Health Care Behavior

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

2009-06-18T04:03:00.000-07:00

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’sfirst brief definition of ‘psychosocial’ as ‘pertainingto the influence of social factors on an individual’smind or behavior, and to the interrelation of behavioral andsocial factors’.¹ This definition is likely to have importantimplications for social epidemiologists and other health researchers,because it implies that psychosocial factors, at least in thecontext of health research, can be seen as: (1) mediating theeffects of social structural factors on individual health outcomes,or (2) conditioned and modified by the social structures andcontexts in which they exist. The definition thus raises thequestion of what the relevant broader social structural forcesare, and how such forces might influence health through theireffects on individual characteristics. To our mind this is auseful working definition of ‘psychosocial determinantsof health’. In fact, it would imply that psychosocialexplanations of health might be more accurately referred toas ‘social-psychological’ explanations of health.

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

The term ‘psychosocial’ is also quite widely usedin the literature in connection with health outcome. The rootsof ‘psychosocial health’ lie in the World HealthOrganization’s (WHO) definition of health as ‘astate of complete physical mental and social well-being, andnot merely the absence of disease and infirmity’. ThisWHO 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 ‘psychosocialhealth’, in some cases, may combine traditional medicaldefinitions of disease and infirmity with measures that reflectindividual responses to disease and even in some cases indicatorsof the social context itself. Such measures have merit in recognizingindividuals’ experiences and quality of life, a dimensionthat is becoming increasingly recognized for example, in clinicaltrials. But researchers using health outcomes based on suchdefinitions 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 healthresearch it can be suggested a distinction between macro-, meso- andmicro-levels^2,3 as a useful sociological framework (Figure-1). We regard psychosocial as a meso-level concept, just as religiousinstitutions, the family, the firm, and the club are meso-levelsocial formations. These exist at a level below and are modifiedby macro-social structures that relate to ownership and controlof land and businesses, legal and welfare structures, as wellas distribution of income and other resources between groupsand 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-familyconflict are all produced within meso-level social formations.All these are manifested in interpersonal relationships. Thus,psychosocial explanations of health are essentially viewed hereas processes that cannot be fully captured by single measuresat one level, but require due attention to macro and micro (individual)level factors as well. However, not all processes from macrothrough meso to the individual micro level are psychosocial.

To our mind a central constituent of a psychosocial explanationof health is that macro- and meso-level social processes leadto perceptions and psychological processes at the individuallevel. These psychological changes can influence health throughdirect psychobiological processes or through modified behaviorsand lifestyles (Figure 1). However, many psychosocial exposuressuch as unemployment (so called ‘stressful life-event’)and social networks/supports need not necessarily invoke psychosocialprocesses or require psychosocial explanations. Thus, unemploymentthat leads to loss of income and an inability to buy materialnecessities of life does not constitute a psychosocial explanationof health. However, a psychosocial process is operating whenunemployment leads to loss of self-esteem and feelings of worthlessnessthat affect health via direct psychobiological processes orthrough modified behaviors and lifestyles.⁴ Similarly, socialnetworks may provide instrumental and material benefits andopportunities as well as close person-to-person social contactsand emotional support; yet only the latter path seems to qualifyas a psychosocial process.

The researchers are not entirely certain whether psychosocial processes canbe evoked in the absence of conscious individual level changes,such as perceptions of stress or social isolation (dashed linesin Figure 1). Research into the effects of working conditionson health, where control at work has been measured using self-reportsand independent assessments, provides an interesting illustrationof this issue. Both measures of control have been associatedwith health outcomes, although these associations are independentof one another and differ in magnitude somewhat.⁵ While thismight be interpreted as evidence that including both measuresprovides a more accurate assessment of control at work, it alsosuggests that these measures influence health through differentpathways.

⁽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)

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 interventionsfor the poor will enhance their material and social capacitiesto prevent ill health and to seek appropriate and timely care.Using cross-sectional data from surveys undertaken in 1995 and1999 as part of the BRAC-ICDDR,B Joint Research Project in Matlab,Bangladesh, this paper explores patterns of health-seeking behaviorover time, with the hypothesis that exposure to integrated socioeconomicdevelopment activities will enhance gender equity in care-seekingand the use of qualified medical care. While there is tentativeevidence of greater gender equity in treatment choice amonghouseholds benefiting from development interventions, a preferencefor qualified medical care is not apparent. Findings reveala striking and generalized rise in self-treatment over the 4-yearperiod that is attributed to the economic repercussions of amajor flood in 1998, and greater heath awareness due to thedensity of community health workers in Matlab. Also noteworthyis the substantial reliance on informal and often unqualifiedpractitioners (over 20%) such as pharmacists and itinerant drugsellers. Factors associated with the type of health care soughtwere identified using logistic regression. Self-care is associatedwith female gender, the absence of low cost health servicesand illnesses of relatively short duration. Medical care, onthe other hand, is positively predicted by male gender, geographiclocation, greater socioeconomic status and serious illness oflong duration. The paper concludes by emphasizing the importanceof enhancing local capacities to determine whether self-treatmentis indicated, to self-treat appropriately, or in cases wherehealth care is sought, to judge provider competence and evaluatewhether treatment costs are justified. The provision of pharmaceuticaltraining to the full spectrum of health care providers is alsorecommended.

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 associatedwith female gender, the absence of low cost health servicesand illnesses of relatively short duration. Medical care, onthe other hand, was positively predicted by male gender, geographiclocation, greater socioeconomic status and serious illness oflong 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.

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.

Health Care Behavior Study in Bangladesh-Socioeconomic information

2009-06-16T07:09:00.000-07:00

Socioeconomic and demographic information:

1. About 71.8% respondents were interviewed from Rangpur District and the rest 28.2% were from Kurigram District.

71.8% respondents were interviewed from Rangpur District and the rest 28.2% were from Kurigram District. Rangpur district was sampled as a typical Rajshahi Division district for the mentioned research study. It was shown in the previous chapter regarding methodology and the sampling that sampled rural respondents of Rangpur District would fulfill the requirements for typical Rajshahi Division samples. But Bangladesh has about 2% other ethnic minority population apart from the majority Bengalis in totality and Rajshahi Division possesses a little of that ethnic population or their successors. In the social-anthropological points of view, they have some different traditional beliefs, customs and manners and behaviors. So, to document those and to minimize these "ethnic gaps", the researcher took about 28.2% respondents from Kurigram District where there live some descendants from once Pundro-Khastrio/Rajbanshi/Kuch and Bairagi/Nath-hath-yogi/Baisnab and the Khyan tribes (detailed anthropological discussion was done in the previous chapters).

2. Rangpur Sadar Upazilla was accounted for the highest number of interviews (71.8%), Rajar Hat and Ulipur Upazilla, both within Kurigram District, were accounted for about 14.4% and 13.8% interviews respectively. For the same reason mentioned above, Sadar Upazilla of Rangpur District accounted for highest number of respondents and two Upzillas of Kurigram District were accounted for the rest of the sampled respondents.

3. Uttam Union of Rangpur Sadar Upazilla was accounted for the highest number of interviews (71.8%), Chhinai Union of Rajar Hat Upazilla and Pandul Union of Ulipur Upazilla, both within Kurigram District, were accounted for about 14.4% and 13.8% interviews respectively. Sampled Unions were accounted for mentioned sampling.

% Respondents by Unions

4. Among the respondents for in-depth interview, 37.4% live in Goalu, 34.5% is from the village of Bahadur Singha, whereas, Purbo-Debottor and Joykumar both accounted for 7.2% and Apuar Khata and Paschim Apuar Khata accounted for 6.9% respondents. Villages were purposively chosen purposively in sampling (details in the sampling technique chapter).

5. About 6.6 % respondents were from East Para of the Goalu village, where as other Paras of Goalu namely West Para, Khayan and "other" Paras accounted for 10.1%, 16.1% and 14.7% respondents respectively. Paras in the village Bahadur Singha accounted for 13.5% of the interviewed respondents. Mollah Para, Kamar Para and Char Joy kumar accounted for 10.9%, 6.9% and 7.2% respectively.Random/systematic random sampling techniques have been used (details in the sampling technique chapter).

6. About 51.7% of the interviewed respondents were female. Attempt was made to take females as at least half of respondents to achieve the gender variations in response.

7. Mean age of the respondents interviewed was 44.4 years. The highest aged respondent interviewed was/were of 62 years and lowest of 30 years. The ages of the respondents were between 30-62 years. These are the ages in which a respondent can be mentioned as of normal age of knowledge and capable of understand and disseminate any information normally.

8. Among the interviewed primary respondents 8.9% was Pundro-Khastrio/Rajbanshi/Kuch1. About 74.4% and 4.3% was Muslim and general mainstream Hindu, Bairagi/Nath-hath-yogi/Baisnab2 and the Khyan were accounted for 5.2% and 7.2% respectively. It is interesting that although the mentioned population claim that they belong to the religion of Hindu, the mainstream of the Hindus have been continually refuse to admit the claim. In the observation at the field, it was seen that most of these unconventional Hindus are the descendants of the ethnic aboriginals, mostly the mongoloids anthropologically i.e. mostly possibly from Garos. Moe or less, it is the same scenario in everywhere of the rural population of Bangladesh, where this scheduled Hindus constitute a considerable portion of the total Hindu population of the area.

(1= they are not real Khastrio who are rare in East Bengal or Bangladesh. Real Khastrio are the martial race of the ancient Hindu religion and use to be the rulers, fighters etc. and the Rajputs and other north Indian castes are known as Khastrio. Population in the northern Bengal identifies them as Khastrio for some mythical reasons that were introduced by their kings like king Bishwashor of Kuch kingdom. According to the myth, 3^rd Pandob Arjun came to this land and married the indigenous princess Chitrangada. Arjun was one of the top most Khastrio of the era, hence the Kuch king defined themselves as the Khastrio. Typical Khastrio likely to have pure Aryan builds, whereas these Pundro- Khastrio are of Mongolian origin without doubt in their body and skull builds and in appearances!

2= Other than the Muslims, all counted as the Hindus)

9. Among the interviewed primary respondents, 44.5% were illiterate and 55.5% respondents were claimed to be literate. Again about 32.2% respondents interviewed were literate to the extent of primary level. Only 5.7% respondents interviewed were educated up to the S.S.C. level and above. Reflecting the situation in rural Bangladesh as a whole in the context of education. Only 5.7% SSC level education leaves the rural Rajshahi areas extremely vulnerable to superstitions and obstructs positive changes in the contexts of any modern and scientific knowledge and practice among the population.

10. Among the interviewed primary respondents, about 34.5% accounted for number of family members as 4, whereas about 17.2% have 8 member families. About 24.2% have family members more than 6. Only about 3.5% have families with 3 members. Expresses the excessive population in the rural areas and the family size in the households which is important to any design for health delivery system in the study population.

9. Among the interviewed primary respondents, about 29.3% belonged to the agriculture as their occupation, whereas about 46.6% were the housewives. About 8.3% were different professional groups. As we saw in previous table analyses, more than half of the respondents (51.7%) were females and here it is seen that about 46.6% of the total respondents are housewives. So, some of the females respondents had been doing something other than their roles as housewives.

10. Among the interviewed primary respondents, about 65.5% respondents’ economical condition was assumed as "not good". Only about 10.3% were identified having "good" or well off economic conditions. (Dresses, household utensils and other assets were indicators for the assumption). As the interview process was totally participatory and community based, interviewers were deployed from the community and they applied their indigenous techniques as they usually use to describe the economical conditions in their community and no highly precision scaling system was used due to the nature of the interviews. They could do it most preciously as the researcher thought. Economic conditions were predicted by the interviewer on certain general findings/criteria. How they pass their lives, what they eat, what they wear and what they do for income earning. Also idea was taken by observing their household for built and other criteria. This is the general understanding of the economic condition expressed in their livelihoods, not a very technical analysis and in most cases, it fulfills the objective to understand population’s situation. No strict economic measurement scale from any institute has been used, rather assumptions have been made with the indigenous idea found in the locality among the population to tell some one having "good", "average" or "not good" economic condition and those are dependent on the livelihood indicators of the assessed families or households (this is common practice in the rural Bangladesh to describe anyone’s economic condition)

11. Among the interviewed primary respondents, about 58.6% have the income source related to agriculture. About 20.7% have the income source related to the business i.e. small business like grocery shop or village market shops, tea-stalls etc. Different types of low-graded services contributed for about 13.8% of the income source, whereas different professional activities constituted the rest 6.9% of the responses regarding the income sources. Showing a predominantly agrigarian society, but a large proportion of the ethnic originated population are dependent on the other professions like craftsmanship in different trades. The later is partly due to their family heritage and partly due to their lack of cultivable lands, most of which have been known to be grabbed by the majority Muslim and mainstream Hindu populations since hundreds of years!

12. As per the statement of the interviewed primary respondents, their mean family income earning per month had been seen as about Tk. 2345 of which Tk. 4000.00 is the highest and Tk. 800/month is the lowest income earning per family. This expresses the income earning per household as stated by the respondents.

13.Among the interviewed primary respondents, about 58.6% are income earning, whereas about 41.4% are not income earning members of their families (mostly the housewives and the old/disabled persons). The finding shows that some female respondents were also accounted for the income earning (51.7% respondents are females)

14. Among the interviewed primary respondents income earners, the mean income earring were about Tk. 1306, whereas, Tk. 3000.00 and Tk. 500.00 were the maximum and the minimum income earrings respectively. About 82.4% respondents stated their monthly income earning as Taka 1500 or less.

15. Among the interviewed respondents’ families, about 86.2% lived in the houses owned by them; however about 13.8% were sheltered in the houses of their relatives or known families. Absence of rented house as any interviewed family’s living place reflects the normal rural phenomenon of the area.

In the rural Bangladesh, rented houses are rarely seen except the areas adjacent to the Thana or Distrcit headquarters. Majority of the respondents have their own homes, others are sheltered in their relatives’ households.

17. Among the interviewed respondents’ families, about 13.8% live in houses with good road communications and 41.4% with average road communication. About 44.9% has the household with bad road communications. Here only 13.8% respondents, who live at the side of the highways and other subways, stated they had good road communications. Other stated it as "average" or "bad". Road communication has a great role in the health seeking behavior as people have to go to the service centers through the roads. However, not only the road, also the transportations are required, and in most good roads, some types of transportations are present.

18. Among the interviewed respondents’ families, about 55.7% have no tube wells or electricity in their houses, whereas, 39.4% and 20.4% have tube wells and electricity respectively in their houses. It is of value to the interested quarters as it is reflecting the WatSan (water and sanitation) situation in the study population which cries significance for disease prevalence and health care behaviors of the population in general.

Household amenities

Pct of Pct of

Count Responses Cases

Tube well 137 34.1 39.4

Electricity 71 17.7 20.4

No tube well or electricity 194 48.3 55.7

------- ----- -----

Total responses 402 100.0 115.5

19. Among the interviewed respondents’ families, 74.7% and 69% owned watches and radios respectively, whereas, 52.9% owned bicycles (proportion is seen pretty higher, possibly for transport of the adult males to Rangpur or other places wherever necessary in the mud road). About 4.6% had televisions (mostly in their grocery shops), whereas, 12.4% had nothing such in there houses. About 10.3% have rickshaw or bull-carts, mostly for giving rent for income earning. Important for understanding of message dissemination processes through media, bicycles are pretty higher in number for communications.

Ownership of household commodity

Count Responses Cases

Radio 240 30.6 69.0

Television 16 2.0 4.6

Watch 260 33.1 74.7

Bi-cycle 184 23.4 52.9

Rickshaw/Bull cart 36 4.6 10.3

Boat 6 .8 1.7

Nothing 43 5.5 12.4

------- ----- -----

Total responses 785 100.0 225.6

20. Of the interviewed respondent females, 36.1% husbands were illiterate, whereas, 40.7% were literate to the extent of primary levels. Only 2.8% husbands were educated up to degree (Bachelor) level. This is a very important account as predominantly the males are the decision makers, so their educational levels can contribute/influence the health care behavior of the family members to a great extent. About 76.8% of the female respondents’ husbands are either illiterate or of primary level educated, thus limits the scopes for dissemination of modern knowledge through printed media and recalls importance of audio-visual approaches.

21. Of the interviewed respondent males, 54.8% wives were illiterate, whereas, 32.1% were literate to the extent of primary levels. Only 3.6% wives were educated up to S.S.C. level. About 1.8% has no wives then, either died or separated. About 86.9% of the wives of the respondent males are either illiterate or primary levelers. It is also an important indicator in the health care behavior as the women are the household caretakers for the diseased persons in the family.

Chapter –II: Methodology

2009-06-16T06:42:00.000-07:00

A. Study design:

Main theme of the study is a survey, was planned to investigate the health care behaviour of the representative sample rural population under Rajshahi Division. Health seeking behaviours of the sampled population have been documented through a Knowledge, Attitude and Practice (KAP) survey and their links or relations were investigated with different factors like knowledge, traditional beliefs (perceived etiologist), economic condition, education, gender and distance with the health facilities etc.

In the research study entitled "Psychosocial Factors related to Health Care Behaviour of the rural people under Rajshahi Division", the survey planned was qualitative and methodology was adopted for qualitative data collection in the survey.

Rationale for intensive study of the population in limited study areas for qualitative data:

An in-depth study of rural population with samples of statistically valid number in limited study areas of Rajshahi Division (in Uttam Union of Rangpur and Chhinai and Pandul Union in Kurigram) was "representative" for whole Rajshahi Division rural people for yielding result. Study of the rural population all over the Rajshahi Division was not required for the qualitative behavioural study "Psychosocial Factors related to Health Care Behaviour of the Rural people under Rajshahi Division".

The rationale is as follows:

For qualitative data of a population with homogenous culture, language, and ethnicity etc. in a very small but populous country, intensive study of the typical population in any place is enough and repeating the procedures in the other places within the same typical population groups allover the Division or country is not absolute as they have almost the similar traditional beliefs, socioeconomic conditions, cultures and practices etc. so, results will be almost similar. This is particularly true for Bangladesh. Mentioned factors are almost similar for whole Bangladesh (homogenous culture), or more truly for whole Rajshahi Division would be almost similar for the following reasons (reasons for cultural homogeneity population):

1. Unlike India, Russia or other very large counties (where number of population groups inhabit in different areas and have individual own cultures), Bangladesh is a small country with tiny area of 147.570 Sq. Km. (56977 Sq. miles) only. Bangladesh has almost homogenous population in respect to religion, linguistics, socioeconomic conditions and traditional beliefs etc. Typical population groups (98% Bengali) in this country are homogenous so as the Rajshahi Division. Rajshahi Division is one of the 6 administrative Divisions and has same characteristic population groups.

"Except for about 400,000 Bihari, the Muslims who immigrated from Bihār, India—and some small groups in the southeast, the Bangladeshis consider themselves homogeneous people. They have an Indo-European heritage, with some Arab, Persian, and Turkish influence. The people of West Bengal in India are of the same ethnic group as the Muslim Bangladeshis, but they are mostly Hindu. To emphasize this difference, most people refer to themselves as Bangladeshi rather than Bengali, the cultural-linguistic term for Bangla speakers. With a population density of 864 persons per square kilometer (1998) (more than 2,239 persons per square mile), Bangladesh is one of the most densely populated countries in the world. Most of the people live in thousands of small villages that blanket the country. Only about 19 percent (1997) live in cities."¹

2. Unlike other countries depicted above, there is only one language (Bangla) among all the inhabitants (sometimes with negligible local variations in spoken forms i.e. in he Districts of Chittagong, Sylhet Noakhali etc. but the written script is same everywhere). For Rajshahi Division, the fact is more conspicuous, language is more strongly typical allover its areas regarding the common and only language, Bengali compared to other administrative Divisions of Bangladesh.

Unlike the described countries, Bengali is the only local newspaper language through out the country. Text and other books are published in the only local language (Bengali). Radio and Television media broadcast programs in the Bengali. So, information and knowledge disseminations and all communications are in the same language (Bengali). No ethnic community in this area has any functional written language other than Bengali and their spoken ethnic languages are mostly Bengali in variant forms. Regardless the religious identities, all of them have the same language both spoken as well as written.

"Bangla (also known as Bengali), the official language, is also spoken in India’s West Bengal. Spoken Bangla has several distinct dialects, the most guttural of which are spoken in the northeastern and southeastern districts of Bangladesh. Most Bangla dialects are soft and somewhat musical. People with a university education usually also speak English, but they often incorporate various colloquialisms derived from Bangla. The Bihari speak Urdu, an official language in Pakistan. Small groups along the southeastern border speak in their own languages"².

3. Religious proportion of the typical population groups is almost same in all parts of Bangladesh and that is more evident in Rajshahi Division, i.e. Muslims, Hindus, Buddhist and Christians.

"Bangladesh has the second largest Muslim population in the world; more than four-fifths of the people are Muslim, mostly Sunni Muslim. Most of the rest of the population is Hindu, although there are also Buddhist and Christian minorities. Education system is same for whole country"³.

"Ethnic divisions - Bengali-98 percent, Other-2 percent

Languages --

Bangla (official), Urdu, English

Religions: -

Muslim-88 percent, Hindu-10 percent, Other-2 percent"⁴

Literacy rates are almost similar in the regions. Similar political trends are observed. Almost all people have similar appearance, height, hue and other anthropological aspects.

As the behavioral aspects like health care behavior etc. depend mainly on the above determinants or factors, intensive study of a population in a single place would satisfactorily yield the expected qualitative data for the total population or the statistically defined "universe".

B. Rationale for the Sample size:

For qualitative data, intense and in-depth study (qualitative survey) of statistically defined "large" Sample size among the population fulfilled the demand of the study (qualitative survey) and give statistical validity. In the study, 348 in-depth interviews were conducted. The number is statistically valid for the followings:

1. When over more than 30 were taken as the samples and selected for in-depth study, it can be called statistically "large" sample⁵. So, total number of respondents >=300 proposed for the study can be defined as "large" statistical sample for investigation or in-depth study of a population.

2. "If you intend to analyze cross-tabulations of variables, you should keep two points in mind when determining sample size. First, each category of an independent variable included in a cross-tabulation should contain at least 50 cases, since percentages calculated on the basis of fewer than 50 cases tend to be unreliable. The minimum sample size required ensuring at least 50 cases in each category of the independent variables is obtained by dividing 50 by the proportion (Ps) of total cases you expect in the smallest category of variables"⁶:

m = 50/ Ps

3. "Qualitative data can be collected through qualitative methods such as unstructured interviews, focus group discussions, direct observations, and content analysis etc.

The chief drawback of structured interviews is that the responses obtained tend to be superficial. An alternative approach to interviewing, which allows greater depth of exploration, is to seek detailed, open-ended responses to questions. Such interviews are usually known as in-depth interviews. In this procedure, instead of reading formal questions from a structured interview schedule, the interviewer has an outline of topics or a set of general questions to serve as a guide to the kind of information required. Details that are not brought out initially are sought through follow up questions, called probes.

The chief drawbacks of unstructured interviews are (1) the responses, being un-standardized, are difficult to quantify; (2) the interviews require highly skilled and experienced interviewers; (3) the analysis is extremely time-consuming. The shortage of qualified interviewers and analysis, and the high cost of conducting and processing such interviews usually mean a small sample size must be used (sometimes as few as 20-30 respondents).

In-depth interviews are generally most useful exploratory studies that seek to clarify important concepts or generate hypothesis prior to developing questionnaires for quantitative surveys. They also are useful for generating supplementary, explanatory data to augment the relatively superficial findings from larger surveys"⁷.

References:

1, 2, 3, 4: © & (p) 1995-1999 Microsoft Corporation, sources:

United States Census Bureau, International Programs Center; International database, 1999; (www.census.gov). Population density data are from the individual country statistical bureaus, and the United States Census Bureau, International Programs Center; International database, 1999; (www.census.gov).Ethnic divisions and religion data are largely from the latest Central Intelligence Agency (CIA) World Fact book, as well as various country censuses and reports. Language data are largely from the Ethnologue, Languages of the World, Summer Institute of Linguistics; (www. sil.org).-

5. Dr. Md. Zainul Abedin. A Handbook of Research for the Fellows of M.Phill and Ph.D. Programmes (Dhaka, Chittagong: Book Syndicate, 1996). Pp. 66-67.

6. Andrew A. Fisher, John E. Laing, John E. Stoeckel, John W. Townsend. Handbook for Family Planning Operations Research Design (2^nd ed.; New York: The Population Council, 1991), pp.43-44.

7. Andrew A. Fisher, John E. Laing, John E. Stoeckel, John W. Townsend. Handbook for Family Planning Operations Research Design (2^nd ed.; New York: The Population Council, 1991), pp.50

C. Sampling technique

1. The study was designed to conduct in the typical villages of rural areas under Rajshahi Division of Bangladesh and all the respondents were selected from there for study as per the subject of the study. For the purpose, a two-fold methodology was adopted to select respondents for the study for in-depth interview: i) from a Union of Rangpur District, about 250 (covering about 5% of the total number of households in the Union) were taken as the respondents. ii) To minimize the possible gaps and variations in responses regarding the social, traditional and cultural beliefs for aboriginal, tribal or ethnic populations (of Rajshahi Division/Bangladesh, approximately 2% population of the total for Bangladesh), a number of in-depth studies (100) were conducted in two pockets in Kurigram District within the geographical area of Rajshahi Division (District of Kurigram, from Pandul and Chhinai Unions of Upazillas of Ulipur and Rajarhat) where significant number of ethnic population is present (Rajbanshi, Khen and Kuch etc.).

Thus in total about 350 (250+100) respondents were selected for interview and 348 of in-depth interviews were conducted with them.

Stratified Random, Systematic Random and Purposive sampling techniques were adopted for drawing the samples for the study as follows:

Among the Districts of Rajshahi Division, 2 Districts were taken (Rangpur and Kurigram)-Random Sampling technique

Among the Thanas of Rangpur District and Kurigram District, 1 Thana was taken from Rangpur District and 2 Thanas from Kurigram Districts (Rangpur Sadar from Rangpur and Ulipur and Rajarhat from Kurigram ) though Random Sampling technique

Among the Unions of Rangpur Sadar Thana, Ulipur Thana and Rjarhat Thana, 1 Union was taken from each Thana (Uttam Union from Rangpur, Pandul Union from Ulipur Thana and Chhinai from Rajarhat Thana) through Random Sampling technique

Among the Mouzas/villages/clusters of Uttam union, 2 Mouza/cluster/village is taken (Golau and Bahadursinha) for Rangpur through Random Sampling technique and for Kurigram from Pandul Union and Chhinai Union through Random Sampling technique among purposively identified ethnic/aborigine population.

In Goalu and Bahadursinha villages of Uttam Union of Rangpur Sadar Thana of Rangpur District, households have been chosen through Systematic Random Sampling technique. In places, Purposive sampling technique also has been used.

2. Effective and proper data management has been ensured throughout. Tabulation plan has been complied with the objectives of the study. Data and information from the in-depth interviews have been gathered and compiled in the reporting forms with proper importance to the salient and atypical findings in respect of the track of the study subject.

Strange and interesting issues, incidences, stories, findings etc. explored and elicited from the in-depth interviews in the process of the study have been noted, preserved, and analyzed for further clarifications in the compiled report. From the in-depth interviews, salient features of the quantitative data and the quantitative accounts of the qualitative data have been presented first in words followed by the corresponding tabular presentations. Interesting findings have been compiled and compared against the prevailing knowledge about the topics and emphases have been given to establish the causes and justifications of the exceptions of the common norms in subsequent chapter.

The information has been compiled in the report in relevance with the in-depth interview end products for the qualitative presentations.

Case studies gave an opportunity to track the study topics in the individual variations and made possible for the researcher to re-examine and re-observe the individual trends, variations and scopes in the topics.

D. Study period

The period of the study was planned for a time relevant to the time length for the M. Phil and Ph.D. course and was planned to conclude at least within August 2003, thus providing enough time for data management and writing the final report within June 2004. A period of three months was required for the preparatory works for the thesis; almost two years were taken for fieldworks which were not done at a time as time was required for different works like primary reporting for seminar for transfer to Ph.D. and suggestions from the supervisor to select valid sample size for the samples etc. Rest of the time was required for data compilation, analysis and report writing.

E. Study area

The study area was the Village of Golau in Mouza Goalu of Union of Uttam in Rangpur Sadar Thana of the District of Rangpur. The particulars of the study area are as follows:

Locality Name					Population
District	Thana	Union	Mouza	Village	All	Male	Female
Rangpur	Rangpur Sadar	Uttam	Golau*	Golau	192	259+16%**	( )	727+ 6% ***	677+ 6%
Kurigram	1.Ulipur 2.Rajarhat	1.Pandul 2.Chhinai	Pockets of Ethnic population	-	-	-	24,637 in Pandul 26,302 in Chhinai

* Golau Mouza contains only one village.

(Census 1991, published by BBS)

**/*** as suggested for 2001 counts by the officials of the Rangpur Sadar Thana Statistical Officials

Goalu and Bahadur Sinha are the typical villages of rural Rajshahi Division of Bangladesh and inhabited by typical rural population. They are nearly within 8 kilometer radius from the Rangpur town. Like other typical Bangladeshi villages, the rural populations of the village enjoy the usual facilities and drawbacks with respect to their health care access. Literacy rate of the village for 7+ years is 23.2 for all, of which males and females accounted for 32.5 and 13.3 respectively.

As mentioned earlier, Chhinai and Pandul are 2 Unions under Rajarhat and Ulipur Upazillas (Thanas) respectively of the District of Kurigram and they are at about 10 and 14 km. from Kurigram District Headquarter respectively.

F. Data collection technique (quantities/qualitative)

Data collection technique was participatory and community based. Two eligible volunteers (Female) were deployed from the same community, trained by the researcher who himself took part in conducting the interviews. They charged only a pocket expense. As from the same community, they could penetrate maximum while interviewing and observing.

A) Surveys have been conducted with the sampled respondents determined through sampling techniques as mentioned in households among family members (adult females and males depending upon the opportunities) i) two villages in Uttam Union of Rangpur Distrcit’s Sadar Upazilla and ii) in the Unions of Pandul and Chhinai of Ulipur and Rajarhat Upazillas of Kurigram District through prior-visit by a team headed by the researcher to make a list of addresses and names all the households and family adults/heads

B) In order to collect data to meet the study objectives and queries, respondents were interviewed in-depth with a semi-structured questionnaire.

A total of 256 in-depth interviews have been conducted in the village of Goalu and Bhahadr Sinha in the Uttam Union of Rangpur Sadar Upazilla. A total of 106 in-depth interviews were conducted in the villages under Pandul and Chhinai Unions of Ulipur and Rajarhat Upazillas respectively of the District of Kurigram.

C) Direct observation by the data collection/investigation team whenever/wherever required.

G. Data collection instruments

Semi-structured in-depth questionnaire (each questionnaire with 397 fields and of both single and multiple responses))

Direct observation (whenever and wherever possible)

H. Data collection plan/ Work Plan (field work):

Data Collection

Data collection constituted a most important task of the proposed study. However, obtaining accurate and reliable data depends on, among others, realistic planning, data collection procedure and constant monitoring, therefore elaborate and proper arrangement was done for the purpose.

The whole operation was conceived to entail three steps: planning, procedures and monitoring (or quality control). These three steps had been planned in conjunction with each other so that the whole operation was carried out smoothly and timely.

Planning for Data Collection

The planning of field data collection is outlined below:

Our previous experience on field operations called for a well-thought, realistic and feasible work plan. It was essential for ensuring timely completion of fieldwork and to obtain high quality data. In this regard, therefore, the first priority had been to prepare a work plan before the actual fieldwork was started, and it was done accordingly.

Work Plan for Data Collection:

The researcher collected relevant reports and research findings for literature review with the help of the respected supervisor Professor in the Department of Psychology, Rajshahi University mostly using the latest Internet technology from the websites. He reviewed the collected literatures and prepared a synopsis of those reports. For the purpose of collection of data from the respondents, a team of 3 was deployed for conducting in-depth interviews. As the best data could be obtained through a participatory and community based data collection procedure, i.e to involve community members in data collection and as the in-depth interviews were lengthy and time consuming process; hence more manpower was required in excess to the researcher alone, able volunteers were collected from the indigenous community to collect conduct the interviews and for observations. They were duly trained by the researcher and field tests were conducted. As male investigators seemed to be less welcomed in the extremely rural households for interview, female data collectors were deployed by the researcher.

The team was formed as under:

Designation	Number
Researcher	1
Field Assistants (female)	2
Total	3

The researcher himself conducted interviews as well as supervised the Field Assistants’ interviews for ensuring the quality of the fieldwork.

A total of 248 sampled respondents from village of Goalu and Bahadur Sinha were interviewed for the Rangpur District study area. Again about 100 respondents were interviewed in Kurigram study areas of the Pandul and Chhinai Unions in the ethnic pockets. Special efforts were taken to maintain gender equity among the interviewed respondents by trying equal percentage from both the sexes (50% female and 50% male)

Systematic Random Sampling technique was applied to select respondents in the Rangpur District segment, whereas in Kurigram District segment, ethnic pockets were identified purposively and then Systematic Random Sampling technique was used to draw respondent samples.

I. Quality control of the data

Researcher’s past experiences as a investigators for a number of research works greatly helped him in the data collection procedures.

The questionnaires were printed (please see the appendix). Monitoring of listing/data collection work has been ensured in different ways. The researcher undertook some specific steps for monitoring the data collection and listing works of interviewers. The researcher reviewed daily activities of the team and discussing problems with the other team members at the end of each day and used to edit all the listing formats/schedules at the field camp as well as check for inconsistencies and incompleteness. For ensuring quality of data, the researcher checked the consistencies of the completed schedules, re-visited a few of the already interviewed cases to make sure whether they were properly interviewed and solved/clarified any new problem that arose in the field. Furthermore, the researcher took assistance from one of his friend experienced in quality control of the data who also contributed as quality controller for the interview.

Also the following mechanism was exercised for quality control of the data collected:

- 100% questionnaires were scrutiny checked in the field by the researcher

- 20% questionnaires were back checked by the researcher

- 20% Interview were cross accompany called by the team members

- 20% questionnaires were scrutiny checked in the field by the researcher

- 10% questionnaires were back checked in the field by the researcher

- 10% Interview were accompany called by the researcher

- 100% questions in a questionnaire were checked at the time of back check.

J. Confidentiality of the data

As the study design was an "ethical study design", the confidentiality was kept as followings:

- Data collected from the respondents were kept fully confidential

- Unless felt absolutely essential for the interest of the study, sensitive issue was avoided in the interview.

- For data management including the coding, editing, computerization and analysis, always code numbers were used instead of the names of the respondents.

- No other persons/parties have access to the information collected except the supervisor and the Rajshahi University authority.

- Interviews were always conducted with the willingness and informed consent of the respondents.

K. Data management (tabulation-coding/editing and analysis plan)

Data management

Data management consisted of registration of schedules, editing, coding, and computerization, preparation of dummy tables (tabulation plan), analysis and matching of data.

The researcher undertook the responsibilities of the technical matters of editing, coding and computerization.

Computerization

The process of computerization have been carried out through the following stages

i) Designing of databases and program in Statistical Package in Social Science (SPSS/PC 11.0)

ii) Data entry

iii) Data cleaning (by validity check, consistency check, etc.)

iv) Report/table/information generation and printing

v) Taking backup for further/future analysis.

Total data management including the compilation of computer program, data editing, data entry and analysis has been performed by the researcher himself.

Survey data were analyzed according to the purpose of the specific objectives and research questions. Simple tables were preferred. Frequency tables were made for all the relevant variables and cross-tabulations were also prepared for necessary highlighting of any existing correlation between two sets of variables, such as gender and knowledge etc.

Also attempt was taken to present key findings through bar, line or pie charts wherever comparative analysis was felt necessary.

Report has been prepared with frequency and cross-tables, followed by write up. In suitable cases, multi-variate analysis has been performed.

Statistical tests (t-test, chi-square) were used for assessing the significance of difference between two sets of data for drawing inference whenever felt necessary.

The report contained an abstract with a set of recommendations.

L. Dissemination of the research finding (Dissemination strategy and report writing)

Dissemination strategy:

- Emphases were given to the objective related issues for making the information useful to the potential users (i.e. policy makers etc.) so that they could use those for the betterment of the health facilities of target population (the rural people).

- Emphases were given to highlight the most significant but achievable problems unveiled by the research.

- Both printed hard copy and soft copy in the CD were submitted for the convenience of the supervisor Professor, the Department and for the University of Rajshahi.

- Except the University of Rajshahi, Department of Psychology, the report or any part of the data was not disseminated to anybody.

- Researcher hopes that the report and the data will be disseminated through multiple approaches using a variety of channels to maximum number of audience/ readers after its final acceptance by the University of Rajshahi authority for the betterment of human beings and for the improvement of the knowledge of the mankind.

M. Writing of report

As per the general rule, primarily, the whereabouts of the study including findings was presented through a report as per the given outline by the supervisor professor of the study that suits with the requirement of the Department of Psychology, University of Rajshahi protocol. As the present report is an academic one, special thrust were put on the methodology and other academic issues as prescribed by the Department of Psychology, University of Rajshahi.

Health Care Behavior Study in Bangladesh-Knowledge, Attitude and Practice -First part

2009-06-16T04:18:00.000-07:00

They informed of their knowledge, perceptions and practices related to their health care behavior in relation to their world of imagination and myths. They freely described about the presence of the government health service delivery centers nearby them also informed about their interests in those. They didn’t hesitate to express the causes of their interests and disinterests regarding those. Thus one of the main objective of the research study is fulfilled by knowing the traces of the views of the rural population of Rajshahi Division about Government health services and opportunities can be made by examining these views, comments and causes to explore the actual situation in the ground to submit those before the state level policy makers to compile real people oriented national policy through which the health service requirements of the vast rural population can be dealt effectively.

Also the most important context of the findings for the study exist here as these are the responses from where one can find the relation of the existing social factors with their health seeking practices.

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 acciden.

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.)

22. Among the interviewed respondents, 48.3% had no knowledge of any UHC/MCWC /FWC nearby, whereas, 51.7% had that knowledge. Lack of the knowledge in the issue reflects possibly their lack of interest in the government service delivery outlets.

The factors related to the development of such knowledge influence health care behavior of an individual for their service seeking.

Here we see that large proportion of the respondents have no knowledge about the presence of UHC (Upazilla Health Complex) or Mother and Child Welfare Centers (MCWC) or Family Welfare Centers, the Government health service delivery centers nearby. It became a burning question, whether is it possible that residing in the area and facing health problems, even if in very small extents, still they didn’t know their presence in the area? In cross-checking of the interview results, it was seen that they really told so. Now, it is a clear cut psychological manifestation. It might be very much possible for a portion of the respondents who responded as they didn’t know the presence of these Government service centers around them, even after knowing the presence, they simply denied their knowledge regarding their presence as they didn’t like them. The social factors here are influencing their mind affecting the development of such "knowledge" of options of health care facilities nearby. This may be possible that they refused to acknowledge the presence of the Government health facilities as they couldn’t satisfy them.

Knowledge of UHC/MCWC/THC nearby
	Frequency	Valid Percent
Within knowledge	168	48.28
Not within knowledge	180	51.72
Total	348	100.00

23. Among the interviewed respondents, none informed of their regular contact with the Government hospitals for treatment, whereas 27.6% stated that they never go GoB (Government of Bangladesh) outlets for treatment. However, 72.4% go there for treatment only occasionally—factors influencing their propulsion to Government health centers are of importance.

The picture showed the extents of non-confidence in Government health service delivery as most of the respondents informed that they went there only occasionally, i.e. when they badly needed the service, but no body stated that they were going in those government service enters regularly when their family members were diseased! A large proportion of the respondents (27.6%) informed that they never went to the Government health service centers, i.e. hospital etc. So, the health care behavior of the population is special about the Government service centers or hospitals, but what are reasons behind that? It may be the confidence underlying. They know that the services there are not enough effective to meet their needs.

Whether going government hospital for treatment
	Frequency	Valid Percent
Don't go to government health facilities	96	27.59
Occasionally go to government health facilities	252	72.41
Total	348	100.00

24. Among the interviewed respondents, only 6.9% expressed their satisfaction in treatment in Government service outlets or hospitals any where. A vast majority of 89.7% expressed their dissatisfaction for treatment in Government hospitals, whereas, a much lower proportion (3.5%) stated differently in the issue i.e. too much rush causes trouble for treatment in Government hospitals, without medicines what the doctors would do? There are certain factors like presence of doctors, availability of the medicines, friendly environment in the hospitals etc. influence the individuals’ satisfaction in the service of any care facilities which came later in the findings.

It is interesting that only 6.9% respondents expressed their satisfaction (client satisfaction) in the treatment in the Government hospitals/service centers and about 89.7% expressed their dissatisfaction for their treatment in Government hospitals. But this is also interesting that still they are occasionally going there for their treatment as they have only a few alternatives where they can go for the treatment.

Whether satisfied in treatment in GOB
	Frequency	Valid Percent
Satisfied	24	6.90
Not satisfied	312	89.66
Others	12	3.45
Total	348	100.00

25. Among the interviewed respondents, 82.8% informed "no medicines available" as their reason for not going to Government hospitals (anyone) for treatment, whereas, 65.5%, 44.8% and 41.4% informed of their reasons as the absence of doctors, bad road communication for going for treatment and "bad" behavior of the doctors respectively— "availability of medicines", "absence of doctors", "bad road communication" and "behavior of the doctors" revealed as the factors those play an important role in their perceptions of "satisfaction" in the management of disease in Government hospitals. These are the quantitative and qualitative aspects of a service which are the determinants for service seeking.

-This finding expresses how the service providers’ service quality can affect health care behavior of any population. In health ailments management, the extents of quality and quantity are important factors to attract the beneficiaries and are capable of influencing the target populations’ health care behaviors.

Reasons (if anyone) of not going to GOB

Pct of Pct of

Count Response Cases

Doctors available rarely 228 21.8 65.5

Doctors/providers behavior not good 144 13.8 41.4

No medicines available 288 27.6 82.8

Road communication to government hospital 156 14.9 44.8

Transport not available/expensive 36 3.4 10.3

------- ----- -----

otal responses 1044 100.0 300.0

26. Among the interviewed respondents, all (100%) informed of quack/non-MBBS private doctors as the service outlet for the treatment of their family members, whereas, 82.8% informed both of religious/spiritual healers and Homeopath/Kabiraji/traditional healers for the same indicating the strong affinity of the rural population of Bangladesh for medieval treatment procedures for different reasons. Curiously NGO outlets had been described for the same by only 6.9% of the respondents. These are the health seeking practices evolved for the benefit of the individual as a result of different influencing factors. Factors associated with the choice of the service providers are related with this finding.

All the respondents (100%) informed of their treatment outlets as the quack/non-MBBS private doctors and 82.8% respondents informed both the religious/spiritual healers and Homeopath/Kabiraji/ traditional healers as their treatment outlets. This is really very much interesting! Didn’t they understand any thing about the qualities of treatment of the mentioned outlets? I think at least they assume up to an extent. Then why again they thought theses outlets as their highest hopes? In the next discussion, we shall see the reasons behind this psychology. In practical, they are the "doctors" or the "remedy outlets" where the poor and lees knowledgeable rural people can go in their health problems as they are present in their vicinities, at least the rural people can get them and of course, their treatment is cheap regardless the qualitative standardizations! In medical science, we care about several factors which can affect the healing process strongly like placebo effects (psychological perception of taking appropriate medications), assurance and re-assurances etc which are scientifically proved phenomenon. So, apart from the extents real pharmacological effects, added psychological boost benefits the service seekers and thus contributing to the health care behaviors, i.e. the people come to them in diseases.

Outlets for family treatment

Pct of Pct of

Count Responses Cases

Government hospital 240 18.3 69.0

Private M.B.B.S. doctors 120 9.2 34.5

Quack/non-M.B.B.S. private doctors 348 26.6 100.0

Homeopath/Kabiraji/traditional healers 288 22.0 82.8

Religious/spiritual healers 288 22.0 82.8

NGO hospital 24 1.8 6.9

------- ----- -----

Total responses 1308 100.0 375.9

27. Among the interviewed respondents, all (100%) respondents described "low cost treatment" as the reason to select treatment outlets for the family members. Again 58.6% and 51.7% respondents described the reasons as "treatment facilities always available" and "nearer to the patient's house" respectively. About 44.8% respondents accounted for "treat with care and listen/counsel well" as the reason for the same. Here the factors influencing their choice of the service providers have been revealed.

-In the finding, the reasons related with the demand versus capacities for spending were describe by the service seeking rural population. Treatment costs, availabilities, counseling and the easier ways of approach etc. have been described by the beneficiaries as the indicators which they use to assess while go for a treatment to coup up with their own capacities.

Reasons to go to the outlets for family

Pct of Pct of

Count Responses Cases

Treatment/medicines are good 120 11.5 34.5

Low cost treatment/expenditure 348 33.3 100.0

Nearer to the patient's house 180 17.2 51.7

Treatment facilities always available/do 204 19.5 58.6

Treat with care and listens/counsel well 156 14.9 44.8

Others 36 3.4 10.3

------- ----- -----

Total responses 1044 100.0 300.0

28. Among the interviewed respondents, only 17.3% expressed their satisfaction in treatment wherever they get that. Curiously interesting is the finding is that, a vast majority of 82.8% remained "unsatisfied" with treatment, even in their outlets/hospitals of choice for the treatment of their family members! Here, the service seekers expressed their satisfaction/dissatisfaction in the service provided by any service providers. There are some factors causes their perceptions of client satisfactions.

-Only 17.3% of the respondents expressed their satisfactions in the treatment from anywhere they availed while diseased (they went in the service outlets where they could fit themselves in regards to the treatment costs and other factors!). It is interesting to note that about 82.8% respondents stated their dissatisfaction even after taking treatment in the outlets of their own choice! The mentioned satisfaction of the service seekers plays an important role in their health seeking behaviors and thus in their health care behaviors!

Whether satisfied or not in treatment there
	Frequency	Valid Percent
Satisfied in treatment there	60	17.24
Not satisfied in treatment there	288	82.76
Total	348	100.00

29. Among the interviewed respondents, 75.9% disclosed their reason for dissatisfaction as "Needs time to cure/can’t diagnose properly", whereas, 51.7% for "high fee", 41.4% stated their reasons of dissatisfactions for both "requires repeated visit" and "frequently prescribing injection/I.V. saline". About 31% described their reason for dissatisfaction as "bad behavior of the doctors and staffs of the hospitals".

Among the reasons for satisfaction, "see the patients with care" and "good treatment" accounted for 17.2% and 6.9% respondents respectively.

Factors causes their perceptions of satisfactions have been described here by the respondents. Those are again associated with many other factors .i.e. the factor "high fee of the doctors" is associated with financial capacity of the respondents to utilize his services.

-The respondents expressed their reasons for satisfactions and dissatisfactions which are directly related with their health care behavior. By careful following the reasons and the findings can be very efficiently utilized by keeping the reasons and their possible remedies in the mind during the health policy formation in different levels.

Cause of satisfaction/dissatisfaction

Pct of Pct of

Count Responses Cases

They see the pts. with care 60 6.1 17.2

Needs time to cure/can't diagnose prope 264 26.8 75.9

Requires repeated visit 144 14.6 41.4

Frequently prescribing injection/I.V. sa 144 14.6 41.4

High fee 180 18.3 51.7

Ordering costly pathologies 60 6.1 17.2

Behave badly 108 11.0 31.0

Good treatment 24 2.4 6.9

------ ----- -----

Total responses 984 100.0 282.8

30. Among the interviewed respondents, 93.1% believed the etiology of disease as "from the anger of Allah/God", whereas, 65.5% thought the etiology as "from infection by germs". About 41.4% informed of "other" reasons as the etiology i.e. "dissatisfaction of gods", "dissatisfactions of the nymph" etc. The factor like the traditional belief plays the major role in the context.

-Here, the findings show the extents of the resultants evolved through the dynamic interactions between the traditional beliefs of the population and the influences of the modern knowledge disseminated through different sources regarding the etiology (cause) of the diseases. Surprisingly, still 93.1% respondents stated the etiology as the "punishment from the Allah/God for sins". There are a large proportion of the respondents who believe that also the scheduled Gods/Goddesses and the nymphs are also capable of inflicting diseases to the human beings. It is still unclear to them about the mode of the transmission of the diseases but they thought that as a very complicated method, i.e. some respondents among them who believe in the mentioned "anger or dissatisfactions of the Allah/God or nymph", also believe in the infections by the germs (microorganisms). Their health seeking or care behavior will be thus dependent on the perceived etiology of the diseases!

Etiology of disease

Pct of Pct of

Count Responses Cases

Through bacterial/virus infection 228 32.8 65.5

From the anger of Allah/God 324 46.6 93.1

Others 144 20.7 41.4

------- ----- -----

Total responses 696 100.0 200.0

31. Among the interviewed respondents, 72.4% informed of providing first aids in home for patients, whereas, 27.6% informed of not providing first-aid in home. This is the community based resource playing role in need. These are the skills existing in the community and transferred to the next generation.

A large proportion of the respondents informed about the presence of the important health care behavior in the family diseases in their households, first-aid arrangements in the family.

Whether providing first aids for diseases in home
	Frequency	Valid Percent
Providing first aid in home	252	72.41
Not providing first-aid in home	96	27.59
Total	348	100.00

32. Among the interviewed respondents, 65.5% informed that the female chiefs of the corresponding families had supervised the family first aid. Only 17.2% informed that the male chiefs did it. Another 17.2% informed of the supervision by others like other family members etc. By tradition in Bangladesh, mothers usually are the caretakers in the family members’ sickness. The tradition passes from the mother to her daughter and skills are also transferred. This is an important community based participatory sustainable service option as the solution is available within the family or community. This is again the community resources. If limited modern skills can be infused in this level with modern information and the household level possible skill with the knowledge of effective referral, health hazards could be minimized to a great extent.

-Among the respondents informing their arrangements for family first aid, 65.5% respondents informed of the females in their households as family health care takers which signifies the importance of dissemination the health knowledge among the household females to achieve desired health care behaviors in a population. Traditionally in Bangladesh, specially in the rural areas, mothers, sisters and wives are the caretakers in almost all the places

Supervising home treatment
	Frequency	Valid Percent
Supervised by female chief	228	65.52
Supervised by male chief	60	17.24
Others	60	17.24
Total	348	100.00

33. Among the interviewed respondents, 93.1% expressed their beliefs in traditional/folk medicine, whereas, the rest 6.9% informed of their no belief in traditional/folk medicine. This reflects the important issue of the traditional beliefs and it causes people’s decision for the type of management they would seek for the illness of the family members.

-This finding expresses the strong traditional beliefs of the rural population on folk/traditional medicines. To bring positive changes in their health care behavior, this issues should be keenly considered with respect to indigenous and traditional practices and thus to introduce the modern practice or health care behavior with logics or instances in their own languages and through their own community people in a community based participatory way.

Belief in traditional/folk treatment
	Frequency	Valid Percent
Believe in traditional/Kabiraji/country medicine	324	93.10
Not believing in traditional/Kabiraji/country medicine	24	6.90
Total	348	100.00

34. Among the interviewed respondents, all (100%) respondents stated "green coconut water/ liquid /ORS/ laban-gur preparation (salt-molasses solution)" as the traditional/folk or indigenous treatment of diarrhoea, whereas, 93.1% respondents informed of the "holly water/talisman/exorcism" as the as the traditional/folk or indigenous treatment of diarrhoea. "Herbal extracts/herbs" accounted for 31%, whereas, unfortunately another 51.7% and 24.1% of the respondents opted for "heals spontaneously" and "closure of feeding" respectively indicating existence of potential grave public health risk in the issue still existing in the rural Bangladesh regardless the highly advertised optimistic views of government and many NGOs. These harmful practices evolve from the traditional beliefs of the population, although the lack of education and the financial conditions are also the factors to propel them towards such choices. Their knowledge for home fluids possibly the effects of the information dissemination community based field programs and media campaigns.

-This finding shows the natural modifications of the traditional/indigenous health behaviors in the community by the dissemination of the modern knowledge. It is interesting to note that regardless all respondents’ believe in both traditional and modern remedy of "green coconut water/ liquid /ORS/ laban-gur preparation (salt-molasses solution)" for diarrhea (replenishing depleted body water and electrolytes), almost all them also believe in holy water/talisman or verities of exorcisms! We shall see later in this report the so called presence of influential Ola and Obba, the supernatural deities who were frequently blamed for the disease diarrhea in the rural areas as per the existing traditional myths!

Traditional/folk treatment for diarrhea

Pct of Pct of

Count Responses Cases

Green coconut water/liquid/ORS/laban-gur 348 33.3 100.0

Holly water/talisman/exorcism 324 31.0 93.1

Herbal extracts/herbs 108 10.3 31.0

Closure of feeding 84 8.0 24.1

Heals spontaneously 180 17.2 51.7

------- ----- -----

Total responses 1044 100.0 300.0

35. Among the interviewed respondents, 96.6% described "massaging warm oil/garlic-warm oil in chest" as the traditional/folk treatment for the respiratory infections including pneumonitis in the rural Bangladesh. About 72.4% opted for "ingesting tulsi/other herb extracts", whereas, 48.3% and 31% had opted for "drinking honey with or without hot water" and "eating onion-rice" respectively. About 10.3% opted for "spontaneous healing" signifying potential public risk in the disease still prevailing in rural Bangladesh.

Traditional beliefs, lack of education, lack of information and also the poverty etc. factors are responsible for their options for respiratory tract infections.

-The respondents informed about the various health care behaviors related with indigenous remedies for respiratory infections. But the important most issue is the 10.3% respondents, who informed about the spontaneous healing processes, which may result in grave conditions some times as the patients are not given any treatment.

Traditional/folk treatment of respiratory infection

Pct of Pct of

Count Responses Cases

Massaging warm oil/garlic-worm oil in th 336 33.7 96.6

Hot water drinking/gargling 96 9.6 27.6

Ingesting tulsi/other herb extracts 252 25.3 72.4

Drinking honey with or without hot water 168 16.9 48.3

Eating onion-rice 108 10.8 31.0

Heals spontaneously 36 3.6 10.3

------- ----- -----

Total responses 996 100.0 286.2

36. Among the interviewed respondents, it was curiously unveiled that 62.1% stated the traditional/folk treatment or remedy of RTI/STD as "coitus with virgin/fresh women"! Again 55.2% described "ingesting herbal extracts" as the traditional/folk treatment of RTI/STD, whereas another 69% had opted for "ingesting country elixirs (Saribadi salsa etc). Only 34.5% and 20.7% had been accounted for the more scientific approaches like "irrigating/washing genital organs with saline" and "drinking excess of water" respectively. However, 34.5% opted for potentially risky "heals spontaneously". These harmful knowledge are the results of partially the traditional beliefs, partially for the lack of the proper information in the RTI/STD in the rural areas. Here also the education, poverty and the prohibition of the information flow are the causative factors to retain this knowledge. When the issue becomes forbidden, imaginary information are usually added to that issue, fabrications are made. So, it is better to arrange a limited information flow in the community even on the most forbidden issue to avoid such harmful beliefs and to restrict malicious practices.

-This finding reveals some of the most interesting findings of this study. It is necessary to look after the health care behaviors of the population to design any fruitful and outcome oriented health policy but to do that with appropriate carefulness for the sensitive issues. However, community based strong participatory programs should be taken in right direction to diffuse the confusions and the malpractices in a community’s health care behaviors like the one as "coitus with a virgin to be cured from any venereal disease"! In no circumstances, that can be allowed, but the knowledge dissemination about the etiology and remedy of any venereal disease should be conducted with sufficient skills and through the respects to the indigenous good values of the community.

Health Care Behavior Study in Bangladesh-Knowledge, Attitude and Practice -2nd Part

2009-06-16T02:44:00.000-07:00

37. Among the interviewed respondents, 89.7% opted for "holy water or talisman" as the traditional/folk remedy of abortion, whereas 79.3% depends on the "exorcism and different religious rites" as the traditional remedy for the same. Again 37.9% stated on behalf of "ingesting herbal extracts/Kabiraji /salsa" as the remedy. However, 48.3% opted for alarming "heals spontaneously"! These are results of the traditional beliefs possessed by the rural population and also reflect the lack of knowledge in the context within the community. Also lack of availability of the service options in the community worsens the situation.

The abortion is a comparatively complicated situation in social or medical contexts. Socially in the rural Bangladesh this is like a forbidden issue, a taboo or prohibited issue which can’t be discussed normally. For the reasons, modern knowledge and health care practices about the abortion couldn’t be disseminated in the rural community and thus the abortion remains vulnerably medieval! Thus, we can see abundance of the rituals to satisfy supernatural powers to get rid of it! Since last decade, family planning services are often discussed in the rural community of Bangladesh, however, no such discussions or counseling on abortion is still lacking. It can be mentioned that, Bangladesh’s on of the major development partner and donor USAID never donates money in any project where there is plan for abortion! But abortion is seen as a must in a society (whatever the number of percentage!) and has been practiced in every community since the inception of the human civilization including the rural Bangladesh! So, if any one wants abortion for medical or social causes, so option is present in the community. Most of the religious leaders of Islam in the rural Bangladesh deny family planning or contraception, a known reason is contraception may obstruct or even diminish the chance for Emam Mahdi to be born in the earth for salvation of the human races! In this way, the abortion remains one of the most forbidden issues among the population.

Traditional/folk treatment for Abortion

Pct of Pct of

Count Responses Cases

Exorcism/religious rites 276 30.3 79.3

Holly water/talisman etc. 312 34.2 89.7

Heals spontaneously 168 18.4 48.3

Others 24 2.6 6.9

Ingesting herbal extracts/Kabiraji /sals 132 14.5 37.9

------- ----- -----

Total responses 912 100.0 262.1

38. Among the interviewed respondents, 72.4% opted for "eating rice with herbal preparation’ and also another 69% described "ingesting herbal extracts/elixirs" as the traditional/folk remedy of jaundice. "Exorcism/religious treatment" as the remedy of jaundice opted by 51.7% respondents, whereas, 37.9%, 24.1% and 37.9% informed of "bathing under supervision of a holly man", "applying herbal pulp on the body and head" and "wearing sanctified talisman/necklace/wristband" respectively as the traditional or folk remedy of jaundice. Whereas, the scientific approach "ingesting sugar cane juice" practiced as remedy of jaundice by only 3.4%.

-Jaundice still remains as a most mysterious disease among the rural population in Bangladesh. It is important to see that the health care behaviors are mostly practiced in the line of the perceived etiology of the diseases. For jaundice, many myths and descriptions are prevailing in the rural community and those are all very strongly embedded in the traditional and indigenous beliefs of the rural population. Even the educated people also have certain degree of superstitions. For Jaundice, the prevailing superstitions are much more in numbers, so in this finding, we observe the various remedy procedures.

Traditional/folk treatment for jaundice

Pct of Pct of

Count Responses Cases

Exorcism/religious treatment 180 17.2 51.7

Eating rice with herbal preparation 252 24.1 72.4

Ingesting herbal extracts/elixirs 240 23.0 69.0

Wearing sanctified talisman/necklace/wris 132 12.6 37.9

Applying herbal pulp on the body and hea 84 8.0 24.1

Others 12 1.1 3.4

Bathing under supervision of a holly man 132 12.6 37.9

Ingesting sugar cane juice 12 1.1 3.4

------- ----- -----

Total responses 1044 100.0 300.0

39. Among the interviewed respondents, 96.6% described the traditional or folk remedy of hysteria through "exorcism/religious treatment/religious rite", whereas, 86.2% stated the remedy as "through use of "holly water/talisman etc." Curiously interesting that 48.3% opted for "smelling burn chilly in the nostrils" as the remedy for hysteria. Again 6.9% described the remedy as "goddess Kali's worship"! Whenever there is knowledge gap in any issue in the community and also the flow of knowledge in the issue is not available, , traditional beliefs and the myths become the only means through which the rural population describe the issue.

-Like Jaundice, hysteria also have varieties of etiologies and the remedy procedures also follow those, but only difference is the hysteria is much less known among the rural population and in almost all the instances, it is referred to the phenomenon of "possession" by the nymphs!

Traditional/folk treatment for hysteria

Pct of Pct of

Count Responses Cases

Exorcism/religious treatment/religious r 336 32.2 96.6

Holly water/talisman etc. 300 28.7 86.2

Smelling sole of the footwear 60 5.7 17.2

Smelling burn chilly in the nostrils of 168 16.1 48.3

Drinking herbal extracts/elixirs 72 6.9 20.7

Heals spontaneously 84 8.0 24.1

Through goddess Kali's worship 24 2.3 6.9

------- ----- -----

Total responses 1044 100.0 300.0

40. Among the interviewed respondents, 75.9% described "exorcism/religious treatment" as the traditional remedy for mental retardation. Again another 82.8% opted for the use of "holly water/talisman" as the traditional or folk remedy for mental retardation in the rural Bangladesh. Remedy through spontaneous process had been described by 51.7% of the respondents. "Kali sadhan or special rite to satisfy the nymphs had been prescribed by 6.9%, whereas, 17.2% opted for praying to Allah/God for the remedy. Here also the knowledge gap is the determinant of the evolvement of the story and myths depending upon the traditional beliefs and other old myths.

-Like hysteria, mental retardation is also very rarely known, having various perceived etiologies and the remedy or health care behaviors follow those etiological pathways!

Traditional/folk treatment for mental retardation (Multiple Response)

Pct of Pct of

Count Responses Cases

Exorcism/religious treatment 264 27.8 75.9

Holly water/talisman 288 30.4 82.8

Heals spontaneously 180 19.0 51.7

Others 84 8.9 24.1

Pray to Allah (God) for remedy 60 6.3 17.2

Don't know 48 5.1 13.8

Through goddess Kali's worship (Kali-sad 24 2.5 6.9

------- ----- -----

Total responses 948 100.0 272.4

41. Among the interviewed respondents, 79.3% stated that they feel ashamed to be treated (going to doctor, telling to the family members about the disease etc. The feelings evolve from the thinking that the spending of money for him/her for treatment, will worsen the family economic condition (as they are poor). Also if he was income earning, his family will be deprived from his earning when diseased. Even if the family is solvent, still the diseased individual becomes ashamed as she/she is causing extra burden to the family.

-Shame is frequently associated with the feelings of "guilt" and the stigma and in the case of health care behaviors; it is the feeling of guilt and stigma due to be diseased which predisposes to their health care behavior.

Shyness to be treated
	Frequency	Valid Percent
Feel shy to be treated	276	79.31
Don't feel shy to be treated	72	20.69
Total	348	100.00

42. Among the interviewed respondents, 89.7% feel guilty if diseased/possesses stigma if diseased. As stated earlier, factors existing in the community oblige the diseased to feel stigma and guilt.

-As it discussed previously, this feelings of "guilt" or stigma can predisposes to the built of their health care behaviors.

Feelings of guilt if diseased
	Frequency	Valid Percent
Feels guilty if diseased/possesses stigma	312	89.66
Don't feel guilty if diseased/not possessing stigma	36	10.34
Total	348	100.00

43. Among the interviewed respondents 68.97% believed the disease as the punishment from the Allah/God. This is anther example of the combined effect of poverty, lack of education and possessed traditional beliefs.

-Another important finding which is capable of forming their health care behaviors. Some times when diseased, whether they will stick for the remedy procedures through treatment or becoming reluctant to variable degrees depend upon their beliefs how the diseases are evolved.If it is seemed to be a godly affair, then human has naturally to do little in the context!

It reflects the traditional beliefs of the population. Education and poverty (as the any treatment requires money) also play major role in the context.

Believes disease as the punishment from the God
	Frequency	Valid Percent
Think the disease as the punishment from God	240	68.97
Don't think disease is the punishment from God	108	31.03
Total	348	100.00

44. Among the interviewed respondents, 93.1% described "ingesting rotten/decomposed/ contaminated" as the etiology of diarrhoea/Cholera/Bhedbami, whereas, 51.7% informed of "if anybody special watches pt. to eat" as the etiology of diarrhoea/Cholera/Bhedbami. Curiously interesting "anger of scheduled local goddess Ola/Obba" and "Eating in odd time" had been suggested by same proportions of the respondents (34.5% for the both) and respectively. "Night/noon traveling after eating palm cake" was stated as the cause by 31%.

This is a typical example how the traditional beliefs and modern knowledge compromises with each other as we find response from disseminated modern knowledge and possessed traditional beliefs. Traditional beliefs are the determining factors in the context. Again this is a typical example how the traditional beliefs can affect the mind of the individuals and influence his health seeking behavior.

-Here the etiologies perceived by the respondents for diarrhoea/Cholera/Bhedbami and are dominated by the traditional beliefs with the elements of religious and local myths. Although we saw in previous discussions that they are in favor of practicing replenishing fluids and electrolytes as the positively changed health care behavior.

Etiology of diarrhoea/Cholera/Bhedbami

Pct of Pct of

Count Responses Cases

Ingesting rotten/decomposed/contaminated 324 32.5 93.1

Eating food prepared with contaminated/a 96 9.6 27.6

If anybody special watches pt. to eat or 180 18.1 51.7

Traveling in night or noon after eating 108 10.8 31.0

Eating in odd time 120 12.0 34.5

Viewing mysterious cat/dog in night whil 48 4.8 13.8

Anger of scheduled Hindu goddess Ola 120 12.0 34.5

------- ----- -----

Total responses 996 100.0 286.2

45. Among the interviewed respondents, all (100%) described "getting cold" as the etiology of respiratory infection. "Becoming wet in rain/exposed to open space" and "Staying with a patient of cold/cough" both were described as the etiologies by 72.4% of the respondents for the same.

-This finding expresses their perceptions about the etiologies of respiratory infections and their health care behaviors usually follow the routes of the etiologies perceived.

Etiology of pneumonia

Pct of Pct of

Count Responses Cases

If got cold 348 38.7 100.0

Becoming wet in rain/exposed to open spa 252 28.0 72.4

Staying with a pt. with cold/cough 252 28.0 72.4

Others 48 5.3 13.8

------- ----- -----

Total responses 900 100.0 258.6

46. Among the interviewed respondents, 79.3% described going to "bad" places/coitus with prostitute or unknown person as the etiology of reproductive tract infection and sexually transmitted disease. About 51.7% informed of "sexual partner/self/staying unclean/dirty" as the etiology of the same. Considerable high percentage of respondents expressed their various superstitions as the etiology of reproductive tract infection and sexually transmitted infection (table). Here we see, they have some correct and some incorrect information. Correct one is the results of the modern information dissemination in the community and the incorrect one is usually from their indigenous traditional beliefs.

-This finding reflects the perceptions of the respondents regarding the Reproductive tract Infections (RTI) and the Sexually Transmitted Diseases (STD) and those are the mixtures of the facts and the fictions!

Etiology of RTI/STD

Category label

Pct of Pct of

Count Responses Cases

Sexual partner/self/staying unclean/dirt 180 17.2 51.7

Going to/coitus with "bad" places/prosti 276 26.4 79.3

Accompany of RTI/STD pt. 72 6.9 20.7

Wearing dresses of an pt./using pt. bed 48 4.6 13.8

Using a common urinal 36 3.4 10.3

Wet genitalia 144 13.8 41.4

Coitus with women in menstruation 144 13.8 41.4

Too much coitus 144 13.8 41.4

------- ----- -----

Total responses 1044 100.0 300.0

46. Among the interviewed respondents, 72.4% claimed "coitus in pregnancy/repeated coitus". "Eating/drinking/herbal foods/extracts" and Inflicted with unseen influence of black magic", both stated by 51.7% of the respondents as the etiologies of abortion in rural Bangladesh. Claims like "Eating pineapple/leaf/papaya/carrot" had been described respectively by 41.4% respondents. This finding also describes the traditional beliefs of the population; also lack of effective information flow is marked. It is also reflecting their century old knowledge about the use of pineapple leaf, papaya, carrot which can ease abortion due to the pharmacologic components within.

-Reflecting the respondents’ perceptions for the etiologies of the abortion and those are also a mixture of facts and fictions as mentioned above.

Etiology of abortion

Category label

Pct of Pct of

Count Responses Cases

Eating/drinking/herbal foods/extracts/el 180 17.2 51.7

Inflicted with unseen influence of black 180 17.2 51.7

Staying unhealthy 84 8.0 24.1

Coitus in pregnancy/repeated coitus 252 24.1 72.4

"Bad" thinking in pregnancy 24 2.3 6.9

Traveling in old shrines/lonely places 72 6.9 20.7

Traveling in "bad" time (in dawn/dusk) 60 5.7 17.2

Early marriage/late marriage/early/late 48 4.6 13.8

Eating pineapple/pineapple leaf/papaya/ca 144 13.8 41.4

------- ----- -----

Total responses 1044 100.0 300.0

47. Among the interviewed respondents, 79.3% and 72.4% claimed etiology of jaundice as "possession by scheduled goddess" and "black magic/ban or witchcraft or deploying evil power" respectively. Staying in the wet places", "Ingestion of excessive turmeric in food/working in the turmeric field", "attending turmeric day in a marriage ceremony" etc described as etiology by appreciable percentage of respondents. In this finding knowledge gap is evident in the rural community. No respondent, regardless their economic condition could tell about the modern knowledge for the jaundice. However, even most described, jaundice remained as the least clarified syndrome till date in Bangladesh as even the educated people rarely can tell its etiology (the etiology supported by the modern science is also very much complicated to describe). So when there is gap in knowledge, myths appear through the interested quarters and even the educated people submit themselves under the disposal of the traditional healers who disseminate the myth to earn his income earnings.

-In the same way, the respondents’ perceptions on the etiologies of the Jaundice were explored and seen as totally a confused issue. They have variable understandings regarding the etiologies of the Jaundice and unfortunately their health care behaviors are always guided by the etiological perceptions prevailed!

Etiology of jaundice

Category label

Pct of Pct of

Count Responses Cases

Possession by scheduled goddess couple/" 276 28.4 79.3

Black magic/ban/witch craft/deploying ev 252 25.9 72.4

Ingestion of excessive turmeric in food 96 9.9 27.6

Eating rotten/decomposed/day old food/dr 24 2.5 6.9

Repeated work in turmeric field 72 7.4 20.7

Attending turmeric day in a marriage cer 24 2.5 6.9

Others/staying in wet place 120 12.3 34.5

Lack of vitamins 60 6.2 17.2

Don't know 36 3.7 10.3

Eating egg in fever 12 1.2 3.4

------- ----- -----

Total responses 972 100.0 279.3

48. Among the interviewed respondents, 75.9% and 72.4% claimed "possession by spirit of dead died unnaturally" and "possession by supernatural/evil power" respectively as the etiology of hysteria. All the responses seemed to be linked with their traditional myths.

Hysteria is another disease still thought with varieties of myth. As the females are sufferer, the traditional healers and the family elders in the rural areas usually describes it as a disease inflicted by the supernatural powers. The main factors are the traditional beliefs, lack of education and also the poverty. Information gap is the determinant.

-Perceived etiologies for the hysteria are responsible for their health care behaviors in response to this disease and it is seen that all the perceived etiologies are related with supernatural myths prevailing in the rural Bangladesh.

Etiology of hysteria

Category label

Pct of Pct of

Count Responses Cases

Possession by supernatural/"evil" power 252 24.1 72.4

Possession by the spirits of dead died o 264 25.3 75.9

Black magic/witch craft/deploying evil f 96 9.2 27.6

Caught by bad wind containing evil power 228 21.8 65.5

Fed with unconventional meat (vulture,crow) 60 5.7 17.2

Going outside in kali goddess night 144 13.8 41.4

------- ----- -----

Total responses 1044 100.0 300.0

49. Among the interviewed respondents, 58.6% and 48.3% claimed "possessions by supernatural/"evil" power" and "black magic/witch craft/deploying evil force" respectively as the etiology of mental retardation. Mythical "going outside in kali goddess night (Kali puja)" claimed by 37.9% as the etiology of mental retardation. It is surprising that very few admitted that they did not know the scientific etiology and nobody were reluctant to tell something as etiology of "mental retardation". Traditional beliefs are the important factor for the perceptions.

-All the etiologies perceived by the respondents for mental retardation are related with popular myths or legends and are far from the modern conceptions. Health care behaviors in response to this disease so follows the etiological causes!

Etiology of mental retardation

Category label

Pct of Pct of

Count Responses Cases

Possession by supernatural/"evil" power 204 22.1 58.6

Possession by the spirits of dead died o 168 18.2 48.3

Black magic/witch craft/deploying evil f 168 18.2 48.3

Caught by "bad wind" containing evil pow 12 1.3 3.4

Fed with unconventional food (vulture,cr 156 16.9 44.8

Others 24 2.6 6.9

Going outside in kali goddess night 132 14.3 37.9

Don't know 60 6.5 17.2

------- ----- -----

Total responses 924 100.0 265.5

50. Among the interviewed respondents, 82.8% claimed the etiology as "fed with unconventional meat (of vulture, crow, fox etc)" and 69% claimed "possession by supernatural/"evil" power" as the etiology of madness. "Possession by the spirits of dead died" comes here as etiology stated by 55.2% respondents." Black magic/witch craft/deploying evil" and "Going outside in kali goddess night (Kali puja)" claimed by 44.8% and 31% respondents respectively as the etiology of madness. Here also the traditional beliefs are important factors.

-Perceived etiologies of the "madness" are described by the respondents in this findings and are all subjected to the popular myths, legends and tales prevailing in the community and too far from the modern conceptions and thus unfortunately their health care attitudes are formed in the relation of the etiologies perceived.

Etiology of madness

Pct of Pct of

Category label Count Responses Cases

Possession by supernatural/"evil" power 240 23.0 69.0

Possession by the spirits of dead died o 192 18.4 55.2

Black magic/witch craft/deploying evil f 156 14.9 44.8

Caught by "bad wind" containing evil pow 36 3.4 10.3

Fed with unconventional food (vulture,cr 288 27.6 82.8

Others 24 2.3 6.9

Going outside in kali goddess night 108 10.3 31.0

------- ----- -----

Total responses 1044 100.0 300.0

51. Among the interviewed, 89.7% sated for the both "harm by different religious/spiritual rite" and "harm through witchcraft" as the etiology of "Ban"! About 79.3% respondents claimed and justified etiology of their "ban" respectively as "black magic with hair, nail/cloth of victim".

-Similar to their own terminology of the "Ban", their perceptions on its etiologies are also all local myths, tales and legends. Here we see the presence of the medieval "witchcraft" and magic/counter magic conceptions related with the etiologies of the diseases!

Etiology of "Ban"

Pct of Pct of

Category label Count Responses Cases

Doing harm through different religious a 312 29.9 89.7

Fed with unconventional food(vulture, kite 144 13.8 41.4

Doing harm through witchcraft 312 29.9 89.7

Black magic with hair, nail/cloth of vic 276 26.4 79.3

------- ----- -----

Total responses 1044 100.0 300.0

52. Among the interviewed respondents, 100% and 89.7% claimed "doing harm by religious/ kali goddess rites" and "Black magic with hair, nail, cloth of victims" respectively as the etiology of black magic. Interestingly, 6.9% and 3.4% described the etiology for the same as "others" and "impelling a doll for the victim (Voodoo)" respectively which resemble closely with West Indian or African Voodoo black magic.

-"Black magic" is affecting the health as perceived by most of the rural population studied and all the perceived etiologies are related with magic and counter magic businesses! Here we observe similarities between our rural "black magic" with African and West Indian Voodoo magic, at least in the procedures.

Etiology of "black magic"

Pct of Pct of

Category label Count Responses Cases

Doing harm by religious/rites/kali godde 348 50.0 100.0

Black magic with hair, nail, cloth of vi 312 44.8 89.7

Others 24 3.4 6.9

Through impelling a doll in name of victim 12 1.7 3.4

------- ----- -----

Total responses 696 100.0 200.0

53 Among the interviewed respondents, 72.4% and 58.6% claimed "travel in inappropriate places in odd time" and "night travel through the place of cremation" respectively as the etiology of the "evil air". Goddess Kali again blamed for 41.4% response as the etiology of "evil air"!

-The respondents’ perceived phenomenon of "bad air" or "evil air" and the perceived etiologies underlying have been found in this findings.

Etiology of "evil air"

Pct of Pct of

Category label Count Responses Cases

Travel in inappropriate places in odd ti 252 24.4 72.4

Travel under big trees or through jungle 49 4.7 14.1

Travel through the place of cremation o 204 19.7 58.6

Travel in night with palm cake or fish 144 13.9 41.4

Going behind the house in night or odd t 120 11.6 34.5

Traveling near the grave of a person die 120 11.6 34.5

Going out in the Kali/charak puja night 144 13.9 41.4

------- ----- -----

Total responses 1033 100.0 296.8

54. Among the interviewed respondents, interestingly 62.1%, 65.5% and 34.5% claimed etiology of "fearfulness" as "being afraid by any means", "going outside or travel in night of new moon" and "seeing cat or dog in village road or bush in night" respectively. Goddess Kali puja night scored 37.9% response among the people of all religion in rural area of Bangladesh.

The respondents’ perceived phenomenon of "fearfulness" and the perceived etiologies underlying have been found in this findings.

Etiology of "fearfulness"

Pct of Pct of

Category label Count Responses Cases

Through being afraid by any means 216 21.7 62.1

To go outside or travel in night of new 228 22.9 65.5

Seeing a cat or dog in road or bush invi 120 12.0 34.5

Travel in inappropriate places in odd ti 48 4.8 13.8

Travel under big trees or through jungle 24 2.4 6.9

Travel through place of cremation of de 108 10.8 31.0

travel in night with palm cake or fish 48 4.8 13.8

Going behind the house in night or odd t 36 3.6 10.3

Travel near the grave of a person died o 36 3.6 10.3

Going out in the Kali/Shyama puja night 132 13.3 37.9

------- ----- -----

Total responses 996 100.0 286.2

55. Among the interviewed respondents, about 41.4% and 37.9% opted for "quack/non-M.B.B.S. private doctors" and "private M.B.B.S. doctors" respectively for treatment if have sufficient money. Interestingly "government hospitals" accounted for only about 10.3% respondents reflecting rural people’s attitude to these outlets.

-This finding expressed their choice of treatment outlets if they were provided with sufficient money! It is interesting to observe that they opted for relatively modern treatments whatever they perceived like MBBS and non-MBBS paramedics. This finding again expresses the respondents’ one of the main constraints for planning their health care behaviors in response to any health ailment.

Choice of treatment if have sufficient money
	Frequency	Valid Percent
Government hospital	36	10.34
Private M.B.B.S. doctors	132	37.93
Quack/non-M.B.B.S. private doctors	144	41.38
Homeopath/Kabiraji/traditional healers	36	10.34
Total	348	100.00

56. Among the interviewed respondents, 82.8% and 79.3% informed of the disease cured by Allah/God’s wish and through proper treatment respectively. About 31% described healing spontaneously indicating misconception related to grave public health risk.

-This finding informed us the respondents’ perceptions about the remedies of the diseases and vast majority depended on the divine blessings. Almost equal majority of the respondents emphasized on the proper treatment as the remedies of the diseases.

How the diseases are cured

Pct of Pct of

Category label Count Responses Cases

Spontaneously 108 12.9 31.0

Through proper treatment 276 32.9 79.3

Through (both) proper treatment and God' 24 2.9 6.9

God’s wish 288 34.3 82.8

Others 144 17.1 41.4

------- ----- -----

Total responses 840 100.0 241.4

57. Among the interviewed respondents, it is of particular interest, 93.1% informed that their source of health information (whatever the qualities) is "imam/priest/religious personality", whereas, 34.5% described "government health workers" for it. Also of interest that NGO contributed only for 6.9% as the source of health information.

-While exploring the sources of health information, we found vast majorities of the respondents informed of the "imam/priest/religious personality", although the qualities of the information from this source always remain doubtful for known reasons. Far less number of respondents informed of the source as "government health workers", but most of the information from this source are reasonably counted as correct or modern.

Source of health information

Pct of Pct of

Category label Count Responses Cases

Government health workers 120 17.2 34.5

NGO health workers 24 3.4 6.9

Radio/TV/news paper/mass-media 24 3.4 6.9

School teacher 24 3.4 6.9

Imam/priest/religious personality 324 46.6 93.1

Social leaders/local elite/community lea 60 8.6 17.2

Others 84 12.1 24.1

Quack doctor/pharmacist/village doctors/ 36 5.2 10.3

------- ----- -----

Total responses 696 100.0 200.0

59. Among the interviewed respondents, about 41.4% described "private M.B.B.S. doctors" and about 34.5% informed of "Quack/non-M.B.B.S. private doctors" as the best treatment providers. However, only about 13.8% thought "Government hospital" as the best treatment providers.

-The perceived MBBS doctors as the best treatment providers when rendering treatment privately, however, they are not perceived to do so when they render treatment from Government hospitals! It is interesting to note that, the respondents didn’t fail to identify the most modern care givers, but again, the trouble is with their "private" status which is related with their high payments mostly.

Best treatment provider according to the respondents
	Frequency	Valid Percent
Government hospital	48	13.79
Private M.B.B.S. doctors	144	41.38
Quack/non-M.B.B.S. private doctors	120	34.48
Homeopath/Kabiraji/traditional healers	36	10.34
Total	348	100.00

60. Among the interviewed respondents, about 96.6% expressed their dissatisfaction in treatment in government hospitals in general.

-This finding on the service seekers’ satisfactions in the treatments in Government hospitals invariably affects their health care behaviors, adversely in most cases, as they go to some cheaper outlets (homeopathy, kobiraji etc.).

Satisfaction in treatment in the Government hospitals
	Frequency	Valid Percent
Satisfied	12	3.45
Not satisfied	336	96.55
Total	348	100.00

61. Among the interviewed respondents, 69% informed their cause of dissatisfaction as "behavior of the doctors/staffs in government hospitals is not good and less care". About 58.6% were dissatisfied because of unavailability of required medicines, whereas 62.1% showed their dissatisfaction due to absence of doctor in the outlets/hospital. However, only 3.4% respondents are satisfied in government hospitals putting reason of having best doctors there.

-Policy making levels should be aware of these finding as these affect the health care behaviors of the population.

Reasons for not satisfied in Govt. hospital

Pct of Pct of

Category label Code Count Responses Cases

(Dissatisfaction)Doctors available rarely 216 22.2 62.1

(Dissatisfaction)Behavior no good/no care 240 24.7 69.0

(Dissatisfaction)Medicines not available 204 21.0 58.6

(Dissatisfaction)Environment not good 108 11.1 31.0

(Dissatisfaction)Hospital not clean 96 9.9 27.6

Dissatisfaction) Beds not good 48 4.9 13.8

Others 24 2.5 6.9

(Satisfaction)They are the best doctors 12 1.2 3.4

Don't know 24 2.5 6.9

------- ----- -----

Total responses 972 100.0 279.3

62 Among the interviewed respondents, about 55.2% admitted that the disease could be healed through spiritual means. However, about 44.9% did not agree in the issue.

-Majority of the respondents still believe that the diseases can be healed through spiritual means!

Whether diseases can be treated with spiritual means
	Frequency	Valid Percent
Yes	192	55.17
No	156	44.83
Total	348	100.00

63. Among the interviewed respondents, about 89.7% thought male’s permission was necessary for the treatment of female family members.

-Reflecting the governing male roles in the rural Bangladeshi community.

Male's permission for the treatment of the females
	Frequency	Valid Percent
Male's permission required to treat female pt.	312	89.66
Male's permission does not require	36	10.34
Total	348	100.00

64. Among the interviewed respondents who supported the view of male’s permission for female’s treatment, about 38.5% respondents put the cause as "males are the head of the family", whereas about 23% put the cause as "Males are income earning ". However, about 7.7% did not know why they advocated for the male’s permission!

-These are the excuses for those overriding male roles in the community. Answer to these excuses should be made available for a successful health policy.

Causes for seeking males’ permission for treatment of the females
	Frequency	Valid Percent
Males are the head of the family/	120	38.46
Males are income earning	72	23.08
Males re are more knowledgeable/educated	60	19.23
Male's are always decision makers	36	11.54
Don't know	24	7.69
Total	312	100.00
System	36
	348

65. Mean expense for the treatment of diarrhoea was notified as about Tk. 70 where minimum and maximum were Tk. 50 and Tk. 100 respectively.

-Gives us an idea of the specific treatment costs for once according to the respondents

Average cost (in taka) in diarrhea treatment
	Frequency	Valid Percent
50	84	24.14
60	72	20.69
70	72	20.69
75	24	6.90
80	24	6.90
100	72	20.69
Total	348	100.00

66. Mean expense for the treatment of pneumonia/grave respiratory infection was notified as about Tk. 180 where minimum and maximum were Tk. 90 and Tk. 250 respectively.

Average cost (in taka) the treatment of pneumonia
	Frequency	Valid Percent
90	24	6.90
100	24	6.90
150	120	34.48
200	96	27.59
250	84	24.14
Total	348	100.00

67. Mean expense for the treatment of Reproductive Tract Infection (RTI)/Sexually Transmitted Disease (STD) was notified as about Tk.266 where minimum and maximum were Tk. 100 and Tk. 400 respectively.

Average cost (in taka) in RTI/STD treatment
	Frequency	Valid Percent
100	24	6.90
150	36	10.34
200	96	27.59
250	60	17.24
300	24	6.90
400	108	31.03
Total	348	100.00

68. Mean expense for the treatment of abortion was notified as about Tk. 591 where minimum and maximum were Tk. 150 and Tk. 1000 respectively.

Average cost (in taka) in treatment of abortion
	Frequency	Valid Percent
150	24	6.90
400	60	17.24
500	12	3.45
600	132	37.93
700	60	17.24
750	36	10.34
1000	24	6.90
Total	348	100.00

69-An important finding for the management of Jaundice, policy makers should emphasize the respondents’ perceptions about etiology of Jaundice as the health care behaviors depend on that.

Desired modern/scientific treatment of jaundice
	Frequency	Valid Percent
Occasionally keen for modern treatment	96	27.59
Never keen for modern treatment	252	72.41
Total	348	100.00

70. Among the interviewed respondents, 93.1% opted for "homeopath/Kabiraji/traditional healers" if got jaundiced! Again, the rest 6.9% disclosed their desired treatment centers/healers as "religious/spiritual healers" if become jaundiced!

-Vast majority of the respondents opted for Homeopathy if the disease is Jaundice; the rest is opted for the spiritual healings! It is linked with their perceptions of the etiologies of jaundice and thus the health care behaviors are developed.

Desired outlet in the treatment of jaundice
	Frequency	Valid Percent
Homeopath/Kabiraji/traditional healers	324	93.10
Religeous/spiritual healers	24	6.90
Total	348	100.00