Doctors for Tribal Areas: Issues and Solutions

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.

Knowledge Attitude and Practices of Mitanin's (Community Health Workers) in Chhattisgarh: Malaria Elimination Perspective

Background

For the success of any program, its implementation plays a crucial role. Community health workers are of immense importance for malaria elimination from India.

Objective

This study was aimed to assess the knowledge gaps and the responsible factors for mitanins' knowledge on various aspects of and problems faced by mitanins during their work.

Methods

Structured interviewer-based questionnaire was used to collect the data, and ordinal regression was applied to analyze the data.

Results

Only 26% of the mitanins were having a good knowledge attitude and practices (KAP) score about malaria. Malaria endemicity of area [odds ratio (OR) = 0.26, 95% CI = 0.13–0.50), P < 0.001] and education (OR = 0.35, 95% CI = 0.18–0.69, P = 0.002) were the two significant factors affecting the KAP of mitanins.

Conclusion:

This study shows that prioritizing education while recruiting the mitanins and training them in the low endemic areas with a focus on malaria, which will help achieve the malaria elimination goal.

Beyond Maternal Mortality: A Systematic Review of Evidences on Mistreatment and Disrespect During Childbirth in Health Facilities in India

The aim of this systematic review is to examine current evidence on the nature and extent of disrespect and abuse (D&A), mistreatment and practices of respectful maternity care of women during childbirth in India. Electronic databases were searched for published studies relevant to the topic. The search was conducted from May to September 2018. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to conduct the review. A results synthesis was done using the Bowser and Hill landscape analytical framework for D&A of women during childbirth. Eleven studies are included in this review of which six were cross-sectional, four were qualitative, and one used a mixed-method approach. The type of abuse most frequently reported was the lack of respect and dignity (nondignified care) experienced by the women, usually in the form of negative and unfriendly attitudes of the providers. The least frequent form of mistreatment was physical abuse and detention in the facilities. The frequency of reported D&A was high, ranging from 10% to 77.3%. These behaviors were influenced by lack of education and empowerment of the women, their low socioeconomic status, poor training of providers and supervision, and a lack of accountability. Overall, disrespectful and abusive behavior had adverse impact on the utilization of health facilities for childbirth. It created a psychological distance between women and health providers. To our knowledge, this is the first systematic literature review to be conducted on respectful maternity care in India.

Diminishing traditional methods and inaccessible modern healthcare: the dilemma of tribal health in India

Purpose

This paper critically examines the state of tribal health in India by analyzing the accessibility and availability of traditional medicine and modern healthcare.

Design/methodology/approach

This essay is the product of an extensive review of the literature and authors' personal experience in working with the tribal communities.

Findings

The traditional medicinal practices once very prevalent among the tribal communities are diminishing due to various socio-economic, environmental and political factors. Modern healthcare in India's tribal region is characterized by a lack of availability, accessibility and affordability. As a result of the diminishing traditional practices and inaccessible modern healthcare provisions, tribal communities depend on quacks and magico-religious practices.

Originality/value

This essay advocates for urgent policy interventions to integrate traditional medicine and modern healthcare practices to address critical tribal health issues. Preservation of traditional medicinal knowledge-base and improving research in the field have the potential to address the health of tribal communities and of others. The accessibility and availability of modern healthcare facilities in tribal regions should be improved to ensure better health outcomes.

Determinants of Mental Health Care Access in a Tribal District of Central India: Findings from a Health Camp

Objective  Mental health care needs of urban, rural, and tribal regions of India are varied and challenging, which require region-specific approaches. A significant treatment gap calls out for a state-wise introspection of existing service delivery models to cater to the specific mental health needs. In Madhya Pradesh, key findings were noted from a camp conducted in one of the tribal districts. To establish patient-centered services, it is important to understand their mental health care needs. Materials and Methods  A cross-sectional study within a mental health camp was conducted in the east-central tribal district of Madhya Pradesh by using a semi-structured interview. Statistical Analysis  Treatment deficit, pathways to care, and treatment barriers were assessed for correlation with demographic and clinical variables and analyzed by using the Chi-square test and logistic regression method using SPSS version 20. Results  Among 113 patients who sought help, treatment deficit was 85% with patient factors contributing 76% predominantly affecting the unmarried group of patients. Common mental illnesses (CMIs) outnumbered severe mental illnesses (SMIs) of which anxiety spectrum disorder contributed the most. SMIs still appear to remain undiagnosed till late in the course of illness. Nicotine dependence was higher in males ( p < 0.001), and an increase in the dependence pattern was observed with increasing age ( p = 0.001). Conclusion  Rising awareness and recognition of CMIs as a common mental health concern while under-recognition of SMIs among tribal communities needs further research. Considering attribution of symptoms to unknown factors, treatment barriers revolving around patient factors, and higher nicotine dependence in males, a timely evaluation of a multitargeted intervention to establish the balance in access to mental health care among the tribal population of Madhya Pradesh is warranted.

Pathways to Enable Primary Healthcare Nurses in Providing Comprehensive Primary Healthcare to Rural, Tribal Communities in Rajasthan, India

Background: Emerging health needs and uneven distribution of human resources of health have led to poor access to quality healthcare in rural areas. Rural pathways provide an approach to plan and evaluate strategies for ensuring availability, retention, motivation, and performance of human resources for health in rural areas. While effectiveness of primary healthcare (PHC) nurses to deliver primary health care is established, there is not enough evidence on ways to ensure their availability, retention, motivation, and performance. The paper draws on the program experience and evidence from a primary healthcare network (AMRIT Clinics), in which nurses play a central role in delivering primary healthcare in rural tribal areas of Rajasthan, India, to bridge this gap. Methods: Rural, tribal areas of Rajasthan have limited access to functional healthcare facilities, despite having a high burden of diseases. We used the rural pathway approach to describe factors that contributed to the performance of the nurses in AMRIT Clinics. We analyzed information from the human resource information system and health management information system; and supplemented it with semi-structured interviews with nurses, conducted by an independent organization. Results: Most nurses were sourced from rural and tribal communities that the clinics serve; nurses from these communities were likely to have a higher retention than those from urban areas. Sourcing from rural and tribal communities, on-going training in clinical and social skills, a non-hierarchical work environment, and individualized mentoring appear to be responsible for high motivation of the primary healthcare nurses in AMRIT Clinics. Task redistribution with due credentialing, intensive and on-going training, and access to tele-consultation helped in sustaining high performance. However, family expectations to perform gendered roles and pull of government jobs affect their retention. Conclusion: Rural and remote areas with healthcare needs and scarcity of health provisions need to optimize the health workforce by adopting a multi-pronged pathway in its design and implementation. At the same time, there is a need to focus on structural factors that affect retention of workforce within the pathway. Our experience highlights a pathway of up-skilling PHC nurses in providing comprehensive primary healthcare in rural and remote communities in Low and Middle-Income Countries (LMICs).

Tribal population in India: A public health challenge and road to future

India with 8.6% of tribal population is finding it difficult to bridge the gap that exists between tribal and non-tribal population in regards to healthcare. Tribal population suffers triple burden of disease; in fact it is quadruple, namely, communicable diseases, non-communicable diseases, malnutrition, mental health, and addictions complicated by poor health seeking behavior. With increasing needs, an Expert committee on Tribal health has given recommendations with the goal to bridge the current gap in the health status of tribal people latest by the year 2027. An entirely parallel health system has been proposed with key focus areas, governance, and financing. To summarize and report the present scenario in terms of disease burden, health-seeking behavior, healthcare delivery system, and a roadmap for the future along the importance of primary healthcare in achieving it. Mere establishment of more health facilities cannot overcome the poor health of tribal population and so the role of trained manpower to deliver quality healthcare, in which case the role of traditional healers, local Tribal boys and girls comes in handy. It is high time and states should act swiftly to assess the needs, priorities of their own tribal population and set goals, targets to achieve the same through proven public health strategies.

Faith or Rationality - what dominates the health scenario? - Reflections from a non-governmental organization based health center in a tribal area of rural Maharashtra

BACKGROUND

The tribals are considered as an underprivileged community who are dissociated from the health-care system. They are known to adhere to old, ancient methods of managing illness. This study was undertaken to understand the issues and challenges in the tribal areas in seeking healthcare.

MATERIALS AND METHODS

Cross-sectional study was conducted during the year 2017 in a nongovernmental organization-based health center located in a tribal area of rural Maharashtra, India. A total of 383 participants were interviewed using a semi-structured questionnaire about the health-seeking behavior and utilization of health services in the study center as well as nearby government facilities. Strengths, weaknesses, opportunities, and threats of the management of diseases at the study center were also identified.

RESULTS

In the event of an acute illness, 40% preferred government hospital, 40% private, 16% of study center, and 4% sought treatment from traditional healers. On comparison with nearby government facilities, the study center was located far away, travel time and fare to reach was more and was preferred by all over government facilities. The difference in user perspective about both facilities was statistically significant (P < 0.00001). All of them trusted the staff and the services provided at the study center completely. Around 97% thought the services were made according to their convenience. About 59% spent on drugs and logistics after visiting the nearest government facility, whereas only 10.8% admitted to having spent on drugs and logistics after visiting the study center.

CONCLUSIONS

Faith-oriented health-care seeking behavior seems to dominate the health scenario. It is influenced by realistic factors such as accessibility, affordability, and acceptability.

Determinants of Antibiotic Consumption - Development of a Model using Partial Least Squares Regression based on Data from India

Antibiotic resistance, a consequence of antibiotic use, is a threat to health, with severe consequences for resource constrained settings. If determinants for human antibiotic use in India, a lower middle income country, with one of the highest antibiotic consumption in the world could be understood, interventions could be developed, having implications for similar settings. Year wise data for India, for potential determinants and antibiotic consumption, was sourced from publicly available databases for the years 2000–2010. Data was analyzed using Partial Least Squares regression and correlation between determinants and antibiotic consumption was evaluated, formulating ‘Predictors’ and ‘Prediction models’. The ‘prediction model’ with the statistically most significant predictors (root mean square errors of prediction for train set-377.0 and test set-297.0) formulated from a combination of Health infrastructure + Surface transport infrastructure (HISTI), predicted antibiotic consumption within 95% confidence interval and estimated an antibiotic consumption of 11.6 standard units/person (14.37 billion standard units totally; standard units = number of doses sold in the country; a dose being a pill, capsule, or ampoule) for India for 2014. The HISTI model may become useful in predicting antibiotic consumption for countries/regions having circumstances and data similar to India, but without resources to measure actual data of antibiotic consumption.

Prevalence of noncommunicable disease risk factors among the Kani tribe in Thiruvananthapuram district, Kerala

Background & objective

Noncommunicable Disease (NCD) risk factors are on the rise and often linked to the adoption of modern lifestyles. This study explores NCD risk factors in a rapidly modernising indigenous population in Kerala, the Kani tribe.

Methods

A representative sample of 298 adults of the Kani tribe in Thiruvananthapuram district was studied using the WHO stepwise framework for surveillance of NCD risk factors. Descriptive, bivariate and multivariable analysis were done using the R statistical package.

Results

Prevalence of hypertension (48.3%), use of tobacco (81.5%) and alcohol consumption (36.2%) were found to be higher in the Kani tribe compared to the general population in Kerala. Abdominal obesity (22.1%) is found to be higher in Kani tribes compared to other tribal groups in India. The physical inactivity level (9.7%) was similar to urban Kerala and higher than many other tribes in India. Hypertension was scientifically associated (p < 0.05) with higher age, male sex, low education levels, and tobacco intake among them. On multivariable analysis, age and alcohol consumption were found to be the prominent risk factors for hypertension and high education level was found to be a protective factor.

Conclusion

The major modifiable NCD risk factors were found to be higher among the people of the Kani tribe compared to the general population in Kerala. Physical inactivity level was comparable to urban Kerala, and obesity rates were higher than many other tribal communities in India. The findings warrants targeted action in these vulnerable communities for effective control of the noncommunicable epidemic.

Mumps outbreak in a tribal population from the Union Territory of Dadra and Nagar Haveli, India

A cluster of parotitis cases (n = 13) were observed in a tribal population of Vansda village from the Union Territory of Dadra and Nagar Haveli, India between 20th and 22nd week of 2016. Primary information was received by the local Infectious Disease Surveillance Program team, and subsequently field investigations were carried out in the affected area. Active surveillance was conducted till twice the incubation period from onset of the last surveyed case. For the laboratory investigations, 19 serum samples were collected from 11-suspected cases and their close contacts (n = 8). All samples were transported within 12 h on icepacks to the main laboratory at Pune. Majority of the suspected mumps cases were children except four adults. Mumps infection was confirmed in 8 of 11 suspected cases with post-onset ranging from 28 to 43 days and none from the close contacts. Both mumps specific IgM and IgG antibodies were detected in nine cases (including one equivocal) and single contact (equivocal result). Overall, ten cases and eight contacts (including one equivocal) showed mumps specific IgG antibodies. Present investigation provides information about the characteristics of mumps outbreak in a tribal community that resides in the remote areas. In addition, introduction of mumps containing vaccine in the tribal population may have added advantages in the tribal health program.