 Good afternoon and thank you very much for having me here today. My name is Jeroen as already very well pronounced and together with Nell Gray from the Manson unit in London We have conducted a qualitative study to better understand the health perceptions and health-seeking behavior of communities living in Camrangachar and Hazari back in Dhaka Bangladesh Our study is titled working to stay healthy. I Will take you through our study in the following four steps first I will explain a little bit more about the background and the study context Followed by the methodology study findings and finding the conclusion and the results of the implementation This study has been conducted in the south of Dhaka in Camrangachar and in Hazari back marked red in the enlargement Combined they are the biggest slum area of Bangladesh Approximately 500,000 people live here on six square kilometers. That's 80,000 people per square kilometer in comparison here to Delhi It's approximately 25,000 people per square kilometer. So you can imagine how busy and how crowded this area is Most of the labor here is done in the semi formal industries of leather plastic garments and metals This area specifically has area back in the top red Where most of Bangladesh's leather production takes place is one of the most polluted places on the planet the fifth most Polluted place on the planet actually in 2013 MSF OCA started an urban health care program To respond to the needs of this community resulting in an occupational health program For male and female and a sexual and reproductive health program for women between the age of 13 to 18 years old At the time of this study The program run six One main clinic and six satellite clinics currently they chose a more centralized setup and the three marked in red They are still remaining So rapid urbanization in middle and low-income countries have resulted in a rapid growth of informal settings Big cities have difficulties handling the influx of these of these uncontrolled growths In Dhaka is estimated that the current 15 million people living there now will expand to 23 million over the coming eight years Working in these rapidly expanding and constantly changing settings is uncharted territory for MSF and this came with a lot of questions and uncertainties Run in the program and was realized that in contrast to the expectations the number of patients visiting the clinic was low despite the high population density and poor economic situation The question rose why there was no bigger uptake in this free services This study is focused on better understanding The way health is perceived and placed in the social economic setting of this community and to answer The answers of this study will help the program to tailor the services better to the needs of the community This study was conducted amongst 40 patients in three groups factory workers Women in the age of 13 to 49 and key stakeholders in the community such as health workers imams and doctors To enhance the credibility of our sample We used purpose if maximum variation sampling and divided the number of interviews over the four areas that I mentioned earlier In this study we've used participant led interviews based on the topic guide because the study was Conducted by two researchers and cultural gender sensitivity did not allow for interviews to be conducted by the opposite sex We needed to ensure that there was internal validity between the interviewers for this we use obviously the topic guide and we had a constant feedback loop between me and Nell the second researcher in this study as this study is a qualitative study in a better unique setting Only the concepts of this study can be further generalized However, this study itself can be used in comparison to similar settings or similar studies a Limitation to our study was that we encountered that a high percentage of the population was factory workers Which created a false division between the group women and factory workers Even though at the start of each interview we made clear to what group they belonged We still had significant overlap due to self prioritization of issues For this study we obtained ethical approval from both MSF and the local board So on to the study findings our study Shows three main themes, which I will explain in further detail in the coming slides first of all health is seen as an asset to sustain a person or a family's social economic position Secondly contextual factors and barriers have a major influence on the decisions being taken and Lastly in a fragmented health care system that is experienced in this area Informal networks are the most reliable source for search of qualitative care So on to finding one First of all people feel a strong responsibility To remain healthy obviously we all do But in this setting it was the social economic limitations That was the single most persuasive determinant for health seeking behavior It was experienced. I'm sorry Health care decisions were made in many cases a family decision Especially when it came to women The family took a collective decision and often this was linked to the financial implication Many workers in this area work over 60 hours a week hardly earning enough to make ends meet Therefore They lack the freedom To take the necessary measures to maintain their health This status quo however is accepted in this community earning money is prioritized and health is reduced To an asset or a tool for this purpose in this context Time is money So if self-care meaning taking extra vitamins rest or extra food did not quickly result in improvement of the symptoms The first step taken was to visit a local pharmacy Local pharmacies are available on every corner of the Streets in come running a chart here. They were searching for a quick solution for their symptoms Such actions have been proven to have a negative impact On the health of this and other low-income urban areas At the same time our study shows a level of mistress and war wariness The pharmacy drugs were seen as a temporary relief curing symptoms not causes and people are very aware of the risk of over medicating The motivation of their actions resulted from the commodification of functional health as I mentioned before to maintain the family's economic position Decisions made were closely linked to the self or socially attributed seriousness of a disease Sorry experience symptoms not a disease yet when pharmacies when the pharmacy treatments are ineffective Or when symptoms were unknown or the ability to work was tampered The symptoms were seen as serious enough to consider Seeking qualitative care in the form of a hospital visit or a qualified doctor But once they went beyond the pharmacy Healthcare was characterized as a fragmented landscape of partial services of which many many were poorly regulated and varying in quality of care This in combination with inadequate Secondary and tertiary care rule out a comprehensive health care system for this community The limited knowledge that came with this in a highly fragmented and unregulated health care system creates a constant Uncertainty on the availability and the quality of care for this community People consulted different providers offering quick succession often resulting in different diagnosis and incomplete treatments In this context former health advice and support is poor choices informed by previous experience Recommendations of their own networks and other care providers Well, there's little evidence of information flows in urban slum communities Word of mouth seems to be the most important source of information for qualitative care for this community However, in some cases this obviously also resulted in Contradicting suggestions leading to further frustration by not getting the care that you seek in conclusion Improving health in this complex setting Demands a health system that includes a comprehensive health care model Tailor to the rapid needs and effective treatment for this community This seems obviously logical as that would be in every setting However, in this specific setting in doing so there should be an emphasis on encouraging trust between the health care provider and the community and thirdly Community-based mechanisms within emphasis on health education will expand information and services Information services flows particularly to the most vulnerable groups people in this community Based on our study a number of recommendations have been made to the project and the project has implemented these first of all they have Improved the access to our services They're collaborating with factory owners to ensure attendance during worker hours are possible and they Extended the opening hours of the clinic so people can also attend after work time, which was a big problem Um Besides that's for the SRH pillar for women the age limit went up from 18 to 25 to serve a broader group of women in this community Further they worked on sensitizing the staff and outreach workers on the importance of the relationship with the community and on building trust and Lastly they're looking into the possibility of using word-of-mouth communication to spread health messages deeper into the community Finally, I would like to extend a special thanks to Sabir, Ardiba, Fatima and the whole Camaranguichar team And to our translators for their support to this study Thank you very much. Oh right away. There's a question right there Hello, Jean-François from MSF Brazil. I was just wondering if in the interviews came about alternative therapeutic options and Health thinking behaviors such as traditional spiritual Personal yes, it did came it did come up But it was marginal They saw alternative health care, but for very specific Diseases John these sorry. I'm not a medic That was that was one that came up most for the alternative healers, but people realized they actually mentioned that They thought this was the better type of health care, but it took too long and they needed a quicker solution So that's why they went to pharmacies or beyond to a doctor Does that answer the question? Yes What these recommendations Implement these recommendations and did you see an increase in patient flow? Yes. Oh, I forgot to mention it at the last slide We actually I got confirmation from the project that they saw a significant increase of patients Visiting the clinics, so it has helped so I Hope this was the reason but yeah Thank you a very important query. I have was the issue of mental health covered Awareness, thank you Well, it was a self prioritized interviews In cases, obviously it came up, but it was not It was not that didn't come forward as one of our main results. Obviously people Deal with a lot of mental and physical problems in these areas, so yes It did come up That answers the question Before we go to the next session, I have a comment. I think it's a oh there is a Did you a part? Myself in Faisal, I just want to have one thing that for the health thinking behavior Which was the best at committee engagement strategy which was used in the part of the Bangladesh Best strategy committee engagement strategy Well, they're looking into well, they obviously have an outreach team that goes into the community with the health message We now We found in our study that the word of mouth is a very important tool and trust is a very important element in that people Tend to doubt the health workers Since they were not the only health workers in this community There were other groups active that also spread a health message and there were also group groups active that went by doors to sell medicine So there was also a mistrust towards our outreach workers. That's why we advise to use the word of mouth Tool to get this message through key stakeholders in the community towards a broader group Okay, thank you Hello, I'm Mitchell. I'm the medical coordinator for MS submission in Bangladesh So perhaps I can add more on the some of the question and clarifications Regarding the outreach questions. We have a huge network of outreach workers So they are out in the community. So what they do is like they go house to house Give more information about our specific Services which is available in our clinic, which is the services for the occupational health services for that lesson sexual and reproductive Health and also the SGPV program and we also engage schools. We engage college We have a peer educations group where we invite the adolescents to come and have those health education sessions So I hope that answers your question