Department of Primary Care and Public Health

Research has documented that, around the world, women who are childless against their will suffer from an array of social, economic and emotional difficulties. The causes of this suffering are primarily related to their gender position in society and their gender identity. This paper addresses the impact of class differences on the gender-related suffering of childless women in the socially very hierarchically structured society of Bangladesh. The main method was gathering life histories of illiterate rural poor childless women and educated urban middle-class childless women. The rural childless women experience strong stigma in society, as their identity is devalued due to their inability to produce children. As a result, they suffer from feelings of guilt, role failure, loss of self-esteem, abandonment by the family, social isolation, and impoverishment. In contrast, because of their relatively high socio-economic status and good educational background, urban childless women have more opportunities to avail themselves of alternative social identities and thus avoid social isolation. Despite these differences, both groups of women lead frustrated lives, burdened with a deep sense of guilt for not being able to produce children.

Qualitative research was conducted in rural Bangladesh to identify salient illness categories and perceptions of illness severity among women. Data were gathered using the techniques of free listing, pile sorting, and severity ratings. In-depth interviews were also employed for collecting examples of illness episodes and delineating explanatory models. Women's reproductive tract illnesses were among the more salient and serious health problems for which care is sought. Data gathered through pile sorting demonstrate that women in this rural community have clear conceptions of illness groups, with different strategies of treatment for various categories. This analysis suggests that new initiatives concerning women's reproductive health are needed in this rural region.

This article explores the mismatch that exists between what unmarried adolescents in Bangladesh experience, want and need in regard to their sexuality and what they receive from their society, which negatively impacts on their understanding of sexuality and their well-being. The findings provide a picture of Bangladeshi adolescents' (12-18 years) sexual feelings, experiences, behaviours, anxieties and concerns - in particular in relation to desire, pleasure, sexual power, masturbation, virginity, romantic love and dating, and arranged marriage - and how socio-sexual norms and taboos influence these. Curiosity of boys and girls about sex was driven by a need and desire to know and understand, but also because it was exciting to read about and talk about sex. Young people are not just passive recipients of adult norms and messages around sexuality, but agents who actively construe meanings and navigate between what is expected from them and what they want, need and feel themselves. Adolescents have a need for information and support - long before they ever have sex. We call for a positive, rights-based approach to sexuality education for adolescents and a focus beyond health outcomes alone to support adolescents and young people to make sense of the multiplicity of messages they encounter and reduce unnecessary feelings of guilt and anxiety.

Violence against women is a social mechanism confirming women's subordination in many societies. Sexual violence and harassment have various negative psychological impacts on girls, including a persistent feeling of insecurity and loss of self-esteem. This article aims to contextualize a particular form of sexual harassment, namely “eve teasing”, experienced by Bangladeshi adolescent girls (12–18 years) which emerged from a study of adolescent sexual behaviour carried out by young people. The study used qualitative methods and a participatory approach, including focus group discussions, key informant interviews and observation. Despite taboos, unmarried adolescents actively seek information about sex, erotic pleasure and romance. Information was easily available from videos, mobile phone clips and pornographic magazines, but reinforced gender inequality. “Eve teasing” was one outlet for boys' sexual feelings; they gained pleasure from it and could show their masculinity. The girls disliked it and were afraid of being blamed for provoking it. Thus, “eve teasing” is a result of socio-cultural norms relating to sexuality, as well as a lack of access to sexual and reproductive health information and services in Bangladesh. These findings underscore the importance of comprehensive sexuality education that goes beyond a mere health focus and addresses gender norms and helps youth to gain social-sexual interaction skills.

Infertility remains a neglected issue in Bangladesh’s reproductive health policy; instead, the emphasis has always been on the problem of overpopulation. As a result the dominant state ideology in Bangladesh is related to controlling fertility, and the implementation of Family Planning programmes has become a success story for the country (Ahmed and Chowdhury, 1999; Country Report, 2006). Although no epidemiological study has been conducted in the national level to know the prevalence rate of infertility in Bangladesh, a global review of infertility from the World Fertility Survey and others estimated infertility rates in South Asian countries stated 4% in Bangladesh. Another estimate of overall primary and secondary infertility in South Asia, on the basis of women at the end of their reproductive lives in the age group 45-49 years, suggests an infertility rate of approximately 15% in Bangladesh (Vaessen, 1984; Farely, 1988, cited in Kumar, 2007), which is the highest among all South Asian countries.  There is evidence that potential causal factors of infertility are also widely present in Bangladesh. Studies showed that in the South Asian region reproductive health problems such as sexually transmitted diseases (STD), urinary tract infections (UTI), reproductive tract infections (RTI), unhygienic delivery, postpartum infection and unsafe obstetric and abortion procedures are linked to sepsis and pelvic infections, which can cause infertility (Unisa, 2010; Ali et al., 2007; Prasad 2005; WHSEA, 2002a; Jejeebhoy, 1998). A report by WHSEA (2002b) suggested that the prevalence of STDs in Bangladesh is still unknown, but following their analysis of small scale studies conducted between 1989 and 1997, Bangladesh has a high prevalence of STDs. Other investigation reported that the estimated number of people with STDs in the country is around 2.3 million (SDNP-2002). A recent study of truck drivers in Bangladesh found a high prevalence of the herpes simplex virus (HSV-2), at 25.8% (Gibney et al., 2002). WHSEA’s (2002b) report also suggested that in Bangladesh the prevalence of RTIs amongst women is 56% in rural and 60% in urban settings.  It is noted in addition, that because of the under-reporting of secondary infertility in health facility based studies, the information that is available on causes of infertility is likely to consistently underestimate the role of infections, which are the most frequent cause of secondary infertility, 55% as reported by WHSEA (2002a). Compounding the problem is the increasing number of abortions and unhygienic birth practices in Bangladesh, which can also result in a higher likelihood of pelvic infections. It has been observed that only 5% of births in Bangladesh are attended by a health professional (WHSEA, 2002b) and abortion practice have increased in recent times in the country (Rahman, 2000). A cross-sectional study revealed that 66% of the women surveyed reported that they had experienced at least one complication during their last pregnancy and/or childbirth (Ahmed et al., 1998).  Furthermore, the other indirect causal factors of infertility are also worth mentioning here, such as poverty, tuberculosis, malnutrition, anaemia, and low-birth-weight. For example it is already acknowledged that poverty increases the risk of infertility in many ways, for example, the scarcity of water and the lack of access to nutrition and health care make women more vulnerable to RTI, which may cause secondary infertility among them (Unnithan-Kumar, 2001). This is the case in Bangladesh, where 36% of people live below the poverty level. Also a number of studies done in India found that tuberculosis is another indirect causal factor of female infertility (Haque, 2002; Kumar, 2008). Haque (2002) reported globally Bangladesh ranks as the fourth highest country in terms of the prevalence of TB, and contains 3.6% of the TB cases diagnosed worldwide. There is also evidence of the effect of maternal nutritional status, e.g. weight and mid-arm circumference, and anaemia on the incidence of sterility (Jejeebhoy, 1998; Singh, 2007). According to a Human Development report, 59% of young girls suffer from chronic malnutrition in Bangladesh (WHSEA, 2002b). This is further confirmed through the Government of Bangladesh Country Report (2000), which stated that approximately 70% of pregnant mothers in Bangladesh suffer from malnutrition and high rates of anaemia (Country Report, 2000). Another factor contributing to infertility is low-birth-weight, with 50% of all infants in Bangladesh being born underweight (Fuchs, 1992).  In addition to these practical issues, infertility has a deep cultural dimension. Whilst Bangladesh is an anti-natalist state, the society is pro-natalist. For various economic, cultural and religious reasons children are necessary and extremely valued in this society. Consequently, being childless has a wide range of consequences for both rural and urban Bangladeshi women, in terms of social stigma, familial violence, and psychological or economic disadvantages, with the essence of all these consequences being ‘suffering’. Studies show that in a patriarchal society like Bangladesh where motherhood is synonym of womanhood, childlessness destroys the identity of womanhood, which results in marginalisation (Nahar and Richters, 2011; Nahar, 2010b, 2010c, 2012).  However, despite the fact that there are significant potential risk factors for infertility in Bangladesh, and that infertility results is a serious disruptions to people’s/women’s wellbeing, there are hardly any services available for infertility in Bangladesh (UNFPA, 1996). In a comparatively recent discussion of maternal health in Bangladesh, Graham (2001), by using the source of ‘Bangladesh Demography and Health Survey’ data, provided a list of reproductive health care services in Bangladesh. There too was no mention of infertility service in the list.  A more recent qualitative exploration, the experiences of infertile women in terms of their health seeking in Bangladesh, found that there are hardly any public or NGO services for infertile people/ women. Along with a wide range of informal private services, there are only a few biomedical services available in the private sector, and these are expensive (Nahar, 2010a). With this as a backdrop, in this paper I will explore the stakeholders’ views on the lack of infertility services in Bangladesh.

Interactive Voice Response (IVR) platforms have been widely deployed in resource-limited settings. These systems tend to afford asynchronous push interactions, and within the context of health, provide medication reminders, descriptions of symptoms and tips on self-management. Here, we present the development of an IVR system for resource-limited settings that enables real-time, synchronous interaction. Inspired by community radio, and calls for health systems that are truly local, we developed 'Sehat ki Vaani'. Sehat ki Vaani is a real-time IVR platform that enables hosting and participation in radio chat shows on community-led topics. We deployed Sehat ki Vaani with two communities in North India on topics related to the management of Type 2 diabetes and maternal health. Our deployments highlight the potential for synchronous IVR systems to offer community connection and localised sharing of experience, while also highlighting the complexity of producing, hosting and participating in radio shows in real time through IVR. We discuss the relative strengths and weaknesses of synchronous IVR systems, and highlight lessons learnt for interaction design in this area.

This analysis challenges a tendency in public health and the social sciences to associate India's medical pluralism with a distinction between biomedicine, as a homogeneous entity, and its non-biomedical ‘others’. We argue that this overdrawn dichotomy obscures the important part played by ‘informal’ biomedical practice, an issue with salience well beyond India. Based on a qualitative study in rural Andhra Pradesh, South India, we focus on a figure little discussed in the academic literature – the Registered Medical Practitioner (RMP) – who occupies a niche in the medical market-place as an informal exponent of biomedical treatment. We explore the significance of these practitioners by tracking diagnosis and treatment of one increasingly prominent medical ‘condition’, namely diabetes. The RMP, who despite the title is rarely registered, sheds light on the supposed formal-informal sector divide in India's healthcare system, and its permeability in practice. We develop our analysis by contrasting two distinctive conceptualisations of ‘informality’ in relation to the state in India – one Sarah Pinto's, the other Ananya Roy's.

The link between high fertility and poverty is well established. However, this paper shows how infertility may also generate poverty among childless families in Bangladesh. An ethnographic study was conducted, involving various qualitative research methods that revealed economic consequences to be one of the crucial sequelae of childlessness in Bangladesh. This paper details how the poverty/fertility relationship is dependent on social and institutional characteristics, including patriarchal values, education, urban-rural location and health services. Empirical data show that childlessness generates poverty in various ways, including the deprivation of children's earnings, decline in women's mobility, demoralisation of men to earn an income, marriage devaluation by the husband, disbursements for treatment and denial of microcredit (very small loans to those in poverty, which support them to become self-employed to generate income). The current study shows that the infertility/poverty relationship is mostly contingent upon class and gender. It is therefore the rural poor childless women who are most badly affected economically in Bangladesh rather than the urban middle class childless women. In other words, this study reveal that along with gender, class plays a dominant role in terms of the economic consequences of childlessness in Bangladesh. It sheds light on a different and unusual aspect of poverty and aims to contribute to the gender discussion of livelihood and poverty.

Collecting NHS patient experience data is critical to ensure the delivery of high-quality services. Data are obtained from multiple sources, including service-specific surveys and widely used generic surveys. There are concerns about the timeliness of feedback, that some groups of patients and carers do not give feedback and that free-text feedback may be useful but is difficult to analyse. Objective: To understand how to improve the collection and usefulness of patient experience data in services for people with long-term conditions using digital data capture and improved analysis of comments.

Patient feedback in the English NHS is now widespread and digital methods are increasingly used. Adoption of digital methods depends on socio-technical and contextual factors, alongside human agency and lived experience. Moreover, the introduction of these methods may be perceived as disruptive of organisational and clinical routines. The focus of this paper is on the implementation of a particular digital feedback intervention that was co-designed with health professionals and patients (the DEPEND study).

More than one billion people are affected by neglected tropical diseases (NTDs) and many of these diseases are preventable. While the grouping of these conditions as NTDs has generated vast mapping, mass drug administration and surveillance programmes, there is growing evidence of gaps and weaknesses in purely biomedical approaches, and the need for responses that also recognise the social determinants of health. In order to unpack the social and political determinants of NTDs, it is important to view the problem from a social science perspective. Given this background, the Social Sciences for Severe Stigmatizing Skin Diseases (5S) Foundation has recently been established by the Centre for Global Health Research at Brighton and Sussex Medical School. The broad aim of the 5S Foundation is to incorporate social science perspectives in understanding and addressing the problems around three NTDs, namely, podoconiosis, mycetoma and scabies. This protocol paper sets out the aims and approaches of the 5S Foundation while activities such as research, public engagement, training and capacity building get underway.

This book examines the intersectionality and stratified lived experience of rural poor and urban middle-class childless women in Bangladesh.

Childless women in Bangladesh, an over-populated country where fertility control is the primary focus of health policy, are all but non-existent. Papreen Nahar offers an alarming account of stigma, abuse, ostracism and violence against these women, sharing their experiences of marginalisation in a culture that idealises motherhood. In such a reality, the experience of childlessness, particularly for women, can be much more severe than what is defined as ‘infertility’ in the biomedical sense. As childlessness is a complex interaction between biology, society and culture, the book illustrates the ways in which infertility transforms a health problem into social suffering. Although Bangladeshi childless women are systematically excluded by various structural forces, it appears they do not succumb to their circumstances; rather, they develop resilience and agency to become survivors of their new, albeit bleak, lives.

The volume will be of interest to scholars working in anthropology, reproductive and women’s health, global health, gender studies, development studies and Asian studies.

The aim of this study was to explore the effect of epilepsy on the reproductive life and self image of Dutch women with epilepsy. It was intended to investigate how this effect takes shape in a technologically advanced and economically developed society like The Netherlands. The study was explorative and made use of qualitative methods. The thesis is based upon in-depth interviews with twelve Dutch women with epilepsy and with three key informants. Additional sources of secondary data were also consulted. The findings reveal that in spite of tremendous medical technological advancement and social development in the Netherlands epilepsy still may negatively influence the reproductive decisions and the self image of the Dutch women who suffer from this disorder. On the other hand women with epilepsy possess a highly positive attitude towards life. It was also found that the organisations working in the field of epilepsy are not gender sensitive. Based on the findings specific recommendations are made.