Mahendran, J. (2015) Sylhetisation, dependence and ambivalence: a qualitative exploration of paan use amongst older Bangladeshi women in London. PhD thesis. Bath: Bath Spa University. ResearchSPAce http://researchspace.bathspa.ac.uk/ Your access and use of this document is based on your acceptance of the ResearchSPAce Metadata and Data Policies, as well as applicable law:- https://researchspace.bathspa.ac.uk/policies.html Unless you accept the terms of these Policies in full, you do not have permission to download this document. This cover sheet may not be removed from the document. Please scroll down to view the document. Sylhetisation, Dependence and Ambivalence: A Qualitative Exploration of Paan Use Amongst Older Bangladeshi Women in London JANAKI MAHENDRAN A thesis submitted in partial fulfillment of the requirements of Bath Spa University for the degree of Doctor of Philosophy School of Society, Enterprise and Environment May 2015 ABSTRACT This thesis introduces a novel and alternative way of understanding paan addiction among Bangladeshi women by exploring their lived experiences. There is growing medical evidence that Paan, a mixture of betel leaf, areca nut, tobacco and white lime, is injurious to health, causing cancer, oral disease and addiction (WHO, 2004). Paan use is prevalent and visible among the Bangladeshi community in East London. However, paan dependence is principally examined through the dominant medical model, which prioritises the scientific and pharmacological aspects. Research has yet to examine paan dependence from the user’s perspective, which limits health and social care professionals from understanding the practice, the determinants of the habit and the elements contributing to its continued use. Understanding the user perspective would assist in designing and delivering appropriate and targeted interventions. There are no similar studies of this nature into paan use and therefore this study developed a theoretical framework by examining literature pertaining to migration, biographies and inequalities of health. Method: An ethnographic study was conducted and data collected through extensive fieldwork followed by in-depth interviews with thirty Bangladeshi women in Tower Hamlets, East London, who have continuously used paan over a number of years. Participants were recruited through purposive sampling. Interview data was analysed thematically using grounded theory techniques (Glazer and Strauss, 1967) and then triangulated to compare and crosscheck the consistency of the research findings. Findings: Key research findings indicate that while health discourses have explained paan use simply as a result of physical addiction to tobacco, exploring the biographical, historical and social context of paan use developed a deeper understanding of how the participants constituted the experience and meaning of paan addiction. Four key themes emerged - physical and psychological addiction, availability and social acceptance of paan chewing, lack of involvement in the wider social environment and ‘Sylhetisation’, (a concept introduced by this thesis to describe how the Bangladeshi community have created an environment similar to that of Sylhet). The main recommendation is that an understanding of the sociocultural aspects of paan use may help greatly in developing more culturally specific paan cessation strategies within tobacco policies. ACKNOWLEDGEMENTS In this project I have travelled an unfamiliar path and reached a destination far from where I began. Several people guided and supported me during this difficult time. I would like to thank all those without whom I could not have completed this thesis, my dream project ever since I started working with the Bangladeshi women who had inspired me. My first thanks goes to the Bangladeshi women who welcomed me into their homes and gave me the opportunity to listen to their nostalgic tales of two homes. I am very grateful to my supervisors, Rosemary Mckechnie, Rob Mears and Nod Miller who guided me with their wise counsel and unfailing support. My family has always been my great strength in all my academic adventures. Without their love and support I could not have completed this task. My two colleagues Alesa Rahman and Swapna Mookerji were the gate keepers for Bangladeshi groups and also assisted me to gain an understanding of Bangladeshi culture, Sylheti and the Bengali language. They were always ready to help me with arranging groups for my visits as well as talks and discussions for clarifications afterwards. Their support for me was immense. I am thankful to professors Croucher, Warnakulasuriya and Eade for giving their valuable time to meet me and give valuable advice based on their wisdom related to the topic of the study. I am also indebted to the staff of the Royal London Hospital and School of Dentistry and the community leaders in Tower Hamlets who contributed to my knowledge. I cannot forget the enormous support given to me by the shop keepers, the trading standards officers, the local authority officials and many residents during my fieldwork. My heartfelt thanks go to them. My dear friend Dr Kusum Joshi, who has always supported me in my endeavours, helped me to proofread this thesis. I am grateful to her. AUTHOR’S DECLARATION I declare that the work in this thesis was carried out in accordance with the Regulations of the Bath Spa University. The work is original except where indicated by special reference in the texts and no part of the thesis has been submitted for any other degree. Any views expressed in the thesis are those of the author and no way represent those of the Bath Spa University. The thesis has not been presented to any other University for examination either in the United Kingdom or overseas. Signed Date …………………………. ………………….. DEDICATION To my late parents whose life of compassion and tolerance taught me to overcome the hardships of life with creativity. GLOSSARY Bangladeshi People of Bangladeshi origin Banglalog Bangla people Bidesh foreign Bhuth ghost Eid an annual Islamic festival marking the end of Ramadan Gorelog white people Gua areca nut Gutka pocket size tobacco products Koran Holy book of Islam Londonis people who have travelled from Sylhet to London, or their relations Nani grandmother Paan betel leaves or the mixture of the same with areca nut tobacco and slaked lime Paan masala same as above or pocket size paan products Ramadan A month of fasting, 9th month of the Islamic calendar Supari betel leaves Sylheti associated with Sylhet (people, language or commodities) Zarda/ zada tobacco powder/ tobacco leaf CONTENTS CHAPTER 1: INTRODUCTION Introduction 1 Aims of the research 3 Current key issues associated with paan use 4 Paan products 7 Rationale for this approach 12 The research design 15 Outline of remaining chapters 16 CHAPTER 2: BACKGROUND TO THE STUDY Introduction 19 Health and illness: explaining inequalities 21 Health inequalities 23 Ethnicity and Health 26 Gender inequalities in health 29 The role of paan in Asian culture 32 Healing qualities of areca nut and betel leaf 34 Cultural explanations and migrant health 35 Health and illness narrative and lay knowledge 39 Research related to paan use within the Bangladeshi population 43 Government interventions and public policy 47 Current provision for paan prevention: a medical point of view 50 Summary 54 CHAPTER 3 METHODOLOGY: THE NATURAL HISTORY OF MY RESEARCH Introduction 56 Rationale for ethnography 59 Insider/outsider perspectives in doing ethnography 62 Ethical considerations 68 Phase 1: Fieldwork 71 Investigating key stakeholders 73 Meeting with Health Professionals 75 Meeting with local Bangladeshi people 77 Participant observation 78 Field work visits and observations 82 Focus groups 82 Phase two: In-depth interviews 86 Constructing a sampling strategy 86 In-depth interviews 90 Interview process 93 Data Analysis 95 Reflections: Methodological lessons learned 99 Conclusion 103 CHAPTER 4: TOWER HAMLETS, SYLHET AND BANGLADESHI WOMEN Introduction 105 Tower Hamlets: Home for the Bangladeshi women 106 A brief history of racism and intolerance 108 Sylhet: The land of ‘Londonis’ 118 Sylhet migrants then and now 122 Bangladeshi women 127 Cultural dynamics of transition 130 Conclusion 134 CHAPTER 5: RESEARCH FINDINGS: EXPERIENCING PAAN ADDICTION/ DEPENDENCE Introduction 136 Medical definitions of addiction 138 Neurobiological adaptation (first layer) 140 Manifestations of addiction (second layer) 145 i) Drug addiction and emotion: feeling different 146 ii) Preoccupation with behaviour 149 iii) Temporary satiation 153 iv) Loss of control 156 v) Negative consequences 160 Need for Paan cessation projects 166 Conclusion 170 CHAPTER 6: RESEARCH FINDINGS: EXPERIENCES OF CREATING HOME Introduction 172 Nostalgic memories 175 Missing home 180 Getting used to marital life 181 Arriving in Britain/ Language problems 185 Hostilities and achievements 188 Paan was not a problem then/availability 191 ‘Sylhetisation’/creating home 194 Incorporating Sylhet features in Whitechapel 199 Caring role of women 200 Younger generation 204 Effects of sylhetisation 206 Lack of wider social involvement 209 Segregation and uncertainty 213 Change of attitudes 216 CHAPTER 7: CONCLUSION AND RECOMMENDATIONS Introduction 222 To what extent were the aims of the research fulfilled 224 The main areas of agreement and difference between the 226 respondents Connections between findings and other research 228 The way forward 230 Integrating appropriate intervention programmes of paan cessation 231 Education