Health care practices of slum dweller adolescent girls in Bangladesh: The case of Sylhet city

The aim of the paper is to know the health care practices of adolescent girls living in the slum areas of Sylhet city, Bangladesh, understand their health and hygiene issues including treatment, pregnancy, menstruation, vaccination, housing, water and sanitation related challenges they face in their daily lives. The study was based on primary sources of data; however the secondary data e.g. official documents, books, journals, policy papers etc. were used to conduct the study. The study followed qualitative research approach and the case study method to generate sufficient primary data. The study reveals that adolescent girls of slum areas face some menstruation related physical health problems e.g. abdominal pain, irregularity in menstruation cycle, excessive bleeding etc. Sometimes the guardian and doctor do not give much importance on it. The study findings show that adolescent girls of slum areas face multiple health care challenges including low level of personal hygiene, carry on treatment cost, lack of appropriate water, housing and sanitation facilities, etc. The study also highlights that family poverty, behavior of doctors, high cost of medicine, illiteracy of guardian etc. are responsible factors for low uptake of health care services. Therefore, the study suggests for coordinated efforts from the government, local government and voluntary agencies to upgrade their service delivery system.


INTRODUCTION
Bangladesh has experienced a phenomenal growth in the rate of urbanization and total number of urban people. The people living in urban areas and cities constitute 35.86 percent of the total population (Statista, 2017). The growing process of urbanization also causes the increase of slum areas and people living there. Adolescence is regarded as a significant period of human growth and development which shape a person's future personality and potentialities. Adolescent are identified as those persons who belong to the age group of 10 and 19 years (WHO, 2014). The UNICEF Annual Results Report (2017) also recognized that millions of adolescent girls in low-and middle-income countries facing gender inequality along with poverty and other forms of discrimination and disadvantage and access to resources. There are 29.5 million adolescents in Bangladesh, including 14.4 million girls and 15.1 million boys, together representing nearly one-fifth of the country's total population of 144 million. However, the national health policy of Bangladesh (2011) did not give much focus on the issue of adolescent health and challenges, recently the government of Bangladesh has adopted a National Adolescent Health Strategy (2017)(2018)(2019)(2020)(2021)(2022)(2023)(2024)(2025)(2026)(2027)(2028)(2029)(2030) to address the health care needs of adolescents by taking a broad and holistic approach for understanding health issues and care practices for them (MCH Services Unit, 2016). Despite some progress in current activities undertaken by the Ministry of Health and Family Welfare during the 7 th Five year plan (2016)(2017)(2018)(2019)(2020) as it is recognized modernizing health care and expanding population and nutrition services are crucial for the development of the country, critiques argue that initiatives to address adolescent health care services provided by the Government of Bangladesh (GOB) and nongovernmental organizations (NGOs) remained fragmented and less evaluated and health services are often focused on clinical aspects rather than expanding opportunities for preventive measures (Ainul et al., 2017). It is well documented that slums population in developing countries like Bangladesh are facing multiple challenges including different types health problems and diseases, lack of basic services e.g. housing, water and sanitation, treatment, education and many other utility services i.e. gas and electric facilities, telephone, ambulance etc. (Rashid, Gani & Sarker, 2013, Joshi, Fawcett, & Mannan, 2011. The adolescent marriage and early childbearing is also another major health concern in Bangladesh where about one in four women age 20-24 had given the birth of their first child at the age of 18 (BBS, 2015). A recent study conducted by Chandra-Mouli & Patel (2017) points out that in majority cases adolescent girls remained uninformed and unprepared for menarche. However, they get some information from mothers and other female family members, these does not ensure appropriate mental preparation to accept it as a common physical issue, rather feel shame which often lead to misconceptions and unhygienic practices during menstruation. Since, majority of the studies are conducted on the Dhaka city areas and there is a lack of studies in the North East region of the country i.e. the Sylhet division which is characterized by its diversity of environment e.g. famous for its hilly tea garden areas, wetland called haor basin and the plain land. In addition, it is distinct for growing urbanization, both internal and external migration causes a new formation of small and sporadic slum areas commonly known as koloni and Therefore, it is worthwhile to investigate the health care practices of adolescent girls living slum areas of Sylhet city, identify major issues and challenges they face while living in slum areas and propose some policy recommendations to improve their condition.

OBJECTIVES OF THE STUDY
The objectives of the study were twofold: First, to know the situation of health care practices of adolescent girls living in slum areas of Sylhet city and identify major challenges they face in their daily lives.

STUDY DESIGN AND METHODOLOGY
The study followed qualitative research approach and the case study method to generate sufficient primary data. This method was chosen because it was thought more appropriate to gain better understanding of the health condition, health belief, health care practices, and menstruation issues of the adolescent girls living there. The in-depth interviews were undertaken with semi-structured interview schedule to collect necessary information to address the research objectives. In addition, two focus group discussions were arranged with six to eight participants in each group to substantiate the interview data.

The study area and population
The Sylhet City Corporation was selected purposively as the area of study. It was chosen because, the growth of urbanization is much higher than any other city of Bangladesh except Dhaka and the urbanization process is very recent so that we can learn health care pattern of slum dweller adolescent girls. The other reason is that in Bangladesh majority NGOs and INGOs working for slum population and conducting studies focused on Dhaka cities, but there are a few researches have been conducted in the Sylhet city. According to the Bangladesh of Bureau of Statistics report (BBS, 2015), there are 670 slums in Sylhet city with a number of total population are 50129. However, the statistics do not figure out the total number of adolescent girls living in those slums.

Sampling procedure
Primarily three (03) slums were selected purposively selected for recruiting research participants from the Sylhet city corporation area on the basis of high density of slum dwellers. Twenty one (21) adolescences girls were selected from the three (03) slums under the ward no. 9, 13 and 15 and two FGDs were conducted with another two slums under the ward no. 3 and 5 of the Sylhet city corporation area. The following inclusion criteria were selected to recruit the research participants: 1. To be included in the study the participant should girl under the age of 12 to 19 years old and live in the slums, known as 'Koloni' for at least one year. 2. Literate and illiterate, married and unmarried girls of the above mentioned criteria could participate in the study.

Data collection
The interview protocol was designed in the line with established studies e.g. Rodehaver (2008). Open ended interview guideline were prepared and used to lead the interview session smoothly (Kerr and Smith, 2001). For focus group discussions, the ground rules were negotiated with the participants to make the discussions interactive. In many cases, questions were open ended with a number of sub questions, which were substituted for the following two main research questions: 1. What types of health care do they practice e.g. treatment, personal hygiene, water and sanitation etc. 2. What types of challenges do they face in health care practices?
On an average the duration of in depth interviews were 45 minutes to 1 hour and the FGDs were 2 hours to 2 hours and 30 minutes in length. The researcher along with two data collectors carried out the interviews and conducted the FGDs to understand health issues of adolescent girls, their health belief, health care issues including treatment pattern etc. The data collection process was ended when the interview or FG reached at the saturation point when no new data were found and the participants repeated the same information. The data collection period was six month from March, 2017 to September, 2017. A full transcription i.e. verbatim method was followed and the audio recorded interviews were first written in Bangla and then translated and typed into English.

ETHICAL CONSIDERATIONS
Since, there were no any institutional review board (IRB) to direct the research process in the Shahjalal University of Science & Technology, the researcher followed the ethical guidelines offered by Miles and Huberman (1994). Participation in the study was entirely voluntary and relied on the ethical principle of informed consent. At the start of interview and FGD, the study purpose and nature was explained. They were asked to choice whether they can participate or not to participate and those who wanted to participate. A written consent was taken from those who can write and verbal consent was taken from those who did not know how to put signature.

DATA ANALYSIS
The in depth interviews and FGDs were audio recorded with the permission of the respondents. The verbatim recordings were transcribed and translated into English by the researcher and two research assistants. The data were read, re-read and taken for open coding and thematic analysis. From the original data codes were generated in terms of the various concepts and issues and then selective coding was conducted to systematically analyze the data and identify the most prominent themes. The 'iterative' analysis process was followed and a particular attention was given to choosing and using the quotations which is most relevant to the specific issue (Chen, 2013).

THE FINDINGS Socio-demographic information
Majority of the participants of in-depth interview belong to the age group of 12-19 years for in-depth interview and 16-19 years for FGDs. Adolescents below 12 years were excluded from interview and FGD for their tender age. In terms of religion, it is shown that majority of them belong to the religion of Islam. The data on family type shows that majority of them belong to the single family and family size remains 4 to 6 members. Regarding the information education, it is shown that majority of FGD participants completed primary education and Interview participants completed secondary level education. The information about housing reveals that majority of them live in Kaccha houses, made of bamboo and corrugated iron sheet or brick and corrugated iron sheet. The family income varies from Bangladeshi Taka 7000.00 to 20,000.00

Health care practices: Treatment
The study findings show that majority of the respondents go to the public hospital for receiving health care services where they can consult with a doctor with a very little cost. But they face some challenges to avail the services. The following narratives echo the issue: " The study findings also demonstrate that there are some respondents who receive services from the private hospital or clinic, because it is near to their slum, but they cannot continue their full course of treatment due to high cost involved with it. The study also point out that a large number of adolescent girls had no idea about the menstruation period before starting it. Because the family members e.g. their mother, elder sister did not share anything before starting the menstruation. The study also found that there are some married adolescent girls who knew the importance of vaccination and wanted to receive it but cannot get the opportunity, because their mother in laws did not approve it. The following narratives raise the issue: "I am pregnant but I didn't receive any vaccine till now. Health workers suggest me to take vaccine. I have tried many times to make my mother-in law understand about the importance of vaccination. But she said, it is not essential, she had 5 children and never received any vaccine." (FGD 02) "There are some misconceptions prevail in our slum that by vaccination the health condition of pregnant women become vulnerable and require surgery for birth of a baby. Therefore, some guardians e.g. mother in law oppose it and show reason that they did not take vaccines at their time and they were well." (Married AG, 18 years)

Housing, water and sanitation
The study reveals that majority of the adolescent girls of slum live in inappropriate housing settings and overcrowded condition. The following narratives clarify the issue: "Most of the houses of our slums are kaccha i.e. made of mud, straw and bamboo which produce much fiber particles and do not protect us from the cold or heat waves which increases asthma related health problems." "There are seven members in our family and we live in a large room. Our house is kaccha and made of bamboo. We do not have any privacy there." The study findings also show that water and sanitation condition of the slum is very poor. Most of the adolescent girls of the slums use tube-well for the purpose of drinking, bathing, toileting, cooking and household needs etc. But one tube-well in one slum is not sufficient to fulfill the water needs of the residents and as there are no separate tube-well facilities for male and female, the adolescent girls cannot maintain privacy there. The following excerpts echo the issue: "There is one tube well in our slum. When it is damaged, I use pond water without boiling. So, it could be a cause of jaundice for me." (Interview 02, Age: 17 years) There is a tube well in the slum. I took my bath from it. There is a curtain of polythins surrounding the tube well. But there is no privacy for us. (Interview 01, Age: 15 years) "There are two toilets in our slum which has no cover. Most of the residents do not use much water after defecation as the only source of water i.e. tube well is far away from the toilet." (Interview 08, Age: 15 years)

Treatment experiences
The study findings show that majority of the respondents go to the public hospital for receiving health care services where they can consult with a doctor with a very little cost. But they face some challenges to avail the services. For example, there are a very limited number of seats in the public hospital for the patients. The adolescent girls need to share bed with other woman patient which they do not feel comfortable. Sometimes they need to wait one or two days a get a bed. The other challenges include long waiting hours both for outdoor and indoor services and lack of attention of doctors. It is evident from the study that sometimes they are not given sufficient time to listen their health problems and the cost of medicine is also high which in many times they cannot afford. The study findings also demonstrate that there are some respondents who receive services from the private hospital or clinic, because it is near to their slum, but they cannot continue their full course of treatment due to high cost involved with it.
The study findings also reveal that sometimes adolescent girls get allopathic treatment for diarrhea and malaria fever, but prefer 'kabiraji' or herbal treatment for jaundice and skin diseases. The kabiraj or traditional healers provide with 'jarfuk' and some herbal medicines for treatment of jaundice. For menstruation problem, they sometimes prefer to go traditional healers e.g. local religious person who provide 'tabiz' and 'pani pora' etc. The findings also demonstrates that some guardians of adolescent girls rely on homeopathic treatment for menstruation related disease but sometimes they do not get the expected positive outcome. This study mirrors the findings of other study which found that more than 75 per cent slum dwellers receive allopathic treatment 12 per cent receive kabiraji (i.e. herbal or traditional or religious healing) and 9 per cent use homeopathic treatment (Nahid et al, 2015).

Health care during pregnancy
The study findings show that some respondents and their family members are not aware to receive health care during pregnancy. Their health seeking behavior e.g. visiting doctor, health check up and uptake of health care services etc. is governed by husband and mother in law etc. who do not give much importance about this due to illiteracy, unconsciousness or negligence. The family poverty is also responsible for low uptake of health care services and malnutrition or anemia of married pregnant adolescent girls of slums in Sylhet city of Bangladesh. The study also reveals that some married adolescent girls depend on traditional birth attendants 'Dai' and local 'Kabiraj' for treatment of pregnancy related complexities. For example, in one case it is found that depending on traditional birth attendant also result in head injury of baby and ultimately became associated with child disability.

Menstruation related challenges
The study reveals that adolescent girls of slum areas face some menstruation related physical health problems e.g. abdominal pain, irregularity in menstruation cycle, excessive bleeding etc. Sometimes the guardian and doctor do not give much importance on it and suggest that it will recover after marriage. The study also point out that a large number of adolescent girls had no idea about the menstruation period before starting it. Because the family members e.g. their mother, elder sister did not share anything before starting the menstruation. Therefore, some misconception grows among the adolescents that it is a shameful disease of woman and one should not share about this with anybody. More specifically the dropped out or illiterate adolescent girls do not have right information about this and they become tensed and nervous when their first menstruation start. The study also found that some of the adolescent girls are facing some additional challenges e.g. problems of excessive vaginal discharge which is associated with some other symptoms including headache, breast pain and physical weakness etc. But the crucial thing is that they do not share the problem with anyone or seek any treatment due to shy which poses the risk of their reproductive health.

Personal hygiene
The study findings also demonstrates that majority of the adolescent girls of slum areas do not practice the rules of personal hygiene strictly. They wash their hands before or after taking meal and also wash their hands after defecation. By contrast, they forget to wash hands in taking dry food and do not think the importance of washing hands while taking dry food. It is also evident from the study that some of them forget to carry soap while going to common toilet or washroom which is far away from their houses and they do not always clean their hand after defecation by soap. This might have an impact of causing diarrhea and dysentery disease among the slum dweller adolescent girls. It is also found that a significant number of adolescent girls in the slum do not use sandal and remain bare footed in day time.
The study findings also reveal that the vast majority slum girls in Sylhet city use rags instead of sanitary pad or napkin due to high cost involved with it. These rags are made of torn part of old saris. They face additional difficulties to make it clean as there are is no private place to change and wash it because they need to use a common toilet where soap or cleaning materials are not available. By contrast, it is found that adolescent feel shy to bring nekra and soap with them to go to the toilet. Even in their own homes, they struggle hard to find a well-hidden place to dry the rags. These places are often damp, dark and unhealthy which poses a big challenge to maintain hygienic practice and safe reproductive health.

Vaccination
The study findings show that majority of the adolescent girls are not conscious about vaccination e.g. tetanus or others vaccines and do not give much importance on completion of full doses. Some of them thought they can take other doses at any convenient time. The study findings also show that schools going adolescent girls have some knowledge about different vaccination but they cannot receive those are not provided at free of cost due to poverty. For example, they have taken Tetanus and Ham Vaccines provided free of cost by public health workers but cannot afford to take Hepatitis-B vaccine or vaccine of Uterus Cancer which are not provided free of cost. The study also found that there are some married adolescent girls who knew the importance of vaccination and wanted to receive it but cannot get the opportunity, because their mother in laws did not approve it.

Housing, water and sanitation challenges
The present study shows that water and sanitation facility is very poor in the slum areas of Sylhet city and the adolescent girls face some crucial health care challenges e.g. lack of pure drinking water, latrine facilities, overcrowded housing etc. It is evident from the study that some adolescent girls use tape water which was supplied from Sylhet City Corporation. The condition of water supply is not clean; however, there is found small slab in the bathroom which stands in an open place and widely used for the purpose of bathing and daily household activities. These bathrooms are open place which are even visible from the road and both male and female members of the neighborhood use it. So the adolescent girls cannot maintain privacy. Another important challenge they face include unhygienic condition of bathroom and high risk involved in using it as the slab is always slippery and covered with moss. This place is also used for the purpose of cooking and washing things. These entire situations portray a potential threat to their physical health and general wellbeing.

CONCLUSION
The study findings demonstrate that they constitute one of the vulnerable segments of population in our country due to poverty, malnutrition, inappropriate housing condition, lack of pure and safe water, sanitation etc. The study findings also demonstrates that majority of the adolescent girls of slum areas do not practice properly the rules of personal hygiene and not much conscious about vaccination. and face difficulties due to poor housing, water and sanitation problem. However, majority of them seek modern allopathic treatment method, some of them seek alternatives e.g. herbal or kabirazi, homeopathic etc. The study identified some reasons including the high cost involved with modern treatment, long waiting hours to receive health care from public hospitals and lack of responsiveness and attention of doctors etc. which act as barriers to get access and utilization of public health care services. Consequently, majority of slum dweller adolescent girls prefer to go to local pharmacies for primary treatment. By contrast, a significant number of them rely on traditional healing method as an alternative to allopathic treatment. The study findings also demonstrates that majority of the adolescent girls of slum areas do not practice properly the rules of personal hygiene and not much conscious about vaccination and other health care aspects including adolescent pregnancy. Therefore, it is suggested that health care and hygiene practices of the slum dweller adolescent girls can be improved through coordinated efforts by the different government departments, city corporation authority and NGOs working in the areas.