Health conceptions among adolescents of a Bangladeshi rural population

Objective: This study was aimed at understanding adolescents’ conceptions regarding health. Methodology: This was an empirical study conducted applying qualitative methods in a village at Sylhet district in the northeastern region of Bangladesh. Data were collected through in-depth interviews and Focus Group Discussions (FGDs). Result: Most of the adolescents did not have clear conception about the meaning of the term “Health” in term of WHO’s definition. They emphasized that the appearance of body structure is the indicator of health. They divided human body into two parts; inner and outer. The flesh and intestine are covered by skin. Soul is considered as the internal part of body. Respondents explained that female body as less strong than male and female become easily infected. Few adolescents believed health as state of disease free condition. Conclusion: This study revealed that adolescents have diversified thinking on health which demands to provide special attention for improving their understanding on health.

1 absence of disease or infirmity . Similarly, WHO also defines adolescence as the period of life between ages 10 and 19 years. Bangladesh health policy has included these definitions of health and 2 adolescence . Adolescence is a stage of development transition i.e. a bridge between childhood and adulthood. This stage usually develops gradually without proper attention, especially in the developing countries. Adolescent health is a new sphere of thinking and a strong agenda in the health and population sector strategy (HPSS) of Bangladesh. All health and family planning service providers in public sector in Bangladesh are engaged in the delivery of adolescent health services as a sub-component of reproduc- 3 tive health care . Only a minor segment of married adolescent girls get maternal care and family health services. Unmarried adolescents usually do not avail the opportunity of access to health care of any kind. Enough work on adolescent health education is yet to come. Adolescents are a potential resource for the country but the health situation of adolescents indicates that it is not satisfactory.
Adolescent health has been recognized as a priority in Bangladesh. Our government is allocating funds for improving adolescent health. Collaborating agencies and donors are also giving importance to this issue. UNICEF, UNPA and WHO are the frontrunners in helping the government to formulate adolescent health. Muti-sectoral co-ordination between various sectors e.g. education, labor, law and Justice, youth and social affairs is underway to achieve the goal for improving the adolescent health. NGOs are 3 also working in this sector .
Adolescents in Bangladesh, both male and female, constitute about quarter of the total population. The adolescent populations categorized by those between ages 10 and 19 years constitute about 23 percent of total population in Bangladesh. About 48 percent of them are females and 52 Percent are 3 males .
The main rationale of this study was to investigate how the adolescents opined on health. And, this investigation will help us to make a future direction for improving adolescent health status.

Materials and Methods
A focused qualitative study was conducted among adolescents in a village in Sylhet district, the northeast part of Bangladesh, to broaden understanding of adolescents' conceptions on health. The respondents were purposively selected the adolescents (ages between10 and 19 years) from the study village including a known diversity of socio-demographic backgrounds (Table I).
A total of 59 adolescents were interviewed. Among them, we conducted in-depth interview with 10 males and 10 females. We also conducted 4 FGDs among 2 groups of male having 10 and 9 participants and 2 groups of female having 10 members in each.
An open-ended interview guideline was used to explore conceptions of adolescents regarding health, body, skin, blood and function of body. Participants and their guardians, especially father of the adolescent, provided verbal permission which was taperecorded, at the beginning of interview questions. There had been sought permission from father of adolescent, as in other South Asian countries, Bangladeshi men are conventionally considered the 4 breadwinners and the guardians of the family . Each adolescent and his/her guardian were informed of the objectives and purpose of the study and the data collection methods, including the use of a tape recorder and intimate nature of interview questions. Participants were informed they had the right to stop the interview at any time without any obligation, that they could refuse to answer any question and that all information was confidential. Interviews were conducted in a place within their households chosen by the participants. Tape recorded interviews were transcribed. Data analysis was manually performed 5,6 using content, contextual and thematic analysis .

Results
Health is meant in Bengali meaning and the respondents voices " Shashtya.'' This term was carried various meaning by the adolescents in generally their conceptions on health. Adolescents emphasized body images considering health. They didn't separate health from body images. They divided human body into two parts-inner and outer part.
Body image i.e., conceptions on body identifying important organ, their location, and function (etc) influenced health and health seeking behaviors. Adolescents reported that skin covered the parts of whole body. This statement emphasized the outer organisms only. The flesh and intestine is covered by skin. According to the respondents, body was not merely the internal organism of body but internal organs also. On the other hand, the people have suppurated soul from the internal parts of body. They opined that soul was another matter rather than body. One adolescent expressed his opinion regarding soul: "Without soul, body is dead. A dead body has all the parts both internal and external, but it is mora manush'(dead body )'' They also thought that dil (heart) is the control ruler of the whole body. In the activities of any organ of inner part might do inactive the whole body. The outer parts likes hand, eye, foot are the visual expression of the actives of inner part. Working of eyes, hands, walking on feet, feeling of skin etc. prove that body is active, otherwise not. One of the adolescent stated:

"Dom neya-doya (breathing of heart) is the first symbol of life and life in the body."
The adolescents reported that body is the combination of blood and flesh. They did not separate between internal and external part, organs of body. They thought that blood and flesh indirectly cause of Most of the adolescents mentioned opinion was' blood is an element of body that provides energy'. Some female adolescents described that blood is essential for body but the main function of body is to provide energy in the whole internal organ of the body. They also believed that if one person set on a chair at any particular side for a long hours, his/ her foot became inactive i.e., effected by dizzies or buzzing. It is happened circulating blood from one place to another, body i.e, the various organs became strength. Thus blood provided energy to the various parts of body. But, blood is not just hand or foot, according to them more than one part of body. Blood is the sources of energy, and according to them blood had another most valuable function i.e. one drop of semen is formed by 80 drops of blood. And semen is the most common symbol of manly.
Two of adolescents reported that much blood is the cause of blood pressure. Blood is considered here as a balance factor between body and health as well as health and illness. Obesity was the result of over blood. Every person is unique in terms of health, body and blood. Each body is required certain quality of blood. Over eating is the cause of much blood. Blood is a liquid form of food. They compared between the eye diseases and over blood. Eye dis-ease can be cured by providing vitamin but excess of blood could not be reduced easily. Much blood is the cause of obesity and more risk of death.
All adolescents thought 'being male and female is the desire of Allah'. The statement is expressed the Muslim religion beliefs as all respondents were Muslim. Some male adolescents marked male and female body in term of importance. Female body was less strong than male. Their blood is also different. As being less strong than male body, female have been infected by diseases easily. As for their weak physical structure female were selected for household works. Household's works were easier than out side works where male works. 0ne male adolescent expressed different opinion regarding male and female works: " I have been seeing my father and grandfather not to be engaged at household works. And I have been seeing since choto bela (childhood). And my mother, grandmother is engaged in household activities. Thus I have realized that their working area is different". Few adolescents imagined health as free from diseases.

Discussion
This study finding showed that adolescents had various conceptions on health. These conceptions differ from the definition of health by WHO. Adolescents opined their personal views on health. Their views included health appearance and the performance of activities whereas the definition of health from WHO included physical and mental aspect of health.
Bangladesh government followed the definition of health provided by WHO. Health policy of Bangladesh government indicates that health education especially for adolescent emphasized on reproductive health. A great number of adolescent especially male adolescents were excluded from health education. On the other hand, health is not meant only reproductive health and rather it is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. Furthermore, WHO's health definition has been included in the introduction chapter of health policy in Bangladesh 7-8 but there is no clear policy or indication for implementing this definition in the context of Bangladesh.

Conclusion:
This study revealed that adolescents have diversified thinking on health which demands to provide special attention for improving their understanding on health that suggests conducting large scale and diversified study to conclusively comment on the issue. To improve adolescent's conception of health, WHO's definition of health can be included in the curriculum of school and Madrasa. Moreover, movies and drama's depicting conception on adolescent health can be aired to introduce the health issues.