CULTURE, HEALTH & SEXUALITY,

2002, VOL. 4, NO. 2, 173190

Exploring explanatory models of womens reproductive health in rural Bangladesh

JAMES L. ROSS, SANDRA L. LASTON, PERTTI J. PELTO and LAZEENA MUNA
This study illustrates the use of systematic elicitation techniques for cultural domain analysis, including free listing, pile sorting and severity ratings to identify salient illness categories and perceptions of illness severity among rural Bangladeshi women. The complementary strategies of in-depth interviewing and collecting of case studies were also employed for delineating explanatory models. Illnesses in the domain of womens reproductive healthfor example, reproductive tract infections (RTI)were found to be among the most 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. While concerns relating to reproductive tract infections, including those attributed to sexual transmission, and vaginal discharge are important to women, none of the available health facilities is particularly attuned to addressing these needs. Developing health care services taking womens explanatory models into consideration could be of importance for reducing the spread of RTI and sexually transmitted/HIV infection in rural Bangladesh.

Introduction

Womens reproductive and sexual health had for decades been a neglected area of international research (Graham and Campbell 1990, The Ford Foundation 1991, Koblinsky et al. 1993, Pachauri 1994; Sen et al. 1994, Sen and Snow 1994). Now these issues feature more prominently in policy and programme development of government and non-governmental organizations (Dixon-Mueller and Wasserheit 1991, Elias 1991, Germain et al. 1992, Isaacs 1995, Paolisso and Leslie 1995, Measham and Heaver 1996, Petchesky and Judd 1998). Concern with sexual and reproductive health gained momentum with the 1994 International Conference on Population and Development in Cairo (ICPD 1994, Germain and Kyte 1994, Germain 1997). The emerging international consensus on a denition of reproductive health, for women and men, is contained in the report of the Cairo conference itself:
James L. Ross is a medical anthropologist and Country Director for Family Health International, Nepal. Sandra L. Laston is a Research Professor with the Interdisciplinary Anthropology Programme, at the University of Akron, Ohio, USA. Pertti J. Pelto is a Professor Emeritus at the University of Connecticut currently serving as an international health consultant based in Pune, India. Lazeena Muna is a doctoral candidate at the London School of Hygiene and Tropical Medicine. Address all correspondence to: James L. Ross, FHI, GPO Box 8803, Kathmandu, Nepal; e-mail: ross@fhi.org.np
Culture, Health & Sexuality ISSN 1369-1058 print/ISSN 1464-5351 online q 2002 Taylor & Francis Ltd http://www.tandf.co.uk/journals DOI: 10.1080/13691050110096189

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Reproductive health is a state of complete physical, mental and social well-being and not merely the absence of disease or inrmity, in all matters relating to the reproductive system and its functions and process. (ICPD, 1994)

In the context of South Asia, the impetus to bringing these and related issues into the public domain began with a community-based, epidemiological study of gynaecological morbidity in Maharashtra (Bang et al. 1989). In that study, over 90% of 645 women surveyed reported one or more gynaecological problems. The majority of women had never sought treatment. This study not only established the magnitude of the problem but served to highlight the relative neglect of gynaecological problems. Several subsequent community-based studies throughout India not only generally conrmed these ndings, but also demonstrated the value of integrating qualitative and quantitative approaches in reproductive health research (Koenig et al. 1998). Each of these initiatives delineated a signicant unmet need for medical attention. At the same time they began to give insight into the complexity of the cultural domain of reproductive health (Gittelsohn et al. 1994). This complexity requires moving beyond the traditional focus on biomedical/demographic models and supply/delivery issues to examining these and related factors in their socio-cultural and environmental context (Ross 1996). This paper, from a rural region of Bangladesh, is intended to add to the growing literature related to womens reproductive health in South Asia. The objective of the study was to allow women to speak for themselves in order to identify: (1) salient illness categories; (2) perceptions of severity; and, by extension, (3) womens health priorities. These data, taken together with recent work in India, highlight a rich cultural domain as well as a set of practical problems for primary health programmes. Importantly, they illustrate the value of systematic, qualitative methodologies in elucidating this cultural domain.
Setting

With a landmass of 144,000 square kilometres and a population of nearly 120 million in 1994, Bangladesh is the most densely populated country in the world (World Bank 1995). With an estimated GDP per capita of US$220 in 1993, Bangladesh is also amongst the poorest nations of the world, ranking 146 out of 174 countries (United Nations Development Program 1995). The Government of Bangladesh (GOB) spends only 1.5% of its GNP on health. With the exception of family planning services, perhaps as much as 70% of all health-related expenditures are urban based, with a disproportionate amount allocated to the capital citys secondary and tertiary health systems (World Bank 1995). In rural areas, public sector services such as a fully functional, staffed and equipped health facility is a true exception. Service utilization also is limited by the fact that the overwhelming majority of doctors are men, and it is culturally prohibited for a women to be seen, let alone physically examined, by any male other than her husband except under dire circumstances, and by then it is often too late. Over 95% of births take place at home, the majority attended by untrained relatives

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and neighbours without even a rudimentary knowledge of hygiene and safedelivery practices. A majority of women will experience signicant morbidity associated with pregnancy and deliveryfor example, uterine prolapse and vesico-vaginal stula (Akhter 1994, Goodburn and Chowdhury 1994). The prevalence of RTIs/STIs in the general population in Bangladesh is unknown, but available evidence from similar settings suggests that such infections may be common (Hossain et al. 1996, Bogaerts et al. 1997, Husain et al. 1997, Sarkar et al. 1997, Sharma et al. 1997). RTIs/STIs can cause infertility, ectopic pregnancy, cervical cancer, foetal loss, low-birth weight, infant blindness, and mental retardation. Because of socio-cultural barriers to the care of women with RTIs/STIs, both the incidence and impact of sequelae are likely to be more severe than in situations where treatment is more easily available. There is no effective STI programme in Bangladesh, little training of service providers at any level in RTI/STI management, and services for persons with STIs are severely limited (Ahmed et al. 1997, Chowdhury et al. 1999). As elsewhere, men and women with RTIs/STIs, particularly with ulcerative genital tract diseases, are expected to be at the highest risk of acquiring HIV infection. The HIV prevalence in Bangladesh is still thought to be relatively low (Caldwell et al. 1999, UNAIDS/WHO 2001). The pattern of rapidly rising infection rates throughout South and Southeast Asia, particularly among those identied as engaging in high-risk behaviours, suggests that HIV/AIDS may become a major public health problem in the next several years. The large number of sex workers (SWs) in urban and major port areas, increasing rates of drug injecting, and the widespread transfusion of untested, commercially sold blood suggest increasing HIV infection rates are likely (Caldwell et al. 1999). This is the general context in which the reproductive health of women (and men) in Bangladesh must be considered.
Methods and results

Data were gathered employing several qualitative methods, including free listing, pile sorting and severity ratings with a sample of women in a `comparison area community of the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR, B) on the Dhonagoda River, approximately 40 minutes boat ride from Matlab Bazaar. The eld research area of the Centre, Matlab, includes a regular surveillance of 150 villages almost equally divided between `treatment communities where various Maternal and Child Health and Family Planning (MCH-FP) interventions are introduced and evaluated, and the `comparison area where communities not receiving these interventions are observed. Case studies of reproductive illnesses as well as vocabularies related to symptoms and illness categories were also collected from 40 women identied through the course of collecting free lists and rank-order data. Respondents were all married women of reproductive age, i.e. 1545 years. All of the women were Muslim and most were illiterate. The women were selected from 23 baris (groups of households sharing the same courtyard) throughout

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Table 1. Most commonly mentioned illnesses in free listing (n 68). Local term Jor Meho Boat Gastic Amasha, Kamri Thunda, Shardi-Kash Matha betha Jontish, Hoilda palang, Maitta Palang Mashiker samassya Durbalata Chulkani, Khaujani, Godagadi Daatbatha Approx. English Fever White discharge Arthritis Gastric, heartburn, ulcer Dysentery Cold Headache Jaundice Menstrual problem Weakness, giddiness, numbness Itching Teeth problem Frequency 40 40 23 21 20 18 18 17 17 17 16 12

Note: Other reproductive illnesses in top 25 include: Shutika (postpartum diarrhea); Uterine prolapse (many different terms, e.g. padda rog, padda phul, pamnari, bodnari ); Promeho (more serious white discharge).

the village based on their availability at the time of study. Interviews were conducted by female researchers of the Social and Behavioural Science Programme of the ICDDR, B. Data gathering took place during the period from November 1994 to October 1995. In so far as these data elucidate deepseated cultural models and the fact that service provision is little changed, they remain salient.
Free listing

To understand the cultural beliefs, knowledge and behaviours related to health and health priorities, it is necessary to elicit emic construction of the illness condition, or the denitions and perspectives of those experiencing the health problem. Exploring the cultural domain of `womens illness began with informant interviews. In an open-ended format, individual women were asked to name (i.e. free list) `all the general illnesses and ailments they can think of. Often even such simple questions require prompting, rephrasing and other explanations. Normally women will respond with two or three names and it is necessary to ask again: `please, tell us any illness you (other family members, or neighbours) have experienced, and nally, `name any other illnesses you have heard about. Conducting a free listing exercise can produce a near-exhaustive inventory of illnesses, words and phrases, as well as identify symptoms and treatment strategies. Generally, interviews with 2025 key informants will lead to a point where additional interviews fail to produce any new information. In this instance, 68 informants named a total of 118 illnesses. Table 1 shows the frequency of commonly mentioned illnesses among the top 25 named by respondents. While this list may seem relatively unremarkable at rst glance, it is important to note that reproductive-health-related problems feature prominently among the most commonly mentioned illnesses. That is, they are `on womens minds.

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Table 2. Numbers represent the illnesses on the cards used in pile sort. 1. 2. 3. 4. 5. 6. 7. 8. 9. Urinary problems Papri Measles Abdominal ache Nocturnal emission Gastric Worm Stomach upset Weakness 10. 11. 12. 13. 14. 15. 16. 17. 18. Jaundice Blood pressure Arthritis Itching Eczema Ringworm Menstrual problem Fever Shutika 19. 20. 21. 22. 23. 24. 25. 26. 27. Ear problem White discharge/meho Chicken pox Asthma Headache Cold/cough Alga Cholera Promeho (discharge)

Pile sorting

To obtain more systematic information on the domain of womens illnesses, a set of cards was prepared representing the 35 most commonly mentioned illnesses to aid respondents in a card-sorting procedure. For example, jauntis was represented by a totally yellow gure of a person; red drops represented menstrual problems; a slice of papaya with white drops coming from the slice represented `white discharge, or meho. This illustration arose because village women referred to the drops from the papaya as similar to their own white discharge. After pre-testing, it was decided to reduce the list of illnesses to 27 (table 2), in order to simplify slightly the pile-sorting task and to shorten the overall interview time requirements. The 27 illness cards were spread out in front of each of the 33 respondents and each card was explained. Each woman was instructed that she could make as many piles as she wished, and there is no `right way or `wrong way to sort the cards; she was simply instructed to put those that are most alike in the same pile. These structured interviews with cards also include a series of questions such as `why do these seem similar to you? and probing systematically as to the criteria for selection and sorting based on seriousness, treatment and gender, for example. During the course of each pile sort, a record was kept of how many piles were made, and which illness was placed in which pile. These data were used to construct a matrix showing how many times each illness was grouped with others in the same pile sort. The greater the number of times items are placed together by independent respondents in the same pile, the closer they are conceptually.

Multidimensional scaling (MDS)

This matrix of similarities or `proximities can be converted into a cognitive map by multidimensional scaling. Such a map is represented in gure 1. The numbers of times two illnesses have been placed in the same pile have been transformed into distances. Items never occurring together can be expected to be quite far apart. Cognitive maps such as this are useful in the process of exploring the patterns and relationships among illnesses. Exploration of the manner and

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Figure 1. Multi-dimensional scaling of illnesses.

reasons by which people group illnesses, that is, which are considered `similar, can help us to begin better to understand their `explanatory models of illness, sequences of illness development, and health care-seeking behaviours. In this map it is evident that reproductive health problems, for example meho, promeho, shopnodosh (nocturnal emission) and urinary problems, are clustered or grouped together. Conceptually then, they are similar and distinct from other illness groupings such as those associated with itching (even though papri is, in fact, considered a reproductive health-related illness) and respiratory illnesses. Thus, reproductive health-related illnesses spontaneously emerge in the process of free association described previously, and rural Bangladeshi women `see these illnesses as a clearly identiable category or class occupying a discrete illness domain. In other words, these illnesses exhibit a high level of salience in this cultural context.

Severity ratings

To examine the degree of seriousness of womens illnesses and other characteristics, a variation on pile sorting described above was employed. Instead of simply grouping the illnesses, 35 women were asked to arrange the items in terms of their perceptions of high, intermediate and low severity. These interviews also included a series of questions relating to why these illnesses seem most serious to them. Twenty-seven cards prepared for the earlier pile sort procedure, representing the illnesses mentioned here, were employed. Women were asked to group the illnesses into `most serious and `least serious, with provision for an intermediate group. Cards were spread on the oor and each respondent requested to pick up the most serious illness and to place that card on one side (e.g. on the left). They were then asked to pick up the least serious illness and to place that card over on the right hand side. They were then asked to pick up any others considered most serious

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Table 3. Severity ratings of womens illnesses (n 30). Average Asthma Arthritis Blood pressure Meho Promeho Jaundice Stomach ache Alga (evil spirit) Gastric Worm Durbalta (weakness) Cholera Pansha (chicken pox) Ear problems Papri (vaginal itching) Shutika Lunti (measles) Eczema Shopnodosh (noct. emission) Menstrual problems Fever Urinary problems Headache Stomach problems Ringworm Itching Cold Note: Ratings: 1 most serious 2 Intermediate 1.17 (most serious) 1.23 1.23 1.47 1.47 1.47 1.53 1.57 1.57 1.63 1.60 1.60 1.67 1.70 1.77 1.83 1.83 1.93 1.93 1.95 1.95 1.97 2.03 2.23 2.27 2.40 2.42 3 Least serious

which should be grouped on the left. They can pick up as many (or few) as they consider `quite serious. They then again were asked to pick out others that are `not very serious for the right hand side. Finally, when all illnesses had been assigned to one of three groupings, informants were asked to explain their reasons for sorting them in this manner. In this way it is possible to construct a matrix of illnesses by perceived seriousness. Most cases require little probing as the stated rationale for the classication was, for example, `most likely to do long-term damage or even cause death. The ratings displayed in table 3 provide additional information about how women conceptualize, and presumably react to, different problems. They also serve as a means of establishing womens health priorities. Here, we can see that asthma, arthritis and problems with blood pressure are considered the most serious illnesses. Respondents explained their reasons for grouping illnesses in this manner. Both asthma and arthritis bring long-term suffering to the patients and there is no cure. Asthma patients do not die easily. Both of the diseases leave the individual in a state of long-term dependency on others. Blood pressure was the second highest in average ranking. It is another life-threatening disease, and causes sudden death of the patients. People have very little time and scope for receiving treatment.

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Table 4. Indigenous terms for discharge. Vernacular term Meho K hich K hichm eho K hich pradar Shada Shadasraab Shetpradar Shada prosrab Prom eho Translation white discharge white discharge white discharge white discharge coming out white white discharge white discharge coming out white urination severe discharge; uterine prolapse

The reproductive health problems meho and promeho attained the third highest average rating. They are considered very serious. Most women report that these are illnesses of such a part of the body that people cannot speak out and feel shy, so that these remain chronic. As a consequence, these illnesses need a long time to cure, if ever. Other women responded:
If someone has meho she might have pain in sexual intercourse. Meho is not an illness to get cured totally, I have not heard any body who cured fully. Meho is the cause of weakness. Meho can turn into uterine prolapse or promeho. Meho is such a disease, nobody can see it but slowly the blood becomes watery. Meho lessens the strength of the body.

From these statements, it is evident that women consider both meho and promeho as very serious illnesses. It hampers their sexual health, causes other types of illness and long-term suffering. Bang and Bang (1994) found that women in their study area in central India provided 12 different terms for `white discharge, indicative of the importance of the problem. Bangladeshi women in this study also employ a number of terms in the local vernacular to refer to vaginal discharge (table 4). Women ordinarily use the word meho for white discharge in their general conversation, but the term khich was not uncommon. Other terms, such as pradar and sraab are also commonly used. It appears these are known from canvassers or leaets from the bazaar or indigenous healers. Promeho is the term most often employed to refer to severe vaginal discharge. In its most severe form it is known as padmaphul nama, i.e. uterine prolapse. Women in this study generally speak of two kinds of discharge, meho and promeho. Classication was based on the following dimensions: 1. 2. 3. 4. 5. 6. 7. severity; colour; smell; duration of discharge; density of the discharge; timing of discharge; gender of the person with discharge.

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Figure 2. Vaginal discharge as illness.

In fact, these terms represent opposite ends of a continuum in this illness domain, progressing through several stages from the less or least severe (meho) to the most severe ( promeho) based on the dimensions identied above. Each of these dimensions, in turn, is differentiated on the basis of several characteristics within the category. The nature of this cultural construction is illustrated in gure 2. In its least severe or threatening form meho is described as `shorirer shokti noshto hoye jai , that is, the strength of the body decreases with white discharge (noshto hoye jai decreasing). Untreated meho may be associated with increasing weakness, especially for women. This concept refers not only to physical strength, but to the depletion of sexual energy or power as well, especially in the male. In women in this form the discharge is white, may be virtually odourless, the density of rice water, and appears drop-by-drop just prior to menstruation. While this may be a common or frequent occurrence for many women it is still of concern because of the belief that if left unresolved it may, almost inevitably, progress to a much more serious, even lifethreatening state of promeho. This progression, perhaps better thought of as retrogression in terms of health status, is characterized by increasing severity among the features

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identied with the illness domain. The colour of the discharge changes from white to yellow to green and nally red. In its severest form the odour is described as the smell from water of washed sh. Density becomes increasingly viscous, and occurs without interruption throughout the entire day and night.
Causation

The perceived causes of folk aetiology of such discharge is attributed to several factors. Note should be taken of the fact that some women were unable or unwilling to ascribe an underlying cause for their illnessit is just something that is part of being a womanor it is attributable perhaps to evil spirits or it is a God-given ailment. One respondent who was unsure of the cause of her discharge said, `I do not know [the cause]. All depends on Allah. He is the controller of everything including happiness and sorrow. Another woman said, `God has given me such [an] illness. There is no other reason. Most women commonly associate discharge with childbirth, especially after their rst delivery, or hard and heavy work immediately after childbirth. For example, several women believe that unless certain proscribed behaviour is followed after delivery, meho may be the consequence. Such behaviour falls into two categories. The rst includes physical precautions such as not carrying water in a pitcher or big pans of heavy rice or curry, and avoiding heavy, strenuous work in general. The second relates to spiritual-cultural expectations, for example walking by the graveyard alone after dark, having untied hair at midday or failing to have a piece of iron on the bed to protect the mother and baby from evil spirits. Other women clearly associate meho with contraceptive use. Here it is important to note that women themselves not only associate the relative risk of discharge with contraceptive use in general, but also are quite able to articulate clearly their perception that the risk is greatest to women who undergo IUD insertion or sterilization. Their perceptions may be well founded. Clinical studies in Bangladesh suggest women who have had a tubal ligation or use an IUD are seven times as likely as non-users to develop RTIs (Wasserheit et al. 1989). Tangentially, no women mention the use of a condom as a means of infection prevention. This is signicant as women clearly understand the possibility of sexual transmission of promeho; comparing its potential for transmission to that of lunti (measles) and pansha (chicken pox). Several women relate acquiring an infection from their husbands. It should also be noted that these women reported that their husbands were cured, but they still suffer from the ailment themselves, and gradually it is becoming worse. In its severest form informants state promeho can result in a sexual illness known as jauno rog, that is, one that can lead to a loss of sexual power in both sexes, including impotence in the male (dhaja bhongo). They use the term kharap oshukh or oshot rog to refer to sexual illness. One respondent said, `Whatever the illness is, it is bad. But it is important that they perceive kharap oshukh in two ways. First it is severe (kathin), mostly meaning life

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threatening or expensive to cure, or the cause of great suffering. Second, it is an illness that occurs in the genital area, which is indicative of a stigma, and likely a misdeed. It transfers easily from spouse to spouse. It causes itching and persons aficted pass khich (white discharge). When it becomes severe both itching and khich come out. `Hishaber baire cholle oshukh dekha dibe. Kaj kom korle shorirer khoti kom hoi, beshi korle beshi hoi. In effect, if someone is not careful he or she may get kharap oshukh. Less `work (kaj is translated as work and is a euphemism for intercourse) brings less harm to the body and much work does just the opposite. Respondents mentioned meho (for male), promeho or padda, papri, shopnodosh, and urinary problems as kharap oshukh.

Case study

This young woman is 25-years-old, has two children and has been married for 5 years. She has had white discharge for the past 10 years, since she began menstruating. She did not tell anyone until after her rst child was born.
I did not tell anyone because the household of my husbands parents was new and I could not nd anyone to tell such a thing. I felt shy to tell my husband. But later on, after having my rst child, I had to tell him. He took me to a doctor (allopathic) in a nearby village. But it did not cure me.

She felt if she could have gone to the hospital regularly for medicine, they might have cured her. Next, they went for Ayurvendic treatment. He gave them tablets and a mixture in a bottle. She took the medicine three times a day, but it had no effect. The white discharge remained the same, very sticky and like lime water. Her petticoat was often wet. She was asked if the discharge affected her relationship with her husband. She said, `The main problem with me is the problem to stay with my husband. He hates to have a sexual relationship with such a wife. Her husband is afraid he may get a disease from her. She was also afraid the meho may turn to promeho (uterine prolapse). She said, `I am now taking medicine, other things depend on Allahs will. Her mother-in-law entered the room and she stopped talking, saying she had some clothes to wash.
Social consequences

Regardless of the perceived cause, the consequences of such infections for women are incalculable. Inexorably, vaginal discharge is grounded in the cultural concepts of purity and pollution. A woman experiencing vaginal discharge, i.e. menstrual or white discharge associated with an infection, is considered impure and thus restricted in social interaction. In its least severe manifestations meho may simply be a minor inconvenience, but it can rapidly progress to something more than that, for example, interfering with a womans ability to conduct her daily routines of prayer, cooking or to bed with her husband. In its more severe presentation women, in effect, become bound by the disorder. Unable to perform routine tasks, women describe themselves as

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becoming `useless objects. Continuous discharge not only constricts their social interaction generally but also may seriously affect their sexual relationship with their husband, and consequently their marital union. This is an extremely grave matter because women fear desertion or divorce more than death.
Health-seeking behaviour

The cultural constructs of meho and promeho (and other terminology for white discharge) inuence womens health-seeking behaviour and expectations concerning outcomes of treatment. These are conditions that women nd difcult, but not impossible, to talk about; and they worry about the possible long-term consequences. They are more likely to talk about these problems with women rather than men, and to solicit advice from other women, including community health workers. Importantly, women nd it difcult to discuss the illness with their husbands despite their concerns about imperiling their marriage. Earlier studies of health-care-seeking behaviour often assumed that both the belief systems and the resulting behaviours were homogenous patterns characteristic of entire cultures. It is now acknowledged generally among social science researchers that illness domains are inherently complex cultural systems, with variations from household to household, and subject to situation-specic decision making at various points (Pelto and Pelto 1997). Peoples decisions about illnesses and treatment-seeking are certainly inuenced by their explanatory models of the ailments, but are also affected by other factors, including social and economic costs and availability of relevant services. While women are anxious to get treatment for gynaecological problems, they are in many ways bound and restricted by their cultural milieu. The majority of Bangladeshi women will not go to male practitioners for these sensitive matters. Instead, they are more likely to seek help from indigenous female healers (mohila kabiraj). This is particularly true for those who suspect that their illness may be due to supernatural causes. The mohila kabiraj (healers) are available in most rural areas, and are particularly important for treatment of womens illnesses (Ross et al. 1998). The majority of the mohila kabiraj are disciples of pirs (Islamic spiritual healers), from whom they acquired a variety of treatment methods, including `naturalistic techniques. The women of this region do, however, utilize other sources of treatment for white discharge. Since most treatment regimens fail to produce a cure, they are likely to seek remedial help from a series of providers, including chemists, homeopaths, and allopathic practitioners, as illustrated in the case presented above. Resort to such `cosmopolitan resources is especially likely if the woman attributes her problem to exogenous factors such as IUDs, or sexual transmission. Unfortunately, regardless of which practitioners they go to, the majority of women do not nd an effective cure. Both the traditional kabiraj and the various allopathic and homeopathic sources are often ineffective in treating cases of vaginal discharge. The womens perception is, therefore, that meho and promeho are incurable, and they must learn to live with

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the condition, though still hoping to nd someone whose remedies at least bring some lessening of the symptoms.
Discussion and conclusions

Our data about womens cultural constructions of vaginal discharge among rural Bangladeshi women show that they consider these gynaecological problems to be serious, possibly leading to life-threatening consequences. Their explanatory models do not support the claim that they accept this condition as simply a `natural event that all women must bear in silence. The multiple dimensions by which women distinguish the severity of discharge attests to their sensitivity and discrimination in relation to this illness domain. While white discharge may be attributed to `fate by some women, it is also evident that women include concepts of sexual transmission, as well as infection or `disturbance due to contraceptive devices, in their explanatory models. Despite our focus on the importance of womens own perceptions of white discharge, we do not of course assume that meho, promeho, or the other terms for white discharge invariably point to `real reproductive tract infections. In fact, it has been pointed out in a number of studies, particularly those reported in India by Koenig et al. (1998) that womens reports of white discharge are often poorly correlated with actual infections as identied by clinical examination or laboratory tests. In the rst place, there are numbers of women who report no symptoms, yet are found to have RTIs. In the same general area of rural Bangladesh from which our data were gathered, Hawkes et al. (1999) have reported that, of the women reporting vaginal discharge in their sample, less than half actually had infections. Also significant was the nding that sexually transmitted infections (STIs) were found in only about 1% of those women who reported symptoms (Hawkes et al. 1999). The relationships of womens reports of white discharge to actual RTIs varies considerably from region to region. In some areas with higher rates of STIs, for example in a study in urban New Delhi (Garg 2000), vaginal discharges were often related to STIs, but in most areas of South Asia it appears that STIs are relatively infrequent, compared with high rates of non-sexual bacterial and other infections (Hawkes et al. 1999). Some of the discrepancies between womens reporting of white discharge and the medical diagnoses lies in the fact that a portion of `normal white discharge experienced by women may be `excessive in causing physical discomfort. Trollope-Kumar has recently advanced the hypothesis that some of womens complaints about white discharge represent a culturally dened way of presenting more diffuse, general feelings of psychosocial problems. She reported that `many women attended our outpatient clinics [Uttar Pradesh, India] complaining of vaginal discharge, as well as symptoms such as dizziness, burning hands and feet, backache, and weakness. These women were generally undernourished and anaemic, but they seldom had signicant physical ndings referable to the reproductive tract . . . (Trollope-Kumar

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1999: 17451746). Very similar observations have been reported by Nichter in research in southern Karnataka. He labelled the womens complaints as `idioms of distress, noting that women with very limited opportunities to ventilate their frustrations and tensions can nd indirect, culturally appropriate channels by presenting somatic symptoms to health services. Nichter (1981) found that the local practitioners associated complaints of white discharge with psychosocial problems, and they also recognized that Brahmin and Muslim womens mobility outside the home environment was restricted and a trip to a practitioner constituted one of the only opportunities for them to approach an outside source of guidance or support (Nichter 1981: 386). Researchers at a national psychiatric institute in Bangalore (NIMHANS) carried out a study of women reporting vaginal discharge along with other somatic complaints. They reported that `it appears that . . . the passage of non-pathological vaginal discharge is an important aspect of womens health belief system . . . . Nearly 65% of the women associated it with harmful affects on the body . . . . The symptoms attributed to discharge were mainly in the form of lethargy, weakness, aches and paints and fatigue with psychological symptoms featuring low in the list (Chaturvedi et al. 1995). Our research in Bangladesh, along with studies of similar phenomena in India, support the view that women in South Asia generally regard vaginal discharge as symptomatic of serious problems, for which medical relief is sought, if possible. At the same time, the correspondence between womens reports of white discharge and actual presence of RTIs is far from one-toone, and varies from region to region. In our study population we can assume that some of the reported cases of meho or promeho corresponded to gynaecological infections, but the possibility is strong that some of these somatic complaints represent underlying psychological and social stresses and conicts. Health practitioners dealing with gynaecological problems need to be alert to the psychosocial dimensions, in addition to treatment of infections. The data in our study point to very complex issues in developing effective reproductive health care for rural women in South Asia. At the same time, the high frequencies of complaints concerning white discharge offer opportunities for more effective health care strategies. Armed with thorough understanding of the clinical picture of RTIs, knowledge of womens cultural explanatory models of white discharge, and the expectation that some of these complaints may also reect `non-medical social and psychological stressors, community health workers and other providers can develop effective mixtures of medical treatment and personalized counselling. Often the rst task is to discuss with patients about the wide range of normal manifestations of vaginal discharge. At the same time, sensitive health personnel can explore individuals recent histories for possible sources of both sexually transmitted and endogenous infections, including hygienic practices. Careful counselling can also be sensitive to social and psychological stressors in the home environment that may be manifested in somatic complaints. We believe that a more rened and sensitive RTI strategy can be developed, which will be in tune with the cultural beliefs and

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expectations of rural women, and at the same time realistic in relation to the epidemiological and clinical realities in South Asia. A more comprehensive, client-oriented strategy would be potentially signicant in reducing the prevalence of RTIs (including STIs) in the population. More importantly, it would have the effect of reducing the heavy burden of gynaecological problems presently endured by women, particularly in low-income rural areas.
Acknowledgements

Funding for this research was provided by The Ford Foundation. We acknowledge the support of the International Centre for Diarrhoeal Disease Research, Bangladesh for its support, particularly the researchers in the Social and Behavioural Sciences Programme. We also thank the anonymous reviewers for their suggestions in improving the manuscript. The views and opinions expressed in the paper are those of the authors and are not necessarily shared by any sponsoring organization or agency.
References
Akhter, H. (1994) Dissemination Workshop on Maternal Morbidity Study. Bangladesh Institute of Research for Promotion of Essential and Reproductive Health and Technologies, Dhaka, Bangladesh. Ahmed, M., Ahmed, S., Khan, P. and Khan, M. (1997) Management of sexually transmitted diseases by rural practitioners. In S. Hawkes et al. (eds) ASCON VI, 6th Annual Scientic Conference: Programme and Abstracts (International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka). Bang, R., Bang, A., Daitule, M., Chaudhury, Y., Sarmukaddam, S. and Tale, O. (1989) High prevalence of gynaecological diseases in rural Indian women. Lancet, January 14. Bang, R. and Bang, A. (1994) Womens perceptions of white vaginal discharge: Ethnographic data from rural Maharashtra. In Listening to Women Talk About Their Health: Issues and Evidence from India (New Delhi: The Ford Foundation). Bogaerts, J., Ahmed, J., Akhter, N. and Begum, N. (1997) Prevalence of reproductive tract infections among women attending the BWHC clinic in Mirpur, Dhaka. In S. Hawkes et al. (eds) ASCON VI, 6th Annual Scientic Conference: Programme and Abstracts (International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka). Borgatti, S. (19851999) ANTHROPAC (Cambridge, MA: Analytic Technologies). Campbell, O. and Graham, W. (1990) Measuring Maternal Mortality and Morbidity: Levels and Trends (LSHTM, London: Maternal and Child Epidemiology Unit Publication. Caldwell, B., Indrani, P., Barkat-e-Kuda, Caldwell, J. and Caldwell, P. (1999) Sexual regimes and sexual networking: the risk of an HIV/AIDS epidemic in Bangladesh. Social Science and Medicine, 48, 11031116. Chaaturvedi, S., Chandra, P., Sudarshan, C. and Isaac, M. (1995) A popular hidden illness among women related to vaginal discharge. Indian Journal Of Social Psychiatry, 11, 6972. Chowdhury, S., Bhuiya, I., Huda, S. and Faisel, A. (1999) Are providers missing opportunities to address reproductive tract infections? Experience from Bangladesh. Family Planning Perspectives, 25, 9297. Christian, P., Bentley, M., Pradhan, R. and West, K. (1998) An ethnographic study of night blindness `Ratauni among women in the terai of Nepal. Social Science and Medicine, 46, 879889. Dixon-Mueller, R. and Wasserheit, J. (1991) The Culture of Silence: Reproductive Tract Infections Among Women in the Third World (New York: International Womens Health Coalition).

188

JAMES L. ROSS ET AL.

Elias, C. (1991) Sexually Transmitted Diseases and Reproductive Health in Women in Developing Countries. Working Paper No. 5 (New York: The Population Council). Fronczak, N. (1996) Early Maternal Morbidity and Utilisation of Delivery Services by Urban Slum Women of Dhaka, Bangladesh. PhD dissertation, The John Hopkins University, Baltimore, MD. Garg, S. (2000) An epidemiological and sociological study of symptomatic and asymptomatic reproductive tract infections and sexually transmitted infections among women in an urban slum, New Delhi, Maulana Azad Medical College (unpublished research report). Germain, A. (1997) Addressing the demographic imperative through health, empowerment, and rights: ICPD implementation in Bangladesh. Health Transition Review, 7 (Supplement), 3336. Germain, A., Holmes, K. and Pet, P. (eds) (1992) Reproductive Tract Infections: Global Impact and Priorities for Womens Reproductive Health (New York: Plenum Press). Germain, A. and Kyte, R. (1994) The Cairo Consensus: The Right Agenda for the Right Time (New York: International Womens Health Coalition). Gittelsohn, J., Bentley, M., Pelto, P., Nag, M., Pachuri, S., Harrison, A. and Landman, L. (1994) Listening to Women Talk About Their Health: Issues and Evidence from India (New Delhi: Har-Anand Publishers and The Ford Foundation). Gittelsohn, J., Pelto, P., Bentley, M., Bhattacharyya, K. and Russ, J. (1995) A Protocol for Using Ethnographic Methods to Investigate Womens Health. Ofcial Distribution Draft, The Johns Hopkins University and The Ford Foundation. Goodburn, E. and Chowdhury, M. (1994) An Investigation into the Nature and Determinants of Maternal Morbidity Related to Delivery and the Puerperium in Rural Bangladesh: End of Study Report (Dhaka: Bangladesh Rural Advancement Committee). Graham, W. (1998) Outcomes and effectiveness in reproductive health. Social Science and Medicine, 47, 19251936. Graham, W. and Campbell, O. (1990) Measuring maternal health: Dening the issues (London: Maternal and Child Epidemiology Unit, London School of Hygiene and Tropical Medicine). Hawkes, S., Morison, L., Foster, S., Gausia, K., Chakraborty, J., Peeling, R. and Mabey, D. (1999) Reproductive-tract infections in women in low-income, low-prevalence situations: assessment of syndromic management in Matlab, Bangladesh. Lancet, 354, 17761781. Hossain, S., Bhuiya, I. and Streateld, K. (1996) Professional blood donors and risk of HIV/AIDS: A study in selected areas in Bangladesh. Population Council South and East Asian Regional Working Paper No. 6 (Dhaka: The Population Council). Husain, M., Islam, M., Suttan, M., Begum, H., Islam, M., Kabir, S. and Chowdury, T. (1997) Prevalence of HBV, HCV, HIV and syphilis markers in preganant women in Bangladesh. Population Council South and East Asian Regional Working Papers (Dhaka: The Population Council). Hussain, R., Lobo, M., Inam, B., Khan, A., Qureshi, A. and Marsh, D. (1997) Pneumonia perceptions and management: An ethnographic study in urban squatter settlements of Karachi, Pakistan. Social Science and Medicine, 45, 9911004. ICPD (1994) Programme of Action (New York: UNICPD Secretariat). Isaacs, S. (1995) Incentives, population policy, and reproductive rights: Ethical issues. Studies in Family Planning, 26, 363367. Kleinman, A. (1980) Patients and Healers in the Context of Culture (Berkeley, CA: University of California Press). Koblinsky, M., Campbell, O. and Harlow, S. (1993) Mother and More: A Broader Perspective on Womens Health. In M. Koblinsky, J. Timyan and J. Gill (eds) The Health of Women: A Global Perspective (Boulder, CO: Westview Press). Koenig, M., Jejeebhoy, S., Singh, S. and Sridhar, S. (1998) Investigating Womens Gynaecological Morbidity in India: Not Just Another KAP Survey. Reproductive Health Matters, 6, 8496. Lovell, C. H. (1992) Breaking the Cycle of Poverty: The BRAC Strategy (West Hartford, CN: Kumarian Press). Measham, A. and Heaver, R. (1996) Indias Family Welfare Program: Moving to a Reproductive and Child Health Approach (Washington, DC: World Bank). Nichter, M. (1981) Idioms of Distress. Alternatives in the Expression of Psychosocial Distress: A Case Study from South India. Culture, Medicine and Psychiatry, 5, 379408. Osmani, S. R. (1990) Notes on some recent estimates of rural poverty in Bangladesh. The Bangladesh Development Studies, 43, 5574. Pachauri, S. (1994) Womens reproductive health in India: Research needs and priorities. In J. Gittlesohn et al. (eds.) Listening to Women Talk about Their Health: Issues and Evidence from India (New Delhi, The Ford Foundation).

EXPLANATORY MODELS OF REPRODUCTIVE HEALTH

189

Paolissa, M. and Leslie, J. (1995) Meeting the changing health needs of women in developing countries. Social Science and Medicine, 40, 5565. Pelto, P. J. and Pelto, G. H. (1997) Studying knoledge, culture nd behaviour in applied medical anthropology. Medical Anthropology Quarterly, 11, 147163. Petchesky, R. and Judd, K. (1998) Negotiating Reproductive Rights: Womens Perspectives Across Countries and Cultures (New York: Zed Books). Ross, J. (1996) The Program Response of the Social and Behavioural Sciences to the ICPD-POA (Dhaka, Bangladesh: ICDDR, B Special Publication No. 46). Ross, J., Laston, S., Nahar, K., Muna, L., Nahar, P. and Pelto, P. (1998) Womens health priorities: cultural perspectives on illness in rural Bangladesh. Health, 2, 91110. Sarkar, S., Durandin, F., Mandal, D., Corbett, G. and Islam, N. (1997) High STD and low HIV prevalence among commercial sex workers (CSWs) in a brothel in Bangladesh: scope for prevention. In S. Hawkes et al. (eds) ASCON VI, 6th Annual Scientic Conference: Programme and Abstracts (Dhaka: International Centre for Diarrhoeal Disease Research). Sen, G. and Snow, R. (1994) Power and Decision: The Social Control of Reproduction (Cambridge, MA: Harvard University Press). Sen, G., Germain, A. and Chen, L. (eds) (1994) Population Policies Reconsidered: Health, Empowerment and Rights (Boston, MA: Harvard School of Public Health). Sharma, A., Nahar, P., Sabin, K., Begum, L., Ahsan, K., Arifeen, S. and Baqui, A. (1997) Sexual behaviours among cases with sexually transmitted diseases in Dhaka slums. In S. Hawkes et al. (eds) ASCON VI, 6th Annual Scientic Conference: Programme and Abstracts. (Dhaka: International Centre for Diarrhoeal Disease Research). The Ford Foundation (1991) Reproductive Health: A Strategy for the 1990s (New York: The Ford Foundation). Trollope-Kumar, K. (1999) Symptoms of reproductive tract infection: not all that they seem to be. Lancet, 354, 17451746). UNAIDS/WHO (2001) Bangladesh: Epidemiological Fact Sheet on HIV/AIDS and Sexually Transmitted Infections, 2000 Update (UNAIDS/WHO Working Group on Global HIV/AIDS and STI Surveillance). United Nations Development Program (1995) Human Development Report 1995 (Oxford: Oxford University Press). Uzma, A., Underwood, P., Atkinson, D. and Thackrah, R. (1999) Postpartum health in a Dhaka slum. Social Science and Medicine, 48, 313320. Wasserheit, J. (1989) Reproductive tract infection in a family planning population in rural Bangladesh. Studies in Family Planning, 20, 6980. World Bank (1995) World Development Report 1995: Workers in an Integrating World (Oxford: Oxford University Press).

Re sume

Cette etude illustre lutilisation de techniques de choix systematique telles que lassociation libre (free listing), larrangement dimages (pile sorting) et les classements de gravite, dans lanalyse des contextes culturels, an didentier les principales categories de maladies et les perceptions de la gravite des maladies, chez les femmes des zones rurales du Bangladesh. Les strategies comple mentaires de lentretien en profondeur et de la collecte detudes de cas, ont egalement ete utilisees pour determiner des mode les explicatifs. Dans le domaine de la sante de la reproduction chez la femme, il est constate que les maladiespar exemple, les infections du systeme repro ductifsont parmi les problemes de sante les plus aigus, pour lesquels les soins sont recherches. Des donnees rassemblees gra larrangement ce a dimages (pile sorting) demontrent que les femmes de ces communaute s rurales ont des conceptions tres claires des categories de maladies et des differentes strategies the rapeutiques qui leur correspondent. Tandis que les

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preoccupations concernant les infections du systeme reproductif (parmi lesquelles celles qui sont attribuees la transmission sexuelle) et les pertes a vaginales sont importantes chez ces femmes, aucune des structures de sante disponibles ne propose de reponse specique ces besoins. Le developpe a ment de services medicaux prenant en compte les modeles explicatifs des femmes pourrait jouer un ro le important dans la reduction des infections du systeme reproductif, des MST et du VIH dans le Bangladesh rural.
Resumen

Este estudio ilustra el uso de tecnicas sistematicas de elicitacion para el analisis de los dominios culturales, incluyendo las listas de cuotas, las clasi caciones y porcentajes de gravedad a n de identicar las categor de as enfermedades predominantes y las percepciones de gravedad de enfermedades que padecen las mujeres en zonas rurales de Bangladesh. Tambien se utilizaron estrategias complementarias de entrevistas en profondidad y recopilacio n de casos practicos para delinear modelos explicativos. Se observo que las enfermedades que afectan a la salud reproductiva femenina, por ejemplo, las infecciones del aparato reproductor, eran los problemas de salud mas predominantes y graves que se atienden. Los datos recogidos en la clasicacio n de respuestas demuestran que las mujeres de esta comunidad rural ten ideas muy claras de los grupos de enfermedades, con estrategias an diferentes de los tratamientos en varias categor Si bien para las mujeres, as. los problemas relacionados con las infecciones del aparato reproductor son importantes, incluyendo las que estan relacionadas con la transmision sexual y el ujo vaginal, los centros de salud no estan capacitados para atender estas necesidades. Para poder disminuir las enfermedades del aparato reproductor y las infecciones de enfermedades de transmision sexual/VIH en las zonas rurales de Bangladesh, ser importante que al crear servicios de salud se a tuvieran en cuenta los modelos explicativos de las mujeres.