The Hidden Problem: Shadows of Mental Stress Over Urban Adolescents

By Seama Mowri

CHILDMARRIAGE_AJ_03 (1)
Photo Credit: Allison Joyce 2015

“He had a bottle of poison in his hands and told me he would drink it if I didn’t agree to marry him.” 
– A 16-year-old girl living in a Dhaka slum explaining the circumstances that led her to consent to marriage.

Whilst this might read like teenage melodrama, the girl’s story is not unusual. During the last six months of our research (a project funded by IDRC and led by Professor Sabina F Rashid) in urban slums the research team encountered several stories of manipulative suicide threats and evidence of mental angst among both male and female adolescents and young people. Initially, a love interest may spark such incidents of dramatic behaviour but these are symptomatic of much deeper troubles. The rapid hormonal, physical and mental changes brought by puberty are difficult for any adolescent to navigate but these challenges are intensified when they are experienced simultaneously with the social, economic and structural instability of surviving in poverty in Bangladesh’s dense urban slum communities, where adult responsibilities are imposed on children before they are ready.

The multiple stressors experienced by adolescents in these settings are little discussed but include: fathers abandoning families, parents remarrying, children being forced to drop out of school, unemployment, abusive gossip and rumours about girls’ characters and “morality”, bullying, daily sexual harassment, physical abuse for dowry, taunts regarding dark skin from in-laws, and entrenched gender norms that place unachievable expectations on girls and boys. Any one of these factors – including the dynamics of the overcrowded slums they navigate, living out of cramped one-room households – can have debilitating effects on a person’s mental well-being.

Our research also highlights a complex interplay of age and identity. Amongst the slum dwellers, there is an embedded assumption that ‘married’ implies ‘adult’, and most of these married ‘adults’ are 15-16 years old. In other words, there’s almost no sense of transition about the stages of adulthood that they go through. As we’ve noted, most of the early married adolescent girls face the challenge of forming their adult identity at the same time as they are required to assume the duties of a wife and a mother which can create a great deal of mental stress. But who do they turn to?

“I have nowhere to go, no one to seek help from. I see my nonod (sister-in-law, who is only eight months younger than me) roaming around with her friends, gossiping, going to fairs… but I can’t do any of that. I am ghorer bou (bride of the house). I have to take permission from my husband and my father-in-law before stepping out of the house. The only guidance I get from relatives and programme interventions is related to family planning,” shares Ayesha about her experience after marriage.

The WHO constitution states: “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” An important implication of this definition is that mental health is more than just the absence of mental disorders or disabilities. Mental health is defined as a state of well-being in which an individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community.

In Bangladesh, there is a dearth of knowledge around systematically-collected data on mental disorders and so the extent of the problem remains unknown. A recent systematic review (by Hossain et al.) suggests that females are more vulnerable to mental disorders in both rural and urban settings compared to males. These findings are consistent with another rural study (Ara et al. 2001) which reported that social stigma inhibits women from seeking medical treatment for their mental problems.

The BRAC School of Public Health has undertaken a number of research projects that focus on exploring mental health issues among adolescents. One of the projects is trying to understand how early marriages change the life opportunities and well-being of girls in urban slums, and their coping strategies in coerced marriages. Qualitative cases pertaining to sexual coercion in early marriages have provided some insight into the challenges faced by adolescent females living in a society fraught with gender disparities. Another research study funded by NWO-WOTRO – “Psychodrama as Transformative Intervention in the SRH of Young Men in Urban Slums” – aims to identify the spectrum of risks and health issues affecting young men. “Sexual and reproductive health (SRH) education for young men, particularly those from vulnerable communities like urban slums, is a neglected issue,” says Dr Malabika Sarker (Professor and Director of Research at James P Grant School of Public Health) who is leading the study.

As Dhaka transitions into being the sixth largest megacity by 2030, the urban challenges of structural poverty and inequalities, steep social gradients, risky environment, deprived living conditions, entrenched and changing social and gender norms will start to have serious impacts on the well-being of the population at large. What does that mean in terms of the stress resilience of an increasingly urban population? What are the health consequences of higher social stress exposure and vulnerability of urban-dwellers, given that stress is the most likely cause of many mental disorders, particularly depression? And from a policy perspective, what actions can be taken to protect people living under dense metropolitan conditions from urban stressors and their negative mental impact? With this article I wish to stimulate a conversation in the hope of facilitating a more nuanced understanding of how urban living conditions impact our mental health. And it is imperative that we start the conversation sooner rather than later.


This article was first published in The Daily Star on World Health Day. The writer is a project manager at the Centre for Gender and Sexual and Reproductive Health Rights, James P Grant School of Public Health. 

Psychodrama as a New Form of Health Education for Young Men in Dhaka’s Urban Slums

By Rafee Muhammad Tamjid

 

Shujon* is a 19-year-old man living with his mother in Bhashantek, an urban slum in Mirpur, Dhaka. His father left his mother when he was a child, leaving him with too many responsibilities and unable to cope. He feels depressed because of the expectations projected on him by his family and peers. Recently he broke up with his girlfriend, because her parents wanted her to get married, but Shujon was not ready. “If I married her now, I would have to be a rickshaw puller, and that won’t make us enough money.” He admits that sometimes he feels confused and doesn’t have anyone to talk to, which takes a toll on his mental health.

To our surprise, when we explained to Shujon that the research project we were conducting would examine the physical and mental wellbeing of young men just like himself, he was immediately interested to speak to us. His eagerness was probably a reflection of the fact that in Bangladesh there is little to no attention given to mental health education, particularly related to sexual and reproductive health (SRH).

Due to shame and stigma, there is a lack of comprehensive SRH education in Bangladesh. Although several successful interventions exist around family planning for married couples, SRH education is still limited for others, particularly the target group for this research project: young vulnerable men who live in urban slums and engage in risky sexual behavior. While this study will also detect exactly which types of behavior are involved, similar studies in Africa show that risky behavior is influenced by one’s social environment.

Currently Dhaka is one of the fastest growing megacities in the world. By 2025, the UN predicts Dhaka will be home to more than 20 million people. As the population of the city grows, so will the population and size of the slums. Thus it is very important to make sure the wellbeing, including health of men in these slums are attended to just as much as women and adolescents. Generally, SRH knowledge of slum dwellers in Bangladesh is very low and they have a higher probability of being confronted with early marriage, drugs and violence.

This research project aims to identify the spectrum of risks and health issues affecting other young men like Shujon living in urban slum. Psychodrama (a group psychotherapy method) would then be used as a “transformative intervention” to help participants discover alternatives to the choices they would usually make. Psychodrama uses role-playing, dramatisation, and self-presentation to explore and gain insight into one’s life, incorporating theatre and conducted in groups under a licensed trainer, educator and practitioner.

bhashantik_pyschodrama
Young men living in Bhashantek slum. Photo Credit: Rafee Tamjid

Since psychodrama is a very new concept in Bangladesh, we want to adapt this therapeutic approach and create an innovative and interactive educational tool to see if it can be used as new form of health education. It will engage young men to explore existing and alternative attitudes towards their own and their peer’s health and relationships. The hope is to use psychodrama can help these young men evaluate their decision-making process so as to decrease the risky-behaviors they engage in which may adversely affect their health.

“SRH education for young men, particularly those from vulnerable communities like urban slums, is a neglected issue,” said Dr Malabika Sarker (Professor and Director of Research at JPGSPH) who is leading the study. “An innovative approach that blends traditional methods of mental health counseling and SRH education with a more humane touch like psychodrama could help reach this population more effectively.”

*Note: Name has been changed for anonymity purposes.


Rafee Muhammad Tamjid is a research assistant at the James P Grant School of Public Health.

Stay tuned on #VitalSigns for more updates from this project!

Why Does Child Marriage Happen?

By Seama Mowri and Saraban Ether

20160727_101253
Poster on child marriage seen during a field visit to Bhashantek slum. It reads, “Out of 100 Bangladeshis, 66 young girls are victims of child marriage.”

Although only 16 years old, Ayesha had already been married for nine months when we met her in the Bhashantek slum in Mirpur, Dhaka. While conducting research for the Preventing Early Child Marriage in Urban Slums project, we spoke to Ayesha to get a better understanding of the reasons behind her decision to marry. This is her story.

As an orphan from birth, the responsibility for Ayesha’s care fell on her grandmother. But when her grandmother also died, Ayesha was passed on to the care of one of her paternal aunts. Unfortunately, this arrangement didn’t last either, as Ayesha’s uncle was not keen on having another mouth to feed.

She was then sent to live with another aunt and her cousin who wilfully took her in their care. They loved Ayesha and it seemed that she was finally happy. But when her cousin married a few years later, his new wife disliked Ayesha’s presence and treated her badly. She refused to sit or eat at the same table as Ayesha and blamed her for everything that went wrong in the house. This made life so unbearable for Ayesha that she decided her only option was to get married and move out of the house.

The first suitor her aunt found for Ayesha was interested in the union until his family found out she was an orphan. “His parents were concerned that their son would miss out on jamai-ador (the cultural tradition of pampering the son-in-law with food, accommodation, dowry and all other means of hospitality),” said Ayesha.

The next suitor was Ayesha’s distant cousin. “I heard that he loved me,” she said. “I was so desperate to get married and have a home that I said yes to him. I did not think of anything else.” But after they got married, Ayesha realized the magnitude of responsibilities that came along with being a wife. “I had never seen a wooden stove before getting married,” she said. “But I needed to cook on that stove now. I never cooked or washed clothes before [getting married]; now I have to do all that and more.”

Even though she performs her daily chores, Ayesha’s husband is still displeased and uses any opportunity to beat her. “I cannot sleep on my right side from the beating he gave me last time.”

Now she regrets the decisions she made, which led up to her getting married in such haste. She says that one of the greatest impacts of her marriage is the loss of her independence. “I could go to my cousin’s house whenever I wanted to go. I used to visit Dhanmondi Lake every afternoon with my aunt. But now I don’t have that independence. I want to visit her, but I can’t.”

In addition to Ayesha’s loss of freedom, she now faces pressure to have a baby. “My husband and in-laws want me to have a baby as soon as possible,” she said. “They do not think of my age and that I am only 16.”

Ayesha decided to get married because she felt she had no other way out. She could no longer tolerate the difficulty of living in the same house as her cousin’s new wife. She believed that marriage would give her a better life. But at just 16 years old, she has lost her childhood and opportunities for a brighter future.

20160713_143355
Women in Bhashantek with adolescent children participate in a focus group discussion for the Preventing Early Child Marriage project. The majority of these mothers were married as young children themselves.

In a country where 64% of girls are married before the age of 18, it is crucial to examine how to end this all too common practice, and empower girls to overcome the hardships, which lead them to seek early marriage as a means to escape their difficulties.

This particular project on preventing early child marriage is examining the underlying factors that lead girls and their families to make such decisions. While Ayesha’s story is only a snapshot of the research being conducted, the three-year long project will delve deeper into identifying how to delay early marriage and its impact on both girls and boys. Ultimately, the findings from this project aims to help the Government of Bangladesh inform future programme interventions and policies to better serve girls like Ayesha.


Seama Mowri, Project Manager and Saraban Ether, Research Associate work on the Preventing Child Marriage in Urban Slums project under JPGSPH and International Development Research Center (IDRC). Stay tuned for more updates on this project here on the #VitalSigns blog.

New Study: Husbands and Mothers-in-Law Can Help Decrease Adolescent Pregnancy in Bangladesh

runa_allisonjoyce
Photo credit: Allison Joyce, 2015

Bangladesh has actually done exceptionally well in increasing contraceptive use by more than 50% in the last 40 years. Yet it still has the highest rate of adolescent pregnancy (31%) in all of South Asia. In a society where child marriage remains common practice, tackling adolescent pregnancy can be an uphill battle.

But a recent study conducted about decision-making and contraception use among married girls in Bangladesh has helped shed more light on how to address this issue. Findings revealed that approaching husbands and mothers-in-law through targeted interventions may serve as an effective method to encourage more use of contraception.

The study took place in Rangpur district, which has the country’s highest number of adolescent pregnancies. Conducted by a research team including JPGSPH’s very own Malabika Sarker, the study followed 35 married adolescent girls for a year through interviews about their maternal healthcare-seeking behaviour.

The aim was to understand the girls’ rationales for using or not using contraception. The most common reason they gave for having a child right after marriage was the expectation to bear a child from their husbands and mothers-in-law. They also conveyed a mistrust and fear about the quality and usage of contraception. Further apprehension is caused by misconceptions from other women in the family or neighbourhood, who become the primary sources of information for girls after marriage.

In rural Bangladesh, husbands and mothers-in-law act as the main decision makers in all matters related to childbearing. As the main breadwinners, men ultimately get to make all household decisions regarding health care. But because family planning is still considered a “woman’s issue,” mothers-in-law are also given authority to make decisions.

Thus by creating interventions that target husbands and their mothers and educating them about the benefits of contraception use and the severe detrimental effects associated with adolescent pregnancy, several of the barriers keeping girls from making these decisions can be lifted.

Child marriage cannot be expected to end overnight, but public health practitioners and policymakers need to start considering the matters at hand. Community health workers with the most exposure to these populations must also be trained in order to provide accurate information so that people fully trust and understand why and how to use contraceptives.

However, these findings are not a means to an end; it is now imperative that the wider community and societal actors begin implementing programmes to increase the uptake of contraception to delay pregnancy among adolescent girls. Only then can further policy formulation and implication lead towards decreasing the rate of adolescent pregnancy in Bangladesh.


To find out more about the study, read it here

 

Mapping Uncharted Territory – Sexual Rights and Reproductive Health of Bangladesh’s Urban Youth Using Digital Technology

unnamed-600x338

The Centre for Gender, Sexual and Reproductive Health and Rights at BRAC University, in partnership with University of Amsterdam (UvA) are excited to announce the launch of an innovative research project, Digital Sister for Urban Youth: Using New Technology for Effective SRHR Communication for Urban Youth of Bangladesh (Digital Sister in short).

Funded by the prestigious NWO-WOTRO Science for Global Development programme, the project is joining forces with ground-breaking technology company, Maya.com.bd, which developed the first ever anonymous online and app-based help service, Maya Apa that provides tailor-made solutions in areas of medical, legal, and psychosocial problems using the digital platform in matters of hours. The support service is free for all users, of any age.  

Because of the anonymity feature of Maya Apa, users from all around the country (and Bangladeshis living abroad), send highly personal problems which are otherwise kept secret in a society of fear and stigma, especially around the issues of sexual reproductive health, mental well-being, and bodily rights.  The Digital Sister project aims to understand the realities and challenges associated with sexual rights and reproductive health (SRHR) of especially young people in urban areas by analysing questions from Maya Apa and using it as an effective communication tool for the youth of Bangladesh.

What makes this research unique is its aim to provide insight on a population otherwise overlooked. With an overwhelming amount of public health research on poor rural populations, and an impressive track record in implementation of family planning across the country, there is now a growing demand for understanding SRHR-related behaviors of Bangladesh’s growing middle-income population – particularly urban-based adolescents and young adults.  

According to a report by the POLICY project, Bangladesh’s adolescent population (ages 15–24) was estimated at about 28 million in 2000, and is projected to increase by 21 percent to reach 35 million by 2020.  This is also the first generation of Bangladeshis to have access to affordable technological devices such as smartphones, computers, with built in Internet services. In 2013, there were over 29 million Internet users and over 100 million mobile subscribers, making Bangladesh one of the most lucrative nations for ICT-based growth and development.

Yet with a lack of SRHR education available at school, adolescents appear to be poorly informed with regard to their own sexuality, physical well-being, health, and bodies. Whatever knowledge they have been able to gather is disjointed and confused. Moreover, in addition to limited sex education, the taboo-nature of such issues and inhibited cultural attitudes towards sex also contribute to this ignorance.

That’s where Maya Apa comes in – the anonymous nature of the app has subsequently helped to remove the cultural stigma associated with asking their burning questions, decreasing the barriers that keep people from seeking access to information they crucially need. So far the platform has answered nearly 100,000 questions, with a vast majority coming from the 15-30 age group on a wide range of issues pertaining to SRHR.

The questions that have accumulated on the platform serve as an excellent database to study the SRHR-related behaviors and concerns of Bangladesh’s young people. By examining the questions, the researcher will be able to better understand the needs of this growing urban population segment. The projected strives to identify and address the gaps by providing recommendations to further improve Maya Apa, or even develop new communication tools to supplement the digital platform and other potential adolescent health policy implications that arise as a result of this research.


Stay tuned on the #VitalSigns blog for more updates from the Digital Sister project!

Exploring Lessons Learnt From CTC Worker Programmes: A Symposium

DSC_1709

On 12 June 2016, REACHOUT team members from all six of its working countries came under one roof for a symposium on ‘Strategies for Optimizing Close To Community (CTC) Worker Programmes to Create more Resilient and Responsive Health Systems’. As part of a larger consortium of eight partners, the sixth consortium meeting was held in Bangladesh from 6-15 June, hosted by the REACHOUT Bangladesh team, at BRAC University’s James P Grant School of Public Health (JPGSPH).

Panel presentations highlighted lessons learnt from CTC programmes in Bangladesh, Ethiopia, Indonesia, Kenya, Malawi and Mozambique. From each country, we see that CTC health providers stand at the intersection of several forces – such as the community, the health system and the market. They are not only deliverers of programmes, but often also health activists, engaging the community. They are also increasingly subjected to the forces the evolving health market, and must navigate this with very little guidance.

As a result, these health workers face a range of challenges. In Kenya, for instance, the programme is confronted with high dropout rates due to financial constraints. In Malawi, a lack of senior officers makes supervision of CTC workers more difficult. Meanwhile in Bangladesh, where CTC health workers mainly tend to hard-to-reach populations and rural villages, the programme now has to adapt to provide access to healthcare in urban slums, a dynamic space with pluralistic health services.

Overall, across each country, the findings show the need to provide support on both the supply and demand side; this includes retaining staff, sustaining CTC worker motivation, addressing lack of governance, and the overall sustainability of these programmes. There also needs to be greater investment in training and tools.

Looking at the obstacles and what the future holds for these programmes is particularly crucial as we go on to address more complex health targets. However there is a lot of scope to develop and assess interventions with the potential to make improvements to CTC services. Speakers from Malawi and Kenya discussed the opportunity to incorporate the use of mobile phones to strengthen and increase accuracy in data management. In Kenya, mobile applications for training CTC workers have also been established to reinforce their capacity development efforts. These are some examples of solutions to issues that seem to similarly challenge programmes in all six countries.

REACHOUT examines the big picture across each country and across time – this will not only reveal the larger story but also help each country learn from one another and implement improvements according to their context. Bringing REACHOUT team members together to examine the findings thus far continues to help generate informed, evidence-based and context-appropriate policies for future CTC services.

As we transition from Millennium Development Goals to the next set of Sustainable Development Goals, countries striving to achieve universal health coverage are increasingly depending on CTC health services. Now more than ever, there is a need for health systems to understand the context and conditions in which these services operate in order to realise their potential.


For more information on the work REACHOUT is doing in Bangladesh, click here