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Towards Health Equity and Transformative Action on Tribal Wellcome Open Research 2019, 4:202 Last updated: 28 MAY 2020 STUDY PROTOCOL 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 [version 1; peer review: 2 approved] Prashanth Nuggehalli Srinivas 1, Tanya Seshadri 2, Nandini Velho3, Giridhara R Babu 4, C Madegowda5,6, Yogish Channa Basappa 1, Nityasri Sankha Narasimhamurthi 1, Sumanth Mallikarjuna Majigi 7, Mysore Doreswamy Madhusudan8, Bruno Marchal9 1Institute of Public Health, 3009, II-A Main, 17th Cross, KR Road, Siddanna Layout, Banashankari Stage II, Bengaluru, Karnataka, 560070, India 2Vivekananda Girijaya Kalyana Kendra, Biligiriranga Hills, Yelandur Taluk, Chamarajanagar District, Karnataka, 571441, India 3Department of Ecology, Evolution and Environmental Biology, Columbia University, New York, 10027, USA 4Indian Institute of Public Health-Bengaluru, Public Health Foundation of India, Bengaluru, Karnataka, 560023, India 5Zilla Budakattu Girijana Abhivruddhi Sangha, Hosapodu, Biligiriranga Hills, Karnataka, 571441, India 6Ashoka Trust for Research in Ecology and the Environment, Royal Enclave, Sriramapura, Jakkur Post, Bengaluru, Karnataka, 560064, India 7Department of Community Medicine, Mysore Medical College and Research Institute, Mysore, Karnataka, 570001, India 8Independent Researcher, 3076/5, 4th Cross, Gokulam Park, Mysore, Karnataka, 570002, India 9Institute of Tropical Medicine, Antwerp, Nationalestraat 155, 2000, Belgium First published: 13 Dec 2019, 4:202 Open Peer Review v1 https://doi.org/10.12688/wellcomeopenres.15549.1 Latest published: 13 Dec 2019, 4:202 https://doi.org/10.12688/wellcomeopenres.15549.1 Reviewer Status Abstract Invited Reviewers Background: In India, heterogenous tribal populations are grouped 1 2 together under a common category, Scheduled Tribe, for affirmative action. Many tribal communities are closely associated with forests and version 1 difficult-to-reach areas and have worse-off health and nutrition indicators. 13 Dec 2019 report report 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 1 Shridhar Kadam , Indian Institute of Public Health Equity and Transformative Action on tribal health (THETA) study has Health, Bhubaneswar, India three objectives: (1) describe and analyse extent and patterns of health inequalities, (2) generate theoretical explanations, and (3) pilot an 2 Prathibha Ganesan, Tata Institute of Social intervention to validate the explanation. Sciences, Mumbai, India Methods: For objective 1, we will conduct household surveys in seven Any reports and responses or comments on the forest areas covering 2722 households in five states across India, along a gradient of socio-geographic disadvantage. For objective 2, we will article can be found at the end of the article. 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 Page 1 of 20 Wellcome Open Research 2019, 4:202 Last updated: 28 MAY 2020 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. Keywords Health inequity, indigenous health, realist evaluation, participatory action research, tribal health, social determinants of health, forests and health This article is included in the Wellcome Trust/DBT India Alliance gateway. Corresponding author: Prashanth Nuggehalli Srinivas ([email protected]) Author roles: Srinivas PN: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Software, Supervision, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing; Seshadri T: Conceptualization, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing; Velho N: Conceptualization, Funding Acquisition, Methodology, Writing – Review & Editing; Babu GR: Conceptualization, Funding Acquisition, Methodology, Writing – Review & Editing; Madegowda C: Conceptualization, Funding Acquisition, Project Administration, Supervision; Channa Basappa Y: Investigation, Methodology, Project Administration, Software, Validation, Visualization, Writing – Review & Editing; Narasimhamurthi NS: Investigation, Project Administration, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing; Majigi SM: Investigation, Resources, Supervision, Validation; Madhusudan MD: Data Curation, Funding Acquisition, Methodology, Resources, Software, Writing – Review & Editing; Marchal B: Conceptualization, Funding Acquisition, Methodology, Resources, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing Competing interests: No competing interests were disclosed. Grant information: This work was supported by the Wellcome Trust/DBT India Alliance Intermediate Clinical and Public Health Research Fellowship awarded to Prashanth Nuggehalli Srinivas [IA/CPHI/16/1/502648]. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Copyright: © 2019 Srinivas PN et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite this article: Srinivas PN, Seshadri T, Velho N et al. 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 [version 1; peer review: 2 approved] Wellcome Open Research 2019, 4:202 https://doi.org/10.12688/wellcomeopenres.15549.1 First published: 13 Dec 2019, 4:202 https://doi.org/10.12688/wellcomeopenres.15549.1 Page 2 of 20 Wellcome Open Research 2019, 4:202 Last updated: 28 MAY 2020 Introduction Inequity and inequality Over 8.6% of India’s population is comprised of tribal According to the World Health Organization, inequities are communities1. Constitutionally recognized for affirmative action “unjust differences in health between persons of different as Scheduled Tribes (STs), they are mostly forest-dwelling and social groups, (which) can be linked to forms of disadvan- have lived in and around legally protected forest areas in south, tage such as poverty, discrimination and lack of access to serv- central and north-east India2. Among various social categories ices or goods”13,14. A related term, health inequality, needs to in India, the ST population have poorer access to healthcare as be distinguished from health inequity. Whereas inequalities in well as poor national and state-level average population health health are related to differences between population groups, outcomes3–5. These include higher maternal and infant mortality arising from genetic, biological or other factors that may and morbidity due to communicable diseases, higher childhood be randomly distributed, inequities, on the other hand, malnutrition and higher rates of non-communicable diseases, have a strong social causation and a non-random pattern of which have increasingly been reported in recent years. Com- distribution; they tend to aggregate in specific socially parison of various demographic, health and nutrition indicators constructed groups due to underlying societal characteristics shows nearly uniformly poor health status among ST popula- that mediate access to power and resources14,15. The conceptual tions but with variations across Indian states (see Extended data underpinnings of inequities is in social justice and in line with for a table showing comparison)6,7. The social group Scheduled this, health inequities are characterised by: (a) systematic Tribe (ST) has its origins in state-specified lists for implementing and consistent patterns of advantage or disadvantage across affirmative action policies as per the Indian constitution. specific population groups (pattern of consistent differences Several communities that may not have a close associa- in access to health services between rural and urban popula- tion with forests are also in this list. Hence, several tribal tions); (b) social, rather than biological, processes (nearly global communities closely associated with forests prefer the term pattern
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