Sexual & Reproductive Health Concerns of Males & Role of Providers in Chakaria, Bangladesh

1. Sexual & Reproductive Health Concerns of Males & Role of Providers in Chakaria, Bangladesh Research Team Ilias Mahmud (Research Associate, Supervisor RPC) Dr. Sabina Faiz Rashid, (Assistant Professor, Coordinator of RPC) Dr. A. Mushtaque R. Chowdhury, Dean, Principal Investigator, RPC) Nabil Ahmed (Research Associate, RPC) Advisors: Dr. Hilary Standing, IDS Dr Kaosar Afsana, BRAC

2. Presentation • Understand SRH concerns and SRH experiences of 711 married males in Chakaria (rural area of Bangladesh) • Community concerns of SRH • Friends/family SRH experiences • Individual experiences • Whom do they access (providers) • Perceptions about providers • Community level recommendations

3. SRH & Bangladesh • There is no nationwide survey in RTIs and STIs • About 56% of women in rural areas of Bangladesh suffer from RTIs; among them 21% have STIs • The high prevalence of STIs in women is an indirect indicator of high prevalence of these diseases among men

4. Informal Service Provision in BD • Simultaneous existence of different healing professions is a reality in Bangladesh like most of the developing countries • Indeed a wide range of therapeutic choices is available, from self-care to folk and western medicine (allopathic) • The public sector is largely used for inpatient and preventive care while the private sector is used mainly for outpatient curative care

5. Informal Service Provision in BD... • This private sector includes 300,000 informal health care providers such as village doctors, homeopaths and traditional healers • At least half of the health care services are provided by these informal providers • Expenditure on health is mainly met by out-of-pocket payment by the households • This mode of payment for health-expenditure is the most regressive one and exposes people, especially poor and other disadvantaged people, to great financial risk and makes the health system inequitable

6. Methodology • 1000 HH selected randomly from 7000 HHs of eight unions of Chakaria, nested in a larger study of informal provision (ICDDR,B) • 711 married males interviewed (study of married females underway) • Semi-structured questionnaire developed – qualitative/quantitative • Pre-testing of the questionnaire • 5% re-interview

7. Description of Study Site • Chakaria is one of 465 upazilas (sub-districts) of Bangladesh • Population: around 400,000 • Low performing area in terms of health and family planning • ICDDR,B HDS site • East side hilly, west side towards Bay of Bengal - lowland or flat

9. Findings

10. Respondents’ Profile • Average age: 41 years • All married and sexually active • Average married life: 17 years • Education: • None: 38% • 1-5 years: 35% • 6-10 years: 18% • 10 years +: 9%

11. Community SRH Concerns

12. Ten leading Concerns in Community

13. Ranking of conditions by perceived severity

14. What Makes them Perceive a Condition as Severe? Afraid of losing wife or masculinity… Jamir a 25 year old man, who was married for three years and had no schooling, and considered the “inability to maintain an erection” as one of the most severe SRH concerns. He said... “A wife would not be satisfied. She would call her husband a hermaphrodite and leave him”

15. What Makes them Perceive a Condition as Severe? Losing semen causing weakness “Nocturnal emission causes semen loss equivalent to seven times intercourse. This is nothing but waste of semen that could have been useful in conceiving. So I think this is a severe problem”(a 45 years old man with primary schooling). “This is a very bad problem as excess semen loss weakens the body a great deal”(a 32 years old man who finished college!).

16. What Makes them to Perceive a Condition as Severe? May cause serious diseases “This [discharge of pus from penis] is a very severe problem. Continuous discharge of pus can lead to severe diseases like Cancer. The sore inside the penis becomes bigger at a later stage. So this is a really bad problem” (a 45 years old man with primary education)

17. Providers usually visited by the community people

18. Most Popular SRH Service Providers mentioned

19. What Makes a Service Popular? Education and Experience “Since they [MDs] are highly educated and experienced, they know well about these diseases. Besides, people think that since they charge a higher fee, their treatment would be better. That’s why they are so popular”(a 39 years old man without any formal schooling)

20. What Makes a Service Popular?... Cost of treatment “Most of the people in our area are farmers. They are poor. These health centers [Government] are very helpful for them as they provide treatment at a very low cost. Sometimes they give free treatment”(55 years old man having only primary education)

21. What Makes a Service Popular?... Speaking in the same language “Street vendors of medicines make people understand their disease well and patients feel comfortable to discuss about these issues (SRH) with them which they don’t feel with a doctor”(A 25 years old respondents who does not have any formal schooling )

22. What Makes a Service Popular?... Availability of Services “They (Kabiraj) are local people. They are always available [closely located]. If one goes to them they try to understand his problem. Sometimes they also give treatment to those who have no money. There is nobody who can give treatment. So, those providers who live here are so popular” (a 47 years old respondents having primary education)

23. What Makes a Service Popular?... Common understanding of where to go for treatment: “The local belief is that the Kabiraj can treat these (SRH) problems very well. So more people go to them”(a 45 years old man without any formal education)

24. SRH Concerns of a Known Person of the Respondents

25. SRH concerns of a close kin/friend/neighbor • Out of 711 respondents 431(61%) said that at least someone they knew (family/friend) has/had SRH problems • Out of these 431 respondents 59 (14%) could not say anything about treatment of their known person • And 372 (86%) said their close kin/friend/neighbor with SRH concerns received treatment • Type of problems are similar as community concerns

26. First Provider for the Close kin/friend/neighbor

27. SRH Concerns of Respondents themselves

28. Overview of Respondents’ SRH Concerns • 429 (60%) of 711 respondents said that they had/were suffering from SRH concerns • 270 (63%) of 429 received treatment • 126 (47%) of 270 are satisfied with the treatment outcome

29. Leading SRH Concerns of Individual Respondents’ • Duration (less) of sexual intercourse: 175 • Frequent urination: 135 • Nocturnal emissions: 105 • Loss of semen before and after urination: 97 • Burning and pain when urinating: 94 • Unable to maintain an erection: 77 • Itching or burning in genitals: 49 • Ejaculation before coitus: 36 • Pain during sex: 30 • Anxieties about penis: 29 *Multiple response; n=429

30. Health seeking: top three providers by conditions 84 respondents suffered: Duration of Sexual intercourse 34 visited MBBS doctor 30 visited Local Kabiraj 18 visited Palli Chikitshak 62 respondents suffered: Frequent Urination 28 visited MBBS doctor 16 visited Local Kabiraj 12 visited Homeopath *Multiple visits

31. Health seeking: top three providers by conditions 57 respondents suffered : Loss of semen before and after urination 22 visited MBBS Doctor 20 visited Local Kabiraj 11 visited Palli Chikitshak 49 respondents suffered: Burning or pain when urinating 21 visited MBBS doctor 16 visited Palli Chikitshak 11 visited Homeopath *Multiple visits

32. Health seeking: top three providers by conditions 48 respondents suffered: Nocturnal emissions 22 visited local Kabiraj 17 visited MBBS doctors 13 visited Palli Chikitshak 33 respondents suffered: Itching or Burning 13 visited Palli Chikitshak 12 visited drug seller 9 visited MBBS doctor *Multiple visits

33. Health seeking: top three providers by conditions 29 respondents suffered: Inability to maintain an erection 13 visited MBBS doctor 13 visited Local Kabiraj 7 visited Palli Chikitshak 17 respondents suffered: Ejaculation before coitus 8 visited MBBS doctor 4 visited Local Kabiraj 4 visited Palli Chikitshak *Multiple visits

34. Money spent for treatment of SRH concerns • 69 respondents • Average money spent: 5740 taka (about US$40) • Source of treatment costs (multiple sources)

35. Community level recommendations • Despite low resort to public facilities, high felt demand for improved services in the public sector: • Experienced doctors/specialists in hospitals • Centres need to be much closer to communities for ease of consultation • Services should be free or low cost

36. Conclusion • It was observed that perceived SRH concerns/experiences do not always fit into existing biomedical models • Need to address beyond ‘disease’ model of SRH concerns • Gaps in service delivery – men’s services?? access, location, costs • Lack of integration/linkages among providers (formal and informal) • Regulation? Referrals, partnerships training…How can we move forward?