A systematic review of population health interventions and Scheduled Tribes in India

Advancing Equity in Health Care Among Dalits and Tribal People in India: The Progress, Current Realities, and the Way Forward

The caste system and resulting social exclusion are important social determinants of health inequity in India. This article critically analyzes the influence of the caste system on health inequity in India, starting with a historical perspective and moving to the current status. The article argues that the caste system has deprived Dalits and tribal people in India of achieving health equity. The programs to promote health are often disease-specific and not culturally informed, leading to poor attention at the policy level to the intersecting disadvantages that make Dalits and tribal communities vulnerable, resulting in poor health. The authors suggest strengthening and promoting primary care, improving health access for Dalit and tribal populations, and the need for pivotal changes in the medical education system, shifting the emphasis from specialized care to training family physicians to be oriented toward community health needs, keeping health equity in perspective.

An environmental justice analysis of air pollution in India

Due to the lack of timely data on socioeconomic factors (SES), little research has evaluated if socially disadvantaged populations are disproportionately exposed to higher PM2.5 concentrations in India. We fill this gap by creating a rich dataset of SES parameters for 28,081 clusters (villages in rural India and census-blocks in urban India) from the National Family and Health Survey (NFHS-4) using a precision-weighted methodology that accounts for survey-design. We then evaluated associations between total, anthropogenic and source-specific PM2.5 exposures and SES variables using fully-adjusted multilevel models. We observed that SES factors such as caste, religion, poverty, education, and access to various household amenities are important risk factors for PM2.5 exposures. For example, we noted that a unit standard deviation increase in the cluster-prevalence of Scheduled Caste and Other Backward Class households was significantly associated with an increase in total-PM2.5 levels corresponding to 0.127 μg/m3 (95% CI 0.062 μg/m3, 0.192 μg/m3) and 0.199 μg/m3 (95% CI 0.116 μg/m3, 0.283 μg/m3, respectively. We noted substantial differences when evaluating such associations in urban/rural locations, and when considering source-specific PM2.5 exposures, pointing to the need for the conceptualization of a nuanced EJ framework for India that can account for these empirical differences. We also evaluated emerging axes of inequality in India, by reporting associations between recent changes in PM2.5 levels and different SES parameters.

Tracing the Disparity Between Healthcare Policy-Based Infrastructure and Health Belief-Lead Practices: a Narrative Review on Indigenous Populations of India

Most Indian tribes have limited access to healthcare facilities and rely heavily on traditional healing practices. This narrative review aimed to identify the disparities in the implementation of healthcare services and in accessing and availing these services by the indigenous population in India. We also have tried to throw light on the plausibility in strengthening the efficiency and efficacy of the public health system, by utilizing the available resources to its maximum potential, so that there will be a measurable outcome in the health status of these populations in India, coherently with the relevant sustainable development goals (SDG). The evidence from published literatures supports the fact that the disparity exists in the health status of indigenous populations in India as compared to the general populations. It emphasizes the need to address the key determinants such as the lack of knowledge, traditional healing practices and poor utilization of healthcare services provided to them. Various factors such as accessibility to healthcare resources, traditional healing practices, lack of awareness regarding healthcare services and schemes provided by the government, insufficient data regarding their issues and challenges and cultural and language barriers worsen the health status of indigenous people. However, our review reiterates that a well-structured and sustainable policy with reframed infrastructure and administration of healthcare system might bring a positive change in the health status of indigenous population in India.

When social identities intersect: understanding inequities in growth outcomes by religion- caste and religion-tribe as intersecting strata of social hierarchy for Muslim and Hindu children in India

BACKGROUND

Minority social status determined by religion, caste and tribal group affiliations, are usually treated as independent dimensions of inequities in India. This masks relative privileges and disadvantages at the intersections of religion-caste and religion-tribal group affiliations, and their associations with population health disparities.

METHODS

Our analysis was motivated by applications of the intersectionality framework in public health, which underlines how different systems of social stratification mutually inform relative access to material resources and social privilege, that are associated with distributions of population health. Based on this framework and using nationally representative National Family Health Surveys of 1992-93, 1998-99, 2005-06, 2015-16 and 2019-21, we estimated joint disparities by religion-caste and religion-tribe, for prevalence of stunting, underweight and wasting in children between 0-5 years of age. As indicators of long- and short-term growth interruptions, these are key population health indicators capturing developmental potential of children. Our sample included Hindu and Muslim children of <  = 5 years, who belonged to Other (forward) castes (the most privileged social group), Other Backward Classes (OBCs), Schedule Castes (SCs) and Schedule Tribe (STs). Hindu-Other (forward) caste, as the strata with the dual advantages of religion and social group was specified as the reference category. We specified Log Poisson models to estimate multiplicative interactions of religion- caste and religion-tribe identities on risk ratio scales. We specified variables that may be associated with caste, tribe, or religion, as dimensions of social hierarchy, and/or with child growth as covariates, including fixed effects for states, survey years, child's age, sex, household urbanicity, wealth, maternal education, mother's height, and weight. We assessed patterns in growth outcomes by intersectional religion-caste and religion-tribe subgroups nationally, assessed their trends over the last 30 years, and across states.

FINDINGS

The sample comprised 6,594, 4,824, 8,595, 40,950 and 3,352 Muslim children, and 37,231, 24,551, 35,499, 1,87,573 and 171,055 Hindu children over NFHS 1, 2, 3, 4, and 5, respectively. As one example anthropometric outcome, predicted prevalence of stunting among different subgroups were as follows- Hindu Other: 34.7% (95%CI: 33.8, 35.7), Muslim Other: 39.2% (95% CI: 38, 40.5), Hindu OBC: 38.2 (95%CI: 37.1, 39.3), Muslim OBC: 39.6% (95%CI: 38.3, 41), Hindu SCs: 39.5% (95%CI: 38.2, 40.8), Muslims identifying as SCs: 38.5% (95%CI: 35.1, 42.3), Hindu STs: 40.6% (95% CI: 39.4, 41.9), Muslim STs: 39.7% (95%CI: 37.2, 42.4). Over the last three decades, Muslims always had higher prevalence of stunting than Hindus across caste groups. But this difference doubled for the most advantaged castes (Others) and reduced for OBCs (less privileged caste group). For SCs, who are the most disadvantaged caste group, the Muslim disadvantage reversed to an advantage. Among tribes (STs), Muslims always had an advantage, which reduced over time. Similar directions and effect sizes were estimated for prevalence of underweight. For prevalence of wasting, effect sizes were in the same range, but not statistically significant for two minority castes-OBCs and SCs.

INTERPRETATION

Hindu children had the highest advantages over Muslim children when they belonged to the most privileged castes. Muslim forward caste children were also disadvantaged compared to Hindu children from deprived castes (Hindu OBCs and Hindu SCs), in the case of stunting. Thus, disadvantages from a socially underprivileged religious identity, seemed to override relative social advantages of forward caste identity for Muslim children. Disadvantages born of caste identity seemed to take precedence over the social advantages of Hindu religious identity, for Hindu children of deprived castes and tribes. The doubly marginalized Muslim children from deprived castes were always behind their Hindu counter parts, although their differentials were less than that of Muslim-Hindu children of forward castes. For tribal children, Muslim identity seemed to play a protective role. Our findings indicate monitoring child development outcomes by subgroups capturing intersectional social experiences of relative privilege and access from intersecting religion and social group identities, could inform policies to target health disparities.

Marginalised social groups differentials in nutritional status (BMI) among reproductive-aged women in West Bengal

BACKGROUND

SCs and STs, historically marginalized communities in India, have been subjected to social and economic discrimination for centuries. Despite affirmative action policies, these communities face systemic discrimination and exclusion in various aspects of their lives. Poor health conditions among SC and ST women are caused by insufficient consumption of nutritious food, leading to undernutrition and related health issues. To address gaps in the literature regarding the nutritional status of these women, this study aims to compare the BMI of SC and ST women in West Bengal and investigate the factors affecting their BMI. The study's findings can inform targeted interventions to improve the nutritional status of SC and ST women in West Bengal and reduce disparities in their health outcomes.

MATERIALS AND METHODS

This study analyzed data from the National Family Health Survey (NFHS-5) to examine the distribution of underweight and  non-underweight SC and ST women in West Bengal. The sample included 5,961 non-pregnant reproductive-aged SC women and 1,496 non-pregnant reproductive-aged ST women. A binary logistic regression model was used to determine how background characteristics affect the nutritional status (BMI) of respondents, while a multivariate decomposition analysis was conducted to identify the covariates contributing to the nutritional status difference between SC and ST women. QGIS 2.18.25 software was utilized to map the spatial distribution of underweight and non-underweight SC and ST reproductive-aged women.

RESULTS

This study examines the nutritional status and differential background characteristics among SC and ST women in West Bengal, India. Results show that undernutrition affects the ST population more than the SC population, with age, marital status, religion, place of residence, educational status, and wealth quintile being significant factors affecting nutritional status. Food and dietary habits also impact nutritional status, with milk or curd, pulses or beans, dark green leafy vegetables, eggs, and fish being associated with lower rates of underweight. Binary logistic regression analysis reveals significant associations between socio-demographic factors and underweight status among SC and ST women. Socio-demographic factors were found to be the major contributors to the gap between SC and ST women, followed by food and dietary factors. The study highlights the need for targeted interventions to improve the nutritional status of marginalized communities like SC and ST women in West Bengal.

CONCLUSION

The study highlights a significant population suffering from underweight in West Bengal, with socio-economic factors and dietary habits significantly contributing to the nutritional gap between SC and ST reproductive-aged women. Policy implications suggest targeted interventions to improve access to education and employment opportunities and promote a healthy and balanced diet to reduce the gap. Future studies could explore vulnerability risks of these domains.

The G-NORM Scale: Development and Validation of a Theory-Based Gender Norms Scale

Gender norms are increasingly recognized as important modifiers of health. Despite growing awareness of how gender norms affect health behavior, current gender norms scales are often missing two important theoretical components: differentiating between descriptive and injunctive norms and adding a referent group. We used a mixed-methods approach to develop and validate a novel gender norms scale that includes both theoretical components. Based on qualitative data, the theory of normative social behavior, and the theory of gender and power, we generated a pool of 28 items. We included the items in a baseline questionnaire among 3,110 women in Odisha, India as part of a cluster randomized controlled trial. We then ran exploratory factor analysis which resulted in 18 items. Using a second wave of data with the same sample, we evaluated psychometric properties using confirmatory factor analysis and structural equation modeling. The analysis resulted in two subscales with nine items each, “descriptive gender norms” and “injunctive gender norms.” Both subscales represent high internal validity with Cronbach’s alpha values of 0.81 and 0.84 and the combined scale has an alpha of 0.87. The G-NORM, gender norms scale, improves on existing measures by providing distinct descriptive and injunctive norms subscales and moving beyond individual attitudes by assessing women’s perceptions of community-level gender norms.

Health status of Koraga community: A pilot study among a particularly vulnerable tribal group of Udupi District, Karnataka, India

Background & objectives

Undertaking tribe-specific assessment of health status provides the required data for planning appropriate interventions. Hence, a study was conducted to assess the health profile of the Koraga tribe.

Methods

This community-based cross-sectional study was conducted among a particularly vulnerable tribal group, the Koragas residing in the Udupi district. Data were collected using a pro forma and were analyzed using the SPSS software version 16.0.

Results

A total of 273 participants aged ≥18 yr and 94 children aged ≤17 yr were recruited through screening and referral services organized in Koraga hamlets of the Udupi district. Among the adults, 59.7 per cent were females and their median age was 35 yr. About 13.9 per cent had elevated blood pressure and 18.4 per cent had impaired/elevated random blood sugar levels. About 47.6 per cent were underweight and 35.2 per cent were anaemic. Multivariate logistic regression analysis showed that individuals with morbidities were more likely to be aged ≥45 yr [45-60 yr: adjusted odds ratio (AOR)=4.3; 95 per cent confidence interval (CI)=1.3-13.8 and >60 yr: AOR=6.4; 95 per cent CI=1.7-23.7] and overweight or obese [23-24.9 kg/m^[2]: AOR=8.1; 95% CI=1.3-48.2 and >25 kg/m^[2]: AOR=7.9; 95% CI=1.6-38.4]. Of the 26 Koraga children aged ≤5 yr, 30.7 and 42.3 per cent had their height for age and weight for age below the third percentile, respectively. Further, 15.3 per cent of under-five children and 27.9 per cent of 6-17 yr old children were severely wasted. About 21.2 per cent of the children aged ≤17 yr were found to be anaemic and 56.3 per cent had symptoms of respiratory tract infection in the past 15 days.

Interpretation & conclusions

Malnutrition was prevalent among Koraga adults and children, which warrants designing and implementing appropriate social and health interventions in this population.

Synthesizing habitat connectivity analyses of a globally important human-dominated tiger-conservation landscape

As ecological data and associated analyses become more widely available, synthesizing results for effective communication with stakeholders is essential. In the case of wildlife corridors, managers in human-dominated landscapes need to identify both the locations of corridors and multiple stakeholders for effective oversight. We synthesized 5 independent studies of tiger (Panthera tigris) connectivity in central India, a global priority landscape for tiger conservation, to quantify agreement on landscape permeability for tiger movement and potential movement pathways. We used the latter analysis to identify connectivity areas on which studies agreed and stakeholders associated with these areas to determine relevant participants in corridor management. Three or more of the 5 studies' resistance layers agreed in 63% of the study area. Areas in which all studies agree on resistance were of primarily low (66%, e.g., forest) and high (24%, e.g., urban) resistance. Agreement was lower in intermediate resistance areas (e.g., agriculture). Despite these differences, the studies largely agreed on areas with high levels of potential movement: >40% of high average (top 20%) current-flow pixels were also in the top 20% of current-flow agreement pixels (measured by low variation), indicating consensus connectivity areas (CCAs) as conservation priorities. Roughly 70% of the CCAs fell within village administrative boundaries, and 100% overlapped forest department management boundaries, suggesting that people live and use forests within these priority areas. Over 16% of total CCAs' area was within 1 km of linear infrastructure (437 road, 170 railway, 179 transmission line, and 339 canal crossings; 105 mines within 1 km of CCAs). In 2019, 78% of forest land diversions for infrastructure and mining in Madhya Pradesh (which comprises most of the study region) took place in districts with CCAs. Acute competition for land in this landscape with globally important wildlife corridors calls for an effective comanagement strategy involving local communities, forest departments, Appendix 1 and infrastructure planners. This article is protected by copyright. All rights reserved.

A model for sustainable, partnership-based telehealth services in rural India: An early process evaluation from Tuver village, Gujarat

Background

Telehealth can improve access to high-quality healthcare for rural populations in India. However, rural communities often have other needs, such as sanitation or employment, to benefit fully from telehealth offerings, highlighting a need for systems-level solutions. A Business of Humanity approach argues that innovative solutions to wicked problems like these require strategic decision-making that attends to a) humaneness, e.g., equity and safety and b) humankind, or the needs and potential of large and growing markets comprised of marginalized and low-income individuals. The approach is expected to improve economic performance and long-term value creation for partners, thus supporting sustainability.

Methods

A demonstration project was conducted in Tuver, a rural and tribal village in Gujarat, India. The project included seven components: a partnership that emphasized power-sharing and complementary contributions; telehealth services; health promotion; digital services; power infrastructure; water and sanitation; and agribusiness. Core partners included the academic partner, local village leadership, a local development foundation, a telehealth provider, and a design-build contractor. This early process evaluation relies on administrative data, field notes, and project documentation and was analyzed using a case study approach.

Results

Findings highlight the importance of taking a systems perspective and engaging inter-sectoral partners through alignment of values and goals. Additionally, the creation of a synergistic, health-promoting ecosystem offers potential to support telehealth services in the long-term. At the same time, engaging rural, tribal communities in the use of technological advances posed a challenge, though local staff and intermediaries were effective in bridging disconnects.

Conclusion

Overall, this early process evaluation highlights the promise and challenges of using a Business of Humanity approach for coordinated, sustainable community-level action to improve the health and well-being of marginalized communities.

Examining intentions to take iron supplements to inform a behavioral intervention: The Reduction in Anemia through Normative Innovations (RANI) project

BACKGROUND

More than half of women of reproductive age in India have anemia. Over the last decade, India has made some progress towards reducing anemia in pregnant women, but non-pregnant women, who make up the largest sub group of people with anemia, are largely disregarded.

OBJECTIVES

The objective of this paper is to examine intentions to take iron supplements and factors associated with intentions to inform a social norms-based behavioral intervention to increase uptake of iron supplements and reduce anemia in Odisha, India.

METHODS

We collected data from 3,914 randomly sampled non-pregnant women of reproductive age in 81 villages. We conducted a survey and took hemocue (anemia level) readings from each participant. We analyzed data using linear regression models beginning with demographics and social norms and adding other factors such as self-efficacy to take iron supplements, anemia risk perception, and knowledge about anemia in a subsequent model.

RESULTS

63% of women in our sample were anemic but less than 5% knew they were anemic. Despite national guidelines that all women of reproductive age should take weekly iron supplements to prevent anemia, less than 3% of women in our sample were currently taking them. While actual use was low, intentions were rather high. On a five point Likert scale where higher numbers meant more intentions to take supplements, average intentions were above the midpoint (M = 3.48, SD = 1.27) and intentions and iron supplement use were significantly correlated (r = .10, p < .001). Both injunctive norms and collective norms were associated with intentions to take iron supplements but descriptive norms were not. Other significant factors included age, breastfeeding, knowledge, self-efficacy, and outcome expectations. The final model accounted for 74% of the variance in iron supplement intentions.

CONCLUSIONS

In this context, where the actual behavior is low but intentions to enact the behavior are high, starting an intervention with injunctive norms messaging (expectations around the behavior) and self-efficacy to enact the behavior is the step we recommend based on our results. As an intervention unfolds and iron supplement use increases, descriptive norms messaging (that people are indeed taking iron supplements) may add value.

Effect of Maternal Healthcare Utilization on Early Neonatal, Neonatal and Post-Neonatal Mortality in India

This paper examines the effect of maternal healthcare utilization on early neonatal, neonatal and post-neonatal mortality in India using the recent round of National Family Health Survey (NFHS-4) data. At the national level, for the last live birth of women during the five year preceding the survey, the early neonatal mortality rate was about 16, neonatal mortality rate was 19 and post-neonatal mortality was 7 per thousand live births. Also, only one-fifth of women who had a birth in the past five years received full antenatal care (ANC), 83 percent women received safe delivery and 65 percent women received post-natal care. Findings of the study indicate that full ANC and postnatal care were significantly associated with early neonatal and neonatal mortality. However, no significant association between safe delivery and newborn mortality were found after adjusting the socio-economic and demographic characteristics. Therefore, for a policy point of view, there is a dire need to strengthen supply dependent factors regarding public awareness, accessibility, and affordability of maternal and child healthcare services. It is also necessary to focus on increasing utilization along with continuum of care of maternal and child healthcare services to sustain the reduction in mortality during infancy.

A qualitative study of the barriers to utilizing healthcare services among the tribal population in Assam

OBJECTIVE

We aim to explore the barriers to accessing modern healthcare services in two tribal populations in Assam.

METHODS

In March 2018, we conducted qualitative research through 60 in-depth interviews with men and women aged 15 to 50 from Bodo and Rabha tribes in Udalguri and Baksa districts of Assam. We interviewed a group of health-service providers from public health facilities to understand the demand-supply balance in those facilities.

FINDINGS

On the demand side, direct and indirect financial obstacles, distance to health facilities, poor public transportation, perceived negative behavior of hospital staff, and lack of infrastructure were the main barriers to utilizing healthcare facilities. On the supply side, doctors and nurses in government health facilities were overburdened by demand due to a lack of human resources.

CONCLUSIONS

Our study highlights the barriers to utilizing health facilities; these are not always driven by factors linked to the patient's socio-economic status but also depend significantly on the quality of the health services and other contextual factors. Although the government has made efforts to improve the rural healthcare system through national-level programs, our qualitative study shows that these programs have not been successful in enhancing the rural healthcare system in the study area.

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

Despite South Asia's promising social inclusion processes, staggering social and health inequalities leave indigenous populations largely excluded. Marginalization in the South Asian polity, unequal power relations, and poor policy responses deter Adivasi populations' rights and opportunities for health gains and dignity. The ongoing COVID-19 pandemic is likely to result in a disproportionate share of infections and deaths among the Adivasis, given poor social conditions and exclusions. Poor health of indigenous people, inequalities between indigenous and non-indigenous groups, and failures in enforcing constitutional and legal provisions to reclaim indigenous land and cultural identity herald deeper structural and political fractures. This article unravels health inequalities between the Adivasis and non-Adivasi populations in their social context based on a critical review of secondary sources. We call for intersectoral policies and integrated health care services to address systemic inequalities, discrimination, power asymmetries, and consequent poor health outcomes. The current COVID-19 pandemic should be viewed as a window to pursue real change.

Towards Health Equity and Transformative Action on tribal health (THETA) study to describe, explain and act on tribal health inequities in India: A health systems research study protocol

Background: In India, heterogenous tribal populations are grouped together under a common category, Scheduled Tribe, for affirmative action. Many tribal communities are closely associated with forests and difficult-to-reach areas and have worse-off health and nutrition indicators. However, poor population health outcomes cannot be explained by geography alone. Social determinants of health, especially various social disadvantages, compound the problem of access and utilisation of health services and undermine their health and nutritional status. The Towards Health Equity and Transformative Action on tribal health (THETA) study has three objectives: (1) describe and analyse extent and patterns of health inequalities, (2) generate theoretical explanations, and (3) pilot an intervention to validate the explanation.    

Methods: For objective 1, we will conduct household surveys in seven forest areas covering 2722 households in five states across India, along a gradient of socio-geographic disadvantage. For objective 2, we will purposefully select case studies illustrating processes through which socio-geographic disadvantages act at the individual, household/neighbourhood, village or population level, paying careful attention to the interactions across various known axes of inequity. We will use a realist evaluation approach with context-mechanism-outcome configurations generated from the wider literature on tribal health and results of objective 1. For objective 3, we will partner with willing stakeholders to design and pilot an equity-enhancing intervention, drawing on the theoretical explanation generated and evaluate it to further refine our final explanatory theory.

Discussion: THETA project seeks to generate site-specific evidence to guide public health policy and programs to better contribute to equitable health in tribal populations. It fulfills the current gap in generating and testing explanatory social theories on the persistent and unfair accumulation of geographical and social disadvantage among tribal populations and finally examines if such approaches could help design equity-enhancing interventions to improve tribal health.

Exploring biocultural models of chewing tobacco and paan among reproductive-aged women: Self-medication, protection, or gender inequality?

OBJECTIVES

Tobacco and areca nut are two of the most widely used psychoactive plant substances worldwide, yet the biocultural factors that account for variation in use patterns are not well understood. Here we attempt to understand the high prevalence of, and variation in, tobacco and areca nut use among reproductive-aged women.

METHODS

Research was carried out in Mysore, Karnataka, India. First, we conducted a qualitative investigation where participants engaged in semistructured interviews and focus group discussions to uncover cultural norms of women's tobacco use. Findings informed the second stage of research which quantitatively tested three models of tobacco and areca nut use (N = 74).

RESULTS

The qualitative study found that women were more likely to chew "natural" forms of tobacco and areca nut products (kaddipudi and paan). Quantitative tests of our hypotheses revealed that kaddipudi and combined tobacco use were best explained by the self-medication model, with somatic and environmental stress as strong indicators of use. The presence of cotinine, our biological indicator of tobacco use, was best modeled by gender inequality. We also found that men and women reported approximately equal tobacco use, even though their preferred types of tobacco and areca nut products differed.

CONCLUSIONS

Findings did not support the protection hypothesis as it relates to plant toxins. Instead, this study suggests that women might exploit neurotoxins such as nicotine and arecoline to offset the cognitive and energetic costs associated with iron deficiency in stressful environments.

Why ethnicity and gender matters for fertility intention among married young people: a baseline evaluation from a gender transformative intervention in rural India

BACKGROUND

Social inequities in early child bearing persist among young married people, especially among tribal populations in India. Rural women belonging to tribal groups and those coming from poor households are more likely to give birth before age 18. This paper explores the connection between ethnicity, gender and early fertility intention among young married people in rural India.

METHODS

The data is drawn from a cross sectional baseline evaluation of an intervention programme in rural India. A sample of 273 married young people was taken. Respondents were selected using systematic random sampling. Logistic Regression was used to assess the effect of being a tribal on early fertility intention and also to determine if covariates associated with early fertility intention differed by tribal status. Qualitative data was analysed using deductive content analysis approach.

RESULTS

Bivariate and logistic regression results indicated that young married people from tribal communities had higher odds of planning a child within one year of marriage than non-tribals (OR = 1.47, p-value-0.079). Findings further suggest that early fertility intention among tribals is driven by gender factors and higher education and among non-tribals, higher education and awareness on contraception are key predictors. Among tribals, the odds of planning a child within one year of marriage was strongly associated with inequitable gender norms (OR = 1.94, p-value-0.002). Higher education showed significant positive association with non-tribals (OR = 0.19, p-value-0.014) and positive association with tribals (OR = 0.56, p-value-0.416). Qualitative investigation confirms that fertility desires of young married people are strongly influenced by gender norms especially among tribal populations.

CONCLUSION

Early child bearing was underpinned by complex ethnic factors and gender norms. Preference for early child bearing was seen most among tribal communities. Gender attitudes were a cause of concern especially among tribal groups. These results suggest that efforts to improve early child birth will require changing gender norms related to fertility among tribals as well as social equity issues including higher education among non-tribals and tribals.

Research and the health of indigenous populations in low- and middle-income countries

In low- and middle-income countries (LMICs)-when there are available data-a 'health divide' exists between indigenous and non-indigenous populations living in the same society. Despite the limited available evidence suggesting that indigenous populations have high levels of health needs, there is scant research on indigenous health, especially in Africa, China and South Asia. Pursuing research, however, is clouded by the prior negative experiences that indigenous populations have had with researchers. In this paper, we describe the current evidence base on indigenous health in LMICs, propose practical strategies for undertaking future research, and conclude by describing how global health researchers can contribute to improving the health of indigenous populations.

Treatment-seeking and out-of-pocket expenditure on childhood illness in a migrant tribal community in Bhubaneswar, Odisha State, India

BACKGROUND

In India, migrant status, tribal affiliation and poverty render tribal migrants more vulnerable than any other group which leads to high treatment costs and the risk of low access to health care.

OBJECTIVE

To examine treatment-seeking behaviour and out-of-pocket (OOP) expenditure on the treatment of childhood illnesses, with a focus on gender in a migrant tribal community in Bhubaneswar, eastern India.

METHODS

A total of 175 households with a child aged 0-14 years and who had migrated within the last 12 years were selected from tribal-dominated slums. Data on health-seeking behaviour and expenditure on a recent illness in the youngest child were collected by interviewing mothers during October 2007 to March 2008.

RESULTS

Of the 175 children, 78.8% had at least one episode of illness during the previous year. Of the total number of episodes, 71% had been treated and 61% of them had incurred OOP expenditure. A significantly lower proportion of episodes of illness in girls had been treated than in boys (P = 0.01) and incurred OOP expenditure (P = 0.05). Private health care was preferred and only 16.5% availed themselves of the government sources. About 89 and 87% of households of boys and girls, respectively, incurred OOP expenditure. A child's gender (female) (P = 0.05), mother's education (P = 0.002) and type of illness (P = 0.002) were significantly associated with total OOP expenditure.

CONCLUSION

Further studies are warranted to address the low access to government health care and thereby reduce high OOP expenditure by tribal migrants on low incomes. Efforts are required to increase the ability of communities and health providers to identify and address the issues of gender and equity in health care along with a focus on culture-sensitive service provision.

Caste- and ethnicity-based inequalities in HIV/AIDS-related knowledge gap: a case of Nepal

Caste- and ethnicity-based inequalities are major obstacles to achieving health equity. The authors investigated whether there is any association between caste- and ethnicity-based inequalities and HIV-related knowledge within caste and ethnic populations. They used the 2011 Nepal Demographic and Health Survey, a nationally represented cross-sectional study data set. The study sample consisted of 11,273 women between 15 and 49 years of age. Univariate and logistic regression models were used to examine the relationship between caste- and ethnicity-based inequalities and HIV-related knowledge. The study sample was divided into high Hindu caste (47.9 percent), "untouchable" caste (18.4 percent), and indigenous populations (33.7 percent). Within the study sample, the high-caste population was found to have the greatest knowledge of the means by which HIV is prevented and transmitted. After controlling for socioeconomic and demographic characteristics, untouchables were the least knowledgeable. The odds ratio for incomplete knowledge about transmission among indigenous populations was 1.27 times higher than that for high Hindu castes, but there was no significant difference in knowledge of preventive measures. The findings suggest the existence of a prevailing HIV knowledge gap. This in turn suggests that appropriate steps need to be implemented to convey complete knowledge to underprivileged populations.

Determinants of neonatal mortality in rural India, 2007-2008

Background. Despite the growing share of neonatal mortality in under-5 mortality in the recent decades in India, most studies have focused on infant and child mortality putting neonatal mortality on the back seat. The development of focused and evidence-based health interventions to reduce neonatal mortality warrants an examination of factors affecting it. Therefore, this study attempt to examine individual, household, and community level factors affecting neonatal mortality in rural India. Data and methods. We analysed information on 171,529 singleton live births using the data from the most recent round of the District Level Household Survey conducted in 2007-08. Principal component analysis was used to create an asset index. Two-level logistic regression was performed to analyse the factors associated with neonatal deaths in rural India. Results. The odds of neonatal death were lower for neonates born to mothers with secondary level education (O R = 0.60, p = 0.01) compared to those born to illiterate mothers. A progressive reduction in the odds occurred as the level of fathers' education increased. The odds of neonatal death were lower for infants born to unemployed mothers (O R = 0.89, p = 0.00) compared to those who worked as agricultural worker/farmer/laborer. The odds decreased if neonates belonged to Scheduled Tribes (O R = 0.72, p = 0.00) or 'Others' caste group (O R = 0.87, p = 0.04) and to the households with access to improved sanitation (O R = 0.87, p = 0.02), pucca house (O R = 0.87, p = 0.03) and electricity (O R = 0.84, p = 0.00). The odds were higher for male infants (O R = 1.21, p = 0.00) and whose mother experienced delivery complications (O R = 1.20, p = 0.00). Infants whose mothers received two tetanus toxoid injections (O R = 0.65, p = 0.00) were less likely to die in the neonatal period. Children of higher birth order were less likely to die compared to first birth order. Conclusion. Ensuring the consumption of an adequate quantity of Tetanus Toxoid (TT) injections by pregnant mothers, targeting vulnerable groups like young, first time and Scheduled Caste mothers, and improving overall household environment by increasing access to improved toilets, electricity, and pucca houses could also contribute to further reductions in neonatal mortality in rural India. Any public health interventions aimed at reducing neonatal death in rural India should consider these factors.

Data-Driven Decision Making in the Prevention of Substance-Related Harm: Results from the Strategic Prevention Framework State Incentive Grant Program

The Strategic Prevention Framework State Incentive Grant Program (SPF SIG) is a national public-health initiative in the United States to prevent and reduce substance-related harm. The model promotes data-driven decision making (DDDM), with an emphasis on using epidemiological data to help select prevention priorities and to allocate prevention resources. This article examines how well the first two cohorts of SPF SIG states (N = 26) implemented DDDM, and also explores what factors facilitated and hindered the process. Data were collected by reviewing and coding states' strategic plans, supplemented by interviews with state project directors, evaluators, and epidemiological workgroup chairs. Fidelity to the process was scored as high, medium, or low, based on transparency and support from relevant evidence. On selecting prevention priorities, 81% of states received high or medium scores on all priorities selected. On allocating prevention resources, 85% received a high or medium score. Facilitators included collaboration among stakeholders, training and technical assistance, and efforts of epidemiological workgroups and evaluators. However, states that lacked established data infrastructures for prevention were at a decided disadvantage in implementing the model. Future implications for SPF SIG states and ongoing challenges to DDDM in general are discussed.

Reducing inequalities in health and access to health care in a rural Indian community: an India-Canada collaborative action research project

Background

Inadequate public action in vulnerable communities is a major constraint for the health of poor and marginalized groups in low and middle-income countries (LMICs). The south Indian state of Kerala, known for relatively equitable provision of public resources, is no exception to the marginalization of vulnerable communities. In Kerala, women’s lives are constrained by gender-based inequalities and certain indigenous groups are marginalized such that their health and welfare lag behind other social groups.

The research

The goal of this socially-engaged, action-research initiative was to reduce social inequalities in access to health care in a rural community. Specific objectives were: 1) design and implement a community-based health insurance scheme to reduce financial barriers to health care, 2) strengthen local governance in monitoring and evidence-based decision-making, and 3) develop an evidence base for appropriate health interventions.

Results and outcomes

Health and social inequities have been masked by Kerala’s overall progress. Key findings illustrated large inequalities between different social groups. Particularly disadvantaged are lower-caste women and Paniyas (a marginalized indigenous group), for whom inequalities exist across education, employment status, landholdings, and health. The most vulnerable populations are the least likely to receive state support, which has broader implications for the entire country. A community based health solidarity scheme (SNEHA), under the leadership of local women, was developed and implemented yielding some benefits to health equity in the community—although inclusion of the Paniyas has been a challenge.

The partnership

The Canadian-Indian action research team has worked collaboratively for over a decade. An initial focus on surveys and data analysis has transformed into a focus on socially engaged, participatory action research.

Challenges and successes

Adapting to unanticipated external forces, maintaining a strong team in the rural village, retaining human resources capable of analyzing the data, and encouraging Paniya participation in the health insurance scheme were challenges. Successes were at least partially enabled by the length of the funding (this was a two-phase project over an eight year period).