The Health of Indigenous Populations in South Asia: A Critical Review in a Critical Time

South Asia's unprotected poor: A systematic review of why social protection programs fail to reach their potential

The incongruity between South Asia's economic growth and extreme poverty has led to a growing interest in social protection and subsequent implementation of anti-poverty initiatives. However, many programs have consistently fallen short of their full potential in reaching the poor. We reviewed the literature to understand the factors behind this failure. A search of EconLit, Global Health Database, MEDLINE and SocINDEX, supplemented by an external search, yielded 42 papers evaluating 23 programs. Inclusion criteria included social and political determinants of program outcomes. Articles were assessed for quality using the GRADE and GRADE CERQual criteria and analyzed using Thomas & Harding's thematic synthesis approach. We identified five themes: (1) structurally flawed program theories overlook the complexities of poverty and are rooted in simplistic cause-and-effect approaches; (2) elite capture through appropriation of benefits, powerful positioning in program implementation, and gatekeeping through relationships of patronage; (3) insufficient targeting strategies to reach the poorest; (4) neglect of gendered restrictions, hidden costs, lack of legal documentation, and physical and social exclusion; (5) active self-exclusion from social protection to maintain dignity, a perception that programs are substandard, and a lack of resources required. The review highlights the well-documented disconnect between South Asian social protection program designs and the ground realities of their 'ideal' beneficiaries. This stems from a dominance of Western-led poverty discourse that disregards the influence of caste, the challenge of effective engagement with a group whose identity remains unclear, and fast-paced funding calls that do not lend themselves to meaningful identification and collaboration with the invisible poor. We suggest this disconnect is intentional and reflects a broader power dynamic rooted in geopolitical interests and national priorities. Study limitations reflect the shortcomings of the existing literature, which largely uses quantitative research methods that fail to capture the multidimensional experiences of the poor.

Prevalence of dyslipidemia, hypertension and diabetes among tribal and rural population in a south Indian forested region

While NCDs are in rise globally, tribal and rural populations residing near to reserve forests with limited exposure to modern lifestyles may bear a unique burden. This study investigates the prevalence and risk factors of hypertension, diabetes, and dyslipidemia among these communities. We conducted a cross-sectional study between 2018 and 2020 in the forest-dwelling population of Chamarajanagar, India. Using multistage stratified sampling based on caste and remoteness, we enrolled 608 participants aged over 18 years, including 259 non-tribal and 349 tribal individuals. Data collection includes the administration of STEPS questionnaire and measurement of fasting blood sugar, lipid levels, and blood pressure. The prevalence of diabetes, hypertension, and dyslipidemia were 4.6%, 28.8%, and 85.7%, respectively, among the study population. We also found abnormal levels of low-density lipoprotein (LDL), high-density lipoprotein (HDL), Triglycerides (TGA), Total cholesterol (TC), and very low-density lipoprotein (VLDL)in 4.9%, 82.4%, 22.7%, 5.8%, and 7.4% of participants, respectively. Significant differences were observed in diabetes, LDL abnormality, TGA abnormality, VLDL abnormality, and TC abnormality, but not in hypertension, dyslipidemia, or HDL abnormality, across the Socio Geographic Discrimination Index. We found a significant difference in diabetes and HDL abnormality, but not in hypertension, dyslipidemia, LDL abnormality, TGA abnormality, TC abnormality, or VLDL abnormality, between tribal and non-tribal populations living in the forest-dwelling area. Waist circumference was a significant independent predictor of diabetes among tribal participants, while wealth index, age, and waist circumference were significant predictors of hypertension. There were no significant predictors for dyslipidemia among tribal participants. Our study suggests that tribal population living in a remote area are at a lower risk of developing diabetes compared to non-tribal populations living in the same geographic area. However, the prevalence of hypertension and dyslipidemia among tribal populations remains high and comparable to that of the general population.

Social Determinants of Child Undernutrition in Adivasi Population in Northern Kerala: A Study Using Syndemic Framework

OBJECTIVES

To understand the complex interaction of structural inequalities, co-occurring health conditions, and child undernutrition among the Adivasi population in North Kerala, India.

METHODS

A mixed-method approach was employed in this study, which combined a cross-sectional survey and a case study design. A multistage cluster sampling method was used to select 167 children aged 24 to 60 mo from the study population. The mothers of these children were interviewed using a structured questionnaire to assess individual, parental, and household-level factors associated with child undernutrition. Two Paniya settlements, one with a high prevalence of child undernutrition (HPS) and the other with a low prevalence (LPS), were chosen as the primary units of the case study.

RESULTS

The study found that the absence of a kitchen garden with fruits and vegetables [adjusted odds ratio (AOR) 2.85; 95% confidence interval (CI): 1.04-7.81] and a history of cough and fever (AOR 2.93; 95% CI: 1.24-6.93) were both associated with a higher risk of undernutrition in children. The case studies revealed that Adivasi children are undernourished due to a complex set of factors that persist throughout their lives, including unequal access to social capital, healthcare, and food security, as well as differences in hygiene practices due to the lack of access to clean water and sanitation.

CONCLUSIONS

The findings underscore the need for social interventions to complement the current focus almost entirely on food supplementation programmes. Equitable action on Adivasi child malnutrition requires urgent policy and programmatic attention to social inequalities and access to basic amenities in Adivasi areas.

Parental perceptions, attitudes, and beliefs regarding vaccination of children aged 0-5 years: A qualitative study of hill-tribe communities, Thailand

The widespread availability and use of vaccines have tremendously reduced morbidity and deaths related to infectious diseases globally. However, in hill-tribe communities in Northern Thailand, vaccination rates remain low, and there is limited literature on parental perceptions, attitudes, and beliefs about vaccination for children under five years of age. We conducted a qualitative study employing semi-structured interviews to understand parents' perceptions, attitudes, and beliefs about vaccinations. A purposive sample was used to recruit participants. Data were analyzed using thematic analysis. 74 hill-tribe parents (14 Akha, 11 Hmong, 12 Lahu, 13 Lisu, 12 Karen, and 12 Yao) were interviewed. Four themes emerged from the interviews: 1) traditional beliefs, and practices 2) traumatic experiences, 3) lack of information and effective communication, and 4) trust and support from the community. Findings highlight that it is crucial to build trust by providing knowledge, appropriate information, and advice about vaccinations in order to improve vaccine coverage in children under five years of age in the hill-tribe context.

Identifying non-communicable disease multimorbidity patterns and associated factors: a latent class analysis approach

OBJECTIVE

In the absence of adequate nationally-representative empirical evidence on multimorbidity, the existing healthcare delivery system is not adequately oriented to cater to the growing needs of the older adult population. Therefore, the present study identifies frequently occurring multimorbidity patterns among older adults in India. Further, the study examines the linkages between the identified patterns and socioeconomic, demographic, lifestyle and anthropometric correlates.

DESIGN

The present findings rest on a large nationally-representative sample from a cross-sectional study.

SETTING AND PARTICIPANTS

The study used data on 58 975 older adults (45 years and older) from the Longitudinal Ageing Study in India, 2017-2018.

PRIMARY AND SECONDARY OUTCOME MEASURES

The study incorporated a list of 16 non-communicable diseases to identify commonly occurring patterns using latent class analysis. The study employed multinomial logistic regression models to assess the association between identified disease patterns with unit-level socioeconomic, demographic, lifestyle and anthropometric characteristics.

RESULTS

The present study demonstrates that older adults in the country can be segmented into six patterns: 'relatively healthy', 'hypertension', 'gastrointestinal disorders-hypertension-musculoskeletal disorders', 'musculoskeletal disorders-hypertension-asthma', 'metabolic disorders' and 'complex cardiometabolic disorders'. Additionally, socioeconomic, demographic, lifestyle and anthropometric factors are significantly associated with one or more identified disease patterns.

CONCLUSIONS

The identified classes 'hypertension', 'metabolic disorders' and 'complex cardiometabolic disorders' reflect three stages of cardiometabolic morbidity with hypertension as the first and 'complex cardiometabolic disorders' as the last stage of disease progression. This underscores the need for effective prevention strategies for high-risk hypertension group. Also, targeted interventions are essential to reduce the burden on the high-risk population and provide equitable health services at the community level.

Exploring the Linkages Between Non-Communicable Disease Multimorbidity, Health Care Utilization and Expenditure Among Aboriginal Older Adult Population in India

Objective: The study investigates the magnitude and correlates of non-communicable disease multimorbidity and explores its linkages with health care utilization and out-of-pocket expenditure among aboriginal or tribal older adults.

Methods: The study employed data on 11,365 older adults from Scheduled Tribes from the Longitudinal Ageing Study in India, 2017-18. A disease score was computed integrating sixteen non-communicable diseases. Descriptive, bivariate, and multivariable analyses were performed to identify the magnitude and correlates of multimorbidity. The study further explored the linkages between selected diseases and multimorbidity with health care utilization and expenditure.

Results: The findings suggest that 27.1 and 14.5% of the aboriginal population lived with single or multiple disease, respectively. Hypertension and gastrointestinal disorders were frequent diseases. Higher age, Muslim religion, higher education, unemployment, and affluent background were the major correlates of multimorbidity. Health care utilization, mean expenditure on hospitalization, and outpatient visits increased significantly with multimorbidity.

Conclusion: Multimorbidity is emerging as a health care challenge among the aboriginal population. Measures need to be taken to assess the multimorbidity burden and reduce health care expenditure, ensuring health equity among country’s vulnerable population.

How is Inclusiveness in Health Systems Research Priority-Setting Affected When Community Organizations Lead the Process?

Community engagement is gaining prominence in health research. But communities rarely have a say in the agendas or conduct of the very health research projects that aim to help them. One way thought to achieve greater inclusion for communities throughout health research projects, including during priority-setting, is for researchers to partner with community organizations (COs). This paper provides initial empirical evidence as to the complexities such partnerships bring to priority-setting practice. Case study research was undertaken on a three-stage CO-led priority-setting process for health systems research. The CO was the Zilla Budakattu Girijana Abhivrudhhi Sangha, a district-level community development organization representing the Soliga people in Karnataka, India. Data on the priority-setting process was collected in 2018 and 2019 through in-depth interviews with researchers, Sangha leaders, and field investigators from the Soliga community who collected data as part of the priority-setting process. Direct observation and document collection were also performed, and data from all three sources were thematically analyzed. The case study demonstrates that, when COs lead health research priority-setting, their strengths and weaknesses in terms of representation and voice will affect inclusion at each stage of the priority-setting process. CO strengths can deepen inclusion by the CO and its wider community. CO weaknesses can create limitations for inclusion if not mitigated, exacerbating or reinforcing the very hierarchies that impede the achievement of improved health outcomes, e.g. exclusion of women in decision making processes related to their health. Based on these findings, recommendations are made to support inclusive CO-led health research priority-setting processes.

Beyond behaviour as individual choice: A call to expand understandings around social science in health research

The focus of behavioural sciences in shaping behaviour of individuals and populations is well documented. Research and practice insights from behavioural sciences improve our understanding of how people make choices that in turn determine their health, and in turn the health of the population. However, we argue that an isolated focus on behaviour - which is one link in a chain from macro to the micro interventions - is not in sync with the public health approach which per force includes a multi-level interest. The exclusive focus on behaviour manipulation then becomes a temporary solution at best and facilitator of reproduction of harmful structures at worst. Several researchers and policymakers have begun integrating insights from behavioural economics and related disciplines that explain individual choice, for example, by the establishment of Behavioural Insight Teams, or nudge units to inform the design and implementation of public health programs. In order to comprehensively improve public health, we discuss the limitations of an exclusive focus on behaviour change for public health advancement and call for an explicit integration of broader structural and population-level contexts, processes and factors that shape the lives of individuals and groups, health systems and differential health outcomes.

Sickle cell disease in India: a scoping review from a health systems perspective to identify an agenda for research and action

INTRODUCTION

Sickle cell disease (SCD) disproportionately impacts Adivasi (tribal) communities in India. Current research has focused on epidemiological and biomedical aspects but there has been scarce research on social determinants and health systems aspects. Given its fragmented distribution, resources and programmes have emerged in west and central India. This scoping review seeks to identify geographical and evidence gaps for action on SCD from a health systems lens.

METHODS

We followed a scoping review protocol, using Google Scholar and PubMed for published literature. Keywords used included sickle cell anaemia/disease, health systems, tribal and India. We used Google search for grey literature. We compiled a list of 55 records (of which 35 were retained), with about half pertaining directly to India and others relevant to similar settings. Results were organised and analysed using the WHO health systems framework to identify geographical and evidence gaps.

RESULTS

We found substantial literature on biomedical and clinical aspects of SCD but little on the design and implementation of programmes in community and Adivasi-specific contexts as well as on social determinants of SCD. There were regional gaps in knowledge in southern and northeast India. Wherever community-based programmes exist, they have originated in civil society initiatives and relatively limited state-led primary healthcare-based efforts pointing to weak agenda setting.

CONCLUSION

Both research and action on SCD especially among tribal populations need immediate attention. While geospatial epidemiology has been well understood, gaps remain in context-specific knowledge for action in several parts, as well as evidence gaps across several health system building blocks, including governance and financing of care. Despite publication of a draft policy, delayed adoption and lapses in implementation have limited the response largely to local communities and non-governmental organisations.