge can be used in future planning of rural health system and in other researches.

iv) The study would also prescribe the idea how health care services can be better and effectively extended among the rural poor within our limitations as well as indicating how health professionals can improve the present environments in the service facilities.

Scientific and public attention to issues concerning psychosocial determinants of health has intensified in recent years. Despite increased focus on medical and epidemiological aspects of health and disease, research has not adequately addressed psychosocial and behavioral factors that contribute to health status particularly in the developing countries. The present study is intended to addresses that gap.

Research findings and the research substrates of the present study are expected to play a decisive role for the top-level health service delivery planners for their contributions for the rural poor. They would better understand their psychological formations/preparedness for seeking health care services in the rural areas. A study aiming at identifying and isolating the socio-cultural, psycho-social, economic and institutional determinants and chronologies including the other prevailing factors in the rural Bangladesh that act as barriers, are of vital need for bringing necessary changes in the policy or strategy by the policy making bodies and for the advocacy programs for the concerned NGOs for serving the health needs of the rural poor in a country like Bangladesh. Although the primary focus is on research relating to health care behavior, it would also provide valuable insights for health educational and policy priorities that intersect with the research objective. The study would hopefully show the track for the trackers for compilation, organization and constitute a cost effective welfare health service delivery system for the deprived millions in rural Bangladesh blending the flavor of their own, indigenous and traditional beliefs and values. The study would fill up the knowledge gaps regarding what precisely the communities have been thinking and perceiving under the sleeve of their health care behavior. It would also explore the knowledge associated with their responses in different health ailments and diseases. In brief, this study would enable the concerned quarters for their future endeavors for formulation of strategic health delivery system for the rural poor in Bangladesh. The study would also prescribe the idea how health care services can be better and effectively extended among the rural poor within the limitations of the national economy as well as it would indicate how health professionals can improve the present service rendering environment in the hospitals, clinics and health service delivery outlets through their manifold limited opportunities otherwise.

f) Significance of the Study

Significance of the study would be an exploration, tracking and studying the health care behavior of rural people for unveiling the real situations, truths, problems and the scenarios that can guide us to solve many problems in the health sectors, especially towards developing a strategic health service delivery system for Bangladesh emphasizing optimal health service delivery to the vast rural population. Frequent experimentations are not suitable for a country like Bangladesh.

In addition, her capacity for spending money is much lower than the rich countries (has the capacity of $ 4 to $ 7 per capita to spend for health according to "the Fifth Five Year Plan: 1997-2002" by Planning Commission, Ministry of Planning, Government of people’s Republic of Bangladesh"). So, effective planning and execution in the organization and service delivery in the minimal costs to ensure most effective health service delivery for each citizen is vital to us. To realise such goal, we need to devise the way of health service organization and service delivery system keeping close resemblance to the traditional thinking, practice and behavior of the common people as well as to incorporate them in the total process for community based actions. A (health) program would have its intrinsic pacemaker (community initiative) in the community if it enjoys the popular support and the popular support is again the result of the involvement of the people in their own health system organization and delivery. When community based intrinsic action has been made available for a (health) program, it would have desired sustainability.

For such result in the health service organization and service delivery, studying the health care behavior is imperative. The huge unveiled and revealed truth, situations, problems etc. in such behavior study would provide substantial contribution towards constituting an effective health service organization and delivery system in the minimal cost for the population groups in Bangladesh and they are more likely to accept it as it is only the modified version of their own traditions for their betterment.

Now days, Behavioral Change Communication (BCC) is an emerging vital concept in the different development sectors including the health arena. Study of the health behavior would enable the high-level policy makers, managers and the related quarters to use the lessons learnt for their initiatives in the future.

More over, presently, the urban people have access to many of the modern facilities including those of the health services; they are also more educated and aware, living in the limelight of the consciousness of the state. Therefore, they are more flexible to adopt recent scientific breakthroughs available in their hands. They are also affluent and more income earning in most cases. In addition, the Government and NGOs have been investing more in the urban area for mitigating their problems and miseries than the rural.

The majority of the population groups in Bangladesh live in the rural area. But unfortunately many issues and problems of these rural populations have not been duly addressed till date with the intelligentsia and scientific procedures available in country. Therefore, the study of the health care behavior of the rural population of Bangladesh would perform a thorough study of the health care practices of the rural population and would reveal and unveil many fact sheets of its social, cultural and religious draw backs and associated political and economical aspects and also would explore the potentialities for further intervention. Illuminating the factors that constitute the psychological basis of such variations in health behavior among the rural Bangladeshi people would also enable the stakeholders and policy makers to understand their problems better and pave the path to incorporate them in the future programs in the health sectors, thus ensuring success of the programs with effective social or community participations in the community interfaces.

As we know, social and psychological experiences that are significantly related to health outcomes are important components of any research relating to health behavior. The interactions between health conditions and socio-cultural factors predisposing to the psychological getups for health care behavior and the organization of health services are the central concerns of health-care behavior studies.

Main quest/challenge of the study:

The main quest of the study is to explore, identify and pinpoint the multiple and interwoven social/cultural/religious etc. factors associated with the prevailing behavioral patterns of the Bangladeshi rural populations towards their health care behavior. These would unveil their nature of responses to health issues and the degree of the influences of the traditional beliefs, social customs and manners etc. for modifications in those responses. In plain, the main quest and challenge of the researcher is to establish these determinants or factors, dissociating out them from their normal day-to-day life. Theses are the elements integrated and intermingled inextricably with the normal day-to-day life of the rural Bangladeshi population, which are very difficult to be identified and crystallized separately for their prevailing mode of conjugation with day-to-day life. The main challenge lies here, to isolate them as separate entities requiring highly skilful qualitative research methodology. The prevailing "naturals" of these mass behaviors are to be investigated for fixing possibilities of an influence, modification or resultant of some other near, remote or distant factors that are embedded in the culture or traditional beliefs in the society. Main quest is to bring them into the limelight for further research that would act as the starting point for various health-promoting program to allay the health sufferings of the deprived millions in the rural Bangladeshi.

Importance of the study /policy makers/donors interest in the study

Policy makers and donors’ interest in the study are as follows:

i) The study have importance as it was capable of unveiling factors associated with diversified ranges of health care behavior among the rural Bangladeshi population and the relation with the traditional beliefs, social, cultural and religious customs and manners. If those factors can be explored and documented, the donors can understand the points of interventions with ease and can do their best for utilization of their money.

ii) Information derived from the present study would enable national and local level policy makers to design, compile and execute appropriate programs to establish a cost effective and people oriented health service delivery system.

iii) Donors or "development partners" of Bangladesh, the westerns now days want their money to be spent in a participatory manner, i.e. with people’s participation. This study recorded the voices of the field, thus satisfies most of the requirements of the international donor community. As a result, it can be expected that donors will be interested in the present study for considering its findings/recommendations for their programs.

f) Scope of the research

Boundaries of the present study include:

In-depth interviews and direct observations have been adopted as the methods for the following coverage of areas:

The study covers representative sample of the rural population under Rajshahi Division for in-depth investigation of their psychosocial factors including the cultural norms, values, practices and traditional beliefs, especially for those influencing their health care behavior as a whole.

The study covers investigation of different health care behaviors among the rural population in Rajshahi Division for their relations with number of social factors influencing individuals mind to adopt those.

The study covers a thorough investigation process on the influence of the traditional beliefs and economic condition of the rural poor under Rajshahi Division on their willingness to avail different health care facilities.

The study covers vast areas of the perception and awareness of the rural population of Rajshahi Division, which directly/indirectly influence their attitudes towards different health care facilities in the locality.

The study covered a vast area for in-depth investigation on prevailing relations/environment in rural society of Rajshahi Division between service seekers and providers

The study covers areas for investigation of qualitative coverage of the existing health facilities for common diseases in rural areas of Rajshahi Division and the investigation for the corresponding impacts of that qualitative coverage.