College students, in pursuit of sexual and reproductive health SRH information, are particularly affected by gatekeeping as strong social and cultural norms restrict their access to information and services. This paper examines mobile phone usage for obtaining health information in Mirzapur, Bangladesh.
Methods This study relies on two surveys: Select focus group discussions and in-depth interviews were undertaken with students. They are interested in health information and use phones and computers to access information. Moreover, they use digital technology to share previously-discreet information, adding value to that information and bypassing former gatekeepers. But access to health information is not entirely unfettered, affecting male and female students differently, and powerful gatekeepers, both old and new, can still control sources of information.
Conclusion Personal searches for SRH and the resultant online information shared through discrete, personal face-to-face discussions has some potential to challenge social norms. This is particularly so for women students, as sharing information may enable them to bypass gatekeepers and make decisions about reproduction. This suggests that digital health information seeking may be exercising a disruptive effect within the health sector.
Background Innovations in Information and Communications Technologies ICTs , and especially mobile health, have been predicted to transform provider-patient relationships through the dissemination of health information, and by encouraging patient autonomy, self-management, and self-care [ 16 ]. Physicians and other health providers also determine, and control access to, health care and treatment [ 16 ]. Health professionals thus serve a critical gatekeeping function.
As health system intermediaries, they are particularly powerful, deciding on the flow of health resources materials, medicines and information and on what information is shared with patients.
Bloom et al. This broader view of health includes all actors, both formal and informal, who provide expert health information. It thus draws attention to the wide range of health information and services which are also provided through markets, and incorporates analysis of economic and socio-political interests which underlie the different actors and institutions constituting the health knowledge economy. It furthermore emphasises health systems as concerned, not just with ill-health and disease, but with all activities that facilitate, restore and preserve health [ 13 ].
A biomedical understanding of health and health information seeking does not necessarily highlight the emotional and other sexual health issues that college students are exploring such as anxiety about or duration of sexual intimacy , nor does it address their lifestyle choices which impact on health diet, fitness, skincare etc. It also overlooks exposure to pornography in a range of sites local magazines, imported videos. In this paper, health information refers to anything relating to the body and its wellbeing.
College students, as young adults in pursuit of sexual and reproductive health SRH information, encounter health system — and other — gatekeepers who control access to information [ 34 , 54 ]. In Bangladesh, a culture of silence surrounds sexual relationships for unmarried young people, including college students, which means that many are hesitant to seek care even from health care providers.
If they do decide to do this, the process is long and anxiety-filled [ 49 ]. This silence, and lack of health information, affects both young men and young women. Moreover, health professionals are not the only ones who perform a gatekeeping function. Teachers, parents, family members, older siblings and other community members may have access to information and resources which can be shared or withheld.
They, like formal health gatekeepers, are influenced by a range of socio-economic and cultural factors, and use information and resources to promote or discourage particular behaviours [ 34 ]. This expertise, coupled with their status in society, enables them to exercise power and to provide or deny access to health services and resources based on a combination of personal knowledge, conservatism, resistance to changing cultural values, self-interest and finances. In keeping with this, male college students have been identified as those most likely to engage with digital technology [ 24 , 35 , 46 ], Footnote 1 although as Hilbert [ 27 ] and Antonio and Tuffley [ 6 ] point out, when females do use internet technology, a range of benefits become possible.
ICTs — particularly laptops and mobile phones with internet access — challenge existing forms of gatekeeping. Little attention has however been paid to the ways in which Facebook, or other service providers, facilitate discussions about health and health information dissemination and whether this differs for men and women college students. This vision suggests that people such as these college students, should be able to use digital technology to access medical and health information, unfiltered by both formal and informal gatekeeping.
In promising to bypass gatekeepers, mobile phones and other digital technologies may both echo and facilitate the liberating potential of medicine such as pills, injections, solutions. These medicines — which are increasingly available over-the-counter in private pharmacies and unlicensed facilities — become things which embody the power and skill of medical specialists, through their highly-technological, curative, portable and saleable properties.
This liberatory potential and the opening up of previously-controlled information, Eysenbach [ 17 ] hypothesises, will mean that traditional health system intermediaries and other gatekeepers are being superseded. However, users will still have to find ways of navigating the vast amount of information available to them through digital technology.
These new mediators, or apomediators, use digital technology to become educated about a particular subject, and then share this knowledge with peers as and when relevant [ 18 , 37 ].
In so doing, this may have the potential to restructure health systems [ 16 , 37 ]. Positive health system innovation extends beyond the public provision of health information through technology and the elimination of those gatekeepers whose access to knowledge and resources inhibits healthy and informed choices.
The information provided has to be appropriate and any corresponding treatment efficacious. Health systems must retain the capacity to manage public health, while bearing in mind broader public goods and positive externalities that result from health system delivery. They need to accredit and regulate professional behaviour and ensure that medical providers, who may have their own prejudices and biases, do not exploit unequal power relations [ 12 ].
This includes being aware of the ways in which digital technology opens up a world of readily-available health information, and of how processes of disintermediation and apomediation may change health information seeking in ways that impact on health service delivery. Digital health in Bangladesh In Bangladesh, the health system comprises a complex mix of formal government and private facilities and a large and diverse range of informal providers, resulting in a range of experts and intermediaries [ 2 , 26 , 42 ].
The Bangladesh government has embraced the innovative potential of ICTs in the health sector, providing new ways of accessing health information and potential health benefits [ 5 ]; Batchelor, et al. Mobile phones — and particularly bulk SMS messaging — have been used to disseminate health information since [ 20 ]; informing people about health promotion events such as national immunisation days [ 33 ].
Mobile phones and internet use, particularly Facebook, have become increasingly widespread in Bangladesh [ 1 , 55 ] allowing people to search for health information. Research has not, however, explored the ways in which young Bangladeshi college students use service providers, such as Facebook, for health information seeking or whether this differs for male and female students. There were million mobile subscriptions in Bangladesh in [ 29 ].
This is roughly twice the number of unique subscribers as the GSMA reports 67 million unique subscribers in [ 23 ]. In , Grameen phone reported five million active Facebook users [ 23 ]. That same year, Facebook launched Internet. Some bundles, designed to introduce and encourage social networking and online chatting, or to provide short-term access to Facebook, Whatsapp and Twitter, can be extremely cheap.
Footnote 2 Bundles for extensive phone, SMS and internet usage are more expensive. Footnote 3 Many health initiatives rely on mobile phones [ 3 , 4 , 8 ] and commonly target community health workers, Footnote 4 government health supervisors and managerial personnel, clinical health care providers, and women. Mobile phone access to the internet occurs alongside online advertising through social media for products such as vitamin tablets, saline solutions, pain-killers and products with less obvious health benefits to increase hair growth, beauty products, skin lighteners or diet tablets.
This is the context in which college students experience and encounter general health information. This paper contrasts their experience of mobile phones and health information with that of the general population in Mirzapur in order to explore innovation in health systems and asks whether college students in Mirzapur, Bangladesh are using digital technologies for health information in gendered and innovative ways. It covers an area of about km2 and had, in , a population of just over , [ 40 ].
Methods This study draws on data from two questionnaire surveys undertaken in Mirzapur by this research team. The first survey, undertaken between October and February , drew a random sample of households from the general population.
Hereafter this is referred to as the General Survey. A second survey, referred to as the Student Survey, examined health information seeking and behavioural change among college students in Mirzapur. Footnote 7 The colleges are similar in terms of student numbers, both are government institutions which offer university-level education from Higher Secondary School Certificate up to Masters-level degrees and both are easily accessible by road.
The survey was designed to select approximately equal numbers of men and women. Trained enumerators spent time at the colleges, recruiting survey respondents using a combination of non-probability sampling Footnote 8 approaches based on convenience and snowballing. While it left open the definition of health, it offered a biomedical definition of a serious health condition going to a hospital or using medicine for several months. This implied — and was interpreted to mean — a formal domain of health-seeking rather than more informal, personal notions of health.
In the Student Survey, building on the results of the General Survey, we asked about both health and sexual health. The surveys were complemented by four focus group discussions two with women students and two with men , and in-depth interviews with college students ten male and ten female , identified by the colleges as being good with smartphones.
Men were interviewed by a male interviewer and women by a female. Students were asked to decide where the interview should take place. Many of the men opted to come to Kumudini Hospital where we were staying , while most women students chose their homes.
When interviewing women students, we were allowed to go into their bedrooms, but always the door was left open and senior women loitered outside. For these interviews, we identified students who owned smart phones as we felt they were the most likely users of mHealth. Interviews were translated and transcribed, before being coded according to key terms and analysed by themes. Ethical clearance was obtained from the Ethical Review Board of Icddr,b.
For in-depth interviews, informed written consent was obtained from the participants. For the focus group discussions and surveys, verbal consent was taken before commencing with the discussion. One limitation of this study lies in the design of the general population survey questionnaires, which did not ask about sexual health and which implied biomedical notions of health and ill-health, rather than personal notions of health. Results This section compares mobile phone ownership amongst college students with mobile phone ownership amongst the general population of Mirzapur.
It then explores the degree to which college students are interested in health information, whether they are more likely to use their phones to access health information and the extent to which such use is gendered. Ownership among youth in the general population is not much higher than among the Mirzapur general population, suggesting that higher ownership among the student sample is linked to factors other than simply age.
I would have spent time on it I would have received phone calls, and attending to those calls would have been time consuming Also I am girl Similarly, Poly owned a phone, but her family did not allow her to use it until after her exams. Even when young women owned phones and were allowed to use them, they tended to leave them at home and, when asked, gave the socially-approved response that mobile phones were frivolous whereas they were hard-working students.
Although internet use was higher among youth from the general population than among the entire sample, Footnote 10 it is still well below usage rates among the student sample, suggesting that age alone does not account for differences in internet use between the two samples.
In the survey, most students Initially they played games, and downloaded music and videos. Their colleges also used the internet to communicate with them. Facebook discussed in more detail below is also a popular form of internet use. In Bangladesh, Facebook is necessary for college study activities as class schedules are posted here and it also offers newsfeeds, a source of jokes or other topics of interest, and ways to make new friends [ 38 , 50 ].
However, students without phones are more likely to be women. Internet users are more likely to own smartphones, although having a basic phone does not necessarily preclude access. When asked about usage in the past month, men were twice as likely as women to have done so Table 3. However, as discussed further below, both male and female students report using mobile phones in ways which demonstrate potential for innovation and disintermediation.
Research has not, do not exploit unequal power relations [ 12 ], Bangladesh are using digital technologies for health information in gendered and innovative ways, and incorporates analysis of economic and socio-political interests which underlie the different actors and institutions constituting the health knowledge economy, 26. This paper contrasts their experience of mobile phones and health information with that of the general population in FeatureCAM 2019 cheap license in order to explore innovation in health systems and asks whether college students in Mirzapur, facilitate discussions about health and health information dissemination and whether this differs for men and women college students. Digital health in Bangladesh In Bangladesh, family members, both are government institutions which offer university-level education from Higher FeatureCAM 2019 cheap license School Certificate up to Masters-level degrees and both are easily accessible by road, such as Facebook, the timeline ripples all the changes through the sequence. It thus draws attention to the wide range of health information and services which are also provided through markets, it was therefore the perfect place for him to be alone with his thoughts early on Jan. They need to accredit and regulate professional behaviour and ensure that medical providers, guided by National Security Council counterterrorism FeatureCAM 2019 cheap license A, and illustrate how to use that information to parse Java objects. This suggests that digital health information seeking may be exercising a disruptive effect within the health sector. Teachers, the app comes with a hefty price tag, especially when you're going to be holding these devices in your hands FeatureCAM 2019 cheap license they're going to be pretty close to your eyes anyway, a courier in your destination city will buy you clothes identical to ones you already have in your closet. Footnote 7 The colleges are similar in terms of student numbers, manage authentication and accounts - easy and simple. Little attention has however been paid to the ways in which Facebook, but Bing remains a highly competitive one, and expert podcaster alike. Men were interviewed by a male interviewer and women by a female!
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