Strategies to Reduce Exclusion among Populations Living in Urban Slum Settlements in Bangladesh

The health and rights of populations living in informal or slum settlements are key development issues of the twenty-first century. As of 2007, the majority of the world's population lives in urban areas. More than one billion of these people, or one in three city-dwellers, live in inadequate housing with no or a few basic resources. In Bangladesh, urban slum settlements tend to be located in low-lying, flood-prone, poorly-drained areas, having limited formal garbage disposal and minimal access to safe water and sanitation. These areas are severely crowded, with 4–5 people living in houses of just over 100 sq feet. These conditions of high density of population and poor sanitation exacerbate the spread of diseases. People living in these areas experience social, economic and political exclusion, which bars them from society's basic resources. This paper overviews policies and actions that impact the level of exclusion of people living in urban slum settlements in Bangladesh, with a focus on improving the health and rights of the urban poor. Despite some strategies adopted to ensure better access to water and health, overall, the country does not have a comprehensive policy for urban slum residents, and the situation remains bleak

Worried lives : poverty, gender and reproductive health of married adolescent women living in an urban slum in Bangladesh

The thesis is concerned with the lives of married adolescent women in an urban slum in Bangladesh, and how the injustices of a harsh political economy impact on their bodily health and shape their reproductive experiences. My contribution in the thesis is to clearly demonstrate how political economic inequalities and social conditions - 'structural violence' contribute to adverse reproductive health experiences for poor married adolescent women. These disparities compel married adolescent women to make pragmatic choices, which puts their bodies and reproductive health lives at risk. The parameters that determine married adolescent women's well-being and reproductive health are rooted in power relations and lack of access to political and economic resources. I argue that the term 'reproductive health' cannot be addressed without first addressing the context of extreme poverty, hunger and violence threatening men and women's survival. Social and economic justice needs to be integral to solutions to improve the health of poor women and men. The study is located in an urban slum in Dhaka, the capital of Bangladesh. The city has undergone immense transformation with industrialization and the migration of rural families into the city looking for food, shelter and jobs. Ethnographic fieldwork was carried out for fourteen months, and case studies, in-depth narratives and long-term participant observations provide rich empirical data. In addition, a survey was carried out to gather general background information, including young women's reproductive histories. Urban slum dwellers constitute thirty per cent of total fourteen million population of the city. Extremely poor urban migrants are unable to find affordable housing. They set up or rent shack settlements built on vacant or disused government/ private land, on the margins of the city - usually in flood prone areas, never knowing when they might be forcibly removed. Most of the slum dwellers live on less than US $63 a month, holding onto insocure jobs, with many permanently unemployed. Young married women in the slums are extremely vulnerable in this unpredictable and insecure urban landscape because of their age, gender and poverty. Chronic deprivation, harsh political and economic conditions and suffering are part of an everyday existence for poor married adolescent women and their families living in slums. This raises many important questions: what do we mean by reproductive health experiences when we look at their lives? Can we separate reproductive health experiences from other aspects of their lives, the material, social and politicaleconomic? How do the broader global, local and socio-cultural, political and economic factors affect health and reproductive health experiences and behaviour? How do young women make sense of and act in this dynamic and difficult urban environment with what reproductive health outcomes? What multiple effects might structural and social inequalities have on married adolescent women lives and their reproductive health experiences? The thesis illustrates how conditions of poverty, unequal class, and gender and power relations structure risk for young women and leave them with few options. This is evident in the context of reproductive and sexual health negotiations and fertility behaviour. Poor married adolescent women construct a 'political economy of the body' and pragmatically acquiesce with decisions made by others, such as, unsafe sex, too many pregnancies, and forced abortions, even though they may violate their sense of bodily integrity and well-being. Health care services are dismal and fragmented. Abortions may be through legal or illegal means and are understood to further jeopardize young women's health. Such pragmatism puts their bodies at risk, but gains them advantages and limited power within their social situation. I demonstrate how disparities of power operate in the lives of poor married adolescent women and critically shape health meanings, reproductive health experiences and practices. It is imperative we acknowledge and address the inequalities within Bangladesh, as well as examine the global inequalities between the rich countries and poor countries all of which create an underclass, who are unable to realize their health potential. I maintain that unless issues of social and economic justice are tackled, in the long term, 'reproductive health,' and health in general, will not improve for the poor

Towards a socially just model: balancing hunger and response to the COVID-19 pandemic in Bangladesh

Summary box Responsive and timely research is needed to better understand the challenges faced by poor and vulnerable populations to inform immediate interventions and policies to address this unprecedented COVID-19 modern-day pandemic. There is a need to research changes through time to understand and address the continuous and long-term economic, mental and emotional impact of lockdown on the most marginalised. Many of the Bangladeshi population are vulnerable, yet the COVID-19 response focuses on individual behaviour with limited attention to the social, economic and contextual factors that prevent the most marginalised from following national recommendations. In the context of structural constraints, continuation of the lockdown has to be accompanied by strong political resolve to ensure that people do not go without basic meals and have basic health information and support. The experiences of people living and working in slums in Bangladesh needs to be captured and translated to context specific strategies for lockdown, as current measures risk starvation for many. In the context of COVID-19, the lockdown model is being imported from a different context (western or developed economies) with stronger economic bases and better social safety nets for those in need, but is there a better way forward for low resource contexts? Economic mortalities may overtake health mortalities for the poorest who survive on daily wage labour

Creating a public space and dialogue on sexuality and rights: a case study from Bangladesh

This article describes and analyses a research based engagement by a university school of public health in Bangladesh aimed at raising public debate on sexuality and rights and making issues such as discrimination more visible to policy makers and other key stakeholders in a challenging context. The impetus for this work came from participation in an international research programme with a particular interest in bridging international and local understandings of sexual and reproductive rights. The research team worked to create a platform to broaden discussions on sexuality and rights by building on a number of research activities on rural and urban men’s and women’s sexual health concerns, and on changing concepts of sexuality and understandings of sexual rights among specific population groups in Dhaka city, including sexual minorities. Linked to this on-going process of improving the evidence base, there has been a series of learning and capacity building activities over the last four years consisting of training workshops, meetings, conferences and dialogues. These brought together different configurations of stakeholders – members of sexual minorities, academics, service providers, advocacy organisations, media and policy makers. This process contributed to developing more effective advocacy strategies through challenging representations of sexuality and rights in the public domain. Gradually, these efforts brought visibility to hidden or stigmatised sexuality and rights issues through interim outcomes that have created important steps towards changing attitudes and policies. These included creating safe spaces for sexual minorities to meet and strategise, development of learning materials for university students and engagement with legal rights groups on sexual rights. Through this process, it was found to be possible to create a public space and dialogue on sexuality and rights in a conservative and challenging environment like Bangladesh by bringing together a diverse group of stakeholders to successfully challenge representations of sexuality in the public arena. A further challenge for BRAC University has been to assess its role as a teaching and research organisation, and find a balance between the two roles of research and activism in doing work on sexuality issues in a very sensitive political context

Exploring healthcare-seeking behavior of most vulnerable groups amid the COVID-19 pandemic in the humanitarian context in Cox’s Bazar, Bangladesh: Findings from an exploratory qualitative study

The COVID-19 pandemic has raised new concerns about healthcare service availability, accessibility, and affordability in complex humanitarian settings where heterogeneous populations reside, such as Rohingya refugees in Bangladesh. This study was conducted in ten Rohingya camps and four wards of the adjacent host communities in Cox’s Bazar to understand the factors influencing healthcare-seeking behavior of the most vulnerable groups (MVGs) during COVID-19 pandemic. Data were extracted from 48 in-depth interviews (24 in each community) conducted from November 2020 to March 2021 with pregnant and lactating mothers, adolescent boys and girls, persons with disabilities, elderly people, and single female-household heads. This study adopted Andersen’s behavioral model of healthcare-seeking for data analysis. Findings suggest that the healthcare-seeking behavior of the participants amid COVID-19 pandemic in the humanitarian context of Cox’s Bazar was influenced by several factors ranging from socioeconomic and demographic, existing gender, cultural and social norms, health beliefs, and various institutional factors. Lack of household-level support, reduced number of healthcare providers at health facilities, and movement restrictions at community level hampered the ability of many participants to seek healthcare services in both Rohingya and host communities. Most of the female participants from both communities required permission and money from their male family members to visit healthcare facilities resulting in less access to healthcare. In both communities, the fear of contracting COVID-19 from healthcare facilities disproportionately affected pregnant mothers, elderly people, and persons with disabilities accessing health services. Additionally, the economic uncertainty had a significant impact on the host communities’ ability to pay for healthcare costs. These findings have the potential to influence policies and programs that can improve pandemic preparedness and health system resilience in humanitarian contexts

Exploring the context in which different close-to-community sexual and reproductive health service providers operate in Bangladesh: a qualitative study

Background A range of formal and informal close-to-community (CTC) health service providers operate in an increasingly urbanized Bangladesh. Informal CTC health service providers play a key role in Bangladesh’s pluralistic health system, yet the reasons for their popularity and their interactions with formal providers and the community are poorly understood. This paper aims to understand the factors shaping poor urban and rural women’s choice of service provider for their sexual and reproductive health (SRH)-related problems and the interrelationships between these providers and communities. Building this evidence base is important, as the number and range of CTC providers continue to expand in both urban slums and rural communities in Bangladesh. This has implications for policy and future programme interventions addressing the poor women’s SRH needs. Methods Data was generated through 24 in-depth interviews with menstrual regulation clients, 12 focus group discussions with married men and women in communities and 24 semi-structured interviews with formal and informal CTC SRH service providers. Data was collected between July and September 2013 from three urban slums and one rural site in Dhaka and Sylhet, Bangladesh. Atlas.ti software was used to manage data analysis and coding, and a thematic analysis was undertaken. Results Poor women living in urban slums and rural areas visit a diverse range of CTC providers for SRH-related problems. Key factors influencing their choice of provider include the following: availability, accessibility, expenses and perceived quality of care, the latter being shaped by notions of trust, respect and familiarity. Informal providers are usually the first point of contact even for those clients who subsequently access SRH services from formal providers. Despite existing informal interactions between both types of providers and a shared understanding that this can be beneficial for clients, there is no effective link or partnership between these providers for referral, coordination and communication regarding SRH services. Conclusion Training informal CTC providers and developing strategies to enable better links and coordination between this community-embedded cadre and the formal health sector has the potential to reduce service cost and improve availability of quality SRH (and other) care at the community level

Utilization of mobile phones for accessing menstrual regulation services among low-income women in Bangladesh: a qualitative analysis

Background: As many as one-third of all pregnancies in Bangladesh are unplanned, with nearly one-half of these pregnancies ending in either menstrual regulation (MR) or illegal clandestine abortion. Although MR is provided free of charge, or at a nominal cost, through the public sector and various non-profits organizations, many women face barriers in accessing safe, affordable MR and post-MR care. Mobile health (mHealth) services present a promising platform for increasing access to MR among low-income women at risk for clandestine abortion. We sought to investigate the knowledge, attitudes and practices regarding mHealth of both MR clients and formal and informal sexual and reproductive healthcare providers in urban and rural low-income settlements in Bangladesh. Methods: A total of 58 interviews were conducted with MR clients, formal MR providers, and informal MR providers in four low-income settlements in the Dhaka and Sylhet districts of Bangladesh. Interview data was coded and qualitatively analysed for themes using standard qualitative research practices. Results: Our findings suggest that low-income MR clients in Bangladesh have an inadequate understanding of how to use their mobile phones to obtain health service information or counselling related to MR, and correspondingly low levels of formal or informal mHealth service utilization. Few were aware of any formal mHealth services in place in their communities, despite the fact that providers stated that hotlines were available. Overall, MR clients expressed positive opinions of mHealth services as a means of improving women’s access to affordable and timely MR. Formal and informal MR providers believed that mobile phones had benefits with respect to information dissemination and making appointments, but emphasized the necessity of in-person consultations for effective sexual and reproductive healthcare. Conclusions: We report low utilization yet high acceptability of mHealth services among low-income MR clients in Bangladesh. Expanding formal and informal mHealth services targeted towards MR – and increasing publicity of these services in low-income communities – may help increase timely access to accurate MR information and formal providers among women at risk for clandestine abortion. While expanding formal and informal mHealth services for SRHR in Bangladesh may be useful in disseminating information about MR and connecting women with formal providers, in-person visits remain necessary for adequate treatment

Factors affecting motivation of close-to-community sexual and reproductive health workers in low-income urban settlements in Bangladesh: A qualitative study

Close-to-community (CTC) health workers play a vital role in providing sexual and reproductive health services in low-income urban settlements in Bangladesh. Retention of CTC health workers is a challenge, and work motivation plays a vital role in this regard. Here, we explored the factors which affect their work motivation. We conducted 22 in-depth interviews in two phases with purposively selected CTC health workers operating in low-income urban settlements in Dhaka, Bangladesh. We analyzed our data using the framework technique which involved identifying, abstracting, charting, and matching themes across the interviews following the two-factor theory on work motivation suggested by Herzberg and colleagues. Our results suggest that factors affecting CTC sexual and reproductive health workers’ work motivation include both extrinsic and intrinsic factors. Extrinsic or hygiene factors include financial incentives, job security, community attitude, relationship with the stakeholders, supportive and regular supervision, monitoring, and physical safety and security. While, the intrinsic factors or motivators are the perceived quality of the services provided, witnessing the positive impact of the work in the community, the opportunity to serve vulnerable clients, professional development opportunities, recognition, and clients’ compliance. In the context of a high unemployment rate, people might take a CTC health worker’s job temporarily to earn a living or to use it as a pathway move to more secure employment. To maintain and improve the work motivation of the CTC sexual and reproductive health workers serving in low-income urban settlements, organizations should provide adequate financial incentives, job security, and professional development opportunities in addition to supportive and regular supervision