the status of healh of the poor people of gazipur district of bangladesh
TRANSCRIPT
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Chapter One: Introduction
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Chapter 1: Introduction
Introduction
The international conference on primary health care, meeting in Alma Ata, USSR in
September 1998, defined health as- a state of complete physical, mental and social
wellbeing and not merely the absence of disease or infirmity The conference maintained
that health is a fundamental human right and that, a main social target of governments,
international organizations and the whole community in the coming decades should be
the attainment by all peoples of the world by the year 2000 of a level of health that will
permit them to lead a socially and economically productive life. Primary healthcare is the
key to attaining this target as part of development in the spirit of social justice (Alma Ata
report, 1998, p,15) Primary healthcare as essential health care based on practical,
scientifically sound and socially acceptable methods and technology made Universally
accessible to individuals and families in the community through their full participation
and at a cost that the community and country can afford to maintain at every stage of their
development in the spirit of self reliance and self determination, It forms as integral part
both of the country health system, of which it is the central function and main focus, and
of the overall social and economic development of the community. Primary heath care is
the first-level contact of individuals, the family and community with the international
health system bringing healthcare as close and work and constitutes the first element of a
continuing health care process.
Primary health care addresses the main health problems in the community providing
primitive, preventive, curative and rehabilitative services accordingly and includes atleast : education concerning prevailing health problems and the methods of preventing
and controlling them: promotion of food supply and proper nutrition and adequate supply
of safe water and basic sanitation; maternal and child healthcare, Including family
Planning; immunization against the major infectious diseases; prevention and controls of
locally pandemic disease; appropriate treatment of common diseases and injuries and
provision of essential drugs.
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Though the definition and concept of primary health care encompasses a very wide field
of activities, inbuilt in the definition and concept of primary health care is the spirit of
social justice and community participation and self reliance and self-determination. The
concept is also based on intra and inter sectoral linkages and dependence and calls for
cooperation among all courtiers of the world and technical and financial support from the
developed countries and international agencies in support if the primary health care,
particularly in the developing countries.
1.0 Background:
The health is an important part of human being. It is the fundamental right of every
citizen of Bangladesh. The constitution of republic of Bangladesh has described the
fundamental rights of citizen. In this sense, It is essential to ensure the health of the
people all over the world. But the health facilities provided by the various government
and non-government are not adequate. So the health condition of sub cities and rural areas
are very poor especially women and children. So the illness and death rate are
comparatively in sub cities and rural areas. It is a vast issue in the present condition. Since
we are in the 21th century, it is first duty of every nation to ensure the fundamental rights
of citizen specially women. Because of they are being so much vulnerable among the
citizen. It is my desire to find out the primary health condition of women.
1.1 Statement of the problem:
Primary health care system in the world and Bangladesh is a major issue. The
importance of primary health care is importantly assed by the Ministry of health of
Bangladesh (200:15)-To create awareness among and enable every citizens of
Bangladesh irrespective of caste, creed, religion, income and gender and especially
children and women in any geographical region of the country, through media publicity,
to obtain health, nutrition and reproductive health service on the basis of social justice
and reality trough ensuring every ones constitutional rights
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National concerns for providing health care have been reflected in the national
constitution, the planning commission documents, and in various international forums on
primary health care where Bangladesh participated. The constitution of Bangladesh, inter
alia, maintains that (constitution of Bangladesh,1972:15) It shall be a fundamental
responsibility of the state to attain a steady improvement in the material and cultural
standards of living of the people, with a view to securing to the citizens the provisions of
basic necessities of life, including food, clothing, shelter, education and medical care .
The second five year plan (1980-85) reflects the national objective of providing
Minimum care to all in the short run and Health for all by the year 2000 (Bangladesh
1983) Bangladesh is also one of the signatories to the south Asian charter of health, as
well as to the Alma-Ata Declaration on primary healthcare. The health policy of
Bangladesh is based on primary health care as its key approach to providing health care to
the masses of the population.
Though health services in Bangladesh is being provided for a long time, documentation
on health development plans and especially with reference to primary healthcare (PHC) is
of recent origin. A country health programming exercise in Bangladesh was undertaken
for the first time in 1973 focusing on selected health logistical problems (Bangladesh
1973). second country health programming exercise was done in 1977 focusing
comprehensively on healthcare facilities and needs (Bangladesh 1977). In 1980 national
strategies for health for all (HFA) by the year 2000 was formulated by the planning
commission/ ministry of health (Bangladesh 1980) The ministry of health/ planning
commission Director General of health services also formulated in 1981 a health
manpower planning exercise (Bangladesh 1981). Based on these documents and the
second five year plan (Bangladesh 1983), a number of projects have been formulated, and
the health wing of the ministry of health and population control has as of now, 79 projects
of which 39 projects fall under primary health care. Recently country resource utilization
on Bangladesh was published by world health organization (WHO 1983). Bangladesh
government also published a Bangladesh country report-on evolution of the strategies for
health for all by the year 2000. (Bangladesh 1985). But the access of health is not some
for all. Health access is different according to class, age, gender, Income. In this study an
at attempt will be made mainly to focus how primary health service is different according
to gender, economic status, environment of the clinic etc.
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The elements of PHC, it may be noted, are very comprehensive in coverage and include
such items as promotion of food supply and proper nutrition and adequate supply of safe
water and sanitation which are not traditionally covered under the Ministry of Health and
Population Control. The items included under the Ministry of Health and Population
Control are also very wide and their targets are intended to be reached by the year 2000
by the Ministry of Health and Population Control through the development of referral
system between primary, secondary and tertiary levels of health care mechanism,
intersect oral cooperation and coordination, and above ail through active participation of
the community in the delivery of PHC.
In the country paper on health for All by the Year 2000 of June 1980 (Bangladesh 1980)
there are 67 indicators on health status and health care delivery with their targets set for
five year periods ending in 1985, 1990,1995 and 2000. Out of these 67 indicators, over 40
indicators are directly relevant for PHC. The indicators are also very comprehensive in
1.2 Objectives of the study:
As the primary health care system is still in the formative stage of development, it would
be pre-mature and unrealistic to attempt for an impact evolution of primary health care
project. Our Job will be basically limited to a process evolution meaning to assess if right
things are in right place for attaining a right objective in terms of the delivery of primary
health care facility at the union level and below by the ministry of health and population
control.
The study will evaluate both the supply and demand as peels of primary health are and
family planning services and their limitations, especially in the rural areas of Bangladesh.
on the supply side of enquiry, the objective will be to review and assess the supply and
limitations of the services of the ministry of health and population control in the rural
areas. For this purpose a major emphasis to the study will consist of a thorough
investigation of selected union with respect to indoor, outdoor, mobile and domiciliary
services for primary healthcare and family planning as are provided to the renal
population and their limitations.
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The objectives of the study are follows:
1. To know the relationship between level of education and receiving health services.
2. To identify the administrative, financial and other issues at the centre that may
affect primary health care and family planning services.
3. To examine the knowledge about the existing medical and health service
providers, including maternal and child health centers.
4. To identify the knowledge about the existing medical and health service providers.
5. To know the status of family planning and other sources of contraceptive supplies
6. To know the attitudes of the providers toward the patients.
7. Infrastructural facilities and limitations of PHC.
1.3 Hypotheses:
1. There is a relationship between level of education and acceptance of health
service.
2. Poverty and health service are related.
3. Utilization of health care service depend on decision making power of women.
4. Primary health care service is depends on working status of wore.
5. Utilization of the healthcare service depends on environment of the clinic and
attitude of the providers.
1.5 Operational Definition
Operational definition of variables simply means defining the variables in term of specific
measurable indicators. For every variable that must be operational definition, the
researcher should first precisely define that variable that select specific indicators for
measuring the variable as defined. Operational definition is the development of specific
research procedures that will result in empirical observation representation those concepts
in the real world (Babbie1998). The operational definitions of the concepts used in this
study are given below.
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Health:
This is a state of complete physical, mental and social well being and not merely the
absence of diseases and infirmity.
Health care:
Services provided to individuals, families and communities by doctors hospitals, nurses
and other professionals to promote, restore, maintain and monitor health of all people in a
society.
Class:
A group of people with similar command over economic resources and almost commonlife- style.
Rural women:
There is a brought general consensus that the term rural refers empirically to population
living in areas of low density and to small settlements, (Encyclopedia of social science,
Vol-13-14: 582). Therefore rural women refer to those women living in rural areas.
Household:
A household is defined as a dwelling unit where one or more persons live and eat
together with common cooking arrangement. Persons living in the same dwelling unit but
having separate cooking arrangements constitute separate households.
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Chapter Two: Review of
Literature
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Chapter 2: Literature review
Introduction:
Literature Review is an important part of any research to understand the existing scenario
about the issue. It gives an idea about the issue.
2.0 Primary health care:
Health services in Bangladesh had been traditionally geared to curative care and urban
needs, and only in recent years attention has been focused on the requirements for the
rural areas. In 1961 the then Government of Pakistan introduced a scheme for setting up
Rural Health Centers (RHCs) in the rural areas. Under this scheme, one RHC was
envisaged to provide a comprehensive health care service for every thana (now upazila),
and three sub centers were envisaged to be attached to each UHC. The sub centers were
to be supported by the services of the RHC administratively and functionally. In addition,
three vertical projects, viz., malaria eradication, family planning and small-pox
eradication programs were also launched by the health sector. By 1970, 140 RHCs were
built.
After the liberation of the country in 1971, a Thana Health Complex Schemes was
approved, and the implementation of the Review of Primary Health Care.
Scheme commenced in 1972. The First Five Year Plan (1973-78) laid emphasis on
building a net work of thana Health Complex/ (THC). However due to the diversion of
the national efforts for reconstructing the war-torn economy, construction difficulties and
financing constraints, much headway could not be made in the construction of new THCs.
Due to show project performance and high inflation, a revised project proposal for the
THC was prepared and approved in 1976. According to the revised scheme, 356 THCs,
one in each of the rural thana (now 397 rural upazila), and 1,068 sub-centers were to be
established, either through new construction or conversion of the existing ones,1 by the
end of First Five Year Plan period (1973-78), for providing a number of primary health
care services to the rural population.
In August 1976, the Malaria Eradication Board was abolished and the malaria control
activities together with their grass roots level functionaries were integrated in the THC.
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By June 1980, 290 THCs, including conversion of 150 rural health centers, were made
operational with a total 3,800 beds, as against a target of 356 THCs with a total of 11,036
beds, indicating a target achievement of 84.3% for construction/conversion of THCs and
only 34.4% of operational beds. At that time 1,990 HFWC were in operation. The Second
Five Year Plan (1980-85) emphasizing on primary health care as the key approach to
ensure health for all by the year 2000 was launched in 1980-81. To materialize the above
national health objective, the main operational targets that were identified were as under:
Infrastructural development comprised the building of one health complex in each of the
397 rural upazilas by 1985, and building of one Union Health and Family Welfare Centre
(UHFWC) in each union by 1985. Each UHFWC was to cater to the basic institutional
facilities for PHC including family planning for the entire population under each union.
Upazila health complex has a three tier service delivery of health and family planning at
the (1) household (2) union and (3) upazila headquarters levels. The domiciliary services
at the household level include health education, family planning and maternal and child
health services, immunization, control of communicable and other endemic diseases, oral
rehydration etc. which constitute the kernel of primary health care. The services are
provided by FWAs and HAs at the grass roots level.
The Union Health and Family Welfare Centres (UHFWCs), conceived as the first
institutional health care facility, cover among operational responsibilities, medical care
for treatment of common and minor diseases, prevention of contagious diseases, maternal
and child health including nutrition and family planning. UHFWCs are headed by the
Medical Officer/Medical Assistant/Family Welfare Visitor.
Each UHC is to deliver three types of services: (1) in-patient facility including maternal
and child health care and family planning services (2) out-patient facility for general, as
well as, maternal and child health and family planning and (3) domiciliary services by
HAs in the health sector and by the FWAs in the population sector. In addition, there is
mobile health and family planning services organised from the UHC or higher level.
Following the administrative restructuring through decentralised administration in 1983,
the government adopted a policy to raise the status of erstwhile Thana Health Complex
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(THC) into Upazila Health Complex (UHC) with 31 functional beds with addition of
specialist services in medicine, surgery, gynecology and dentistry.
As of now, there are 2,200 UHFWCs which are currently functioning as the primary
health and family welfare centre at the union level and 341 rural upazila health complexes
which are functioning as the first referral level at the upazila. 2 At the second referral level
at the district headquarters, there arc 57 district hospitals. There are in addition 8 medical
colleges (in seven district headquarters), and -five post-graduate institutes with
specialized hospitals at the tertiary level.
There are nine elements of primary health care in Bangladesh.
1. Education concerning prevailing heath problems and methods of preventing and
controlling them.
2. Promotion of food supply and proper nutrition.
3. Adequate supply of safe water and sanitation.
4. Maternal and child health (MCH) including family planning (FP) services.
5. Immunization against major infectious diseases,
6. Appropriate treatment of common diseases and injuries.
7. Prevention and control of endemic diseases.
8. Provision of essential drugs.
9. Promotion of mental health care.
The delivery of primary health care is supposed, to be based on three main
complementary strategies (WHO 1983):
(1) Community participation
(2) Inter-sect oral cooperation and coordination, and
(3) Hospital support for PHC referral system.
nature and include such items as infant and child mortality rate, crude birth rate, crude
death rate, provision of specific services through static health centers, immunization
against and control of specific diseases, de-worming, prevention of blindness, family
planning services, food hygiene, health manpower of various cadres, availability of drugs,
health education, nutrition, water supply, sanitation, housing, education, employment and
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communication. Securing adequate information on them calls for reliable civil
registration /epidemiological surveillance and data generation /comprehensive
management information system on a regular continuous basis and a host of specialized
surveys.
2.1 Physical and Mental health:
Health is a basic need of human being. It is an important issue for both the government
and non- government organization. It is said that the purpose of evaluation in health
program and the services for delivering them. It is essential to perceive evolution as a
decision oriented tool, and to link the evolution pnocess closely with decision making,whether at the operational or policy level. Traditionally there are many research, report
and analyses about the problems, facilities and suggestions of primary health care:
It is important to understand both physical and mental health. Some matters are directly
related with the primary health (Majumder, 1999). He has pointed out both the physical
and mental health status of the people. He found that health problems affect some factors,
In his opinion: various social affecting healths of people. Such as
a) Socio-demographic factors.
b) poverty
c) Natural and environmental factor.
d) Occupational hazards etc.
In his opinion, poverty is the most important cause of the less access of the treatment. In
his opinion-in recording reasons for not seeking any treatment either for the person who
are sick or for the deceased who had died during last one year before the date of survey
within the specified reference periods, multiple reasons were registered with out any
order. While grouping the stated reasons under a few common categories, financial
incapacity of the people and the chronic of diseases inflicting long non-curable sufferings
upon patients were found to be the two major causes that led people in most occasions to
avoid treatment one of the important reasons is financial problem.
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2.2Health and Gender equality
At the policy level, the government would like to know if the health status of the people
is improving, and if revisions of health policy and strategy are required. At the managerial
and technical levels, those concerned would like to know (WHO, 2000), If relevant
programmers are being formulated and if corresponding facilities and activities for
implementing them are being adequately designed.
It discusses (Kabeer, 2005), the third millennium development goal (MDG) on gender
equality and womens empowerment and higher ways in which the indicators associated
with this goal womens access to education can contribute in health service.
There is much discusses much on the empowerment of women (Storomquist, 2002). He
discusses how the concept of empowerment has been applied in health sector. He
identified that prevalence of sickness is more with the rural females than with rural sick
malls were recoded. More than 17.0 Percent (17.4%) of the female as against 15.0 percent
of male were contently suffering at the time of the survey from various diseases in rural
areas.
2.3 Health and diseases
Although an innumerable member of diseases are known to medical science (Khan,
2000), a handful to them primarily give rise to the sicknesses to the rural people in
Bangladesh. Infectious diseases arising out of unhygienic environment, poor living
condition and poor personal hygiene play the majorrole and most of these diseases have
significant scope for prevention through appropriate public health measures.
There are some other scholars have done on this issue. In their articles showed that the
most serious health problems of mothers and children as a whole result from various
irrigated conditions, malnutritions infection, closely spaced and too frequent
pregnancies and the lack of healthcare and other social and economic condition
(Nazmunnessa Mahtab and parveen Ahmed,1999).
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2.4 Changes in health behavior:
There is also found that (Alauddin and Islam 2000), there has been some tangible changes
in the areas of sanitation, health and nutrition in the Project villages. The project has been
successful in improving the situation of safe drinking water supply and use of low cost
sanitary latrine. Besides these positive changes in preventive promotional health, a
significant contribution is the training of village health workers from among the villagers
who are responsible for health and nutrition education, child, and maternal promotion and
immunization and their activities, knowledge and consciousness of child health. This has
strengthened breast feeding practice and has increased nutritious supplementary food
intake of children and thereby has created a better health status of children. It is notablethat the contribution of the project to the promotion of health, sanitation, hygiene and
nutritional status of the village population has been reflected in the lower rates of
mortality and morbidly of the mothers and children in the project Village.
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Chapter Three:
Theoretical Framework
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Chapter 3: Theoretical framework
From the sociological point of view, social factors evaluate whether a person is healthy
or sick. In the preamble of its 1946 constitution, the world health organization defines
health as a state of complete physical, mental and social well-being and not merely the
absence of diseases and infirmity and of our continuum respondents, an ideal rather than
a precise condition. Alongside the continuum, people define themselves as a healthy or
sick based on the criteria determined by each individual, relatives, friends, colleague and
medical practioners, because health is related to various socio-political, cultural issues,
we can consider how it varies in different situations or cultures. (schaefer, 2002: 391).
This chapter attempts to expatiate upon some theoretically significant sociological
perspectives amenable to the topic so that the study entails some pertinence that the study
entails some pertinence
3.0 Germ theory of disease:
Traditionally, health has been viewed as an absence of diseases and if one was free
from disease, then the person was considered healthy. This concept known as the
biomedical concept has the basis in the germ theory of disease by Louis pasteur
(1822-1895), which dominated medical thought at the turn of the 20th country. The
emphasis had shifted from empirical causes (e.g .... bad air) to microbes as the sole cause
of disease. The concept of cause embodies in the germ theory of disease is generally
referred to as a one to one relationship between causal agent and disease. The diseasemodel accordingly is:
Disease agent Man Disease
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The germ theory of disease, though it was a revolutionary concept, is many
epidemiologists to take one sided view of disease causation. That is, they could not think
beyond the germ theory of disease. It is now recognized that a disease is rarely caused by
a single agent alone, but rates depends upon a number of factors which contribute to its
occurrence. Such as
a) Heredity
b) Environment
c) life style
d) socio economic conditions
e) Healthy and family welfare servicesf) Other factors.
3.1 Conflict theory:
The Marxian theory of class conflict appears to be relevant to the social class differences
in health and illness behavior the poor are sicker than the affluent (Maykovich, 1980:46).lower class people are likely to be exposed to physical hazards, such as: over crowded
living, poor sanitation, malnutrition. Where poverty, illiteracy, unconsciousness and
deprivation are more, there the prevalence of various diseases and related sigma and
deprivation are higher.
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3.2 Conceptual Framework:
Fig: Conceptual Framework of the study
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Age
Income
Class
Occupation
Decision making
power of women
Education
Working status of
women
Cost of services
Environment of the
clinic
Attitudes of doctors
First Aid
Free medicine
Family planning counseling
Free contraceptive supply
Delivery care
Child care
Aged people care
Adolescence care
primary healthcare servicesSocio-economic &
demographic Variables
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Dependent Variable:
Primary health care services (First aid, Free medicine, Family planning counseling, Free
contraceptive, Delivery care, child care, Aged people care).
Independent variables:
Age, class, gender, Income, occupation, cost of the service, decision making power of
women, Education, working status of women and many other may other important factors
are found as the independent variables.
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Chapter Four: Methodology
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Chapter 4 : Methodology
Quantitative technique has been used for study. A structured questionnaire has been used
to collect data. Household level samples were selected by using simple random sampling
procedure. Data were analyzed using the SPSS computer program
4.0 Why Quantitative method?
Quantitative research was developed to ensure and expanded the human relationships in
quantitative way. It is usually uses survey method and presents the data in tables, graphs,
charts, etc. It is also analyses the relationships between independent and dependent
variables by measuring various statistical ways. Thus, scientifically the hypotheses can be
tested and analyzed. From the very recent stages of development of technology,
quantitative research was popular for its numerical analysis and easy to present data. The
logic of quantitative research comes in an inductive way but in the time of generalization
it uses deductive formula. It directly generalizes the whole relations as hypotheses and
then tests every probable sample. Thus, quantitative research is more scientific, logical
and easy to conduct.
4.1 Study site and population:
This study was conducted on two unions under kapasia thana in Gajipur District,
Quantitative data were collected from every household under this village who takes
primary health care facilities from the community clinic or union health complex.
4.2 Sampling and sample size:
Sampling is the process of selecting a subset of observations from among many possible
observations for the purpose of drawing conditions about that longer set of possible
observation. (Babbie1998).
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Since sampling is an essential part of are scientific procedure, the key principle in
sampling is representative ness. The purpose of scientific sampling is to selected a few
who can be taken to represent the many,
In this study, 103 respondents were selected to collect information about the research.
They have been selected following simple random sampling procedure. Every household
of that area considered as observation unit of study. The women of each household were
the respondents of this study, on whose, it was conducted.
4.3 Sample Instruments
For conducting survey, a 39- questions structured questionnaire was used. The topics
within the questionnaire included.
o Knowledge about health issues of customary health practices.
o Knowledge about diseases and pattern of medicine use.
o Spousal Health practices based on customary health materials.
o Opportunities of modern Health facilities.
o Perception and Consequences of using customary health.
o Measuring the components of Health Belief Model.
4.4 Pre-test
Pre-testing of Questionnaires adhered to the following procedures:
o
I designed the draft questionnaire and also completing pre-testing.o Based on the pre-test findings I checked the translation, consistency and integrity
of the questionnaire. I finalized the questionnaire and showed it to my supervisor
for final approval.
o After approval of the Bengali questionnaire I then printed the Bengali
questionnaire and translated it later into English.
During pre-testing of the survey instruments, the following issues were considered:
o
The probing techniqueso The language necessary to address specific patterns and customary practices.
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o The sequences of the study
o The techniques/methods/ options for documenting responses
o Providing appropriate skips in the questionnaire.
4.5 Techniques of data collection:
Every research methods have their own instrument of date collection. In this study the
method of interview survey was adopted. This is because ease interview survey can be
used for descriptive, explanatory purpose. A well- structured interview is better than an
oral questionnaire. Interview was conducted in face-to-face situations.
4.6 Data Collection Procedures
Questionnaire was used as the main instrument for collection of data of the study.
The collection data in this study depended on the survey.
4.6.1 Administering Survey
The field work for present study was conducted for 2 days and involved quantitative
techniques and. The researcher himself along with two interviewers administered the
survey to respondents according to the sampling plan discussed above. Before
approaching the respondents, the interviewers informed the respondents that they want to
collect on customary health practices and wanted the cooperation of them.
4.7 Data Processing and Analysis
4.7.1 Quantitative Data Processing
Quantitative data processing involved the following steps:
Questionnaire registration and editing
Edit verification
Listing of open-ended responses and classification
Coding and Code transfer
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Verification of Coding and code transfer
Development of data entry structure
Data entry and entry verification
Entering data as per questionnaire structure in SPSS 16.0 version
Verifying the logic and accuracy of the data as per filled up questionnaire
Keeping and maintaining data back ups
Tabulating as per objective and recruitment in Quantum ( an upgraded version of
SPSS), also tabulating data in SPSS 16.0 version
Development of analysis plan
Program development as per the analysis plan
Program running and report generation.
4.8 Limitations of the Study:
Naturally the topics covered are very broad, and funds allocated for the study was rather
small. So, the great strides were made to obtain the best possible results through
designing of a scientifically efficient survey. Though the total size of the households
interviewed and the upazilas covered under the survey were not large, the stratification
system was so designed as to give reliable and efficient national estimates. There may,
however, still be some sampling error because of the smallness of the sample size, but the
non-sampling errors have been greatly reduced through training and retraining of the
project staff for obtaining reliable information and maintaining adequate supervisory
control on them. Possible errors at data processing stage have also been greatly reduced
through adequate planning of table design, training and supervision of the data processingstaff on a continuous basis.
Given the nature, scope and volume of the work, the project was also completed in a
reasonably short period. The project involving such a voluminous work of primary data
collection and analysis was really .J. completed within a short period of time. Because of
the nature and scope of the work and most importantly due to financial and time
constraint, some issues like investment of NGOs in the primary health care and family
planning projects and the evaluation of the multi-sect oral projects could not be
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adequately investigated. But the scope of such topics is so large that, for example,
each of the primary health care and family planning projects under the Ministry of
Health and Population Control, and other ministries/agencies may call for independent
evaluation. As the primary health care in Bangladesh is still at an infant stage, we
primarily limited our analysis to "process evaluation" with some element of "impact
evaluation". A detailed evaluation, involving assessment of some of the major indicators
for Health for All by the Year 2000 calls for further studies at a future date.
The indicators on health status and health delivery care, as set forth in the Country Paper
on Health for All by the Year 2000, are very comprehensive in nature,8 and securing
adequate information on them calls for reliable vital registration/epidemiological
surveillance/comprehensive management information system, and a host of specialized
surveys.
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Chapter Five:
Results of the study
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Chapter 5 : Results of the study
5.1: Socio-Demographic Characteristics of Respondents
Table no 1: Distribution of the respondents by age.
From the above table, it is evident that 18 of the respondents belong to age group 15-20,
31 of the respondents belong to age group 21-26 and 29.1% of the respondents belong to
age group above 32.
Frequency Percent
15-20 18 17.5
21-26 31 30.1
27-32 24 23.3
Above 32 30 29.1
Total 103 100.0
Table no 2: Distribution of the respondents by religion.
The above chart shows that 75.7% of the rerspondents are Muslim, 18.4% of the
respondents are Hindu and 5.8% of the respondents are Christian.
Frequency PercentIslam 78 75.7
Hindu 19 18.4
Christian 6 5.8
Total 103 100.0
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Table no 3: Distribution of the respondents by Educational qualification.
From the table it is evident that 18.4% of the respondents are illiterate, 21.4% of the
respondents are educated from class 1-5, 12.6% of the respondents are class 5-8, 22.3% of
the respondents are class 9-10, 25.2% of the respondents are above class 10
Frequency Percent
Illiterate 19 18.4
Class 1-5 22 21.4
Class 5-8 13 12.6
Class 9-10 23 22.3
Above class 10 26 25.2Total 103 100.0
Table no 4: Distribution of the respondents by family income
From the above figure it shows that 18.4% of the respondents have family income
between 1000-3000 taka, 63.1% of the respondents have 3001-6000 taka, 12.6% of the
respondents have 6001-9000 taka and 5.8% are above 9000 taka
Frequency Percent
1000-3000 taka 19 18.4
3001-6000 taka 65 63.1
6001-9000 taka 13 12.6
Above 9000 taka 6 5.8
Total 103 100.0
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Table no 5: Distribution of the respondents by occupation
The above table shows that 5.8% of the respondents are service holder, 88.3% are
Housewife and 5.8% are belong to other services.
Frequency Percent
Service 6 5.8
House wife 91 88.3
Others 6 5.8
Total 103 100.0
Table no 6: Distribution of the respondents by the occupation of the family head.
18.4% of the family head are service holder, 52.4% of the family head are Agriculture,
16.5% are Businessman, and 12.6% are others.
Frequency Percent
Service 19 18.4
Agriculture 54 52.4
Business 17 16.5
Others 13 12.6
Total 103 100.0
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5.2: Knowledge about Primary Health Care Center
Table no 7: Distribution of the respondents by having knowledge about Community
Clinic
The table shows that 100% of the respondents know about the clinic.
Frequency PercentYes 103 100.0
No 0 0
Total 103 100.0
.
Table no 8: Distribution of the respondents by taking health service from clinic
It shows that 100% of the respondents have taken the service.
Frequency Percent
Yes 103 100.0
No 0 0
Total 103 100.0
Table no 9: Distance of the clinic from home
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The table shows that 65% of the respondents home are distance from clinic and 35% of
the respondents home are near to clinic.
Frequency Percent
Yes 67 65.0
No 36 35.0
Total 103 100.0
5.3: Decision making power of Respondents about Health access
Table no 10: Distribution of the respondents by the permission of their husband.
The above chart shows that 47.6% of the respondents are permitted to 90 clinic, 40.8% of
the respondents are permitted from time to time, 11.7% are not permitted.
Frequency Percent
Yes 49 47.6
From time to time 42 40.8
Never permit 12 11.7
Total 103 100.0
Table no 11: Taking permission of husbands from the respondents
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From the table it is evident that 30.1% husbands take permission from their wife and
51.5% do not take permission, 18.4% take from time to time.
Frequency PercentYes 31 30.1
No 53 51.5
From time to
time19 18.4
Total 103 100.0
5.4: Primary Health facilities
Table no 12: First Aid Facilities
58.3% of said that they get first aid from clinic, 18.4% do not get and 23.3% get from
time to time.
Frequency PercentYes 60 58.3
No 19 18.4
From time to time 24 23.3
Total 103 100.0
Table no 13: Family Planning Counseling
78.6% get family planning counceling and 21.4% do not get from clinic.
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Frequency Percent
Yes 81 78.6
No 22 21.4
Total 103 100.0
Table no 14: Free contraceptive Supply.
66.0% of the respondents get free contraceptive from the clinic and 34.0% do not get.
Frequency Percent
Yes 68 66.0
No 35 34.0
Total 103 100.0
Table no 15: Child Care Facilities
77.7% of the respondents said that there are child care facilities and 22.3% said there are
no child care facilities.
Frequency Percent
Yes 80 77.7
No 23 22.3
Total 103 100.0
.
Table no 16: Antenatal Care Facilities.
89.3% of the respondents get Antenatal facilities and 10.7% do not get
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Frequency Percent
Yes 92 89.3
No 11 10.7
Total 103 100.0
Table no 17: Delivery facilities
54.4% of the respondents said that they get delivery facilities from the clinic and 45.6%
do not get.
Frequency Percent
Yes 56 54.4
No 47 45.6
Total 103 100.0
Table no 18: Infant Health facilities
76.7% of the respondents said that there are infant health facilities in the clinic and 23.3%
said no infant facilities in the clinic
Frequency Percent
Yes 79 76.7
No 24 23.3
Total 103 100.0
Table no 19: Adolescent facilities
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60.2% of the respondents said that there are adolescent facilities in the clinic and 39.8%
said no adolescent facilities in the clinic
Frequency PercentYes 62 60.2
No 41 39.8
Total 103 100.0
Table no 20: Aged Care Facilities.
55.3% of the respondents agree that there are aged care facilities and 44.7% disagree.
Frequency Percent
Yes 57 55.3
No 46 44.7
Total 103 100.0
Table no 21: Environment of the Clinic.
The chart shows 59.2% said that the environment of the clinic is healthy and 40.8% said
the unhealthy environment.
Frequency Percent
Yes 61 59.2
No 42 40.8
Total 103 100.0
Table no 22: Environmental situation of clinic for child and women
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59.2% 0f the respondents said that the environment is suitable for child and women
another 40.8% said the environment is not suitable.
Frequency Percent
Yes 61 59.2
No 42 40.8
Total 103 100.0
Table no 23: Free Medicine Supply.
12.6% of the respondents get free medicine from clinic, 87.4% of the respondents do notget.
Frequency Percent
Yes 13 12.6
No 90 87.4
Total 103 100.0
Table no 24: Instrument Facilities.
The table shows 12.6% of the respondents said that there are necessary instruments in
hospital and 52.4% said there is no instrument and 35% do not know.
Frequency Percent
Yes 13 12.6No 54 52.4
Don't know 36 35.0
Total 103 100.0
Table no 25: Free Diagnosis Test Facilities.
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The chart shows that 17.5% of the respondents get free test facilities and 82.5% of the
respondents do not get.
Frequency Percent
Yes 18 17.5
No 85 82.5
Total 103 100.0
Table no 27: Attitudes of the Doctors.
The chart shows that 30.1% of the respondents are satisfied about the behavior of the
doctors and 69.9% are not satisfied.
Frequency Percent
Yes 54 52.4
No 49 47.6
Total 103 100.0
Table no 28: Complain against the Doctor
47.6% of the respondents have objection against the doctor and 52.4% do not have any
objection.
Frequency Percent
Yes 49 47.6
No 54 52.4
Total 103 100.0
Hypothesis no 1: There is a relationship between level of education and acceptance
of health care service.
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Cross tabulation
Educational qualification
TotalIlliterat
eClass1-5
Class5-8
Class 9-10
Aboveclass 10
Do you
receive
necessar
y service
from
your
local
health
care
centre?
Yes 19 11 0 17 13 60
No 0 0 13 0 6 19
From
time to
time
0 11 0 6 7 24
Total 19 22 13 23 26 103
Directional Measures
Value
Asymp
. Std.Error(a
)
Approx
. T(b)
Approx.
Sig.
Nominal
by
Nominal
Lambda Symmetric .250 .074 3.011 .003
Q12
Dependent.302 .070 3.857 .000
Q3
Dependent.221 .095 2.089 .037
Goodman
and
Kruskal
tau
Q12
Dependent.388 .025 .000(c)
Q3
Dependent .166 .030 .000(c)
A Not assuming the null hypothesis.
B Using the asymptotic standard error assuming the null hypothesis.
C Based on chi-square approximation
Symmetric Measures
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Value Approx. Sig.
Nominal by
Nominal
Phi.925 .000
Cramer's V .654 .000
ContingencyCoefficient
.679 .000
N of Valid Cases 103
A. Not assuming the null hypothesis.
B. Using the asymptotic standard error assuming the null hypothesis.
Hypothesis no 2: poverty and health care service are related.
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Cross tabulation
Monthly family income Total
1000-3000
taka
3001-
6000
taka
6001-
9000
taka
Above
9000
takaPrimary
health
from
commu
nity
clinic
Ye
s
19 35 6 0 60
No 0 13 0 6 19
Fr
o
mti
me
to
ti
me
0 17 7 0 24
Total 19 65 13 6 103
Directional Measures
Value
Asymp. Std.
Error(a
)
Appro
x. T(b)
Approx.
Sig.
Nominal
by
Nominal
Lambda Symmetric .086 .050 1.626 .104
Q12
Dependent.163 .093 1.626 .104
Q4
Dependent.000 .000 .(c) .(c)
Goodman
and
Kruskal
tau
Q12
Dependent.227 .021 .000(d)
Q4
Dependent.095 .021 .000(d)
A. Not assuming the null hypothesis.
B. Using the asymptotic standard error assuming the null hypothesis.
C. Cannot be computed because the asymptotic standard error equals zero.
D. Based on chi-square approximation
Symmetric Measures
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Value Approx. Sig.
Nominal by
Nominal
Phi.687 .000
Cramer's V .486 .000
ContingencyCoefficient
.566 .000
N of Valid Cases 103
A. Not assuming the null hypothesis.
B. Using the asymptotic standard error assuming the null hypothesis.
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Hypothesis no 3: Access to primary health care service depends on working
status/professional status of women.
Cross tabulation
Occupation of the
respondent
TotalService
House
wife Others
Primary
health
care
from
commun
ity clinic
Yes 0 54 6 60
No 6 13 0 19
From
time to
time0 24 0 24
Total 6 91 6 103
Directional Measures
Value
Asym
p. Std.
Error(a) Approx. T(b) Approx.Sig.
Nominal
by
Nominal
Lambda Symmetri
c.109 .037 2.524 .012
Q12
Dependen
t
.140 .053 2.524 .012
Q5
Dependen
t
.000 .000 .(c) .(c)
Goodman
andKruskal
tau
Q12
Dependent
.139 .012 .000(d)
Q5
Dependen
t
.132 .067 .000(d)
A. Not assuming the null hypothesis.
B. Using the asymptotic standard error assuming the null hypothesis.
C. Cannot be computed because the asymptotic standard error equals zero.
D. Based on chi-square approximation
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Symmetric Measures
Value Approx. Sig.
Nominal byNominal Phi .558 .000
Cramer's V .395 .000
Contingency
Coefficient.487 .000
N of Valid Cases 103
A. Not assuming the null hypothesis.
B. Using the asymptotic standard error assuming the null hypothesis.
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Hypothesis no 4: utilization of health care depends on environment of the clinic and
attitudes of the service providers.
Cross tabulation
Environment of the
community clinic
TotalYes No
Primary
healthcare
from
communit
y clicnic
Yes 48 12 60
No 13 6 19
From time
to time 0 24 24
Total 61 42 103
Directional Measures
Value
Asym
p. Std.
Error(
a)
Appro
x. T(b)
Approx.
Sig.
Nominalby
Nominal
Lambda Symmetric
.424 .093 3.685 .000
Q12
Dependen
t
.279 .118 2.040 .041
Q21
Dependen
t
.571 .076 5.594 .000
Goodman
and
Kruskaltau
Q12
Dependen
t
.246 .063 .000(c)
Q21
Dependen
t
.449 .066 .000(c)
A. Not assuming the null hypothesis.
B. Using the asymptotic standard error assuming the null hypothesis.
C. Based on chi-square approximation
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Symmetric Measures
Value Approx. Sig.
Nominal byNominal
Phi .670 .000
Cramer's V .670 .000
Contingency
Coefficient.557 .000
N of Valid Cases 103
A. Not assuming the null hypothesis.
B. Using the asymptotic standard error assuming the null hypothesis.
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Chapter 6: Discussion
In a low income country like Bangladesh where illiteracy and endemic poverty are too
predominant and the general health standard of the population is too low resulting in high
mortality (both infant and child and adult) and incidence of diseases are also widespread,
the government assumes the responsibility to provide basic health care facilities to the
vast majority of rural population at a low and acceptable cost. Thus along with the
government's stated objectives of providing primary health care to the population, a large
number of projects and programmes have recently surfaced which are national in
character.
Although an innumerable number of diseases are known to medical science, a handful of
them primarily give rise to the Sicknesses to the rural people in Bangladesh. Infectious
diseases arising out of unhygienic environment, poor living condition and poor personal
hygiene play the major role and most of these diseases have significant scope for
prevention through appropriate public health measures.
For older people aged 55 and above, the earlier five diseases as mentioned in Section
6.22.come up again as the most important causes of sicknesses. The additional cause of
suffering to the elderly is the complicacies due to old age. For older people rheumatism is
the most important cause of sufferings followed by lungs and respiratory diseases, old age
complicacies and diarrhea diseases. Skin disease accounting for a major cause of
sufferings of all persons assumes a low significance for the older people.
In recording reasons for not seeking any treatment either for the persons who were sick or
for the deceased who had died during last one year before the date of survey within the
specified reference periods, rnultjple reasons were registered without any order. While
grouping the stated reason sounder a few common categories, financial incapacity of the
people and the chronicity of diseases inflicting long non-curable sufferings upon patients
were found to be the two major causes that led people in most occassions to avoid
treatment. Of the total reasons stated 42.6 per cent fall under the category of financial
problem and 31.0 percent in the other category of chronicity or non-curable nature of the
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diseases. Looking closely into the reasons for non-treatment, financial problems figure
out as the over whelming reason for the same. Besides financial, all other reasons may be
basically classified as "attitudinal".
In theory the demand for health care services to a population should be universal. The
attack of a disease bring enormous mental and physical pressure upon a person. Illness
can result into loss of working days and inefficiency in work performance, and financial
loss, as well, for the working adult persons. Thus, an onset of disease logically calls for
treatment to control the ill effects of the disease.
Ideally, therefore all sick persons should seek treatment for recovery. But in reality it may
not follow in some societies due to a few practical situations. The situations that can lead
to lack of demand for treatment could be both subjective and objective. Cultural
disapproval for medicine or for any deliberate effort exist in some societies causing non-
treatment to the sicknesses. Or it may be that people who believe in medicine are eager to
receive it while they fall sick but a few objective conditions do not allow them to take any
treatment, Under both circumstances, the actual demand for medicine for treatment could
be substantially below the demand that ideally should be.
In rural areas of Bangladesh the cultural barriers to treatment still seem to persist. Besides
other reasons which can be classified as cultural, 5,0 per cent of the reasons reflected
disapproval for the medical treatment. The pervasive objective condition for not seeking
treatment for ailments centre around financial problem.
The above discussion indicates to a fact that alongwith the need for treatment there is
large latent demand for treatment in the rural area of Bangladesh, Both socio-cultural and
financial problems had helped to sustain a low demand for health services. A low demand
for health services. Through adoption of appropriate policy measures the demand for
health services in rural Bangladesh can be greatly increased.
Community participation, though an essential ingredient of primary health care including
family planning, is still in a very rudimentary stage in Bangladesh. Instead of standing on
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their own legs and trying to influence their own and community's destinity through their
own initiatives, people have on the whole been passive recipient of aid and victims of
decisions taken for them from the top. People's participation in health and family
planning has also been miscarried through "village health and family planning
committees" and the NGO activities. The village level population committees in most
cases have either not been formed or have remained inactive. The major reasons for non-
functioning of population control committees are lack of financial or other incentives.
Lack of decentralized authority and clear cut responsibilities of the committee members
also serve as contributing factors for non-functioning of the population control
committees. At the union level or below there is no health committee at all.
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Chapter Seven:
Conclusion and Recommendation
Chapter 7: Conclusion and Recommendation
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Conclusion:
To ensure health facilities all is one of the main tasks of the government. Good health
means not only absence of diseases; it also includes physical, mental and social fitness.
Bangladesh government time and again tried to assure the minimum health service to the
people but it is due to uncontrolled population growth, poor economy, wealth, no
significant progress in the health service could have been guarantee for the majority of the
population. However, in connection with the utilization of health centers in rural areas a
few observations are worth mentioning. If is observed that lower landholding size groupand the females utilize the government health centers in higher proportion than the higher
landholding size groups and males, respectively. Reasons behind the situation are that the
rich people of rural areas and males are economically independent and they can go abroad
without any hindrances. But poor people especially females are usually depends on their
male member of family for their basic needs including health service. Presumably the
higher income group resorts to private practice group resorts to private practice of the
government doctors with the expectation of receiving a larger share of the limited
facilities from the government health centers. It is also worth noting that the private
qualified practitioners are more popular in relative proportions among the middle class
people. It is worth noting that the government doctors play a government role in the
private sector providing quality health services. This indicates in rural areas has benefited
most the unprivileged or disadvantaged group in the society.
Recommendation:
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Although this study was carried out among the women of particular localities in Gajipur,
Kapasia but finding of this study are found very important. The findings of the concerned
report may be summarized in the following manner:
1. From the headquarters level down to the institute/ training area level, the program
should be more properly coordinated with a rigorous management thrust.
Supervision should be frequent and a system of monitoring and feedback should
be instituted and maintained on a continuous basis. Among with other things, a
proper project information system should be devised and be strictly adhered to.
Standard methods of training evolution and programming should be evolved.
2. Lack of transport facilities is a major constraint to take delivery of supplies from
the district to the upazila, transportation condition should be better.
3. The total responsibility of the action program for health and family planning
including MCH will be vested on the ministry of Health, and the ministry will
recognizes itself to meet its mew obligations effectively.
4. Keeping in view the resource constraints of our country, free medical care can not
be provided to all people. So we recommended the imposition of a system of cost
sharing by the well to do people. We also recommended to; examine the cost
feasibility of the installation of mini generator in the health complex for regular
supply of electricity.
5. A large majority of the health complex badly suffer from inadequate supply of
stationary goods and furnitures, pen, ink, paper, chair, table, admiral, type writer,
calculators. Functional x-ray machines, ambulance and blood-bank are almost
totally non-existence. There should be adequate provision of maintenance of all
equipments and furniture.
6. There are so many complain that the attitude and behavior of the providers (Nurse,
doctor) is irritating towards. That the patients do not fell comfort to get services.
So, the behavior of the providers should be changed.
7. Women must have the rights to get services according to their own demand.
8. The institutes do not have sufficient logistics and staff strength and another
significant shout coming of the program is that the trainers not sufficiently skilled
and are not duly motivated.
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References
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References
Khan, M.R (2000) Evaluation of primary health care and family planning facilities in
rural areas of Bangladesh, Bangladesh institute of rural development studies.
Ruth, Simons (1999), Strengthening government health and family planning
programmes: findings from an action research project in rural Bangladesh, In studies in
family planning, vol.15.N.5
Babbie, Earl (1990), Survey research methods, Califronia: world worth publishing
company.
Constitution of the Peoples Republic of Bangladesh (1972),The Bangladesh Gazette,
Extraordinary, part IV, October.
Bangladesh Ministry of health and family planning (1976), Health division,
Establishment of Thana health complex, 1976: A plan for Delivery of Basic health care to
the people of Bangladesh, P:69.
Bangladesh country report (1985), Evaluation of the strategies for health for all by the
year 2000 using a common framework and format, Dhaka.
Hossain, Zakir (1998) , Population growth and health needs in ESCAP, Population of
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Giddens, Anthony (2006) , Sociology; Vol 1; p:172
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Khan, M.A (2000), Health services structure of BangladeshBangladesh Development
Studies, Vol-xII, No, 1,p:65
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Majumder, M.A(2000), Physical and mental status of the people The Internet Journal
of Health 2009, Vol-8, No.2. p:56
Aziz, K.M.A (1999), Recent trends in medical consultation prior to death in rural
Bangladesh Bangladesh Medical Journal, Vol- 6, No- 1,P;58-60
Beguem, Sharifa(2009), Status of primary health care in Bangladesh specially in the
rural areas The Internet Journal of Health , Vol-08, No-2,p:44
Haque, N,(2006) Demand for health care service Middle Journal of Family
Medicine.Vol-7,p:21
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Appendix
Di`vxi bvgtb^
i
ck Di
1. Avcbvi eqm KZ? 15-20 .................1
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21-26..................227-32 .................332 Gi Dci..........4
2. Avcbvi ag wK? Bmjvg ..................1
wn`y .....................2wLvb ...................3e ....................4Abvb ..................5
3. wkvMZ hvMZv AwkwZ ................1
1g -5gkYx ..........25g- 8gkYx ..........39g- 10gkYx .........410g kYxiDci ......5
4. cwievii gvwmK Avq 1000-3000UvKv......13001-
6000UvKv ......26001-9000UvKv .....39000 nvRviiDci ..4
5. Di`vxi ckv PvKzwi.......................1Mwnbx ......................2KwlKvR....................3Abvb .....................4
6. cwievi cavbi ckv PvKzwi ......................1Kwl .........................2eemv.......................3
Abvb .....................4
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7. Avcbvi GjvKvq wK Kvb KwgDwbwUwKwbK AvQ?
nvu ..........................1bv ...........................2Rvwbbv................
.......38. Avcwb wK mLvb KLbv mev wbZ
wMqQb?nvu ...........................1bv ............................2
9. wKwbKwU wK Avcbvi evmv _K `~i? nvu ...........................1bv ............................2
10. wKwbK hvIqvi Rb Avcvbvi ^vgx wK
AvcbvK memgq AbygwZ `b?
nvu ....................
....1gvSgvS`b ........
...2KLbv `bbv ..........3
11. wKwbK hvIqvi Rb Avcbvi ^vgx wKKLbv Avcbvi KvQ _K AbygwZ bb?
nvu ........................1bv .........................2gvSgvSbb............3
12. mLvb _K wK Avcwb cqvRbxqcv_wgK wPwKrmv cq _vKb?
nvu .........................1bv ..........................2gvSgvS ................3
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13 mLvb _K wK cwievi cwiKvbvicqvRbxq civgk `Iqv nq?
nuv .........................1bv ..........................2
14. mLvb _K cwievi cwiKbvi cqvRbxqmvgMx wK `Iqv nq?
nvu .........................1bv ..........................2
15. mLvb _K wK wk`i cqvRbxqwPwKrmv `Iqv nq?
nvu .........................1bv ..........................2
16. wKwbK _K wK MfKvjxb Kvb mev`Iqv nq?
nvu ..........................1
bv ...........................217. mLvb _K wK cmeKvjxb mev c`vb
Kiv nq?nvu ..........................1bv ...........................2
18. bveRvZK wk i wK cqvRbxq mev Kivnq?
nvu ...........................1bv ...........................2
19 mLvb _K wK wKkvix i Kvb mev
c`vb Kiv nq?
nvu ....................
......1bv ...........................2
20. mLvb wK eq jvKi Kvb wPwKrmvieev AvQ?
nvu ..........................1bv ...........................2
21 ^v K`i cwiek wK ^v mZ? nvu ..........................1bv ...........................2
22. ^v K`e cwiek wK bvix I wkeve? nvu ...........................1bv ............................2
23 mLvb _K cqvRbxq Jlya wK webvg~j mieivn Kiv nq?
nvu ...........................1bv ............................2
24 mLvb wK chv cwigvb hcvwZAvQ?
nvu ...........................1
bv ............................2
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Rvwbbv ......................3
25 mLvb wK webvg~j cixv Kiv nq? nvu ...........................1bv ........................
....226 ^vmev c`vbKvix wPwKrmv c`vbi
ci wK LuvR Lei bb?nvu ...........................1bv ............................2
27 Avcwb ^vmev c`vbKvixi AvPibmK wK m?
nvu ...........................1bv ............................2
28 Zvi AvPib mK wK Avcbvi Kvb
AwfhvM AvQ?
nvu ....................
.......1bv ........................
....229 AwfhvM Kij wK Kvb DcKvi cvIqv hvq? nvu ....................
......1bv ...........................2
Acknowledgements
I received understanding support for writing this monograph from different sections. I am
very much grateful to them for their utmost help and substantial support. I express my
profound gratitude to Dr. Shah Ehsan Habib who is my course teacher. It is he, without
whose proper guidelines, it was not possible to complete this research work successfully.
He always allowed me for the access to him in expenses his valuable time for any sort of
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my need relating to my research work, when required, His scholarly instructions shall
remain in my heart for ever.
In acknowledge highly my indebtedness to my teacher for his cooperation, guidance, and
advice. When I was in trouble he sincerely and cordially helped me to understand.
I would like to extend my heartful thanks to the respondents of this.
Finally I thanks all those who helped me divergently and indirectly in my work.
Date 19-12-09