ENVIRONMENTAL RISK FACTORS ASSOCIATED WITH RTI/STD SYMPTOMS AMONG WOMEN IN THE URBAN SLUMS

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1 The Journal of Developing Areas Volume 38 Number 1 Fall 2004 ENVIRONMENTAL RISK FACTORS ASSOCIATED WITH RTI/STD SYMPTOMS AMONG WOMEN IN THE URBAN SLUMS Nashid Kamal* Rumana Rashid* Independent University-Bangladesh, Bangladesh ABSTRACT` To link environmental factors with prevalence of RTI/STD symptoms among women in the urban slums of Dhaka, Bangladesh and also to investigate if there are differences in levels of RTI/STD prevalence among the slums. Fourteen slums from Dhaka city were the secondary units for this study, households were selected according to systematic sampling. One woman from each selected household was interviewed and a total of 3000 women forms the sample. Several RTI/STD symptoms were prompted to them and their reported prevalence in the last on year was documented in structured questionnaires. Almost 65% women were found to have reported at least one RTI/STD symptom in the last one year. Final parsimonious model using multilevel logistic regression of prevalence of RTI/STD symptoms on various correlates found two environmental factors to be significant. Women were more likely to report symptoms if their houses were located more than 10 yards away from the toilet, and they did not practice proper garbage disposal habits. However, age of the woman was the most significant predictor of RTI/STD symptoms, older women having reporting more symptoms compared to women aged below 19. Most slums had similar level of RTI/STD prevalence, only one slum had significantly lower ones. Environmental factors seem to have significant correlationship with reporting of RTI/STD symptoms in the urban slums. Tackling women s reproductive health is more a multisectoral approach than establishment of health clinics alone. JEL Classifications: I12, J13, J16, R31. Keywords: Environmental factors, RTI/STD symptoms, urban slum, multilevel regression, Bangladesh.

2 108 Nashid Kamal and Rumana Rashid INTRODUCTION High rates of urbanization in developing countries has produced innumerous slums and squatters with very poor living conditions. The unavailability of pure drinking water, sanitary latrine and waste disposal from these slums are imminent causes of public health problems for the population living there. Although some studies have looked at the effects of environmental factors like sources of drinking water on diarrhoeal diseases (Myaux et al:1997;hoque et. al: 1997) the other diseases sparked off by such appalling living conditions have not received enough attention. Women in the slums bear the consequences of using common latrines and that too in unhygienic conditions. While men usually do not stay in the slums during the day, women stay home to look after the family and thus have higher exposure to the detrimental effects of waste disposal and other related health hazards (Merkle and Knobluch:1995). The prevalence of reproductive health problems among women of reproductive ages in the urban slums may have associations with environmental risk factors and forms the basis of this study. In Bangladesh, the current growth rate of the urban population is more than six percent. With rapid urbanization, the number of the urban poor have also increased from about 7 million in 1985 to 11.5 million in 1995 ( Islam et al: 1997). According to one survey, this figure is expected to increase to 15 million by the year 2000 and double within the next twenty years (ibid). The living conditions of a majority of the urban population is appalling. According to Afsar (2000) `In the urbanization process of Bangladesh, Dhaka plays the most important role. Dhaka is the capital city of Bangladesh and is home to one third of the total urban population in Bangladesh. Dhaka is three times larger than Chittagong which is the next largest city (UN:1993). It is the main center of administration, trade and commerce. Manufacturing activities are also heavily concentrated in Dhaka making it the center of attraction for migrants from all walks of life (Un:1987,BGMEA:1993).One study shows that for urban slums and squatters in Dhaka city, every person occupies an average area of 2.5 m 2, which does not improve with longer duration of stay in the city (Afsar: 2002). The same study finds that more than 50 percent of the slum dwellers share a common toilet which is not sanitary and longer stay in city does not ensure access to sanitary toilets (ibid). In Dhaka city, an estimated 110 hectares of land is needed for disposal of waste. Problems of garbage collection and poor drainage are acute in Dhaka city due to inefficient disposal management by Dhaka City Corporation (DCC). Existing estimates suggest that whilst nearly half of the generated solid waste (nearly tons per day) is collected by the DCC and poor women and children, the rest lie on road sides, open drains and low lying areas, specially near the urban slums (ibid). To this, is added the wastes from industries such as tanneries, hospitals, chemical, rubber etc all of which are threats to the human population. As slum dwellers and squatters often live in fringe areas of Dhaka city, they have a higher probability of being affected by the deteriorating environment. The alarming public health problems caused by the rapid growth in urban population living in unhealthy conditions is a matter of grave concern to policy makers. Following the International Conference on Population and Development (ICPD) in 1994, reproductive health of women has been receiving increased attention in

3 Environmental Risk Factors 109 Bangladesh. Unfortunately, most health policies are directed towards the rural women and very few health policies exist to alleviate the suffering of women living in the urban slums. However, there are some disjoint Non-Government Organizations (NGOs) which provide some services for various slums. One study states that around 100 NGOS are currently working in Dhaka city and are involved in credit and income generation, general health, non-formal education and skill development. However, it is estimated that these NGOs only cover one-tenth of the total slum population in Dhaka (Asfar:2000). Researchers have reasons to believe that poor environmental conditions and poor personal hygiene cause almost one-third of the population in the urban poor to be afflicted with some kind of disease (Islam et al.: 1997). This study looks at the effects of environmental risk factors on the prevalence of Reproductive Tract Infection (RTI)/Sexually Transmitted Diseases (STD) among women in the urban slums of Dhaka, the capital of Bangladesh. In doing so it wishes to identify the environmental risk factors of the prevalence of reproductive health problems. Because some of the slums are on the fringe areas, with higher exposure to industrial and human waste, researchers would also like to investigate the risk factors of those slums compared to others which are in relatively improved areas. The study therefore includes various community level covariates and indicators such as existence of NGOs in the vicinity of the slum to distinguish between the services available for the slum dwellers. Thus, the study also seeks to investigate whether the environmental risk factors associated with the prevalence of RTI/STD symptoms, vary between the slums under study. METHODS AND MATERIALS This study was conducted in fourteen slums of Dhaka metropolitan area, the capital city of Bangladesh. The study was conducted between May August Three -staged sampling method was employed. Since slums do not have the same size of population, a list of slums having around 220 households was collected from the most recent documentation of the urban slums, available from the CUS (1996). In the first stage, a slum was randomly chosen, one each from each of the fourteen administrative units (thana). In the second stage, these slums were totally mapped and 216 households were chosen from each slum using systematic sampling. In the third stage, one woman in reproductive age group (15-45) was chosen from each household resulting in 3025 women, and a pre-tested questionnaire was filled out by trained female investigators. Women were asked about the prevalence of one or more of thirteen listed symptoms in the last one year, and this was the prime variable of interest. Community level characteristics were obtained from field observations. The validity of the data was tested in a post test study where fifty respondents were asked the same questions and 90 percent of the answers matched their previous ones (regarding self reported RTI/STD symptoms). After condensing information with the help of bivariate analysis and other techniques, logistic regression was conducted. The outcome variable was the self reported RTI/STD symptoms (coded 1 for yes and 0 otherwise). As expected, in bivariate analysis, variations between the slums was found to be significant. A multilevel model

4 110 Nashid Kamal and Rumana Rashid Fig. 1 Conceptual Framework of Prevalence of Reproductive Morbidity & Inter-relationships with other Factors COMMUNITY Garbage disposal facilities Health Complex NGO in slum Private Doctors Garbage disposal habits Awareness of FP, other health factors Reproductive Morbidity Own Television Type of family Cost at clinic BIOLOGICAL FACTORS Age Marital status Number of pregnancies Number of abortions Induced/Spontaneous abortion Tetanus shots during pregnancy I N C O M E Number of household members House Material Distance to toilet Source of drinking water (utilities in slums) Personal hygiene during menstruation (kind of material used, washing those materials & storage) Seek treatment

5 Environmental Risk Factors 111 was therefore used to allow the prevalence of RTI/STD symptoms to vary due to two levels of observation-the individual and community level. Let y ij be the binary response of the ith woman in the jth slum of reporting a reproductive health problem occurring in the last one year, where y ij =1 for yes and 0 otherwise, and let p ij =Pr(y ij =1). Then the two-level random coefficients logistic model can be written as follows: Logit (p ij )= log (pi j /1-p ij )=H ij Where H ij = Xβ+u j η And p ij ={exp(xβ+u j η)}/ {1+ exp(xβ+u j ) } +e ij Where H ij is the linear predictor. X and η are design matrices containing covariates which may be defined at any of the two levels in the model.β is the associated vector of parameter estimates that are known as `fixed effects. Variation at the woman level is represented by e ij which is assumed to have binomial distribution with unit variance, while u j is the level two error term assumed to follow the normal distribution with zero mean and variance/covariance matrix Ω 2. STUDY VARIABLES AND PROFILE OF THE STUDY POPULATION In this study the main variable of interest is the woman s reported RTI/STD symptoms in the last one year. Fig. 1 presents a conceptual framework of the variables included in this study. The biological factors such as age of the woman, marital status, age at marriage, number of living children, tetanus shots taken during pregnancy, number of abortions performed etc were thought to have direct effects on the prevalence of RTI/STD symptoms. Other variables are categorized according to two broad classifications. Family income was considered to be the factor which could determine RTI/STD symptoms through the intermediate variables such as house material, number of rooms in the household (HH), number of members in the HH, distance to toilet, source of drinking water, affording proper hygiene during menstruation etc. The third set of factors would be the community level factors which would have roles on the prevalence of RTI/STD symptoms through the intermediate variables such as garbage disposal facilities in slums, presence of health related Non Governmental Organisations (NGOs) in the slums, presence of health complex, private doctors. The interrelationships are displayed in Figure 1. While 87 percent of women in this study are currently married, only around 4 percent were unmarried the rest being ever married. The mean age of the respondents was 26.5 years and only 24 percent had formal primary education, the rest having none. This was much higher than the 15 percent observed in another study in the urban slums conducted in 1993 ( Jamil et al.:1993) and much lower than the nationally representative sample (46 %) observed by Islam et. al (1997). However, in this study a higher percentage of women (32%) reported earning cash for a living, which matched the Jamil et. al (1993) study (33%) but was higher than the 21% observed by Islam et. al (1997). Almost 50 percent women in this study used the `hanging type of toilet, and almost 28 percent women had a toilet shared by less than seven households. Most women use the toilet 5-6 times daily and for 58 percent women the toilet is within 10 yards of her

6 112 Nashid Kamal and Rumana Rashid house. Only 18 percent women threw their wastes in dustbins while the others used roadside, ponds, alleys etc. This compares to 21 percent dustbin users found by an earlier study in the slums of Bangladesh (Islam et. al:1997). Table 1 shows that in this study 35.6% women reported no RTI/STD symptoms in last one year, and 64.3 % reported some kind of symptom. This finding matches with other studies where laboratory examination of prevalence of RTI was found to be 56% (Hussain et. al: 1997) and 60% in another study (Chowdhury et. al: 1997). Among the symptoms, white discharge had the highest prevalence in this study (43.9%). This finding also matches other studies conducted in rural Bangladesh and India (Chowdhury et. al:1997; Sharmin et. al:1997; Patel et. al:1994). Lower abdominal pain and burning during urination were found to be the next most frequently reported symptoms in this study and matched earlier studies in Bangladesh (Sabin et. al:1997). Table 1 also shows that 39.5 % women are current users of modern contraception, which is quite close to the national figures of 41.6 % (Mitra et. al:1997). Only 21.5 % women have seen doctors for the reported RTI/STD symptoms in the last one year. Of them, 61 percent went to private hospitals and 17 percent went to local quacks. Field observations found that lack of funds was the most important reason for not seeking treatment. From this study it was found that on the average a woman spent Taka 172 for treatment of a RTI/STD symptom (SD2.75) for treatment of one symptom (data not presented here). Among the 14 slums under study, all had mosques, school and pharmacies nearby. All but one slum had market, NGO, health complex nearby and only one slum had gas connection. Almost 36 percent of the slums had no tap water, while 57.1 percent had no tubewell, and 21.4 percent slums had no electric connection. Fifty percent of the slums had hanging type of toilet and 42 percent of the slums had households. RESULTS Bivariate analysis found many variables to have significant association with self reported RTI/STD symptoms. Among individual variables age, education, occupation, duration of stay in city, house material, use of modern contraception, kind of toilet used, distance to toilet, number of households using the toilet and duration of menstruation were found to be significant at the 5 % level of significance. Among slum level variables: Family Planning sessions by NGOs, number of households with electricity, distance to health complex, gas and number of taps in the area were found to be significant in expected directions, more privileged people reporting fewer RTI/STD symptoms. Several variables showed significance at the bivariate level, these variables were then entered into the multilevel model. Principal component analysis (PCA) was used to condense socio-economic information. Possession of electricity in the household was found to be the most prominent socio-economic variable and was retained as such. Each variable, which was significant at the bivariate level (p=5%) was entered into the logistic regression model. Their contribution to the log- likelihood of the regression model was considered to be the criteria for retaining the variable in the model. Table 2

7 Environmental Risk Factors 113 Table 1: Distribution of women according to reproductive health characteristics in the urban slums of Dhaka, Bangladesh 1998 Variable Percent Percent with no symptoms Current use of contraception Pill Condom Injection IUD Female Sterilization Male Sterilization Others Non-User NA No. of RTI/STD SYMPTOMS* problems in last 1 year None One Two Three Four Five or more RTI/STD SYMPTOMS Problems in last one year** Lower abdominal pain White discharge Bloody discharge Vaginal itching Foul smelling yellow/green discharge Burning during urination Grey, sticky discharge Vaginitis Genital ulcers + fever Soft, painful boils in vagina or anus Frequent fever with shivers Painful coitus Genital warts No symptoms at all Pregnancy in last one year Yes No Problems during menstruation** None One problem Two problems Three or more problems Length of menstruation* 3 days More

8 Venue of treatment for RTI/STD SYMPTOMS Govt. hospital Private hospital Homeopath Kabiraj Others None *Reproductive Morbidity (RTI/STD SYMPTOMS) **Multiple responses presents the results of the final parsimonious model of logistic regression of prevalence of any self reported RTI/STD symptoms on other variables. The logistic regression results show that self reported RTI/STD symptoms in the last one year is correlated with two major environmental risk factors. Firstly, distance of the woman s household from the toilet and secondly the site of waste disposal. In this model, women who live more than 10 yards away from their respective toilets have higher probability of RTI/STD symptoms, compared to those living within 10 yards of the toilet. Table 2 Results of logistic regression of prevalence of RTI/STD symptoms on selected variables, urban slums of Dhaka, Bangladesh 98. Variable Odds Ratio Confidence Interval Fixed effects Constant Place of garbage disposal Other Dustbin Distance to toilet More than 10 yards Less than 10 yards Age of the woman 19 Less than 19 Random effects Between slums *p< * * * * The interaction term of frequency of toilet use and distance to toilet did not produce any significant variation in the model. It is possible that those women who live further away from the toilets practice higher retention of the urine and are more likely to

9 Environmental Risk Factors 115 report RTI/STD symptom. However, the exact nature of the inverse relationship between distance to toilet and self reported RTI/STD symptom could not be ascertained from this model. The site of garbage disposal was found to be a significant predictor of self reported RTI/STD symptom. The introduction of this variable into the model produced reduced variation between slums and also rendered the constant term insignificant. The log likelihood also diminished significantly after the introduction of this variable into the model, indicating that it was a significant covariate. In this model, those women who dispose off their garbage into places other than dustbins have higher probability of reporting RTI/STD symptoms. This variable may also be considered as a general indicator of health awareness of the woman. One who throws her waste into open spaces, ponds (other than dustbin) may well be less educated in health consciousness and civic life. The greater probability of these women to have RTI/STD symptoms and report them to the respondents could be linked with their lack of education An earlier study in India also found poor environmental conditions to be highly correlated with morbidity and mortality in the slums of Delhi (Bhatnagar et. al :1988). Another study looking at the influence of environmental factors on under-five morbidity found higher morbidity among children who practiced open field defecation (Agarwal and Katiyar:1981). The finding from this study supports the observation that environmental risk factors are associated with women s self reported RTI/STD symptoms. The demographic variable age of the woman was found to be a significant predictor of prevalence of RTI/STD symptoms. Younger women were less likely to have the symptoms compared to women aged between Similar observations were made by field workers in another study of RTI/STD clinic service improvement project in Bangladesh Bhuiya and Rob (1998). Another study in Bangladesh reported higher prevalence of RTIs among women aged In India, working in Karnataka, Bhatia and Cleland (1995) found women above 25 years had lower probabilities of reporting RTIs. The results from this study therefore matches those obtained for self reported ailment both in Bangladesh and India. None of the slum level variables considered here produced any significant variation in the model, nor was there any random variation caused by covariates included in this study. This means that the slum level variables considered in this study do not differ significantly between slums. However, the model found the level two variation (between slums) to be statistically significant, which means that there are differences in levels of RTI/STD symptoms between slums. This means that there are still differences between the slums which could not be explained by the slum level variables considered here. These differences may be due to other variables not considered here, or may be random ie not explainable.

10 116 Nashid Kamal and Rumana Rashid SLUM EFFECTS The estimates of the level two residuals w k can be used to predict `slum effects', that is the contextual effect of the slum in which the woman lives on her probability of reporting RTI/STD symptoms. Confidence intervals can be constructed for each slum-level residual to illustrate differences in prevalence of RTI/STD symptoms between slums. Goldstein and Healy (1995) have proposed a procedure for the construction of simultaneous confidence intervals to test for differences between any pair of slums where the significance level averaged over all possible pairs is equal to the required value. Simultaneous confidence intervals are determined such that any overlap at all suggests a non-significant difference between groups. If they do not overlap, the differences are statistically significant at the chosen level. To describe this approach briefly, suppose there are K independently normally distributed estimates of level-two residuals u j,, k=1,2,...,k with known standard errors σ k. Suppose we wish to compare a pair of slums k and l, with estimated residuals u k and u l respectively and standard errors σ k and σ l. The standard 95 percent confidence interval for the k th slum residual u k is given by u k ± 1.96σ k. The simultaneous 95 percent confidence interval is u k ± zσ k where z is selected so that the average significance level over all pairs of contrasts (k,l) is 5 percent. An approximation to z is the average of 1.96 σ kl /(σ k + σ l ) over all pairs of clusters (k,l), where σ 2 kl =Var(u k -u l )=σ 2 k +σ 2 l. If there are k clusters there are ½ K (K-1) possible pairwise contrasts. Therefore 2 σ kl z K(K -1) + σ k σ l Figure 2 Comparison of urban than as according to the prevalence of RTI/STD symptoms among women, according to model in Table 2, Dhaka, Bangladesh 98. Where k<l. The calculated value of z in this study is 1.42 for the model in Figure 2 shows the adjusted rankings of slums in this study according to their rates of prevalence of RTI/STD symptoms for each area with approximate 95 percent simultaneous confidence intervals for the slum effects. These probabilities have been calculated for each area while holding all other covariates at their average values. The adjusted rankings of the slums are almost identical to the raw rankings observed from the data (not presented in this paper). Figure 2 shows that the simultaneous confidence intervals overlap for most slums in this study with possible exception of Mirpur thana which has much lower probability of prevalence of RTI/STD symptoms. One possible reason explaining low prevalence of RTI/STD symptoms could be the fact that the NGOs working in this area are very active and from field observations, women here seemed more aware of reproductive health problems, compared to women from other urban slums in this study. Being so conscious, many unmarried women who are in sex trade, may have avoided speaking the truth, fearing the revelation of their active sexual life. The second cause may well be that having been so much aware, many women who live actually had not had such symptoms during the last one year, since the health related NGO has been active over a period of nearly 5 years.

11 Environmental Risk Factors 117 It is interesting to note that the second level variation was rendered insignificant when the Mirpur slum was removed from the model. Mirpur thana therefore contributed the lion share to the significant between-slum variation found in this study. It also indicates that in this study, save Mirpur slum, all other slums have similar levels of prevalence of RTI/STD symptoms. The overlapping confidence intervals for all but one area shows that the model has accounted for most of the level-two variation in this study and most slums are not significantly different from each other in their prevalence of self reported RTI/STD symptoms. However, there are slums in Dhaka city which have lower prevalence of RTI/STD symptoms compared to others. Fig. 2: Estimated Probabilities of Self Reported RTI/STD Symptoms among Women in the Urban Slums of Dhaka, Bangladesh % 80% 70% 60% 50% 40% Low Medium High 30% 20% 10% 0% thana DISCUSSION AND CONCLUSIONS This study supports the belief that unhealthy living conditions and inadequate sanitary facilities in the urban slums have negative effects on womens reproductive health viz. prevalence of RTI/STDs. Low income and inadequate community level characteristics influence the prevalence of RTI/STDs through intermediate variables such as garbage disposal habits and distance to toilet. The study also finds that most slums have similar probabilities of reporting RTI/STD symptoms, although there are some slums where the prevalence is significantly low. This study reconfirms that improving

12 118 Nashid Kamal and Rumana Rashid health of the population in the urban slums in general is a multi-sectoral approach (Walt and Vaughan:1982). The Bangladesh government s investment in urban development accounts for a small proportion of the total planned investment outlays (Asfar:2000). Since 1973 it has also followed a declining pattern resulting to three percent in 1995 from six percent in Additionally, there is no budgetary allocation for urban poverty alleviation by the central government and the City Corporations also give very little priority to this agenda. This has been reflected in the fractional allocation of a mere 0.16% of the total budget of the DCC (ibid). From 1998 to 2002 one project funded jointly by the Asian Development Bank, United Nations Fund for Population Activities, Nordic Development Fund and Government of Bangladesh has been operational in Bangladesh. This project was titled Urban Primary Health Care Project (UPHCP) and covered four city corporations of Bangladesh Dhaka, Chittagong, Khulna and Rajshahi (Hussain,2002). The most important objective of this programme was the improvement of the health of the urban poor and vulnerable population and aimed to reduce preventable mortality and morbidity, specially among the poor women and children as a priority. Some of the evaluation studies showed that although the project had very successful use rates, Dhaka City corporation has been lagging behind in all indicators indicating that much more needs to be done in creating awareness and building up motivation ( ibid). In view of the existing facilities as discussed above, the first recommendation from this study would be to increase budgetary allocation of the DCC in order to alleviate the sufferings of the urban poor. This would include improved means of waste disposal as well as increased input into slum development in general. The Bangladesh government has tried to discourage urban slums and squatters by just demolishing them with bulldozers. According to Asfar (2000) the growth of Dhaka city is a reality and needs `accomodationist or integrationalist measures. Some of the NGOs have practiced these measures by community upgrading projects in the existing location. Among them are the Tondo project of the Phillipines, FSVM project of El Salvador and Urban Community Development Organization of Thailand (Lacquain:1981). Under these projects, basic services such as water, sewerage connections, electricity, garbage collection, schools, health clinics were extended to the urban poor. In Bangladesh, the Slum Improvement Project (SIP) which was initiated with the financial support of the UNICEF in some municipal areas of Bangladesh may be models for future ventures. Small NGOs such as Waste Concern have been active in manufacturing compost from the organic portion of solid waste from all households of one of the administrative wards of the DCC. This employs active participation of the community including women and children and may be replicated in other wards, as well as other cities of Bangladesh (Sinha:1998). A recent proposal has been made by an industrial firm which proposes to produce electricity from the solid wastes of the Dhaka city (Daily Star: July 18 02). This may be looked into in detail and slum children maybe mobilized to collect solid wastes and provide it to such industrial ventures as input in lieu of some monetary compensation.

13 Environmental Risk Factors 119 One limitation of this study was that the investigators were non-medics. Symptoms may have been mis-classified, however this will not effect the final analysis where symptoms have been considered in totality, and no attempt is made to diagnose the disease from the symptoms. Another limitation is the method of self-reporting, where women may have exaggerated or hidden their symptoms. However, one study in Bangladesh using patients from two urban clinics found 23% of the clients presenting to the clinic had RTI/STDs (Begum and Reza:1997). Out of this 23%, 21% was self reported and based on which the present study may be considered reliable. The results from this study may be extended to India (Chhabra:1994) and other developing countries where the slum population live without proper sanitary latrines in overcrowded areas, and where waste disposal does not receive adequate attention by the authorities. In fact, in a news item telecast on Television by the British Broadcasting Service (BBC,2002) it was mentioned that lack of toilets for women in the urban slums of Bombay has led to various health problems for the women. The women interviewed on the screen mentioned how they took very little liquids for fear of frequent urination, they used the conveniences in the small hours of the morning and suffered the consequences of low liquid intake in their diet. Unhealthy and unhygienic living conditions can cause poor reproductive health, which in turn may ruin the chances of the entire family from a healthy living. In order to ensure proper reproductive health for women in these areas, preventive measures in the form of cleaner premises and adequate sanitary facilities should be considered with urgency. Health awareness mass-media campaigns should be held to sensitize women on the negative effects of unhygienic health practice, including garbage disposal. People s participatory group activities where the beneficiaries themselves will be responsible for maintaining cleaner premises may be introduced following successful models in other parts of the world (Brasileiro et. al: 1982). Establishing health clinics alone may not be adequate measures to ensure better reproductive health among women living in the urban slums, improved environmental conditions should receive priority. Community based distribution projects similar to the PROFAMILIA in Latin America (Forum:1994) may also be replicated to ensure best results in reducing gynecological morbidity among women in the urban slums of developing countries. Above all, the slum dwellers must be made to realize that `prevention is better than cure. NOTE * The authors express their gratitude to the UNFPA for funding this research. REFERENCES Afsar, R. (2000) Rural Urban Migration in Bangladesh The University Press Limited, Bangladesh. Agarwal, D. K. and Katiyar, G. P. (1981), Influence of environmental factors on underfive morbidity, Indian Pediatrics, Vol. 18, No 8, pp

14 120 Nashid Kamal and Rumana Rashid Begum,H.A. and Reza, R. (1997), Patterns of RTI/STD Diseases in Two Urban Clinics of Dhaka Paper presented in the Sixth Annual Scientific Conference (ASCON VI), International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B).Dhaka, Bangladesh: March 8-9. Bhatia, J. C. and Cleland, J. (1995), Self reported Symptoms of Gynecological Morbidity and Their Treatment in South India, Studies in Family Planning, Vol. 26, No 4, pp Bhatnagar, S.; Dosajh,U and Kapoor,S. D. (1988)Correlates of morbidity and patterns of mortality in urban slums of Delhi: Part I Health and Population: Perspectives and issues, Vol 11, No. 2, pp Bhuiya, I. and Rob,U. (1998), Srengthening RTI/STD Services in FP-MCH Program. Population Council, Dhaka, Bangladesh. Brasileiro,A.M.; Giffin,K.; Shluger,E.; Ungaretti,M.A. (1982, Extending municipal services by building on local initiatives: a project in the favelas of Rio de Janeiro, Assignment Children,pp Chhabra,S. (1994), Reproductive health care services :letter. National Medical Journal of India. Vol 7, No. 6 : Chowdhury,S. A.; Uddin,Z. and Ali, D.(1997), Breaking the Silence. Paper presented in the Sixth Annual Scientific Conference (ASCON VI), International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B).Dhaka, Bangladesh: March 8-9. Chowdhury, S.N.M.; Ahmed, Y.H.; Karin, E. and Masum, A.E. (1995), A study to determine reproductive tract infections among health care users of a Bangladesh Women s Health Coalition Clinic. BWHC, Bangladesh. CUS (1996), The Urban Poor in Bangladesh, Comprehensive summary Report, Vol.1.Dhaka:Centre for Urban Studies Forum (1994), The first 40 years Vol.10, No. 1, pp Goldstein,H. and Healy, M.J.R. (1995), The graphical presentation of collection of means, Journal of the Royal Statistical Society, A,158 pp Hoque, B.A. ; Ahmed, S.A.; Arifeen, S. E.; Al Mahmud, A.; Saha, S.N.; Sack, R.B. and Shahid, N. (1997), Impacts of Integrated Water-Sanitation Programme on Hussain, Z. (2002) personal communication, Dr. A.M. Zakir Hussain, Team Leader and Partnership Agreement Specialist, Urban Primary Health Care Project, Ministry of Local Government, Rural Development & Cooperatives, Govt. of Bangladesh. Hygiene and Health: A Case Study from Bangladesh. Paper presented in the Sixth Annual Scientific Conference (ASCON VI), International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B).Dhaka, Bangladesh: March 8-9. Islam,N. (1996),Sustainability issues in Urban Housing in a Low Income Country: Bangladesh, Habitat International, Vol 20, No.3. Huda, N.; Narayan, F. B. and Rana, P.B. (1997), Addressing the Urban Poverty Agenda in Bangladesh Published for the Asian Development Bank. The University Press Limited.

15 Jamil, K. Baqui, A. H. and Paljor, N. (1993), Knowledge and practice of contraception in Dhaka urban slums: a baseline survey, Urban FP/MCH working paper No.3 ICDDR,B No 31. Lacquain,A. (1981), A review and Evaluation of Urban Accomodationist policies in Population Redistribution in Population Distribution Policies in Development Environmental Risk Factors 121 Planning papers of the UN/UNFPA Workshop on Population Distribution Policies in Developing Planning, Bangkok,13-14 September, 1999,New York, UN. Merkle, F.and Knobluch,U. (1995) A decade of GTZ s experience in urban health in urban health in developing countries:progress and prospects, eds. Harpham, T. and Tanner, M. London, England, Earthscan Publications pp Mitra,S.N., Sabir,A.A., Cross, A. R and Jamil,K. (1997), Bangladesh Demographic and Health Survey Dhaka and Calverton, Maryland:National Instiute of Population Research and Training (NIPORT), Mitra and Associates, and Macro International Inc.:50. Myaux, J.;Chakraborty, J. and Ali, M. (1997) Monitoring of Diarrhoeal diseases by Spatial Analysis and Exploration of Environmental Factors. Paper presented in the Sixth Annual Scientific Conference (ASCON VI), International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B).Dhaka, Bangladesh: March 8-9. Patel,B.C.;Barge,S.; Kolhe,R. and Sadhwani,H. (1994) `Listening to women talk about their reproductive health problems in the urban slums and rural areas of Baroda.In Listening to women talk about their health: issues and evidence from India, eds. Gittelsohn,J.;Bentley,M.E.; Landman,L.T. New Delhi, India Har-Anand Publications pp Sabin, K.; Hawkes, S; Rahman, M.; Ahsan, K.;Begum,L.; Arifeen, S. E. and Baqui, A. H.(1997).Barriers to seeking treatment for Sexually Transmitted Diseases among the Dhaka Congested areas Dwellers. Paper presented in the Sixth Annual Scientific Conference (ASCON VI), International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B).Dhaka, Bangladesh: March 8-9. Sharmin,T. Nahar,K. Alam, A. M.;Pelto,B. and Ross, J. (1997), Cultural Model of White Discharge Among Rural Matlab Women. Paper presented in the Sixth Annual Scientific Conference (ASCON VI), International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B).Dhaka, Bangladesh: March 8-9. Sinha, M. (1998), Community Based Solid Waste Management : Experience of Waste Concern A Paper presented in the Dhaka City Management Reform workshop, March, BRAC Center, Dhaka. United Nations (1993), World Urbanization Prospect : The 1992 Revision, New York: United Nations. Walt,G. and Vaughan,P. (1982), Primary health care: what does it mean? Tropical Doctor, Vol. 12, No. 3, pp

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