PhD Thesis

SOCIAL CAPITAL, POVERTY AND HEALTH: A STUDY ON HANDICRAFT WORKERS IN BANGLADESH

2025-04-10T00:00:00Z

SOCIAL CAPITAL, POVERTY AND HEALTH: A STUDY ON HANDICRAFT WORKERS IN BANGLADESH Parvin, Jani This paper is an attempt to analyse the linkages between social capital, poverty and health among handicraft workers in Bangladesh. Over the past decades, the successive governments of Bangladesh have put considerable efforts for poverty reductions, improvement of health and socio-economic status of the low-income group of people. However, the roles of social capital in improving poverty and health outcomes of the deprived populations are less explored. The lack of active group membership, social network, and collective actions can contribute towards improving health for the poor. The growth of industrial sector, while effective, can remain inadequate to foster economy growth due to lower productivity of labour in our country. For increasing labour productivity, we need to focus on the social capital at the workplace or lack thereof. Because in a workplace group membership, social support, cooperation, trust, and information sharing increase the social exchange and interaction between workmate and authority, which in turn increases the capacity to serve the workers to raise labour productivity, which ultimately leads to decline poverty. Few empirical studies have examined the link between social capital, poverty, and health in Bangladesh. From this time, we need to investigate the relationship between social capital, poverty and heath within the handicraft sector in Bangladesh. The scope of the field study is based on both institutional and household level surveys of female workers within the handicraft sector in Bangladesh. This study examines the indicators of social capital at the workplace which influences workers healthcare seeking behaviour, health status as well as poverty. It further examines the contribution of handicraft sector in building social capital at individual level, which has a spell over effect on workers‟ health status. In this study it assumes the hypothesis that high value of trust, social cohesion, social support, social network, co-operation and collective action and group participation in workplace create more opportunity to build different forms of social capital which help to improve workers health status and socio-economic conditions. So, the main research question is: “whether workplace social capital improves workers healthcare seeking behaviour and health status as well as poverty”. A field survey is conducted through structured and semi-structured questionnaire from three handicraft enterprises in Bangladesh. Data has been collected from 326 workers of the AAF (Manikganj), HEED (Gazipur) and TMSS (Bogura). The data collection instrument was mostly followed by the Shortened and Adapted Social Capital Assessment Tools for Bangladesh (SASCAT B) which is adopted by the World Bank. This study is primarily a quantitative study where I have empirically analysed the data and tested the hypothesis. It reveals that the majority of workers and their household member received healthcare from professional healthcare providers and public facilities. The choice of providers and facilities by household depends on some important factors such as, distance to providers, travel time, treatment cost, easy access to care, quality of care, perception of providers, type and severity of illness, household education background, household decision of choice of providers, family economic conditions and finally the level of social capital. Workers at the production centres have high value of social capital, and they are more likely to seek treatment from professional healthcare providers than others due to illness. Hence, workers in the production-groups have better health seeking behaviour than the other because they have greater workplace social capital that increase intensity of social network, make more informal support and favours the dissemination of relevant health-related information. From empirical analysis, we find that the mean score of the indicators of workplace social capital (WSC) are statistically significant. A relatively higher proportion of workers in production-group have a higher value of social capital. There is no significant difference between the overall mean scores of indicators of the structural and cognitive form of social capital. The indicators of the bonding social capital, i.e., unity attitude, information sharing, and cooperation norms are statistically significant while trust in supervisor, mutual respect, and cooperation among workmate are significantly associated with social capital. The highest mean score elements of social capital are “cooperation among co-workers” and “trust in manager”. Unity, cooperation, interpersonal trusts are the three important elements for building social capital and the values of the social capital depend on the nature of employees. Permanent workers from the production groups have more opportunities to create social capital, which helps to increase labour productivity and efficiency, than other contractual or temporary employees. So, the permanent workers play more significant role in building social capital than the other. Moreover, there is no significant difference between mean values of the indicators of social capital in the selected three organizations. Hence, unity, understanding, workers‟ together attitude, information sharing and accepted attitude appear to have a significant effect on the constructing social capital at individual-level as well as health status of workers. A majority of workers reported that they were in good health and being energetic. A small fraction of workers had a mobility problem. However, the permanent workers often faced the vitality and psychological distress than others. In case of outpatient care, the majority of household member sought treatments from formal healthcare providers. In case of maternal healthcare, the majority of pregnant women received ANC care three times from the public health facilities, received T.T doses and ultrasound test during their pregnancy period and delivered at hospital, which indicates they have good health seeking behaviour. Greater number of workers reported having good health and being energetic. A small fraction of workers has mobility problem. However, the permanent workers often faced the vitality and psychological distress than others. In case of outpatient care, the majority of household member sought treatments from formal healthcare providers. In case of maternal healthcare, the majority of pregnant women received ANC care three times from the public health facilities, received T.T doses and ultrasound test during their pregnancy period and delivered at hospital, which indicates they have good health seeking behaviour. We applied the ordered probit model to examine the relationship between social capital and health, where the dependent variable is self-reported health (using a 5- point Likert scale from 1=excellent to 5=poor). The estimated model of self-reported health (SRH) and social capital illustrated association between workers, social network, information sharing, cooperation, trust in supervisor, active membership in organizations, participation in a training programs, obedience to organizations, savings, monthly income, and households endowments play a significant role to build social capital at workplace and these indicators has a significant effect on worker‟s health status. The estimated parameter of the social capital shows the pattern of employments and break or leave rules are significantly associated with self-reported health of workers. Mental stress for skill requirement, residence quality and food expenditure per week, time constraint to finished a task, and active memberships are statistically correlated with health status of workers. In addition, residence quality and food expenditure per week of household are statistically correlated with tiredness of workers, while the time constraint to finish task and active association are also significantly correlated with health problem. The estimated model of the psychological distress and workplace social capital (WSC) shows that group membership, age of workers, skill, and skill requirement for organizations, mental pressure to finish a task, demanding workloads, and long working hours has a stronger effect on workers psychological distress. Moreover, the indicators of unity, understanding, information sharing, aggregate concepts, and trust on co-workers have a negative coefficient on workers mental health. The correction between workplace social capital and poverty score is statistically significant. Workers in poor groups more frequently participated in the decision-making process than rich groups of workers. The poor groups of workers have more informal relationship than the richest groups of workers, and the effect of social capital on health according to poverty score is statistically significant. The distribution of social capital, health and demographic variables according to poverty scores shows that most of the workers in the poorer groups are more likely to have high level of understanding between them than the richest groups of workers which indicate poor groups of workers have high value of social capital than the richest quintile. The results also show that the workers of the poorer groups have high value of the workplace social capital than the richer workers, suggesting the workers of poor groups might have more opportunities to improve their individual level social capital and health status than the other. The probit regression model of asset score and 8-item workplace social capital shows that there is positive significant correlation present in workplace social capital (WSC) and assert of households in the handicraft sector. Mutual understanding between co-workers, sharing work related information with workmate, and aggregated idea of workers are significantly associated with household asset score. Hence, high value of the socio-economic status (SES) makes it possible to improve poverty situation and increases the value of workplace social capital (WSC) of workers. Based on the findings of this study, I made some recommendations that could assist the concerned institutions to formulate suitable policy and strategy. It also helps to build a conceptual framework in the hope for increasing the stock of social capital at workplace which may improve health status, income per capita, and reduce poverty of the workers in handicraft sector. Finally, the results of this study suggest us to design and implement the appropriate strategies for increasing the stock of social capital and physical capital in the handicraft sector which can enhance better health status of the poor and disadvantaged workers as well as poverty. This thesis is submitted for the degree of Doctor of Philosophy.

Water usage, diarrhea and economic burden: life in a low-income urban community in Bangladesh

2022-03-15T00:00:00Z

Water usage, diarrhea and economic burden: life in a low-income urban community in Bangladesh Sultana, Rebeca In the last three decades (from 1990 to 2019), numerous efforts have been made globally to improve the water, sanitation and hygiene infrastructure and practices, to reduce diarrhea. Despite numerous public health efforts, diarrhea among all ages remained a major cause of morbidity and economic loss worldwide. In terms of economic indicators, it ranged from the third to sixth leading cause of disability-adjusted life-years (DALYs) between 1990 and 2019. The inverse relationship between low socio-demographic index (SDI) and of water, sanitation and hand washing (WASH) DALYs was noted, and implied that rigorous attention was needed to improve the health and hygiene of low-income populations. In 2015, the Sustainable Development Goals (SDGs) also included low-income urban communities (slums) in Target 6 and Target 11.1, to ensure “equity” and basic services for the slums by 2030. The surveillance data typically capture the number of severe diarrhea cases seen in health care facilities and thus missed to capture information on mild or moderate cases in the diarrhea prevalence estimation. It is estimated that 65-95% of all diarrheal episodes in low-income areas are mild and moderate. Since community-based surveillance is a challenge and scarce, particularly in low-income areas, the estimation of the true burden of diarrheal disease remains a concern. Similarly, the estimation of the household economic burden of diarrhea, which is mostly based on hospitalized patients, may not be pertinent to capture and represent the cost of diarrhea in lowincome urban communities. Hence, a comprehensive and holistic research approach is urged to address this prime public health problem in a contextual manner to enhance understanding of disease burden, transmission and prevention in low-income urban communities. Therefore, the objective of this study is to provide an in-depth understanding of how low-income people perceive, interact with, and respond to diarrheal diseases and related economic hazards. The East Arichpur area, located in Tongi Sub-District, 15 km north of Dhaka, was selected for this study. The population density was around 100,000 per km 2 . The residents of East Arichpur were vulnerable to diseases including diarrhea, cholera and hepatitis E (HEV). In East Arichpur, 97% of the households used improved latrines and improved piped-to-plot water connections within the premises. Data collection for the different components of the study took place from April 2014 to July 2016. Community mapping identified a total of 13,876 households within 1,437 compounds (i.e., clusters of households sharing a common yard and other facilities) in East Arichpur. In East Arichpur, 98% of the compound residents reported sharing water points, kitchen, and toilet facilities with other households in the compounds, and had improved piped-to-plot water connections inside the compound yards. From the 13,876 low-income households, 477 were selected to conform an 18month cohort to collect longitudinal data on water, sanitation, hygiene and diarrhea. A subset of 24 households from the 18-month cohort were selected for in-depth exploration using an ethnographic approach to understand water usage for personal and domestic hygiene, and the determinants of water usage for hygiene practices among the individuals of each household. To capture the cost borne by the households per diarrheal episode, a total of 264 diarrhea cases among East Arichpur residents were enrolled. The mobile phone–based surveillance system, the "cholera phone", captured the real time incidence of this community and thus avoided recall bias/error, which is key in measuring the incidence and prevalence of diarrhea. The incidence rate (IR) per person-year was 0.16 (95% confidence interval [CI]: 0.13-0.19) for the "cholera phone" between August 12, 2014 and June 30, 2015 in East Arichpur. The IR per person-year for children two to five years old was 0.21 (95% CI: 0.12-0.38). The participants perceived the English word "diarrhea" as an identical term to "cholera" or "severe diarrhea". The terms "patla paykhana", "pet kharap (bad stomach)" and "pet naram (soft stomach)" were used by the participants to describe the World Health Organization (WHO) definition of diarrhea (three or more loose stools). The participants also offered their desire to receive treatment after reporting of diarrhea and self-treatment with antibiotic as reasons for not reporting diarrhea. These findings explained the low reporting of diarrhea through the "cholera phone", particularly between August 2014 and June 2015 (before replacing it with a modified intervention). The average total cost of illness per episode for severe diarrhea was 2,147 Bangladeshi Taka (BDT) (US$ 27.39), accounting for 17% of the average monthly household income of a severe patients. The average total cost of illness per episode for non-severe diarrhea was 499 BDT (US$ 6.36), accounted for 4% of the average monthly household income of a non-severe patients. Non-severe diarrhea was defined as three or more loose stools in 24 hours. Severe diarrhea patients were those who were admitted to the hospital and/or received intravenous saline (due to moderate or severe dehydration). The estimated annual cost for severe cases of diarrhea was US$ 6,355, and for nonsevere cases was US$ 55,008 in East Arichpur. The average water use was 75 liters per capita per day (LPCD) and the average water use for personal hygiene only (e.g., cleaning of body parts) was 39 LPCD in the study area. Male participants used more water compared to females. The volume of water used for domestic hygiene(e.g. cleaning dishes, toilets, houses and clothes) reduced to almost half or less among individuals with access to water <24 hours a day compared to individuals with access to water 24 hours a day. For example, the volume of water used for cleaning dishes was 7 LPCD with 24 hour access to water and 4 LPCD with <24 hour access to water. In contrast, access to water did not substantially change the volume of water used for personal hygiene. The volume of water used for personal hygiene was lowest in January (30 LPCD) and highest in September (46 LPCD). The notion of “hygiene” had two separate meanings among the study participants: “cleanliness” and “holiness”. The requirement of cleanliness was linked to feeling fresh, with comfort as an immediate reaction, and the requirement of holiness was related to following religious rules, beliefs and rituals. The distant (underlying) reason for cleanliness was to avoid germs or disease, and distant reason for holiness was accountability to God. The volume of water used was also influenced by the notion of hygiene. Participants practicing regular prayer were concerned about maintaining holiness and used more water (64 LPCD) in comparison to the participants who did not perform regular prayers (40 LPCD). The results of this study suggest that mobile phone surveillance could be useful in capturing the real-time prevalence of diarrhea, when used in conjunction with qualitative evaluation methods at the beginning of the surveillance to improve it and make it compatible and context-appropriate. Thestudy also suggests that though the average cost of non-severe diarrhea at the household level was low (US$ 6.36, 4% of the total household expenditure), the estimated incidence-based economic burden of the community was high (US$ 55,008). The qualitative findings suggest that availability of water alone cannot ensure improved hygiene practices among the residents with piped-to-plot water services, without taking the social norms, individual traits, beliefs and motivating factors into account. Furthermore, the germ theory of disease was not explicitly conceptualized/conceived as the reason for hygiene among the participants in this community; rather, they linked it with individual physical comfort and with their religious rituals and accountability to God. This thesis revealed that, when infrastructure is in place, emphasis should be given to learning the social, environmental and behavioral factors prevalent in the community, as these shape the related risk of disease transmission across the population. A community-tailored mobile-based data collection/surveillance system is useful not only to capture the incidence and prevalence of a disease, but also as an early warning system, particularly compatible with the current world situation dealing with the highly infectious COVID-19 pandemic. While the paucity of data on lowincome communities or slum settlements is well noted, this thesis incorporated some systematically collected holistic insight into this population that could be useful for future research. This thesis has been submitted to the Graduate School of Health and Medical Sciences, University of Copenhagen.

Factors Affecting Outbound Medical Tourism: Evidence from Bangladesh

2021-08-26T00:00:00Z

Factors Affecting Outbound Medical Tourism: Evidence from Bangladesh Sultana, Munira Medical tourism, a form of tourism activity for the patients to cross the borders for medical care, has been growing over the past decades. Health care services are not client focused and need based in Bangladesh. On the other hand, health care services are expansive to the majority of the people. Therefore, thousands of patients, irrespective of their socioeconomic condition, travel to India, Thailand and Singapore for perceivably higher quality of medical care. Existing literature on medical tourism indicates that there is a lack of comprehensive study that provides the information regarding outbound medical tourists in developing country like Bangladesh. In particular, very little is known about the factors that influence outbound medical tourism and the satisfaction level of outbound medical tourists. To fill this gap, this study has been undertaken. This study has the following objectives: (1) to identify the factors that influence outbound medical tourism and (2) to measure the satisfaction level of outbound medical tourists. To achieve the objectives of the study, data were collected from 300 patients who travelled India, Singapore or Thailand for medical treatment purpose and 60 Bangladeshi doctors through semi-structured questionnaire. Non-probability, such as convenience and snowball, sampling methods were used to select the respondents. For analyzing the data different statistical tools and methods were used from STATA software 12.0 versions and SPSS software 20.0 version. The study has employed descriptive statistic, factor analysis, Mann-Whitney U Test, Kruskal-Wallis H Test, Spearman’s rank correlation and Ordinal Logistic Regression analysis. Descriptive statistics has been used to identify most influential pre-travel factors related to outbound medical tourism. Moreover, Factor analysis has been used to identify most important post-travel factors related to outbound medical patients’ satisfaction, thereafter ordinal logistic regression analysis is performed to investigate the influence of independent variables (quality of medical care, Treatment facilities, cost of medical care, environmental aspects, service of medical staff’, tourism facilities and availability of doctor/ medical staff) of patients on the dependent variable (satisfaction level of outbound medical tourists). The findings indicated that the nine pre-travel factors influenced outbound medical tourism. Apart from these all post- travel factors related to medical service in abroad are significantly influenced outbound medical tourism. Quality of medical care is the most influential factor followed by Treatment facilities and Cost of medical care. Moreover, the overall satisfaction level of patients towards medical services in abroad is satisfactory. The main reasons as found are: Experienced, Helpful, reliable and sincere doctors, fast and accurate diagnosis and world standard medical facilities, and affordable treatment cost. On the other hand, the overall satisfaction level of patients towards medical services in Bangladesh is dissatisfactory. The main reasons as found are: insufficient time paid by the doctors to their patients, unnecessary test and poor diagnosis, high treatment cost. The following recommendations have been put forwarded, firstly, to initiate continuous professional training and evaluation program for doctors and nurses. Secondly, international standard hospital and diagnostic centers should be arranged so that local people can receive better medical care in the country. At the same time affordable medical care in-country hospital should ensure. , hospitals must ensure hygiene, cleanliness and adapt best practices of health to support patients. This in turn would help to reduce outbound medical tourism from Bangladesh significantly, which will save heard earned foreign currency significantly for the country. This Dissertation has been submitted to the Institute of Health Economics, University of Dhaka, for the fulfillment of the requirement of the Degree of Doctor of Philosophy (PhD).

Health and productivity of small and medium industrial enterprise (smie) workers: the case of Bangladesh

2015-12-02T00:00:00Z

Health and productivity of small and medium industrial enterprise (smie) workers: the case of Bangladesh Sultana, Nasrin Small and medium manufacturing industries (SMIEs) have significant contribution in terms of employment creation and share of GDP in the economy of Bangladesh.Evidence shows that workers of SMIEs usually work and live in unsafe, unhygienic and unhealthy conditions.As a result, the workers’ are exposed to illness and disability whichlead to a productivity loss of the worker. Therefore, the study seeks to assess the relationship of health with the productivity of SMIE workers in Bangladesh.The specific objectives we like to investigate are: i. To examine the relationship between health and productivity of SMIE workers ii. To find out the association between wages and productivity of SMIE workers iii. To estimate their income and expenditure on health iv. To observe the disease pattern and health care seeking behavior of SMIE workers v. To examine the health and working and residential environment of SMIE workers vi. To discuss the wage determination system of SMIE workers vii. To examine the impact of illness of SMIE workers on their productivity viii. To estimate and monetize the lost productivity of the selected SMIEs and the total SMIE sector due to illness of worker and its importance in the whole economy. A combination of qualitative and quantitative research technique is used to carry out the study. The study interviewed 259 workers and 44 owners/managers from selected 44 SMIEs which are located in three divisions like Dhaka, Chittagong and Khulna in Bangladesh. The workers and managers were interviewed by using two sets of questionnaire, one for the workers and another for the managers. It is found that SMIE workers are mostly below middle aged, married, Muslims, less educated and inexperienced. A good health of SMIE workers is found to have a significant positive impact on workers' productivity by both literally and empirically. The regression finding suggests that decrease in 1 absent day due to illness increases worker’s productivity by 94. 52 unitsand a 1 unit increase in BMI (ill health to good health) increases worker’s productivity by 318.16 units. The studyreveals that labor productivity and wages are positively related; sometimes higher productivity determines higher wages and sometimes higher wages leads to higher productivity. It is estimated that a 1 unit increase in labor productivity increase the wage by 0.28 units from workers’ response and by 0.19 units from managers’ response. On the other hand, a 1 unit increase in wage increases the labor productivity by 1.34 units from workers’ response and by 1.52 units from managers’ response. The study identifies a significant wage-productivity gap of SMIE workers. It finds that insufficient expenditure on health care is a cause of depleted health stock of SMIE workersindicating a 1 unit increase in health care expenditure (insufficient amount to sufficient amount) reduces the ill days of worker by 1.026 units. It is apparent that most of the SMIE workers mainly suffered from occupational asthma, bronchitis, allergic rhinitis, low back pain, anemia, fever, typhoid, headache and diarrhea. The SMIE workers usually seek treatment from pharmacy based doctor, kabiraj/hekim, and paramedics. It is evident that working and residential environment of SMIE worker have considerable impact on workers’ health. The average absenteeism rate due to illness of the SMIE workers is found 7.3 %. It estimates that the workers annually miss 22 work days due to their illness. Monthly mean lost productivity of SMIE worker due to their illness is estimated Tk 413 to Tk 708 from workers’ response and Tk 466 to Tk 739 from managers’ response based on wage and output respectively. This lost productivity is found as 4% to 7% of average productivity from workers’ response and 6% to 9% from managers’ response. Monthly mean lost productivity of total SMIEs in Bangladesh is estimated as Tk 19.44 crore to Tk 33.13 crore from workers’ response and Tk 19.81 crore to Tk 31.38 crore from managers’ response.This lost productivity of total SMIE sector is estimated as 0.05% to 0.09% of GDP, 2.5% to 4.2% of health sector’s total budget and 0.12% to 0.20% of national total budget. Due to unavailability of most recent data, the study uses SMIE data available in the report on survey of manufacturing industries 2005-2006 but it collects the data on productivity of SMIEs workers in the year 2012-2013. Because of this time lag our estimated lost productivity of total SMIE sector is undoubtedly underestimated. The underlying reason for this is that during this time gap both the number and employment of SMIEs increased manifold in the presence of government promotional policies. This thesis submitted to the University of Dhaka in accordance with the requirements for the Degree of Doctor of Philosophy.