Health Issues and Health Seeking Behaviour of Tribal Population

January 2009

CONTRIBUTORS Madhumita Das Nikhil Kumar Shivani Kapoor Suranjeen Prasad

WITH INPUTS FROM Christie Minj Dinesh Singh Deepak Tubid Sudhir Kumar Sharma

EDITOR Aishwarya Pillai Gigoo

Design, Layout and Print: New Concept Information Systems Pvt. Ltd. Email: [email protected]

For further information, contact: Futures Group International DLF Building, No. 10 – B, 5th Floor, DLF Cyber City Phase – II, Gurgaon – 122002 (Haryana) Health Issues and Health Seeking Behaviour of Tribal Population in Jharkhand

This publication was produced for review by the United States Agency for International Development. It was prepared by Futures Group International.

January 2009

Jharkhand Health Society Ministry of Health and Family Welfare Medical Education and Research Government of Jharkhand

The views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government.

TATES S AG ED E T N I C N Y U USAID

I

N

T

T N

E E R N M P USAID A T O IO EL FROM THE AMERICAN PEOPLE NAL DEV

FOREWORD

Jharkhand is home to over 30 tribes constituting 26.3 percent of the total population of the state, as per Census of India, 2001. Due to the gaps in information available on the health practices and service utilisation of the tribal population in Jharkhand, there have been constraints in addressing their requirements through appropriate policy measures and service delivery.

The second phase of the Innovations in Family Planning Services (IFPS) Project focuses on improving access to affordable quality family planning, reproductive and child health services. Creating demand for reproductive health services and products, as well as stimulating health behaviour change is one of the key focus areas of the IFPS project.

We are glad that the Government of Jharkhand in collaboration with ITAP (IFPS-II Technical Assistance Project) has taken this pioneering initiative to carry out a comprehensive qualitative assessment study to understand and analyse the health seeking behaviour of the major tribal groups, with a focus on the traditional system of healing. The study looks at identifying the key behaviours, traditional rituals, beliefs, practices and remedies (specifically related to reproductive and child health) followed by the Santhal, Munda, Oraon and Ho tribal groups, in the Santhal Pargana and South Chhotanagpur regions. There has also been an attempt to grasp the interplay of the physical and political environment within which these select tribal groups live.

The report explains the underlying barriers of geographic access, economic constraints and specific cultural issues which need to be addressed to improve health service utilisation by the tribal groups. We are confident that this study will help boost and guide the state initiatives in ensuring ‘Health for all’.

Kerry Pelzman Director Office of Population, Health and Nutrition USAID/India U.S. Agency for International Development American Embassy Tel: 91-11-24198000 Chanakyapuri Fax: 91-11-24198612 New Delhi – 110021 www.usaid.gov/in

CONTENTS

Foreword iii Executive Summary vii

SECTION A OVERVIEW 1 1.1 Introduction 1 1.2 Tribal Population in Jharkhand 1 1.3 Literature on Tribal Issues 1 1.4 Rationale of Study 2 1.5 Goal and Objectives of the Study 3 1.6 Methodology 3 1.6.1 Study design 3 1.6.2 Qualitative methods 3 1.6.3 Data collection strategies 4 1.7 Training Investigators 4 1.8 Data Analysis 4 1.9 Maintaining Ethical Conduct 4 1.9.1 Talking about the culture 4 1.9.2 Informed consent 4

SECTION B FINDINGS AND RESULTS 5 2.1 Habitation 5 2.2 Occupation 5 2.3 Migration 6 2.4 Local Religion and Festivals 7 2.5 Level of Technological Advancement 7

SECTION C TRIBAL HEALTH SEEKING BEHAVIOUR 8 3.1 Munda Tribe 8 3.2 Santhal Tribe 13 3.3 Oraon Tribe 16

Contents v 3.4 Mal Pahariya Tribe 21 3.5 Ho Tribe 25

SECTION D SUMMARY: MATERNAL HEALTH CARE AMONGST THE TRIBAL POPULATION 28 4.1 Present Practices 28 4.1.1 Institutional care 28 4.1.2 Care at home 28 4.1.3 Care during delivery 28 4.1.4 Maternal mortality and morbidity 29 4.1.5 Treatment modalities employed and preference of service provider 29 4.1.6 Making maternal health a reality in the tribal community 29 4.2 Child Health Care Amongst the Tribal Population 30 4.2.1 Morbidity and mortality in childhood 31 4.2.2 Intranatal and immediate postnatal care 31 4.2.3 Breastfeeding and complementary feeding 31 4.2.3 Immunisation-awareness, decision-making, practices and beliefs 31 4.2.4 Care in illness 31 4.2.5 Reasons for poor child survival 32 4.2.6 Ensuring child survival amongst the tribal community 32 4.3 Family Planning Needs of the Tribal Population 33 4.3.1 Situational analysis 33 4.3.2 Availability and accessibility of services 34 4.3.3 Utilisation of services 34 4.3.4 Traditional methods 34 4.4 Traditional Medicine and its Significance within the Tribal Framework 34 4.4.1 Tribal medicine and practitioners in Jharkhand 35

SECTION E CONCLUSION 36 RECOMMENDATIONS 37 REFERENCES 38 LIST OF ACRONYMS 40 ANNEXURES 41

LIST OF TABLES Table 1: Description of Study Villages 6 Table 2: Major Occupation of the Tribal Groups in the Study Area 7 Table 3: Local Festivals 7 Table 4: Common Illnesses in the Munda Tribe 8 Table 5: Common Illnesses in the Santhal Tribe 12 Table 6: Common Illnesses in the Oraon Tribe 16 Table 7: Common Illnesses in the Mal Pahariya Tribe 21 Table 8: Common Illnesses in the Ho Tribe 25

LIST OF FIGURES Figure 1: Map of Study Area 5

vi Health Issues and Health Seeking Behaviour of Tribal Population in Jharkhand EXECUTIVE SUMMARY

he current study intends to assess the attitude towards health among tribal groups in Jharkhand – their faith, Tbeliefs and health seeking behaviour, as well as the available health facilities and their utilisation, in terms of maternal and child health. An attempt has also been made to look across the cultural variations of various tribes, with regard to their health seeking behaviours, which do not encompass modern medical practices.

The study was conducted among five major tribes in Jharkhand: Santhal, Munda, Oraon, Ho and Pahariya. These tribes are mainly scattered in the Santhal Pargana and South Chhotanagpur regions of the state. It was observed that these tribes still adhere to indigenous rituals, behaviour, beliefs and practices for general illness, maternal and new born care, and also for reproductive and sexual health issues. The study has tried to identify existing healing rituals, perception about the existing health system, the role of indigenous medicine among the tribal population and integration of traditional medicine with the prevailing reproductive and child health programme among the traditional service providers and providers from the mainstream health system.

Qualitative techniques were employed to learn the traditional healing practices of tribal people. Two villages comprising each of the five identified tribal groups were selected, one village being closer to an urban conglomeration and the other classified as ‘hard to reach’.

The study was conducted by five different teams with six members in each team. Each team conducted one participatory rural appraisal exercise, one focus group discussion, five key informant interviews and ten in-depth interviews with the eligible couples.

This study report deals with child health issues (specifically infant and early child care practices), family planning needs and the significance of traditional medicine in the tribal framework.

Child Health: Childhood morbidity and mortality, intranatal and immediate postnatal care, breastfeeding and complementary feeding, awareness and decision making regarding immunisation are some of the key topics touched upon through this study.

Family Planning: In Jharkhand, only 36 percent of married women use any method of contraception, compared with 56 percent at the national level. It could be even less among the tribal people, since factors like acceptance of family planning methods, availability and accessibility of services, utilisation of services and use of traditional methods play an important role.

Traditional Herbal Medicine: Tribal people live in forests and depend completely on the land and forest for their daily needs. Hence, for their medical problems, they prefer to be treated by the vaid raj or vaidya (traditional healer) with traditional medicine, which essentially uses extracts from herbs found in the forests. Due to their easy

Executive Summary vii accessibility and availability, these healers wield significant influence over the health seeking behaviour of the tribal groups.

The findings of the study provide an insight into the reasons why tribal people have different health issues and health seeking behaviours in the present scenario, when, as a nation, we have the most modern health system in place. The study also reflects on why these people still follow obsolete practices and why it may be necessary for them to have a separate system. The tribes, by and large, are animists, that is, they worship nature, and hence, they derive maximum comfort from organic material and methods of treatment. The community feels alienated at institutions such as district hospitals, which are generally staffed by non-tribals, who are perceived as treating the tribals condescendingly. The fact that the distances between health facilities and residences are considerable and the transport system is poor, further, adds to the community’s reluctance in adopting the modern health care system.

This study can prove to be an invaluable reference point for policy-makers and implementers while developing a tribal health initiative strategy for the state of Jharkhand. Section A

OVERVIEW

1.1 INTRODUCTION population shows that the majority these groups are small in number The state of Jharkhand was formed reside in Simdega (72%), Gumla (numbering just over two lakhs), on 15th November, 2000 with Ranchi (70%), Pashchim Singhbhum (66%) have not attained any significant level as its capital. Jharkhand has an area and Lohardaga (56%) districts. The of social and economic progress, and of 79,714 sq. km and a population STs constitute more than half of the generally inhabit remote localities of 26.9 million. The scheduled tribe total population in Lohardaga and with poor infrastructure. Therefore, (ST) population of Jharkhand, which Pashchim Singhbhum districts. they become the most vulnerable numbers 7,087,068, constitutes sections among the STs and priority 26.3 percent of the total population Santhal is the most populous tribal is required to be accorded for their of the state (Census of India, group, numbering 2,410,509 and protection, checking the declining 2001). Among all the states in constituting 34 percent of the total trend of their population and their India, Jharkhand holds 6th and 10th ST population of the state. Other overall development. The PTGs in position in terms of ST population major tribes are Oraon (20%), Munda Jharkhand are Asur, Birhor, Birija, and the percentage share of the ST (15%) and Ho (11%). District-wise Hill Kharia, Korwa, Mal Pahariya, population to the total population of distribution of individual STs shows Parhaiya, Sauria Pahariya and Savar. the state, respectively. The growth that the highest numbers of Santhals of the ST population in the state has are in Dumka district, followed 1.3 LITERATURE ON TRIBAL been lower than the growth of the by Purbi Singhbhum, Pakur and ISSUES total population during 1991-2001. Sahebganj, but they constitute the Several studies have focused on Population density of the state is 338 highest proportion of the total ST the issues of downtrodden tribal per sq. km, which clearly indicates population in Giridih (91%), followed groups, which are a major concern that the inhabitants of the state are by Dumka (90%) and Pakur (85%) for social scientists, since the scattered. districts. The other six major tribes, holistic development of society namely Munda, Ho, Khairwar, Lohra, cannot be achieved, without the The state is divided into five regions , and Kharia are concentrated inclusion of these communities – Santhal Parganas, Daltonganj, in Ranchi, Pashchim Singhbhum, which are mostly illiterate, have Kolhan, North Chhotanagpur and Palamu, Purbi Singhbhum and traditional beliefs and constitute South Chhotanagpur. Jharkhand Gumla districts. the poorest segment of the Indian shares its border with five states population (Mutatkar R.K., 2004). – , , Orissa, Uttar Among STs, there are certain tribal Tribal populations are isolated from Pradesh and Chhattisgarh. communities who have declining the general population by virtue of or stagnant population, low level their own physical, socio-economic 1.2 TRIBAL POPULATION IN of literacy, pre-agricultural level of and cultural environment. JHARKHAND technology and are economically The ST population is primarily rural, backward. Nine such groups exist As the medical systems of any as 92 percent reside in the villages. in Jharkhand, which are identified society are cultural derivatives, The state has a total of 30 ST groups. and categorised as Primitive the traditional health care system District-wise distribution of the ST Tribal Groups (PTGs). Most of of tribal groups persists long after

Overview 1 western innovations in health tribal groups. The main causes of Poverty and poor infrastructural care are implemented (Mahapatra, maternal mortality were found to be development in tribal dominant 1994). In most tribal communities, unhygienic and primitive practices for areas have contributed hugely to there is a wealth of folklore related parturition (Basu, et al., 1990). On the inability of the maternal and to health. Health and treatment the other hand, infant mortality is child health (MCH) programmes in are closely inter-related with the also found to be generally high among reaching out to the tribal population. environment, particularly the the tribal population. Conditions Mobilisation of the people in forest ecology. Many tribal groups in the different tribes depend on collective action for poverty use different parts of a plant, not their socio-cultural, economic and alleviation will pave the way for a only for the treatment of diseases, demographic characteristics, and better and sustainable model for but for population control as on the magnitude and direction of MCH control in these areas. well (Chaudhuri, 1990). Singh the forces of modernisation, such (1994) highlights the effect of the as urbanisation and industrialisation In contrast to the traditional health changing physical environment (Bose, 1970). The influence of care system, the official state health on tribal health, which impacts in some tribal areas has care system is based on western their economic pursuits, access to also played a significant role science and technology, separating nutrition, medicines and so on. Thus, (Madan, 1951). it from broader social and cultural it can be deduced that ecology and influences. It is evident that the state- tribal health are intimately related. Reproductive tract infections (RTIs), supported medical system does not especially amongst women, are a generally recognise the traditional Guite and Acharya (2006) have significant public health problem. medical systems. John Bryant (1988) shown that the acceptance of a 53 percent of women reported sees the involvement of the individual particular health care system among gynaecological symptoms, 38 and the local community in primary the tribal people depends on its percent had laboratory findings of health care not as a social nicety, but availability and accessibility. RTI and 14 percent had clinically as a medical necessity. Services that diagnosed pelvic inflammatory disease are delivered from the outside have The health and nutrition problems (PID) or cervicitis (Prasad, 2005). little effect, unless absorbed by the of the vast tribal population of According to laboratory diagnoses, individual and the community. It has India were as varied as the tribal 15 percent had sexually transmitted been seen that the diverse and deep- groups themselves, who presented infections (STIs) and 28 percent had rooted social and cultural constructs a bewildering diversity and variety endogenous infections. Two-thirds of of a society play an important, and in their socio-economic, socio- symptomatic women had not sought often, decisive role in deciding the cultural and ecological settings. The any treatment; the reasons cited acceptability of a particular health nutritional problems of different were absence of a female provider care option. tribal communities located at various in the nearby health care centre, stages of development were full of lack of privacy, distance from home, Thus, a study exploring the nature obscurities and very little scientific cost and a perception that their and extent of acceptance of modern information on dietary habits and symptoms were normal. Parchure health care facilities among the nutrition status was available due to and Warvedakar (2008) have also target group was imperative, as an lack of systematic and comprehensive mentioned that only 42 percent of input towards policy planning for research investigations (Studies in women with RTI seek care. their overall development. Methods, U.N., 1984). The popular belief that most 1.4 RATIONALE OF STUDY Maternal and child care is an diseases occur due to supernatural The scenario, with respect to important aspect of health seeking powers led to the concept of maternal and child health, in behaviour, which is largely neglected seeking relief through jadoo (magic), the state of Jharkhand calls for among the tribal groups (Basu et keeping the modern medical immediate action. According to the al., 1990). Maternal mortality was practitioners as a last resort recently conducted National Family reported to be high among various (Sumathy S.R., 1990). Health Survey (NFHS-III, 2005-06),

2 Health Issues and Health Seeking Behaviour of Tribal Population in Jharkhand the infant mortality rate (IMR) in the traditional system of healing. Two villages comprising each of the the state is 69 per 1000 births. five identified tribal groups were On the other hand, the maternal Objectives selected. Selection of the villages mortality ratio (MMR) is 371 per  To identify the key behaviour, was purposive, with one village being 100000 live births (SRS, 2005). traditional rituals, beliefs, closer to an urban conglomeration These two critical indicators of poor practices and remedies followed and the other classified as ‘hard health were found to be higher than during critical stages related to to reach’. The habitations were the national average. As for the health and disease chosen with the help of local non- nutritional status of children, which  To assess the knowledge governmental organisations (NGOs), is a determining factor for child level, utilisation and who provided the logistics for the health, about 57 percent of children traditional practices related to study and helped in building rapport are underweight. Only 59 percent contraception with the community. of mothers received at least one  To identify treatment seeking antenatal care in the last three years behaviour during pregnancy, 1.6.2 Qualitative methods period, while 18 percent of pregnant delivery and post-delivery period The types of qualitative techniques women delivered their babies in  To examine the rituals and used for this study are explained in some kind of institution (NFHS-III, practices related to newborn this section. 2005-06). care and breastfeeding  To identify the beliefs and Research tools Lack of proper health care practices perception about RTI/STI issues At each habitation, the following coupled with the traditional form of  To identify existing healing exercise took place: health care followed by this group rituals, perception about the  Transect walk and meeting key renders the women and children existing health system, the role of influential people of the village vulnerable to adverse health indigenous medicine among the for consent. implications. Indigenous healing tribal population and integration  Participatory rural appraisal practices have survived, evolved and of traditional medicine with (PRA) tools: are still widely practiced in the tribal the prevailing reproductive and  Social mapping to list areas. Today, some of these tribal child health (RCH) programme resources and utilisation of healers practice a hybrid form of among the traditional service services healing, that combines rituals with providers and providers from the  Force field analysis, quasi-allopathic or complementary mainstream health system. listing and pile sorting for medical practices. perception of health system 1.6 METHODOLOGY and treatment seeking The study intends to assess the 1.6.1 Study design behaviour attitude towards sickness among the The study used qualitative techniques  Key informant interview (KII) tribes, their faith, beliefs and health to learn about the experiences, with: seeking behaviour, as well as the perceptions and practices of relevant  Auxiliary Nurse Midwife available health facilities and their health seeking behaviour, especially (ANM)/Anganwadi Worker utilisation, in terms of MCH and the traditional healing practices of (AWW)/Traditional Birth RTI/STI services. An attempt has also tribal people. The sample has been Attendant (TBA) been made to look across the cultural drawn from the Santhal, Munda,  Local registered medical variations of various tribes, with regard Oraon and Ho tribal groups in practitioner (RMP), who to their health seeking behaviours. the Santhal Pargana and South practices in the village Chhotanagpur regions. A minority  Traditional healers 1.5 GOAL AND OBJECTIVES tribal group such as Pahariya has been (village-based) OF THE STUDY added to the list of tribal groups being  In-depth interview (IDI) with: To identify the existing health studied, to check their health seeking  At least one woman/couple seeking behaviour of couples in the behaviours and find any differences with experience of neonatal major tribal groups, with a focus on that exist among the tribes. death

Overview 3  At least one respondent the help of the villagers. The six been analysed in accordance with the with experience of maternal member team comprised one team content analysis technique. death in the household or leader and one facilitator from the near miss Child In Need Institute (CINI), along 1.9 MAINTAINING ETHICAL  Focus group discussion (FGD) with two team members who have CONDUCT with eligible couples experience in conducting qualitative research. Two members (one male 1.9.1 Talking about the culture Triangulation of data and one female) from the study It is common knowledge that tribal KII with one or more of the following tribal community were included people are protective about their for each selected tribal group: in the team, who would facilitate cultural settings. They neither allow  Social activists the whole research study and help outsiders to enter with impunity nor do  Herbal practitioners (specialists) the team understand the situation they go outside their settings too often.  Modern doctors/health workers at the grassroots level. The teams The research team used a participatory (at Mission hospitals and conducted one PRA exercise, one approach to come closer to the government hospitals) FGD, five KIIs and 10 IDIs with the participants and also stayed in the village eligible couples. to observe the cultural practices and 1.6.3 Data collection strategies beliefs. The researchers came across The provisional timeline for the 1.7 TRAINING lots of problems while interacting with fieldwork was two weeks, including INVESTIGATORS respondents, especially with respect participatory approach, IDI, FGD The research team went through to taboos. It was very difficult for the and KII (such as traditional healer, intensive training sessions for two research team to ask questions and ANM, TBA etc.). days, where topics related to maternal ascertain what a person knew about and child health care, ethical issues his/her illness and how they felt about Data collection in the study was and qualitative techniques were it. Researchers were cautioned against carried out in a way that ensured discussed. A field practice was carried asking direct questions about illness, data quality. The process of data out immediately after the training. especially any related to STI/RTI and collection started from the second death. In order to comply with ethical week of November 2007. 1.8 DATA ANALYSIS norms, agreement on an informed The interviews with identified consent form was obtained before There were six members in each couples, health service providers and starting the interview. team and these teams stayed in the traditional healers were recorded and village for five consecutive days to fully transcribed with accompanying 1.9.2 Informed consent ensure quality data collection with field notes. All transcribed data has Researching health issues necessarily means engaging with people (both patients and their families) who may be in extremely poor health and experiencing exhaustion, depression, or high levels of stress and anxiety. For this reason, participants were fully informed about their role in the study and about the possible risks and discomforts that might arise during the interview. Even after consent was given, its validity was regularly re-confirmed. Participants were given several opportunities to withdraw during interviews or focus groups. Investigators also ensured confidentiality during and after the interview.

4 Health Issues and Health Seeking Behaviour of Tribal Population in Jharkhand Section B

FINDINGS AND RESULTS

his report is a qualitative The Mal Pahariyas are a primitive varied between the villages and Tassessment of the health tribal group and during the last ranged from 30 to 150 households. situation, the preventive health Census enumeration (Census of care practices, the health seeking India, 2001), their population in the 2.2 OCCUPATION behaviour related to RCH services, state was just over 60,000. Many Most of the tribal groups depend use of traditional and modern years ago, this tribal group was solely on land for their livelihood methods, and the interplay of the forced to leave their lands in the (Table 2). They cultivate their own physical and political environment in plains and move to the hills (pahar), land and practice mono-cropping. which the selected tribal groups live. thus the name ‘Pahariya’ attached All these villages are rain-fed areas with this tribal group. Some of them and depend heavily on the monsoon. This section describes the selected settled in the plains to work as daily They have no access to modern village profile, the people, their wage labourers. The habitation size irrigation facilities. occupation and their ecosystem. Figure 1: Map of Study Area 2.1 HABITATION Two habitations from each tribal group were studied. A brief SAHIBGANJ description of the villages visited is given in Table 1. One village with GODDA access to modern amenities and one PAKUR without were included in the sample KODERMA PALAMU DEOGHAR for the survey. CHATRA GIRIDH DUMKA GARHWA HAZARIBAGH JAMTARA Most of the study population LATEHAR BOKARO DHANBAD were living in the area for many RAMGARH generations and have been LOHARDAGA RANCHI protected by two special Land GUMLA Acts enacted during the British KHUNTI rule, whereby they have limited SARAIKELA-KHARSAWAN opportunity to buy or sell their EAST SINGHBHUM land. SIMDEGA WEST SINGHBHUM The only village in the study where the tribes have no landholdings (Map not to scale) belongs to the Mal Pahariya tribal group in Dumka district. Source: www.jharkhand gov.in

Findings and Results 5 Table 1: Description of Study Villages Tribe District Block Distance Geographical access Remarks from main road Munda Khunti Murhu 10 km Connected by road and is Traditional Munda community. accessible. Religion – Sarna (Animism). 5 km Connected by road and is Predominantly Christian community accessible. and people are literate. Oraon Gumla Raidih 25 km Situated in hilly area and is Predominantly Oraon village, with 25 km from main town. poor access and facilities. 36 km Situated at the top of a hill Predominantly Oraon village, with and difficult to reach. poor access and facilities. Mal Dumka Raneshwar 35 km Situated at the top of a hill Typical Pahariya village on the top of Pahariya and difficult to reach. a hill, accessible through a 30 minute trek, non-motorable. Only one community lives there. 15 km Situated in the plains and is Live with Hindus (Bengalis) and work accessible. as daily wage labourers. Have no land holdings. Santhal Sahebganj Barharwa 15 km Difficult to access but Santhal community is in majority in motorable road exists. this village. Close to the Close to town and is easily Predominantly Santhal village. Highway accessible. Ho West Manjari 32 km In the interiors and is a Has a mixed population and the Singhbhum backward village, very people lack awareness and education. close to the Orissa border. This village lacks basic facilities of health, education and transportation. Khuntpani 5 km Easily accessible, and has People are educated and aware. transportation facility. Missionary school present since 1934.

Paddy, madua (ragi) and pulses are water, the uncertainty of rain or less mainly grown in these areas. The rainfall in particular years leads to tribes also grow vegetables including the movement of these tribal groups cabbage, cauliflower, different kinds to other places. The maximum of beans, spinach and potatoes. migration takes place between Apart from agriculture, the tribes January and May. The tribes also are engaged in other activities such migrate during the winter season, but as collecting wood from the forest the rate of migration is much less. and selling it in the market (carried out mostly by the Oraon tribe). The social activist of the area described various patterns of 2.3 MIGRATION migration that take place among In the studied villages, seasonal these tribal groups. Most of the migration was common amongst the migration is related to distress, Oraon, Pahariya and Ho tribes. Since lack of food availability and the these tribal groups depend mostly opportunity for labour during on agriculture for their livelihood harvesting months in neighbouring and are solely dependent on rain states.

6 Health Issues and Health Seeking Behaviour of Tribal Population in Jharkhand Table 2: Major Occupation of the Tribal Groups in the Study Area Tribe Occupation Summer Rainy Winter Munda Sowing vegetables Sowing paddy Harvesting paddy and vegetables Oraon Sowing paddy and vegetables Sowing paddy Harvesting paddy and vegetables Mal Pahariya Sowing paddy, arhar, bajra and corn Sowing barbatti, kurthi and madua Harvesting paddy Santhal Sowing paddy, mustard, masoor, Sowing paddy Harvesting paddy, mustard, khesari and chana masoor, khesari and chana Ho Sowing paddy and maize Harvesting paddy, maize and Harvesting vegetables like vegetables tomato and cauliflower

A social activist (45 years, graduate, during the harvest season to assist German Lutherans were the first unemployed) commented, “Amongst their family members. Christian missionaries to arrive in the Munda and Oraon, a massive this area in the 1870s. migration of young girls aged 2.4 LOCAL RELIGION AND 10 to 18 takes place, mainly to FESTIVALS Most villages have a designated place major metropolises, especially to Most of the tribes are animists, i.e., for meetings, where the traditional Delhi. These girls migrate to work nature worshippers. Their religion dance called the akhra is held. The as domestic servants, labourers in is Sarna, though in the Census they akhra has been described by a the fields (in states like Punjab) and are marked as Hindus. Most villages social activist as an important local occasionally get into the sex trade.” have a sacred grove, where the institution that needs to be revived people believe the souls of their to instill a sense of pride and bring Most tribal men, who have migrated ancestors live. Some of the tribes the people together on a common for work to other areas, return have converted to Christianity. The platform to discuss issues related to their welfare.

Table 3: Local Festivals 2.5 LEVEL OF TECHNOLOGICAL Tribe Festivals ADVANCEMENT Summer Rainy Winter All the villages in the study lacked Munda Sarhul (Baha Parv) Her Puna and Rova Puna Sukan Buru Mela, adequate electricity. Some were and Holi (Fagu) Poos Mela, Dussehra well connected to the road, but and most could be reached only through Oraon Sarhul and Good Karma and Jitiya Katni Parv, an unmetalled/kuccha road. A few Friday Christmas, New villages had schools and most had Year and Her Puna Anganwadi centres (AWCs), some of Pahariya Holi, Surya Puja Harihar Puja (Nag Durga Puja, Diwali, which, though, were non-functional. and Vishnu Puja Panchmi), Raksha Kali Puja, Aswin Puja (chadicya puja) Bandhan, Mansa Puja and and Bajna Regarding the health system, in most Karma Puja of the villages, injections were only introduced in the last five years. Santhal Holi and Sarhul Karma Dussehra and Diwali Allopathic medicines were also Ho Sarhul and Holi Hearo, Karma and Madhe Parv and Baa introduced to the community within Jomnama Parv Parv the last 5-10 years.

Findings and Results 7 Section C

TRIBAL HEALTH SEEKING BEHAVIOUR

his section highlights the health immunisation services, traditional at a distance of 18 km from one T seeking behaviour of each tribal care and practices village and 28 km from the other, group studied. The general illnesses whereas the private health providers that occur in the villages and the 3.1 MUNDA TRIBE (traditional/tribal healers) are mostly service providers that deal with 3.1.1 Common illnesses located within the village itself. them, are discussed, followed by Common illnesses found in the villages the continuum of care model that of the Munda tribe were classified 3.1.3 Tribal perception of begins with planning for a family to according to the season they occur in existing health system antenatal care, delivery and childcare. (see Table 4), in order to understand Tribal perception about the health Preventive and curative services/ the effect of weather on their health. system partially depends on the behaviours were listed and probed availability of and accessibility to, under the following heads: Malaria is the most common illness health facilities. The perception among the Munda tribe, which of the Munda tribe regarding the Family Planning: Ideal family size occurs specifically during the rainy existing health system differs in the and sex preference, decision-making and winter season. The tribe two villages, due to a variation in the process in family planning (FP), primarily depends on traditional presence of health facilities. traditional FP methods and access to healers/ojha. “Aksar yahan bache FP services malaria ya diarrhoea se maut ke Anganwadi workers are present in kareeb pahunch jate hain.” (Malaria both the villages, but found to be Pregnancy Care: Means of and diarrhoea are the usual causes non-functioning in one of them. No identification of pregnancy, traditional of child mortality) - ANM, Khunti other modern medical facilities were rituals during the antenatal (ANC) available, resulting in a greater belief period, knowledge of ANC, 3.1.2 Availability and distance of in and practice of traditional forms accessibility of ANC services, health services from villages of treatment. Most people in both decision-making to access services The sample villages were located villages prefer modern methods more than 10 km from the of treatment, but due to financial Birth Care: Birth preparedness, Government hospitals. The Primary problems, long hours of travel and decision on place, attendant at Health Centre (PHC) is situated lack of availability and accessibility, birth, birthing traditions and rituals, accessibility to modern birthing care Table 4: Common Illnesses in the Munda Tribe and emergency services Illnesses Summer Monsoon Winter Neonatal Care: Initiation of Itching, loo (heat/sun Diarrhoea, ulcer, boils, Malaria, pneumonia, breastfeeding, care at birth, access to stroke) and white malaria, filaria, Gal cough and cold, sarfatna, emergency services, traditional rituals discharge from genitals fulli (mumps), white and white discharge from discharge and itching in genitals Child Care: Access and usage of genital parts

8 Health Issues and Health Seeking Behaviour of Tribal Population in Jharkhand they have to depend on traditional respondents, a few important points healers. These remedies are used treatments. emerged which are listed below: for menstrual regulation, spacing  Perception that use of FP has of children and for permanent 3.1.4 Health service provider adverse effect on health contraception. The components preference  Low use of FP of these traditional medicines are The preference for health service  Decision-making on FP by both extracts from herbs collected from providers differs between the two the partners the forest areas. The community’s villages, due to their beliefs, the  Use of pills and condoms as faith in the traditional methods is availability of health facilities, the birth spacing methods high and their usage seems to be nature of the diseases and the  Low preference for a permanent quite prevalent. financial condition of the families. method, i.e. sterilisation In case of minor morbidity like  Initiation of FP after three to four There are mainly two forms of tribal swelling of feet, vomiting or children remedies found among the Mundas. weakness, the people first consult One is the use of herbal medicine a traditional healer, then an ANM/ Awareness prepared by the dai and the AWW, and lastly, doctors. In case There seems to be a fair level traditional healer/ojha, which is quite of a normal delivery, they mostly of knowledge of modern prevalent, and the other method is prefer a dai (midwife), and only contraceptives amongst the study rigorous massage of the abdomen of in critical cases, do they visit a population. Few of them had seen women to prevent conception. hospital. For diseases like malaria, and used contraceptives, mostly diarrhoea and white discharge, the the spacing methods. Permanent Access to and utilisation of villagers first try to get medicine methods, however, were not services from an AWW, and if they cannot too popular, because of the Access to condoms and pills depends get the medicine or cure, they visit unavailability of such services in the on the presence of a functional the doctor. immediate surroundings. Anganwadi or a social marketing entrepreneur in the vicinity. While traditional healers/ojhas, Home remedies Intrauterine devices (IUD), such as AWWs and ANMs are available and Many home remedies and traditional Copper–T, were rarely used. In fact, accessible, doctors are hard to find FP methods were mentioned during most ANMs who were interviewed in these villages. the discussion. The traditional said that they were not confident medicine for FP is available with in inserting a Copper-T/had never 3.1.5 Referral and related issues the dais as well as with traditional inserted one in their career. In critical health situations, the patients are referred to the hospital/doctor at Marangada, Khunti and Murhu. However, in many cases, due to unavailability of doctors at the centres or hospitals, the patients are left unattended and untreated.

3.1.6 Family planning Decision-making Knowledge, awareness, perception use and myths/beliefs related to FP were discussed with the couples during the interview. Based on the information provided by the

Tribal Health Seeking Behaviour 9 There is a sizable population with  Stomach ache with headache apparently depends on the availability the felt need for a sterilisation (Suni Ka) of services. There is a myth related operation, but due to non-availability  Blood in urine (Risa Rog) to tetanus toxoid (TT) injections of services, such operations could  Minor complaints like cough, within this community, where they not be performed. Some of the cold believe that taking the TT injections participants in the discussion  Weakness and vomiting. can lead to a large baby and, hence, recollected the FP drive enforced entails difficult labour. “Yahan kahte during the Emergency period in the Weakness during pregnancy was hain ki TT lene se bacha bada aur kada country in the 1970s, and talked cited by most women, which may be ho jata hai.”- Woman (36-40 years), about vasectomy in this context. the result of mild to severe anaemia. uneducated, Khunti.

3.1.7 Maternal health care Home remedies for morbidities Decision-making power with practices The Munda depend on traditional regard to ANC in tribal families Maternal mortality and healers and home remedies for lies with the husband or the morbidities treatment of morbidities during in-laws (usually, the mother-in- Three cases of maternal deaths pregnancies. Some of the popular law), and the expectant woman were reported from the two villages home remedies are: doesn’t have much say in it. In the under study, but the reasons for the  Kurti dal (a kind of pulses) water, Munda community, knowledge deaths were not known. to protect pregnant women and awareness of ANC varies from Chunko disease widely. In one of the study villages, The Munda community has its  Peppermint with water during the AWW herself did not have own set of symptoms to identify delivery to prevent heavy adequate knowledge about ANC, morbidities that commonly occur bleeding from vagina and consequently, the villagers were in women during pregnancy. For  A mix of salukittha, otechampa, ill-informed, too. On the other hand, instance, stomach pain along with tepal, hessa, bakla (local herbs), in the second village, which has headache is identified as Suni Ka jojo jam (seed of imli) and sugar, followers of Sarna and Christianity disease and blood in the urine is thrice a day, for white discharge as well as a functional Anganwadi, known as Risa Rog, two common  Mududa, etoramda, tarimsura the level of ANC knowledge complaints during pregnancy. (local herbs) and sugar mixed and awareness is rather high. In with water for five days for this village, the AWW provides Awareness regarding identification Risa Rog. information and services to pregnant or detection of pregnancy among women, including check-ups and the women was found to be Identification of pregnancy distributes iron and folic acid (IFA) negligible. As quoted by most of The Munda tribe primarily identifies tablets. the women during an FGD, “Pet pregnancy with the bulging abdomen dikhne pur hi pata chalta hai ki woh of the pregnant woman. They are Traditional rituals during pregnant hai…koi aur toh tareeka also aware of other symptoms like pregnancy, delivery and nahin hai.” (They have no specific cessation of the menstrual cycle, postpartum period way to know that a woman is loss of appetite, vomiting, tiredness Among the Mundas, pregnant pregnant, except when her stomach and weakness. The people identify women are not allowed to attend starts showing.) pregnancy simply by observing the any funeral ceremony, owing to the above symptoms and do not go for belief that it may affect the baby Common maternal morbidities any kind of medical check-up for adversely. They also sacrifice a hen  Malaria during pregnancy confirmation of pregnancy. to protect the pregnant woman and  Swelling of body child from the evil eye (buri nazar).  White discharge from genitals Decision-making on ANC In case of any complication during  Miscarriage The decision to register the pregnancy or delivery, the people  Pain in lower abdomen pregnancy and avail ANC services resort to praying to rectify matters.

10 Health Issues and Health Seeking Behaviour of Tribal Population in Jharkhand Only a few cases of institutional the mother is given steamed raw Decision-making regarding delivery were reported within the papaya, so that her milk will flow.) immunisation tribe. In the study village which has - TBA, Khunti Decisions regarding utilisation of a trained TBA, most deliveries are immunisation services are taken conducted by her. The TBA could Breastfeeding practices primarily by the husband and the in- identify the position of the baby in After delivery, the mother’s laws. The woman does not have any the mother’s womb by examining abdomen is massaged and both say in the matter. Some people are her abdomen. If the TBA observes mother and child are given bath. aware and are coming forward for reduced movement in the foetus, After an hour of birth, the child is immunisation, while others do not she gives a massage to the expectant given goat milk, instead of mother’s have much faith in it. woman with karanj (Indian beech) oil milk, as the community believes mixed with garlic. that colostrum is harmful for the 3.1.9 Child health care practices newborn. If the delivery occurs in Common morbidities in children The TBA’s key role is to assist the the early morning, the milk is given  Cough and cold pregnant woman during delivery after 2-3 hours. They dip cotton  Loose motion and to cut the cord with a new cloth in goat milk and put a few  Tongue ulcer blade and a one rupee coin. Using drops in the child’s mouth. Along  Malaria and diarrhoea the coin for severing the cord is with milk, they also start giving  Sarfatna (slit on the head) a common practice; it was found water to the newborn, since they  Naskhinchna (shrinking of veins) that the people do not take any believe that only having milk will  Rangbad (whole body turns measure to sterilise the coin. The make the baby thirsty. reddish) earlier practice was to cut the umbilical cord with an arrow in Decision-making regarding Identification of morbidity and case of a boy, and with a knife, in weaning treatment case of a girl. The family elders like the mother- High fever with shivering and lack in-law or father-in-law and other of appetite in children are some of The newborn is usually given a bath relatives make the decisions the symptoms for identifying malaria. with warm water and turmeric regarding weaning practices. They If a child is suffering from loose immediately after birth. An old guide the mother according to their motions and lack of appetite, then cotton cloth is used to wipe the experience. On the second day it is considered to be diarrhoea. baby after birth. The TBA massages after birth, the baby gets to suckle. A narrow slit on the head (open the lactating mother and the baby, The baby is given solid food only fontanelles and the crevices between till the cord turns dry. Six days after after six months. It was found, that the skull bones) accompanied with the birth, a function called Chhatiyari most children were given rice with fever, locally known as sarfatna, is celebrated, during which the TBA rice water, once they crossed six is quite common among infants. receives grain, money, cloth and months of age. In case of naskhinchna (strained hadia (local liquor) for her services nerves), a sudden movement leads to the mother and the child. 3.1.8 Practice and beliefs to tightening and hardening of the regarding immunisation jaws and the patient finds it difficult “Bacha hone ke baad maa ka pet Knowledge and awareness about to open the mouth. The home malish karte hain. Aur kuchh ek immunisation varies between the remedy used to treat this problem is ghanta baad bache ko bakri ka two villages. Where there is a massaging the jaws with hot mustard dhoodh dete hain aur maa ko kacha functional AWW/ANM, the people oil mixed with garlic. A child stops papeeta bhaanp ke dete hain tub are more aware, than in the location taking milk and food in case of a doodh utarta hai.” (After the baby without a service provider. The tongue ulcer, which is also common is born, the mother’s stomach is utilisation of services is quite good, among this group. A change in the massaged. And after an hour or depending on the availability of the colour of the face and stomach to so, the baby is fed goat milk and service provider. red, described as rangbad by the

Tribal Health Seeking Behaviour 11 local people, is also found to be services provided by the Integrated cloth pieces are usually washed and common in this community. This Child Development Services (ICDS) dried in the sun for reuse. illness is also characterised by a to pregnant and lactating women loss of appetite, and is treated with and children under the programme, If any RTI/STI symptoms persist, a local medicine prepared by the and thus either reluctant to avail the for example, if they feel pain in traditional healer, by combining services or are confused about the the genitals, they consult the vaid honey, pig fat and otechamla (a local services provided to them. raj, and if his medicine has no herb found in the forest). effect, they consult the doctors for 3.1.10 Reproductive health care treatment. In case of any treatment ICDS entitlements Knowledge of RTI/STI and health or consultation related to RTI/STI The children in the villages travel seeking behaviour problems, the couple visits the extensively, sometimes to adjacent People in this community know doctor together and seeks advice. villages, to get rice, pulses and about RTI/STI, but are not fully In most cases, the couples do not turmeric. The community agrees aware of all the diseases which may opt for counselling. At these times, that government health services are occur in the reproductive system couples avoid intercourse. good, but these need to be available or are caused by sexual contact. in the village itself or near the village. Though keeping the body clean is An IDI with a traditional healer Since the health centre is far from practiced universally, the people are reveals that the healers provide the village, reaching the facility at the not aware about cleaning the genital information on RTI, STI and Acquired appropriate time is difficult, and in area before sexual intercourse, Immuno Deficiency Syndrome (AIDS) many instances, the centre is found which is not part of their lifestyle. to all their patients/clients, and if they to be closed for the day. find any symptoms of RTI and/or STI, Adolescent girls use ordinary cloth they refer the patients to the District People are mostly unaware about the napkins during menstruation. These Hospital.

12 Health Issues and Health Seeking Behaviour of Tribal Population in Jharkhand 3.2 SANTHAL TRIBE Tribal perception of existing practices. Herbs are used for 3.2.1 Common illnesses health system children’s diseases and common The villagers were asked to Although the Santhals accept illness. provide a list of illnesses they modern medicine, they also visit  Dysentery: Lemon juice and/or suffer from, so as to understand traditional healers/ojhas, as they a dash of lime added to milk the pattern of illness. Table 5 have complete faith and belief in is given to stop dysentery describes the common illnesses them. Most villagers follow herbal completely. A pulp made of the within the community. Certain or traditional healing practices, not skin of tree, bel (bael diseases feature prominently because they do not want to take tree), and skin of amla (Indian during different seasons. In modern medicine, but because they gooseberry) is also fed to the summer, it is mostly loo/sun cannot afford the cost of visiting a dysentery patient. stroke which leads to a condition doctor outside the village.  Kala azar: The people eat of dehydration, measles and skin ghengha jiv, a kind of snail found problems; in the rainy season, “ Parivar mein bimari ityadi hone par log in the forest area. diarrhoea; and in the winter, jadi-booti ka hi ilaj karate hain, sochte  Diarrhoea: The people use cough, cold, fever and malaria. hain yadi gaon mein hi thik ho jayega jhinuk/jhunaka (shell) which is found in water. First, they Table 5: Common Illnesses in the Santhal Tribe remove the meat in the jhinuk (shell), burn the shell, and mix Illness the resulting powder with sour Summer Rainy Season Winter mango, sugar and sounf (Indian Malaria, mouth ulcer, loo Diarrhoea, malaria, loose Gissi, cough, cold, malaria sweet fennel). motion  Tuberculosis: The patient is made to drink the fresh blood of Santhal people identify diseases like to bahar doctor ke paas jane ki kya a sacrificed dog. kala azar on the basis of symptoms zaroorat.” (If somebody in the family like the body turning black along falls sick, traditional herbal medicine Referral and related issues with fever, while in case of jaundice, is generally used, as it is believed The sick in the Santhal community symptoms like swollen abdomen that if one can be treated within the are usually taken to private medical and yellowing of the body are noted. village, then there is no need to go to consultants, but if they are not cured, Malaria is recognised by shivering a doctor outside the village) - FGD, the patients are moved to Malda accompanied by high fever. male, village Jalalpur, Sahebganj. or Bardhwan town in West Bengal. The people feel that the services Availability and distance of health Some of the respondents were in these towns, which are easily services from villages critical of the government hospital accessible, are better than those in In the sample villages, there are no and believe that the hospital always the Sahebganj and Barharwa towns. doctors available, while traditional prescribes wrong medicine and healers/ojhas are easily accessible gives medicines that have expired. In critical cases, the community within the villages. AWWs and ANMs In one of the FGDs, a participant calls the doctor to their village. At are available in both the villages. said “Sarkari aspatal jane se darr lagta night, they hire a vehicle to take hai, purana dawa deta hai, viswas nahi the patient to the nearby Barharwa The PHC is located within 2 km hai.” (I fear going to the government town. They do not go to the ojha of both the villages. As far as the hospital as they will give me old and in critical cases, because they have district hospital is concerned, one expired medicine). no faith in the traditional healers in community is located far from it these circumstances. As one of the (around 15 km), while the other Home remedies for morbidities villagers remarked, “Ojha bojha hota village is located at a distance of In the Santhal tribe, most people hai.” (Ojha is a burden during two km from it. follow herbal or traditional healing critical cases.)

Tribal Health Seeking Behaviour 13 3.2.2 Family planning hain.” (I had distributed condoms The Santhals identify pregnancy by The size of a family is primarily once, but they do not use them so I noticing symptoms like stopping of determined by its economic status stopped distributing.) menstrual cycle, loss of appetite, and also by the presence of a son in tendency to eat sour food and the family. An interesting issue came The Santhal traditional healers nausea. They say that the taste buds up in an FGD, where a respondent claim to have remedies to prevent of pregnant women are also affected said “Parivar mein jinka jamin jyada pregnancy, which have a permanent for the first five months. hai, usse teen se char ladka hona jaruri effect and can be adopted in lieu of hai, jiska jamin kam hai ek se do ladka sterilisation. However, they refused Traditional rituals during hone se chalta hai.” (If the family has to reveal the composition of the pregnancy, delivery and a large piece of land, then it must medicine, saying that only the dai postpartum period have three to four sons, but if it has knows the same. Among Santhals, on detection of a small piece of land, then one to pregnancy, a puja is performed two sons are fine.) “Bachon ke antaral ke liye bhi jadi-booti and a cock/hen is sacrificed for hai. Aur operation toh kewal mahilayen the well-being of the unborn child. A typical Santhal family generally karati hain.” (For birth spacing, herbs The pregnant woman refrains from has four to five children, are available. Only women go for eating rice after conceiving and is with at least one male child. operations.) - Traditional healer, not allowed to do any household Compared to Christians in the Sahebganj work till delivery. The woman is Santhal tribal group, the Sarna made to fast (narka upwas) for four community does not accept the Access to and utilisation of hours after the delivery, a ritual use of contraceptives, unless it services associated with cleanliness of child is perceived that delivering more “Parivar niyojan ke liye Mala-N dete and mother. Post-delivery, the children has an adverse effect on hain. Condom ek baar diye the, house is cleaned thoroughly. the mother’s health. The TBA prayog nahin karte, isliye nahin dete.” does not suggest any contraceptive (We give them Mala-N for family Most of the deliveries among measures to the villagers, nor planning. We used to give them Santhalis are performed by the does she refer them to the condoms, but they don’t use them, dai (TBA). She provides necessary AWW or ANM. so we stopped.) - AWW, Sahebganj. information on how to maintain cleanliness and hygiene at the place of Decision-making 3.2.3 Maternal health care delivery as well as after the childbirth. On the basis of the information practices She cuts the umbilical cord of the gathered during the discussion with Maternal mortality and morbidities child with a new shaving blade, by couples, it was found that the wife Seven cases of maternal deaths were placing a one rupee coin that has takes the major decisions regarding reported by the respondents from been washed. The TBA massages the use of contraception as well as the the two study villages, but they could lactating woman for three days and size of the family. While deciding the not provide reasons for the deaths. also gives warmth to her stomach by number of children, as mentioned putting arandi leaves on it. earlier, the economic status of the Common maternal morbidities household is the prime factor.  Malnutrition and weakness Breastfeeding practice  Malaria According to a section of the Home remedies  Abdominal pain community, the infant is fed the This tribal group depends on  White discharge from genitals colostrum within two-three hours traditional FP methods. They do  Diarrhoea of birth, after both mother and child not even use condoms provided are cleaned up. Another section free of cost from the AWC. As an Identification of pregnancy claims that the child is initially given AWW stated, “Condom ek bar diya The tribal people have their own goat’s milk and breastfeeding begins tha, prayog nahi karte isliye nahi dete methods to identify pregnancy. much later.

14 Health Issues and Health Seeking Behaviour of Tribal Population in Jharkhand Decision-making regarding  Fever Since most of the women are not immunisation  Kala Dhaba (the child’s head/ registered with the health facility, Both the study villages have ANMs skull divides into three parts) they do not receive any type of and AWWs, and thus, the villagers  Pilha (enlargement of spleen) treatment for reproductive health are aware about immunisation,  Cold and cough problems. As most deliveries but do not really know why it is take place at home under the essential for the child and mother. In Identification of morbidity and supervision of untrained dais, one village, taking decisions related treatment proper care and cleanliness is to immunisation is not a task, since The Santhals identify the Puni disease not ensured, which results in RTI the ANM makes regular visits and when an infant keeps its legs crossed related problems. provides her services to the people. together for a long time, becomes In the other village, though, the very thin and is not able to suckle. Knowledge of RTI/STI and health ANM visits once a month and that A fatal disease called Kala Dhaba, seeking behaviour too, only the houses of the wealthy. generally found among newborns, According to the community, if There seems to be total dependency is identified by continuous fever, any couple shows symptoms of on the ANM in both villages. breathing problem and finally, RTI/STI, they take suggestions appearance of cracks on the head from the husband’s mother and Child health care practices or deep depression on the head use traditional as well as modern There were 15 cases of child death and chest. medicine. When the ANM was reported from the two sample asked about RTI/STI, she said that villages. The reasons for the deaths 3.2.4 Reproductive health care she had not been approached with are not known. Most Santhal women suffer from any such case, and emphasised anaemia. They do not discuss even that the ANMs do explain the Common morbidities in children minor reproductive problems with importance of hygiene and  Puni (the child loses weight and the ANM. For severe problems, cleanliness of the body. the stomach bulges out) they prefer the traditional healer.

Tribal Health Seeking Behaviour 15 3.3 ORAON TRIBE language), the Oraons think that it The recent perception in the 3.3.1 Common Illnesses cannot be cured by the doctor. “Iss community is that it’s better to go Some of the common illnesses bimari (pair fansne wali) ke ilaj ke liye for modern treatment, as there are among the Oraon tribe are given hum doctor ke paas nahi jate hain, too many diseases which traditional in Table 6. The diseases are kyunki doctor iss bimari ka ilaj nahi kar healers are unable to cure. The categorised according to the seasons pate hain.” – Male, 35 years. villagers say that there should be a they occur in. good hospital in their village. There is no hospital, PHC or doctor Tribal perception of existing in the village or near the village. Tribal perception about health system health system The faith in traditional medicine and depends upon the availability of, and Most people in the community prefer treatment within this community accessibility to, health facilities. to go for modern treatment, but is strong, not only due to the due to absence of modern facilities absence of modern facilities, but Health service providers in the village and high expenses also due to the durability of this The traditional healer/ ojha was found associated with these, they have to form of treatment, along with its to be functional in the study villages, depend on traditional providers for easy availability and accessibility at along with the RMP. In one village, treatment. However, in one of the a lower cost. For modern treatment, there were no ANMs/AWWs, while diseases afflicting children where they need to visit Gumla, the district in the other, both of them were the child becomes skinny and keeps headquarters, which is at a distance, found to be functional, providing his legs crossed (pair fansna, in local and thus, expensive for them to reach. services to the community.

Table 6: Common Illnesses in the Oraon Tribe 3.3.2 Family planning Decision-making Illness Family planning decisions primarily Summer Rainy Season Winter concern the number of children Measles Diarrhoea Pneumonia and spacing between children. Most Skin problem Boils Malaria villagers mentioned that the husband Loo Puni Cough and cold and wife jointly take a decision Mouth ulcer Loose motion Sarfatna regarding FP. The role of the mother- in-law never came up in any of the FP Malaria discussions.

CASE STUDY The people prefer to adopt Sujata Giddi (name changed), 24 years, illiterate temporary methods like pills and condoms for birth spacing. My child was suffering from the Adanjho disease after the birth. She became Permanent methods like tubectomy very thin and used to cry a lot. Once we found that her legs were crossed and and vasectomy are preferred by tied with each other. We understood that she is suffering from the Adanjho very few, and only when they disease. I did not go to the doctor, because they would not have any medicine to cure this disease. So, I went to the local vaidya with a bowl of ghee (clarified think they have enough children. butter) which he mixed with some local jadi-booti (herbs) and advised me to Usually, couples with three or more apply this solution on her legs and give some massage. By using that herbal children, and at least one male child, medicine, gradually my child was cured, with the results showing within decide to go for sterilisation. three days. We have full faith in the vaidya and his behaviour is also very good. He gives Awareness the treatment at minimum cost, which is also a great relief to all of us. Going The couples in this community to doctors means lots of money and they do not always have medicine for all were found to be aware of modern the problems. I earn money by farming, so we always have financial constraints. During financial crisis, we consult the Mahila Mandal about money. contraceptives. Most of them have seen and used contraceptives or

16 Health Issues and Health Seeking Behaviour of Tribal Population in Jharkhand know people who have used them. Permanent methods were not as popular, though, chiefly because such services are not available. Interestingly, the Santhal community talked about vasectomy.

It was also seen that in villages with a Christian population, the acceptance of FP measures was higher, though most of them were Catholics who are against FP. FP services are used more widely in the village with ANM and AWW services, than in the one with non- functional ANM/AWW services. This method can be used for a the unlicensed practitioners usually Information on contraceptives was woman who is up to three months give Oxytocin injections. provided by the AWW or the ANM. pregnant. Another medicine used as It is mostly women who access a permanent method is prepared by The common maternal illnesses such information. Most villagers boiling roots of paan (betel nut leaf) identified are listed below. The also have access to radios, which is and old gud (jaggery). list generated is a free list and no an important portal for knowledge ranking of symptoms was attempted. dissemination on FP services. 3.3.3 Maternal health care practices Common maternal morbidities Home remedies Maternal mortality and  White discharge from genitals The home remedies and traditional morbidities  Pain in stomach and lower methods mentioned in the The villagers were asked to prepare abdomen discussions are generally prepared a list of maternal deaths and critical  Swelling of legs during pregnancy at home, or by the dai and some maternal illnesses that they could  Dislocation of baby in the womb are prepared by the traditional recall as having occurred in the past (Bacha Khisakna) healers. These remedies are used three years. The study team was  Bleeding and weakness (Pichily) for menstrual regulation, spacing able to document one death that  Malaria of children and for permanent occurred in the last three years  Loose motions contraception. The composition of during our study visit. All the deaths  Diarrhoea these medicines was not revealed by took place in the village.  Itching in genital area any of the traditional healers/ojhas or dais during the interviews. Faith in the The women are rarely referred Malaria and diarrhoea seem to traditional methods is high and their for emergency obstetric care due be common problems among usage seems to be quite prevalent. to non-availability of services. The pregnant women in the study area. unlicensed practitioner is usually Miscarriages were also a common As stated during an interview summoned to the house, where he/ phenomenon. White discharge and with a traditional healer, there are she administers a few injections. On other RTIs were also described. traditional medicines for abortion. If probing the local community, it was Women usually suffer quietly from a woman wants to get an abortion, found that they were not aware what these illnesses. They do not consider a jadi-booti (local herbs) is kept in the injections were exactly, but said swelling of feet as a dangerous her birth canal for two to three that they ensured a quick delivery. sign, which can be inferred from an days, which damages the embryo. Nurses in the area mentioned that interview with a pregnant woman

Tribal Health Seeking Behaviour 17 who said, “Garbhavastha mein haath- changes. They confirm pregnancy TBAs also receive training from pair ke fulne ko gaon-dehat mein based on symptoms like vomiting, agencies or through the government bimari nahi samjha jata hai.” (During desire for sour things (tamarind, to gain more skill and expertise in pregnancy, if there is a swelling in the pickles etc.), physical changes, their work. The dai assists in most hands and feet, it is not considered tiredness and stopping of menstrual deliveries and stays with the mother as a problem or as a symptom of cycle. They occasionally consult the for a week after the delivery. During illness.) - Surajmani Kindo, pregnant village dai too, who assists in the this time, she is expected to give the woman, Raghunathpur, Gumla. identification of the pregnancy. mother and baby regular baths and massages, and also wash the used Among the Oraons, morbidities Decision-making on ANC clothes. Post-delivery, the mother is are usually recognised by visual The Oraons are slowly catching up taken to the vaidya (local healer) for symptoms like thick white fluid on ANC due to the presence of the a disease locally known as pet pakna, discharge from female reproductive AWW. The mindset of the people as they think it cannot be cured by parts, known as Safed pradar in the is changing and pregnant women the doctor. “Prasav ke baad ki bimari local language. have started coming to the AWC (pet pakna) mein vaidya ke paas for TT injection, IFA tablets and bhejti hoon, doctor ka dawa se theek Home remedies for morbidities advice regarding pregnancy care. In nahi hota hai.” - Albiliya Giddi, TBA, Most households and women addition, at the AWC, the weight Raghunathpur, Gumla. interviewed seemed to prefer home of the pregnant woman is recorded remedies, and in case of severe and information on a healthy and Among the Oraons, the TBA’s role is illness, they resort to ojhas. When balanced diet is provided to those similar to that among the other tribes things get critical, they consult a found to be underweight. included in this study. The community private doctor in the nearby town. prefers TBAs for deliveries rather Most of these decisions are taken by Traditional rituals during than going to a hospital, as they are the head of the family. pregnancy, delivery and easily accessible and their services postpartum period are much cheaper. They also believe The Oraon tribe has its own The community does not allow a that if a delivery can be done at home, indigenous and traditional medicines pregnant woman to cross a river or there is no need to admit a pregnant for common pregnancy-related attend any funeral ceremony. Sour woman in a hospital. health problems: and hot foods are also forbidden.  Loose motions (dysentery) – A Another interesting custom noted During labour pain, the TBA first new guava leaf is eaten early among these people was that in case ensures whether the pain is real or morning of any complication during delivery, merely a false alarm. She does so by  Leg pain – Karanj (Indian beech) the woman is made to wash the feet pouring oil on the stomach of the oil is used of her brother-in-law and drink that pregnant woman, and observing if  White discharge from genitals water. They believe that the reason the oil falls straight. If it does, she – Medicine prepared with old gud behind the complication is her lack confirms that the time has come. If (jaggery) and root of juli flower of respect for her brother-in-law. the labour pain continues longer than  For removal of placenta after the stipulated time, she administers a delivery – A jadi (herb) called There is no specific diet restriction medicinal herb called chirchhiti. If the chirchiti (chireta) is applied on among this tribal group. The TBA finds complications during the any part of the body. women continue with their routine pregnancy/delivery, she then refers work till the time of delivery, and the case to the nearest hospital. Identification of pregnancy sometimes their husbands assist In the Oraon community, the family them in their work. The dai is usually called at the time elders (usually the mother-in-law) of delivery. Most of the dais are not identify pregnancy by checking the The TBA plays a vital role during trained, but are experienced. She stomach and noting other physical delivery in rural areas. Some of these attempts to identify the position of

18 Health Issues and Health Seeking Behaviour of Tribal Population in Jharkhand the baby by feeling the abdomen have become more aware and realise villages because of differences in and pours oil on the stomach of the importance of the colostrum, knowledge and awareness levels. the woman, as cited earlier. During and have started giving the mother’s The varying levels of exposure delivery, the pregnant woman lies first milk, as it helps build the baby’s and knowledge about the benefits on a jute mat and cotton cloth on immunity. Breastfeeding is started of immunisation tend to make a the floor. A family member brings a on the first day soon after birth, huge difference in its utilisation, as new shaving blade, soap and oil for but exclusive breastfeeding is still an observed among this tribal group. the delivery process. The dai uses issue, since most mothers continue the new blade to cut the umbilical to give their infants honey and sugar 3.3.4 Child health care practices cord, by putting it on a one rupee between feeds. The villagers were asked to list coin. After delivery, she bathes deaths in the last one year period the newborn and cleans her/him Practice and beliefs regarding amongst children under five years properly with soap and water. She immunisation of age. The cause of death in any also massages both mother and child The Oraon have knowledge about of the cases was not ascertained. till the cord gets dry. It takes three and are aware of immunisation. Most deaths took place in the to five days for the cord to dry. Immunisation services are mostly village, with very few sick children provided by the AWW at the centre being referred for care. The After six days of birth, the people and the ANM comes to give vaccine villagers also described certain celebrate Chhatiyari, when people on a monthly basis. Apart from serious childhood conditions, such come to see the mother and child, the AWW and ANM, no one else as chronic malaria, kala azar and and give some money or gift to comes from outside for the purpose malnutrition. the child. A day after Chhatiyari, a of immunisation. Polio vaccine, woman takes the mother to the well measles and DPT are given to Common morbidities in children and sacrifices a hen. They, then, put children at the AWC. Some women  Rangbad, where the body of some drops of the hen’s blood in also have cards, which contain the child becomes reddish in the child’s mouth. immunisation details, and this card colour. This disease also leads stays with the parents or the ANM. to mouth ulcers. A child is In the Oraon tribe, if a pregnant Some of the villagers are also aware then unable to eat anything woman has a problem, they refer of the benefit they can get from each or even suck at its mother’s her to a dai or ANM, but for any vaccine. They know that by taking breast. serious complication, they take her polio drops, a child will be safe from  Puni, where the child stops to the Gumla Sadar Hospital or polio. According to the people, they sucking the mother’s milk, as St. Joseph Hospital. get information on immunisation a result of which the mother’s from the radio, television, relatives milk also goes dry. “Agar kisi mahila ko prasav dard shuru and ANM. Some did complain that  Larsut, where the upper part hota hai, to humein bulate hain. Hum after taking the injection, their child of the tongue doesn’t function pet par tail dalkar dekhte hain ki prasav suffered from fever and swelling in properly. kitni der main hoga.” (If a woman has the injected area.  Cough and cold, fever and labour pains, they call us. We put pneumonia. some oil on the stomach and predict Decision-making regarding the time of delivery) - TBA, Gumla immunisation Identification of morbidity The decision-making power resides Among the Oraon tribal group, Breastfeeding practices with the husband and his parents; morbidities are generally identified Earlier, the community did not they decide whether to provide based on the visual symptoms. If provide colostrum to the newborn, immunisation to the child. The the body of the child gets reddish and fed it goat’s milk instead, since woman doesn’t have any say in in colour and there is a loss they believed that the first milk is the decision. The decision-making of appetite, then the disease is harmful to the child. Now the people scenario is different in the two identified as rangbad. If a child stops

Tribal Health Seeking Behaviour 19 diseases, the people identify normal CASE STUDY fever with high body temperature 9 years and 6 months old son of Jailin Giddi (27 years) and a loss of appetite.

My child was fine for first 15 days after birth, and then all of a sudden, he ICDS entitlements started having a problem and cried incessantly. We thought it must be The Oraon community in the study rangbad (in which the whole body turns red in colour) and took him to a vaidya for treatment. The vaidya gave a medicine prepared from medicinal villages is satisfied with the ICDS herbs, advising us to give it to the child for three days, but there was no centre. They confirmed that pregnant relief for the child. We took him to Gumla to see the doctor for treatment, and lactating women get rice, dal but unfortunately could not meet the doctor as he was not in his chamber. and oil, and also get injections and Without any treatment, we returned back to the village. When my child was medicines from the centre. about a month old, he started bleeding from the mouth accompanied by black coloured stool. We got frightened and took him to Gumla, and this time we consulted the doctor. After looking at the child, the doctor suggested we 3.3.5 Reproductive health care take our child to Ranchi for treatment. He gave one injection for the bleeding Knowledge of RTI/STI and and stool, but the bleeding continued. We are poor and so we could not take health seeking behaviour him to Ranchi for treatment. The child developed another ailment called pair It was found that the complaint of chadhna (where the legs get twisted together) and we massaged him with the white discharge (pradar) is quite oil that the local vaidya gave us. We again took him to the doctor at Gumla common among the women in for treatment, and this time with the help of his medicine, the child was cured. both the study areas. The villagers said that two types of discharge This year (2007), in the month of August, a health camp was organised by are quite common – red discharge Krishna Pranami Sewadham at Ranchi. We came to hear about it and took and white discharge. To prevent our child there. In this camp, an operation was done on both the legs. For this the occurrence of discharge, operation, we did not pay anything. The child was given a pair of shoes by they bathe or wash and keep the organisers. The doctor instructed us that the child should always wear these shoes. themselves clean. A family elder shared all the precautions they Now, we are not seeking any treatment for the child because of financial take to maintain hygiene. The problems. However, the doctor told us that he needs to undergo an operation villagers know that the discharge on his head. His mother believes that due to some curse, her child is having all is part of their physical change, a these problems. fact they learn from their elders. If the problem persists, they He suffers from cold and fever. We give him medicine and massages every hardly visit a doctor, as there is morning and evening, but his condition is still the same. some hesitation in describing the problem. Although to date no sucking at its mother’s breast, they disease that’s known as chita rog is single case has been detected, consider it to be puni. If the child’s identified by the vaidya by touching most of them are aware about the tongue gets stuck to the upper part the ear of the child. If one ear is cold process of transmission of diseases of the jaw, they call it larsut, which and other is hot, then it is diagnosed from husband to wife. can lead to dumbness. Another as chita rog. Apart from these

20 Health Issues and Health Seeking Behaviour of Tribal Population in Jharkhand 3.4 MAL PAHARIYA TRIBE practitioners are at a distance of There is also a lack of transport 3.4.1 Common illnesses more than 50 km. facilities to take the sick to health Mal Pahariya is one of the minority centres. Since one of the study tribes in Jharkhand. The common Tribal perception of existing villages is surrounded by hills and illnesses they suffer from in different health system forests, few health personnel opt seasons are listed in Table 7. In the absence of modern health to come to this village. In the other facilities, the Mal Pahariyas believe village, however, one AWC is Sarfatna (crack on the skull) is quite that traditional treatment is better operational. The ANM visits only common throughout the year and than modern treatment, as it is upper caste residences, and that too generally occurs among infants. cheaper and easily available in their just once a month, and ignores the village. However, some believe that Mal Pahariya population. Identification of morbidity modern health facilities are more The community identifies effective and should be available The people first visit traditional morbidities by their symptoms. within the village. healers, keep the ANM/AWW as For instance, brain malaria starts the second choice, and only as a last with vomiting and loose motions, Health service provider option, do they go to the hospital/ while kala azar is identified with preference doctor. the onset of fever accompanied The traditional healer/ojha was with shivering and headache, the found to be operational in both the Referral and related issues body turns yellow, and there is villages, but no doctors were found In this community, people strongly also loss of blood. In pilia, the body in either. One study village has believe that traditional healers can becomes weak and there is swelling both AWW and ANM, but the treat all diseases. They go to modern of feet, hands and stomach. For any other has neither. health providers for treatment only problems in the menstruation cycle, in critical cases. During such critical the initial symptoms are weight loss The preference for service provider situations, the people come down and loss of appetite. varies in both the villages, due from the hills to the plains and to difference in available health consult quacks (untrained health Distance of health services from facilities. In the absence of any health providers) for treatment, and if there villages facility, the community members is any complication, they go to the The village situated at the top of the solely depend on the dai and ojha, Siwadi Hospital. hill does not have easy access to any who are available in the village. In health facility. For the community most cases, the villagers first try Availability of services living in this area, the nearest PHC/ home remedies, specifically in case The tribals, especially the primitive district hospital/private practitioner of common illness, and if they are tribal groups (PTGs), have no is at a distance of more than not cured, they consult an ojha collective voice to demand 50 km. The other village has a or traditional healer. In critical health services. Most villages lack PHC located within 15 km, but here cases, however, they directly visit a educational facilities and there is only too, the district hospital and private hospital/doctor. one primary school in each of the studied villages. Due to the absence of any health facility in these villages, Table 7: Common Illnesses in the Mal Pahariya Tribe the level of knowledge and awareness Illness among the tribal people was found Summer Rainy Season Winter to be very low. However, two Cholera Diarrhoea Malaria study villages in which the AWC is Headache Brain malaria Brain malaria functional, the AWW/ANM provides services occasionally, and the people Brain malaria Loose motion Sarfatna in these villages are found to be Sarfatna Sarfatna comparatively more aware.

Tribal Health Seeking Behaviour 21 Home remedies for morbidities believes that couples who adopt FP family planning. For birth spacing, The Pahariya tribe usually applies cannot worship the sun. It has been they consult the dai who gives them home remedies for some of the found that among couples with five some herbal medicine, and for a common morbidities, while for the to six children, most of the women permanent FP solution, they consult rest they depend on traditional are weak and anaemic. with their janguru, whose medicine healers and doctors. Most of these can prevent a pregnancy for four home-made medicines are prepared Decision-making years. These medicines are meant for with flowers and herbs found in the Decisions regarding family planning the woman only. nearby forest. and birth spacing are taken jointly  If a woman has problems related by the husband and wife. They 3.4.3 Maternal health care to menstruation like abdominal also consult the dai and traditional practices pain and blood clotting, she is healers before taking the decision. Maternal mortality and morbidities given the juice of a leaf, pather- In the Pahariya tribe, couples think The villagers were asked to prepare kucchi (coleus). She is also given about family planning after having a list of maternal deaths and critical the juice of a flower called job. two to three children. maternal illnesses that they could  For normal cuts and bleeding, recall as having occurred in the past they apply the juice of the Awareness three years. The study team was koksima (Hygrophila) flower. The couples do not know much able to document 18 deaths that about the modern FP methods. They occurred in the last three years 3.4.2 Family planning prefer to go for traditional methods; during its study visit. All the deaths Per se, PTGs are not encouraged modern methods have been banned took place in the village; the causes to limit their family size, since in the tribe since the last 10 years, were not ascertained. their populations are small and as the tribe falls in the category reducing at an alarming rate. In of PTG. The community does not Women are rarely referred for fact, a health care provider can go for FP surgery, as they believe emergency obstetric care due to be penalised, if s/he offers family that anyone who worships the sun the non-availability of services. An planning measures to the group. cannot go for a surgery, and opt to unlicensed practitioner is usually Some members of the PTGs have use herbal medicines for FP. summoned to the house, where he or expressed their displeasure with she administers few injections. It was respect to this rule and would Home remedies found that anaemia is the biggest cause like to practice some form of The home remedies and traditional of maternal death in this community. contraception. methods mentioned by the community are generally prepared Common maternal morbidities Child marriage is common in this at home, or by the dai, while some  Malaria tribe and the reason stated by the are prepared by the traditional  Diarrhoea women of the village is, “yahan par healers. These remedies are used  Disturbance in the menstrual bada hone par sharir dikhne lagta hai for menstrual regulation, spacing cycle aur panch log panch tarah ki baaten of children and for permanent  Lack of blood (anaemia) bolte hain.” (When a girl grows up, contraception. The study team  Kala azar her figure matures, which becomes a attempted to find out the  White discharge and itching in topic of discussion for many.) composition and names of the herbs the groin used, but were successful in only Sex preference is not too prevalent some of the villages. Faith in the No ranking of symptoms was in the Pahariya tribe. The average traditional methods is high and their attempted in generating the above number of children per household usage seems to be quite prevalent. list. Malaria and diarrhoea seem to be is two to three. They prefer to have prevalent amongst pregnant women a small family, in order to minimise The villagers take herbal medicine in most of the study area. Miscarriages their cost of living. The tribe for both birth spacing and permanent are also a common phenomenon.

22 Health Issues and Health Seeking Behaviour of Tribal Population in Jharkhand Identification of pregnancy and that too of a black goat Decision-making regarding The Pahariya people identify (mandatory). Colostrum is not weaning pregnancy with symptoms like given to the child. The eldest member of the family stopping of menstrual cycle, loss of  After childbirth, the mother and guides the weaning process. Most appetite, tendency to eat sour food child are kept away from the people in this tribe start giving solid and nausea. The taste buds are also other family members for five food after five months to a boy child affected by pregnancy. days and treated as untouchables. and after seven months to a girl  After five days, the bhandari child. They have a ceremony called Traditional rituals during (barber) is called and the whole Mukhar Bhaat in which the maternal pregnancy, delivery and family cleans their nails etc., and uncle (Mama) of the child feeds the postpartum period takes a bath. baby for the first time. After Mukhar Compared to the other tribal  After 12 days, the family goes to Bhaat, the child is given rice, pulse communities, the Pahariyas do not the pond to worship Jalghari mai and some vegetables. have much belief in superstitions with kajal and sindoor. Only after and traditional customs during this puja is performed, is the Practice and beliefs regarding pregnancy. However, they too don’t mother allowed to touch water immunisation allow pregnant women to go near or work in the household. Amongst the Pahariyas, practice graveyards or attend any funeral and beliefs about immunisation ceremony or cross a river, as they Breastfeeding practices varied between the two studied believe that it may have a bad effect In the Pahariya tribe, people don’t villages. In the absence of an AWC on the unborn child. give colostrum to the child. Instead, and ANM in one village, the people they give goat milk by dipping cotton there were found to be unaware There is no specific restriction in a cloth in the milk and putting the about immunisation. In the other pregnant woman’s diet. The women drops in the child’s mouth. The village, however, immunisation is continue their routine work till colour of the goat has to be black. done at the AWC by the AWW delivery, and often the husband Only after giving goat milk do they and ANM, and the people here assists them in their work. start breastfeeding, which continues believe that due to immunisation, a almost till the next pregnancy. As a child remains healthy and free from In this community, a typical feature substitute for breast milk, they also diseases like polio. They mentioned during delivery is that there have to give mishri, sabudana and barley to that they get information regarding be two TBAs at hand to assist in the the child. In case of excess breast the immunisation services mainly delivery. The TBA from the same milk, the mother usually squeezes from the radio and television. They village assists in the delivery, while out the milk and discards it. also have a Jachha-Baccha card, but the other TBA from any other or adjacent village cuts the cord. This custom is followed rigidly, and in case the second TBA is not available immediately, the family members keep waiting for her to arrive, ignoring the potential danger to mother and child.

Some peculiar practices amongst the Pahariyas are:  After delivery, the TBA gives a massage to the newborn in the morning and evening.  The child is first given goat milk,

Tribal Health Seeking Behaviour 23 they do not know what is written problems are white discharge and One of the practices peculiar to on it. itching in the reproductive organs this tribe is that after childbirth and as well as urinary passage ailments. during menstruation, the mothers Decision-making regarding For the treatment of RTI/STI, the are not allowed to take bath with immunisation people prefer herbal treatment. A cold water. If any problem occurs, In the Pahariya tribe, decision- couple goes together for treatment, the women usually consult their making power resides with the if they have any problem related to mothers. The people use both husband and his family; the women RTI/STI. traditional as well as modern have no say in such matters. medicine for RTI/STI treatment.

Child health care practices CASE STUDY The villagers were asked to list Pannalal (name changed), Male, 28 years, Pahariya tribe, deaths in the last one year amongst Buddidih, Dumka children under the age of five. The causes of the deaths were not I got married in 2000 and became a father in 2001, but the child died after six ascertained. Most of the deaths took days. It was the month of Bhado (Aug-Sept). When the child was born, he was place in the village, with very few fine, but after a couple of days he developed Kala Dhaba and brain malaria. being referred outside for care. In I took him to the doctor. He had high fever and was crying incessantly. The all, 14 child deaths were recalled by doctor examined my child and said that he is suffering from brain malaria. He gave injections on the second and third days, but there was no improvement. the group in the study area in the last five years. One old person said that the baby is suffering from Kala Dhaba. As per suggestion, I took the child to the ojha in Rebdibadi. The ojha gave me an ointment made of some herbs (jadi-booti) to apply on the child. I took him to The villagers also described various the ojha whenever I felt that he is becoming serious, but I could see no change childhood conditions that were of in my child’s condition. On the sixth day, my son could not stand the pain concern, including chronic malaria, anymore and died. kala azar and malnutrition. I spent Rs.1600 for the treatment. The behaviour of the doctor was good, but he was unable to cure my child. I am not satisfied with the treatment given by Common morbidities in children either the doctor or the ojha.  Fever  Cough and cold  Pilia CASE STUDY  Malnourishment Suman Pujar, Male, 22 years, Pahariya tribe, Buddidih, Dumka  Kala Dhaba  Malaria Five years back, I got married. After three years of marriage, I became a father,  Kala azar but my child died after six months. The child was suffering from fever and his eyes were getting prominent. I felt that my child is getting seriously ill and took him to the ojha. He said, “Your child will be fine, if you give me a pair of 3.4.4 ICDS entitlements pigeons and a pair of hens”. I gave him what he wanted, just to make sure that In the Pahariya community, the my child gets better. The ojha gave a medicine made of jadi-booti (herbs) to be villagers reported that they do had for two days, but the situation remained the same. get TT injections. The level of awareness and utilisation of ICDS So I took our child to the doctor in Astha-Joda, which is six km from our village. among this community is poor. The doctor gave an injection and some tablets, but there was no change and most of the time my child was unconscious. I went back to the traditional healer and continued his treatment on the fifth day. But my child became critical that Reproductive health care night and I could not take him to the doctor immediately so I took him the Knowledge about RTI/STI and next morning. The doctor looked at him and declared him dead. I am not at all health seeking behaviour satisfied with the treatment of the doctor; he could not save my child. Some of the common RTI/STI

24 Health Issues and Health Seeking Behaviour of Tribal Population in Jharkhand 3.5 HO TRIBE Home remedies for morbidities saag is used 3.5.1 Common illnesses In the Ho tribe, whenever someone  Cough and cold – Juice of tulsi The common illnesses among the falls ill, they first administer home (basil) and ginger is consumed Ho tribal group are given below remedies, and if the illness persists,  Fever – Crushed mustard seeds according to the season they occur in. the patient is taken to a traditional are tied on the arm of the healer or doctor. patient Tribal perception of existing  Pain – Oil massages are given for health system The community has home remedies body pain There is a lack of health facilities in for almost all common ailments: both villages. There is only an AWC  Dysentery – A guava leaf is Referral and related issues in each village, in terms of a health eaten with sugar Within this community, the ill person facility. Both the villages have a PHC  Itching – Powder of kusum fruit is first taken to the traditional healer, at a distance of two to five km, but is applied on the affected area then to the ANM and RMP. Critical one of these is not functional.  Cough and cold – A cases, however, are taken to the combination of munga saag, hospital. One referral hospital which The perception regarding traditional ginger extract/mixture of pipri this community uses is in Orissa, as and modern treatment differs (Indian long pepper), black the villages are located on the border. between the two study villages, pepper and tulsi (basil) leaves They feel that services across the depending on the presence of health is eaten border in Orissa are of better quality, facilities. Where there are health  Fever – Mustard seed is tied on cheaper and also easily accessible. facilities/providers, the people the arm of the patient perceived modern facilities to  Diarrhoea – Sugar-salt 3.5.2 Family planning be ideal. solution/extract of raw guava, Decision-making pomegranate flower and plum Most of the villagers mentioned that Due to lack of transport facilities to bark is taken. Also, fresh guava couples take FP decisions jointly. the health centres, the community leaves are consumed with sugar The role of the mother-in-law never members totally rely on traditional  Headache – The head is came up in any of the discussions. healers, as they are available within massaged with warm mustard oil Tubectomy and vasectomy are the village itself.  Post-delivery weakness – The not the preferred FP measures, as woman is given a solution made they fear such surgeries can affect Health service providers from the powder of neem their ability to do heavy work. As In both the study villages, except for (Margosa tree) and karanj (Indian stated in one of the women’s FGD, medical doctors, all other types of beech) bark “operation upay hai, par log darte health providers were available such  If, during delivery, the vaginal hain ki operation ke baad bhari-bhari as traditional healer/ojha, AWW, opening is small, soap and surf is kaam nahi kar payenge.” (Operation ANM and RMP. In one study area, used for opening the mouth of is a measure, but people fear it, as both ANM and AWW were found the birth canal they think they would not be able to to inactive.  Liver problem – Kuiley khada perform heavy work)

Table 8: Common Illnesses in the Ho Tribe The couple also consults the AWW and doctors on FP related issues. Illness The woman takes the initiative to do Summer Rainy Season Winter so, but the final decision still resides  Loo  Jaundice  Cough and cold with the man alone.  Mouth ulcer  Diarrhoea  Fever  Measles  Fever  Malaria Home remedies  Headache  Pneumonia The home remedies and traditional  Malaria methods are generally prepared at

Tribal Health Seeking Behaviour 25 home, or by the dai, while some identify pregnancy with symptoms believes that their ancestors live are prepared by the traditional like the stopping of the menstrual in the kitchen. healers. These remedies are used cycle, loss of appetite, tendency to  If the child does not cry after for menstrual regulation, spacing eat sour food and nausea. Within birth, they whisper in its ear, of children and for permanent this community, the pregnancy sprinkle water on its face or contraception. The study team is confirmed after two or three hold it upside down by the legs attempted to find out the months by the village dai, who to make it cry. composition and names of the herbs conducts an internal examination of  After delivery, the lactating used, but were successful in only the expectant woman. mother takes only one big meal some of the villages. Faith in the in a day, if the newborn is a boy, traditional methods is high and their Decision-making on ANC and takes two meals a day, if the usage seems to be quite prevalent. The knowledge and awareness about baby is a girl. ANC differs across the villages  Six days after birth, they 3.5.3 Maternal health care and depends on the availability of a celebrate chhati, where all practices functional AWC as well as PHC. relatives and friends arrive to see Maternal mortality and morbidities the mother and child. A feast is The villagers were asked to prepare Traditional rituals during also arranged on this occasion. a list of maternal deaths and critical pregnancy, delivery and maternal illnesses that they could postpartum period Breastfeeding practices recall as having occurred in the The Ho have very strong belief in The breastfeeding practice in this past three years. Four deaths were black magic and spirits. Hence, they group is different from other tribes. documented and all of them took often visit ojhas. Pregnant women They first give honey to the newborn, place in the village. are not allowed to attend funeral and after half an hour, they start ceremonies or go near graveyards, breastfeeding. If the mother’s milk Common maternal morbidities as they believe that spirits live is not available, they prefer to give  Loss of appetite there which can affect the baby and goat’s milk to the child.  Headache the mother. During solar eclipse,  Vomiting the pregnant woman sleeps with Practice and beliefs regarding  Malaria a cylindrical stone (lodha, in the immunisation  White discharge local language) beside her. In case As with the other tribes, in the  Menstruation problems of pregnancy or delivery-related Ho tribe too, the knowledge,  Miscarriages complications, the people resort to practice and belief in immunisation  Weakness prayers and sacrifice hens. depend on the availability of health  Cold and cough facilities. The community belonging  Pain in hands and feet The TBA performs most of the to the village equipped with better deliveries. However, in contrast to health facilities were aware about The Ho strongly believe in spirits other tribes, in the Ho community, the immunisation and did immunise and black magic and associate husband often assists in the delivery their children. In this village, them with ill health. Hence, they and also cuts the umbilical cord. immunisation is done in the AWC are unable to identify specific by the ANM/AWW. morbidities immediately. Symptoms The Ho people have some peculiar like loss of appetite and high traditions that apply post-childbirth: Most villagers have immunisation temperature are identified as fever,  After the delivery, the family cards and they take vaccine for while loose motions and vomiting prays to god and sacrifices a hen polio, BCG and DPT on a monthly are declared to be diarrhoea. or goat. basis. They get information on  Post-delivery, the mother does immunisation from the radio, Identification of pregnancy not enter the kitchen, till the television and AWC. The Ho, like the Pahariya tribe, cord gets dry, since the tribe

26 Health Issues and Health Seeking Behaviour of Tribal Population in Jharkhand 3.5.4 Child health care practices have a reason for not taking them. Identification of morbidity The villagers were asked to list child “ Anganwadi Kendra se dawai nahi lenge, In the Ho tribe, morbidities within deaths in the last one year period. kyunki waha kewal tablet milta hai aur children are identified based on There were four child deaths bachche tablet nahi kha sakte hain.” specific symptoms for each disease: reported from the two villages. The (Only tablets are available at the  Fever – High body temperature cause of death in each case was not Anganwadi Centre, and small children and loss of appetite ascertained. Most of the deaths took are unable to consume tablets) -  Cough and cold – Discharge place in the village, with very few Sukamati Gop, mother of an ill child, from nose and eyes being referred outside for care. Bhoya village, West Singhbhum  Measles – Body is covered with pimples The villagers also described some Common morbidities in children  Diarrhoea – Loose motions and childhood illnesses that were of  Sarfatna (narrow slit in child’s vomiting concern to them. Most of these head)  Jaundice – Body becomes conditions reflected chronic malaria,  Cold yellowish in colour ka la azar and malnutrition. Although  Fever  Sarfatna – Slit appears on the these diseases can be cured with the  Malaria head of the child. modern medicines provided by the  Diarrhoea ANM or at the AWC, the people

Tribal Health Seeking Behaviour 27 Section D

SUMMARY: MATERNAL HEALTH CARE AMONGST THE TRIBAL POPULATION

aternal and child care is an availing ANC services seems to be Moreover, in spite of cash benefits, Mimportant aspect of health largely dependent on the availability most deliveries still continue to be seeking behaviour, which is largely of services. The distance from the conducted at home. neglected among the tribal groups. nearest town and the availability Wide disparities in ANC among and quality of health services in the Geographically isolated tribal tribal populations may be due to village (AWC, ANM etc.) also play villages are also neglected vis- certain socio-economic variables like a role in the selection of health à-vis schemes like JSY. These low level of education and lower services. Wherever available, communities are not aware of such economic condition (Deb, 2008). In antenatal examinations were, for schemes due to lack of information, some tribal areas of India, maternal the most part, perfunctory, detailed and hence, there is no demand for mortality was observed to be very examinations were rare. Blood such facilities. high with 992 maternal deaths per pressure was seldom measured, one lakh live births (Mallikharjuna, and for most women, getting a TT 4.1.2 Care at home 2008). Besides medical causes, injection was equivalent to ANC. Apart from sundry social restrictions several social factors play an and rituals for pregnant women, important role as determinants of The ICDS scheme assures each in most tribes, there are no major maternal mortality, the chief among pregnant mother a hot cooked changes in the lifestyle and diet these being, delivery by untrained lunch, but none of the sites visited of these women as compared to dais, poor environmental sanitation, mentioned that they received the the pre-pregnant state. There may communication and transport same. Instead, rationed food was be some respite from household facilities, and certain social customs provided to women in villages that activities, if there is another lady (Park, 2005). The health of mothers had an AWC. Villages in remote in the house. Else, she carries out and their children bear an integral areas across all tribes, especially the her daily duties as usual, and these relationship with one another. Mal Pahariya tribe, did not get to tasks may involve heavy physical even register at the AWC. labour, such as fetching firewood In this study, an attempt was made or carrying water from the well. to assess the attitude towards An important development Husbands seldom assist them during sickness among five tribal groups in in recent times has been the this period. Jharkhand, their faiths, beliefs and presence of the Sahiyya and the health seeking behaviour, and the institution of the Janani Suraksha 4.1.3 Care during delivery utilisation of health facilities with Yojna (JSY), a maternal benefit The TBA/dai plays a vital role during particular reference to the care of scheme for pregnant mothers. delivery in rural areas. The dai pregnant and lactating mothers. However, the cash benefits are assists in most of the deliveries and almost always made available to the is present with the new mother for 4.1 PRESENT PRACTICES woman after her delivery, making a week after the delivery. It was 4.1.1 Institutional care no contribution whatsoever to noted that even if a woman wants Registration of pregnancy and her nutrition during pregnancy. to have an institutional delivery, the

28 Health Issues and Health Seeking Behaviour of Tribal Population in Jharkhand final decision rests with the husband, treat them condescendingly. The fact dais. The proportion of institutional who may as well refuse, as was that distances are considerable and deliveries is almost negligible; in reported in one case. transport is poor is another factor fact, there are villages where an for the tribal groups’ reluctance to institutional delivery has never In the Pahariya community, a typical embrace modern medicine. ever taken place, even in cases feature during TBA-assisted deliveries of complications during delivery. is that while a TBA from the same The tribals usually bring in a There are also villages where village assists during delivery, another complicated delivery case on a cot home deliveries are the norm and TBA from a different village cuts the carried by four able-bodied men. hospitals are resorted to only in umbilical cord. Getting these men and ensuring cases of difficult labour. The ultimate their stay at the hospital is usually decision-making power rests with 4.1.4 Maternal mortality and difficult. At Dumka District Hospital, the husband of the pregnant woman. morbidity a place has been designated for The common maternal illnesses caretakers to rest, which has proved One of the reasons mentioned identified by free listing include popular. The space provided is for preference of home deliveries malaria and diarrhoea. Miscarriages, simple and clean and the caretakers was the fact that women find the weakness and swelling of legs or sleep on the floor. familiar surroundings of their home body, menstrual irregularities, white more comfortable compared to the discharge and other RTIs were other 4.1.6 Making maternal health a alien atmosphere of a health facility. common ailments. Maternal deaths reality in the tribal community Moreover, a relative or a lady from were known to have occurred in There have been several changes the same village (dai) is regarded as these villages, but the exact time over time with regard to health a matronly figure, whose years of (with respect to period of gestation/ seeking behaviour for ANC among experience and advice are held in postnatal period) and the cause of tribal populations in Jharkhand. high esteem. A Sahiyya mentioned death could not be ascertained. Over the years with the advent of that it is difficult to change the educational facilities, the presence mindset of these women, who 4.1.5 Treatment modalities of mass media and the government are unwilling to break norms and employed and preference of health facilities has led to an increased take the trouble to seek modern service provider awareness, as well as an increase health services. The poor quality It was observed that the preference in availability of maternal care of services at government hospitals for health service provider depends services in rural areas. The level of and the lack of means to avail on the nature of the disease and the acceptability of modern health facilities services of private hospitals are also financial condition of the family. In and treatment modalities has also key factors. case of illnesses considered to be increased compared to earlier times. minor (swelling of feet, vomiting, More women are accessing ANC In some villages, TT immunisation weakness etc.), the tribal people services including TT immunisation, during pregnancy is believed to first contact the local traditional IFA supplements and institutional result in a large baby, which could healer, then the ANM/AWW, and deliveries. In villages that were difficult lead to difficult labour, hence the lastly, doctors. Most deliveries to reach, and did not have a functional women opt not to get immunised. are conducted at home by the AWC, or where the ANM did not The practice of having the umbilical TBA (dai), and in critical cases, make regular visits, women went cord cut by a particular dai (who the pregnant woman is taken to a without ANC of any kind. might belong to a different village) hospital. may cause undue delays in case of However, in spite of education, a complication (retained placenta, Most of the tribal community feels awareness and the presence of haemorrhage etc.). alienated at institutions such as health service providers, a large district hospitals, which are usually number of women still have their There are several restrictions that staffed by non-tribals, who they feel deliveries conducted at home by the women have to follow post-

Summary: Maternal Health Care amongst the Tribal Population 29 delivery. Several vegetables and Tribal population are willing to is poor and not been monitored fruits are forbidden. There is no access and avail modern health seriously. special/extra food for children or facilities and are not averse to it. c. Cultural access – Most health pregnant and lactating mothers. They just want the health service institutions are not tribal- They usually consume two large providers to be friendly, culturally friendly, since they are staffed meals a day. Among the Pahariyas, sensitive and welcoming. with non-tribals. A long term the mother is given two meals a day, effort in ensuring local tribal if the newborn is a female and one Some of the steps that can be taken staff at the health facilities needs meal a day, if the child is male. to improve the tribal health care to be taken up. TBAs from tribal scenario are listed below: communities could be trained The loopholes in the referral through a six month apprentice complex such as absence of Ensuring availability of services course to become ANMs and connectivity by roads, lack of Across all tribes, those who stay manage the health SC. The tribal transportation and means of near the main road head or town group’s cultural practices need communication, force women are more dependent on health to be respected and encouraged living in remote areas to have services, compared to those in at the health facilities, such as their deliveries at home. At the difficult to reach areas. Institutional handing over the placenta to same time, though, the presence norms for health Sub Centre (SC), the relatives so they can bury of modern communication and PHC and Community Health Centre it in their backyard or at their transport facilities are no guarantee (CHC) in tribal areas are not threshold. Delivery positions that deliveries will not take place in adhered to, and at present, are not practiced by tribals need to be the home. staffed adequately. The community promoted through the skilled is not assured of services, even if birth attendant training imparted The funds provided in the maternal they do make the effort to access to the ANMs, so that the benefit scheme, JSY, which was the services, and so seldom take the expectant mothers need not later renamed as Mukhyamantri trouble to do so. deliver on the labour table. Janani Shishu Swasthya Aiyan (MMJSSA), are almost always Ensuring accessibility to services 4.2 CHILD HEALTH CARE inadequate for referral and a. Geographical access – The AMONGST THE TRIBAL transportation, whenever such a Government through various POPULATION contingency arises. These funds are schemes has been working on Studies among tribal populations in given to the woman after delivery, improving rural connectivity India have shown poor indicators by which time the cash benefit has to economic hubs like the relating to immunisation coverage no impact on the nutritional status weekly markets. The health and and initiation of breastfeeding. of the pregnant woman or her the public works department Infant mortality and prevalence of developing foetus. The popularity need to prepare a micro- under-nutrition also remain high of home deliveries proves that plan for connectivity between (Sharma, 2007). Poverty and poor providing cash benefits need not every village and a point for infrastructural development in tribal ensure institutional deliveries; emergency obstetric care. dominant areas have been the main it is the quality of services in b. Economic access – The costs reasons contributing to inability government institutions that makes involved in reaching the of the MCH programmes from a difference. hospitals for delivery and bribes reaching out to tribal populations. at the hospitals are some of the The scenario with respect to MCH Among tribal populations, low main deterrents to accessing in Jharkhand calls for immediate percent of early registration and services. The JSY scheme had redress. low coverage of antenatal check been launched with an aim to ups indicate the need for improving minimise these costs, but the According to the recently conducted health care during pregnancy. implementation of the scheme National Family Health Survey III

30 Health Issues and Health Seeking Behaviour of Tribal Population in Jharkhand (2005-06), the infant mortality rate the delivery. The sixth day after availability of immunisation services (IMR) in the state is 69 and 57 birth is an occasion of community for children varies among the percent of children under the age of celebration (Chhatiyari), till such different tribes and villages. There five are underweight. The survey also time the mother and child are kept were more mothers in the Oraon reported that about one-third (34 separate from the family and the community with knowledge about percent) of children in the state, aged mother is exempted from household maintenance of immunisation cards 12-23 months, are fully vaccinated work. and the benefits of immunisation, against the six major childhood than among others. illnesses and only 19 percent of 4.2.3 Breastfeeding and pregnant women delivered their baby complementary feeding While ICDS centres are functioning in any kind of institution. Feeding the child with goat’s milk well in some villages, in most prior to initiation of breastfeeding instances, they only provide Behavioural and socio-cultural is common among all the tribes supplementary nutrition, and that conditions, environmental and interviewed. Breastfeeding is also too, in insufficient quantities. In socio-economic conditions are not exclusive; water may also be some villages, there is no AWC important determinants of health fed to the suckling child, as it is at all. The religion of the tribal (Park, 2005). The use of medicinal believed that just having milk may people may also affect awareness herbs is still a tradition adopted by make the child thirsty. Colostrum levels, probably owing to education, ethnic communities in central India is either discarded entirely or as was seen among Christian (Navaneetham, 2000). fed after two or three days, as communities, where there was it is considered harmful for the higher immunisation coverage. 4.2.1 Morbidity and mortality in child. Even in communities where Overall, immunisation of children is childhood awareness is increasing regarding not considered a necessity by tribal The common morbidities among the importance of colostrum feeding people in remote areas (such as the children reported in these tribes (i.e., the Oraon community), the Pahariya and Munda tribes), where included symptoms suggestive child is still given goat’s milk to begin several completely un-immunised of upper and lower respiratory with. Honey may also be given as a children were found, even up to the infection, diarrhoea, febrile pre-lacteal feed (as observed in the ages of five and more. The decision illnesses, malnutrition, jaundice, Ho community). Goat’s milk, mishri regarding immunisation rests with malaria, kala azar, reddish (candy sugar), sabudana (oats) and the husband and his family, and discoloration of skin on entire barley may be given as supplements not with the mother. In any case, body. Of special concern to these to breast milk. Breastfeeding is a child is immunised only if, and tribal people was the non-union of continued till the next childbirth. when, an ANM visits the village. the skull fontanelles of infants. The Tribal parents do not actively seek causes of child deaths reported in Complementary feeding is usually immunisation. the study could not be ascertained. initiated after the child reaches six months of age. The feed may 4.2.5 Care in illness 4.2.2 Intranatal and immediate comprise locally available foods a. Identification of morbidity postnatal care such as rice, rice water, pulses and Health care for sick children Most deliveries are conducted vegetables. Among the Pahariyas, is sought in case of any of the at home by untrained TBA (dai), complementary feeding is started at following symptoms: fever, shivering, except among the Ho tribe, where five months for boys and after the diarrhoea, lack of appetite, stiffening sometimes the husband occasionally seventh month for girls. of limbs (nas tan na), scissoring of assists in the delivery and cuts the limbs (puni), and non-closure of cord. The dai uses a new blade to 4.2.4 Immunisation – fontanelles (sarfatna), tightening of cut the umbilical cord, by placing Awareness, decision-making, jaws with difficulty in opening the the cord on a one rupee coin. Soap practices and beliefs mouth and reddish discoloration of is used to wash the hands after Awareness regarding need for and skin with loss of appetite (rangbad)

Summary: Maternal Health Care amongst the Tribal Population 31 and jaundice (pilia). These and 4.2.6 Reasons for poor child in adulthood. This was particularly other symptoms described may be survival true when the illnesses were suggestive of respiratory infection Various factors determine tribal perceived to be of a serious nature. and other febrile illnesses such as health seeking behaviour in malaria, cerebral palsy (puni), and childhood illnesses. The choice of Besides distance, religion and caste possibly, febrile seizures (nas tan na). provider depends on the duration are important variables in accessing and severity of symptoms. While and utilising maternal health care b. Treatment modalities newer treatment modalities are services. The Oraon population Indigenous and home remedies are gaining acceptance, traditional which has seen conversions to used for several diseases among treatment methods have been Christianity may have higher the tribal population. Diseases for in place for generations, and the awareness levels about modern which home remedies are used people strongly believe in them. health care. Studies in Southern include: stiffness of limbs, reddish India have shown that Christian discoloration of skin (rangbad), In these tribal populations, women are more likely to receive diarrhoea, cold, cough, fever and increasing knowledge and antenatal care than women of other body pain. Often, these remedies awareness levels regarding faiths (Navaneetham, 2000). are used for symptomatic relief immunisation do not always rather than cure. For instance, translate into practice. The There are some peculiar practices although the people are aware that presence of a pro-active and among tribals during and after puni (cerebral palsy) is not curable motivated health care provider child birth. For instance, calling a by herbal or modern medications, (AWW, ANM or Sahiyya) and specific dai from another village they still opt for oil massages their rapport with the villagers for cutting the cord (as practiced to strengthen the stiff limbs. plays an important role in accessing by the Pahariyas) may cause Herbal remedies and traditional immunisation services. The unnecessary delays and have medications are also used in case closeness to a health facility, access serious consequences, in case of of kala azar, diarrhoea, dysentery to road and transport are also key a complicated delivery. Mothers and malaria. For fever and malaria, factors. The Sahiyya can have a are usually given only one or two Calpol (paracetamol) and anti- tremendous impact as an agent of meals a day in the postnatal period, malaria drugs are procured from change, as observed in a Pahariya and there are several restrictions the AWC. village with no health facilities or on the intake of certain fruits and visiting ANM. On her own initiative, vegetables. Separating the mother c. First preference for service she takes the children down the hill and child from the rest of the provider once a month for immunisation. family till the sixth day following In villages that lack modern health birth gives the mother temporary facilities, the tribal people resort to The preference for service respite from household activities traditional healers and indigenous provider differs from village to and can also help prevent exposure medicine. This is often the first village and is influenced by factors to infections. port of call. Moreover, there is a like the nature, duration and tendency to wait and watch for a severity of illness, availability of 4.2.7 Ensuring child survival day or two to see what course the and access to service provider, amongst the Tribal Community illness takes, before seeking any transport facilities and economic Addressing health and nutrition medical help at all. With changing considerations, among others. issues is crucial to ensure that awareness levels and attitudes, more On further probing, it was learnt children in the tribes survive, tribal people are seeking modern that when it came to illnesses in especially amongst the PTGs. methods of treatment since these children, most parents preferred  ICDS should be universalised are gradually being perceived as to seek modern treatment facilities and tribal areas should get more effective, compared to other and were willing to travel to priority in the universalisation methods. hospitals, as compared to illnesses process. Each tribal hamlet

32 Health Issues and Health Seeking Behaviour of Tribal Population in Jharkhand should have its own AWC, managed by a worker from its own community. Norms on the number of children for a Mini AWC need to be reduced for PTGs.  Most of the malnourished children are found amongst the tribal population. ICDS data needs to be dis-aggregated so as to understand and inform policy and action.  Each tribal hamlet should have its own Sahiyya and village health committee (VHC) and should not be forced to merge with the larger village. Sahiyyas and AWW of a particular community must be trained in their own dialect on child care practices and in Integrated contraceptive use. Other methods Acceptance of family planning Management of Neonatal and of contraception practiced by methods Childhood Illnesses (IMNCI). married women include the pill There seems to be a healthy  The Health SC/PHC and the (4 percent), IUD (1 percent), awareness of modern contraceptives CHC need to be fully prepared condom (3 percent), rhythm amongst the study population. Most for admitting sick children and (2 percent), withdrawal (2 percent) of them had seen contraceptives, be responsive to their needs. and folk methods (1 percent). have used it themselves or know people who have used them. 4.3 FAMILY PLANNING 4.3.1 Situational analysis Permanent methods were not NEEDS OF THE TRIBAL Ideal family size popular, mostly because such POPULATION The size of the family, which is a services are not available. In Jharkhand, only 36 percent of determining factor in the usage of married women currently use some contraceptive methods, is mostly Family planning is banned in the method of contraception, compared determined by the economic status Pahariya tribe, since they belong with 56 percent at the national of family, as also by the presence of a to a PTG which is considered as level and 34 percent in Bihar son in the family. A typical becoming extinct. The tribe adopts (NFHS-III). Contraceptive Santhal family generally has traditional methods for birth spacing prevalence is considerably higher four to five children, and a couple, and permanent family planning. The in urban areas (60 percent) than in as mentioned earlier, would tribals described home remedies rural areas (28.2 percent). Female attempt to have at least one male and traditional methods, which sterilisation is, by far, the most child. The Christian community are prepared at home, or by the popular method 23.4 percent of (Oraons) prefers to have two to dai, or procured from traditional currently married women are three children, whereas in the Sarna healers. These remedies are used sterilised. By contrast, only community, the average number of for regularisation of the menstrual 0.4 percent of women reported children is four to five. The Pahariyas cycle, spacing of children and for that their husbands are sterilised. prefer to have small families (two to permanent contraception. The study Overall, female sterilisation three children) in order to minimise team attempted to find out the accounts for 66 percent of total their cost of living. recipe and names of the herbs used,

Summary: Maternal Health Care amongst the Tribal Population 33 but these are closely guarded by presence of a functional Anganwadi methods is dwindling with the practitioners of traditional medicine. or a social marketing entrepreneur advent of modern medicines and in the vicinity. Copper–T was rarely shrinking forests where these herbs Across the study population, the used, in fact, most ANMs interviewed are available. Traditional healers decision to use a contraceptive were not confident in inserting a who make such methods available is a collective one taken by the Copper-T/ had never inserted one in have a deep belief in the fact that the couple. In villages with a Christian their career. usage of methods of contraception population, the acceptance of FP (whether herbal or allopathic) is measures was higher, though most 4.3.3 Utilisation of services akin to going against the laws of of them belong to the Catholic Awareness of contraceptive nature. Wherever such methods faith, which abhors FP. methods was not seen to translate are employed, they are preceded into practice, however, none of by elaborate rituals and sacrificial the health functionaries were able offerings to appease the gods. This Note: The ban on the usage to give actual numbers of women is especially true when the methods of contraceptives among the or couples accessing such services. are used for permanent family Pahariyas is to be questioned. Direct questioning of men and planning. Traditional methods are The fact that their numbers are women, falling in the category almost never attempted for abortion dwindling is of no concern to the tribals themselves, since for them of eligible couples, did not yield of a conceived foetus. the need to limit their family size any convincing information as to is a real need, and they resort to the usage of modern methods. 4.4 TRADITIONAL MEDICINE traditional methods to achieve It was interesting to note that AND ITS SIGNIFICANCE this end. Imposing such a ban while the tribals interviewed WITHIN THE TRIBAL without considering the needs of were not forthcoming in their FRAMEWORK the people, the effect that large families could have on the health responses regarding the usage The term ‘traditional medicine’ of mothers who come from an of contraceptives, most of the (indigenous or folk medicine) underprivileged background, are families had only two or three describes medical knowledge poor in nutritional and health children. This probably points to systems, which were developed status and have little or no the usage of alternative methods, over centuries in societies across access to health care facilities namely traditional methods of the world, much before the era to provide them antenatal and critical intranatal care, is contraception. Some respondents of modern medicine. The genre regrettable. did admit finding traditional includes herbal, Ayurvedic and methods more acceptable. Faith Unani medicine, acupuncture, spinal in the traditional healers and manipulation, Siddha medicine, 4.3.2 Availability and methods employed by them were traditional Chinese medicine, South accessibility of services major deciding factors in the African Muti, Yoruba Ifá, as well It was also noticed that in villages with usage of traditional methods of as other medical knowledge and active ANM and Anganwadi services, contraception. practices all over the globe. the use of FP measures is high. Several AWWs and Sahiyyas reported 4.3.4 Traditional methods The World Health Organization having a stock of contraceptive pills Traditional herbal remedies are HO)(W defines traditional medicine and condoms, and also stated that available for spacing or pregnancies, as the health practices, approaches, people approach them for these which are closely guarded by knowledge and beliefs incorporating services without any apprehensions practitioners of traditional medicine. plant, animal and mineral based or hesitation. This could point to There are several reasons for this. medicines, spiritual therapies, an acceptable level of awareness The foremost among these is the manual techniques and exercises, regarding availability of modern fact that the knowledge of herbal applied singularly or in combination contraceptive methods. Access to medicines and the number of to treat, diagnose and prevent condoms and pills was related to the practitioners specialising in these illnesses or maintain well-being.

34 Health Issues and Health Seeking Behaviour of Tribal Population in Jharkhand 4.4.1 Tribal medicine and play a meaningful role in the tribal available 24 hours. However, practitioners in Jharkhand society. They are mainly challenged his technique and the herbs The tribes use herbs and medicinal by the unlicensed allopathic he uses are getting outdated plants available in the forest for practitioner (commonly known as and less effective. If the treating sickness and pain. Local the ‘RMP’). Traditional medicine traditional healers’ technique traditional practitioners, notably is still preferred because the and knowledge can be studied, Dr. Hembrom, refer to Jharkhand’s practitioners reside in the village documented and disseminated traditional medicine as ‘horropathy’- and provide 24 hour services. They amongst them for a more ‘horro’ translates as the local tribals charge very nominal or no fees, can systematic, cohesive and or ‘us’, as opposed to ‘Dikus’ or ‘the be paid back with kind or with the uniform approach, these service others’ who are outsiders. exchange system, and also provide providers can prove valuable an instalment arrangement for to the government and the Tribal people depend totally on payment of huge expenses. Hence, doctors in providing first aid the land and forest for their daily there is a lot of goodwill and and primary health care to the needs. Their first preference is tremendous faith reposed in the tribal groups. The traditional always traditional medicine and system by the people. healers can join the state to their first choice of health service discuss issues, work on cures provider is the vaid raj. Traditional There is a steady decline in the use and strengthen the system. healers are generally divided into of traditional medicine. With rapid  Tribal healers use herbs two categories – those who serve deforestation and gradual extinction found in the forest, but the role of diviner-diagnostician of some medicinal plants, it is due to industrialisation and (or diviner-mediums) and those proving difficult for the traditional deforestation, much of the who are healers (or herbalists). healers to procure the required forest area and the herbs it is The diviner provides a diagnosis herbs, and thus, they now have to home to have been destroyed. usually through spiritual means, buy the same. These practitioners These herbs are presently while the herbalist chooses and are also unable to find apprentices available only in some forests applies relevant remedies. Colonial to hand down their skills to. or with some institute/ powers and structures have played individuals, who cultivate an overpowering role in changing The government has, till date, only these plants. The herbs used the cultural landscape and practices been paying lip service to traditional by these healers, thus, are not of traditional healers and their medicine. Ayurvedic clinics have easily available or come at a patients, and have disrupted the been opened in certain areas, but heavy price, which reduces distinction between diviners and they do not use local herbs. There is the efficiency of the healers. If herbalists. Additionally, with the a pressing need for the government these herbs can be cultivated encroachment of Western health to recognise and encourage by the government and then care systems, the roles of the traditional herbal remedies as an distributed to the vaid rajs, as is diviner and herbalist have become important system of healing. done in the case of allopathic increasingly blurred. Traditional medicines, then these healers healers are, thus, undergoing a Some steps that can be taken to can prove more productive and strange process of mutation, as institutionalise traditional/tribal help the government directly. Jharkhand modernises. medicines are listed below:  The government needs to promote scientific verification Poor health infrastructure coupled  This study found that in and documentation of traditional with mistrust in the existing health every second village, there medicine, so as to help legitimise system has ensured that local is a recognised tribal healer, and thus, standardise this health traditional healers continue to who is easily accessible and care genre.

Summary: Maternal Health Care amongst the Tribal Population 35 Section E

CONCLUSION

hange is the only constant. the Jharkhand state, more than Government of India to improve CThe tribal society has seen a 50 years later. their general welfare, including health, lot of change in the last century, the tribes still consider modern but still retains some of its basic Through all this change, the tribals health care system as alien. However, characteristics. The main change have continued to lead impoverished they have been showing willingness agents were: lives and the state is ranked in most to engage with the system, if such 1. Industrialisation: In the early development rankings at the bottom opportunities are made available. 1900s, the British penetrated of the list. the forests of for For the tribes, the most common timber to cater to the growing Barely 10 percent of the villages are face of modern medicine is the railway expansion. The Santhals electrified, roads do not exist in the RMP, who provides services at later migrated to the tea estates hinterland and institutions in the their doorstep or at haats (local for work. health, education and women and markets). ANMs are rarely present 2. Advent of missionaries: Lutheran child department are few. in hard to reach areas. Occasionally, and Jesuit missionaries have tribal ANMs do stay in the villages, been operating in Jharkhand Tribal people differ from other but their availability at the time of since the early 1900s, communities by virtue of cultural need is not reliable. AWWs are proletysing and educating the settings. Their health care present but are not considered local tribal people. problems stem from illiteracy, poor health providers, as they are not 3. Jharkhand Movement infrastructure, poor sanitation, well trained or educated in most – A political consciousness and also, from some customs and health care cases. Vaid raj and dai movement was started just traditions peculiar to these groups. are available in the village 24 hours before Independence by a day, but the Government seems Mr. Jaipal Singh Munda, which Despite a number of welfare unwilling and unable to integrate culminated in the formation of measures undertaken by the with the traditional healing systems.

36 Health Issues and Health Seeking Behaviour of Tribal Population in Jharkhand RECOMMENDATIONS

he need of the hour is to ensure Other suggestions include:  Institutionalising traditional Tquick availability and accessibility  Empowering local population to healing practice: of health care services to the tribal plan for health:  University and research and rural people, and institute tribal-  VHC at hamlet level institutes to actively work friendly health services in hard to  Local Sahiyyas at hamlet on herbal medicine reach areas. level  Work with and promote vaid  Community monitoring raj in each village, document With regard to FP, there seems and set up platforms for to be considerable unmet need in  Ensuring functional health and sharing and dialogue the population. Tubectomy and nutrition facilities in every intrauterine contraceptive devices village: Policy-makers need to consider (IUCD) need to be propagated  AWCs in each village these suggestions before and promoted. There is a need to  Adequate and efficient SCs formulating a new policy and reconsider the PTG policy, in terms  CHC/PHC for tribal areas in strategy for the tribal people. of banning FP in tribes considered as all scheduled districts Since the tribes prefer to function getting extinct. in their own habitat, they should  Ensuring all health care facilities not be forced to come out and In case of child health care facilities, are tribal-friendly institutions: accept health systems that are ICDS must be universalised  Personnel to be from the unfavourable to them. Instead, and quality output needs to be tribal community we must cater to their needs, monitored. ICDS data must be  Staff fluent in local dialect respecting their requirements, and disaggregated to understand and  Local tribals in charge of create a more secure and healthy inform policy and action. public relations environment for these groups.

Recommendations 37 REFERENCES

asu, S.K., Jindal, A., Kshatriya, Jain S. and S. Agrawal, 2005, Disease”. Studies in Tribes and Tribals, BG.K. (1990), “The Determinants “Perception of Illness and Health 4(1):1-6. of Health Seeking Behaviour among Care among Bhils: A Study of Tribal Populations of Bastar District, Udaipur District in Rajasthan” Park K. “Preventive Medicine Madhya Pradesh. “ South Asian Studies of Tribes and Tribals, 3(1): in Obstetrics, Paediatrics and Anthropologist11 (1): 1-6. 15-19. Geriatrics.” In: Park’s Textbook of Preventive and Social Medicine, 19th Bryant, J. 1988, “Health for All: The K. Mallikharjuna Rao, 2008, Edition, Jabalpur: M/s Banarsidas Dream and the Reality.” World Health “Utilisation of Reproductive and Bhanot; 2005. p. 414-79 Forum, 9(3): 291-302. Child Health Services in Tribal Areas of Andhra Pradesh – Health Parchure N., Warvedakar J. Bhasin, Veena. 2005, “Ecology and and Nutritional Problems of “Prevalence of Self Reported Health: A Study among the Tribes of Indigenous Populations.” Studies in Symptoms of Reproductive Tract Ladakh.” Studies of Tribes and Tribals, Tribes and Tribals, Special Volume Infection among Currently Married 3(1): 1-13. No. 2: 35-41 (2008) Women in Madhya Pradesh”, cited from http://prcs-mohfw.nic.in/ Deb, Roumi “Utilisation of Services K. Navaneetham, A. Dharmalingam showprcdetail.asp?id=127 accessed Related to Safe Motherhood “Utilisation of Maternal Health on 6th October, 2008. among the Tribal Population of Care Services in South India”, East Khasi Hills (Meghalaya): An (Oct. 2000). Paper presented Primary Census Abstract, Census of Overview.” In Ethno-Med., 2(2): in faculty seminar at the Centre India, 2001 137-141 (2008) for Development Studies, Thiruvananthapuram, Kerala. Prasad J.H., Abraham S., Kurz K.M. Guite, N and S. Acharya, 2006, Available from: http://unpan1. et al International Family Planning “Indigenous Medical Substances and un.org/intradoc/groups/ Perspectives, Volume 31, Number 2, Health Care: A Study among Paite public/documents/APCITY/ June 2005. Tribe of Manipur, India.” Studies of UNPAN012686.pdf Tribes and Tribals, 4(2):99-104. National Family Health Survey Project Implementation (NFHS-III), 2005-06. International Mahapatra, L.K., 1994, “Concept of Plan: Tribal Health. Available Institute for Population Sciences Health among the Tribal Population from: http://mohfw.nic.in/ (IIPS) and ORC Marco. Groups of India and Its Socio- dofw%20website/pip.pdf Economic and Socio-Cultural Sachchidananda (1978). “Social Correlates”, (pp.1-12) in S. Basu Raj Pramukh and P.D.S. Palkumar, Structure, Status and Mobility (ed.), Tribal Health in India. Delhi: 2006. “Indigenous Knowledge: Patterns – The Case of Tribal Manak Publications Pvt. Ltd. Implication in Tribal Health and Women, Man in India, Vol. 58 No. 1.

38 Health Issues and Health Seeking Behaviour of Tribal Population in Jharkhand Sharma, Ravendra K. “Newborn Navaneetham K., Dharmalingam U.N. Report (1984). V. Health Health among Tribes of Madhya A. “Utilisation of Maternal Status of Women. Improving Pradesh – An Overview” RCMRT Health Care Services in South Concepts and Methods for Statistics Update Vol. 4, No.1, April 2007 India”(Oct 2000). Paper and Indicators on the Situation of presented in faculty seminar at Women. Studies in Methods - Sumathy, S.R. “The Health Practices the Centre for Development series F.No. 33. of Tamil Nadu Tribes”. Bulletin of the Studies, Thiruvananthapuram, Madras Government Museum; 1990. Kerala. Available from: http:// Madan, T.N. (1951). Education of unpan1.un.org/intradoc/groups/ Tribal India. Eastern Anthropologist Park, K. “Concept of Health and public/documents/APCITY/ Vol. V (4) pp. 179-82. Disease, Paediatrics and Geriatrics.” UNPAN012686.pdf In: Park’s Textbook of Preventive and Mutatkar, R.K. (2004). Report Social Medicine19th Edition, Jabalpur: Chaudhuri, Buddhadeb (1990). Social on Health Issues in Nandurbar M/s Banarsidas Bhanot; 2005. and Environmental Dimensions District: Maharashtra Human p. 12-47. of Tribal Health (In) Cultural and Development Action Research Environmental Dimensions of Health Study, The Maharashtra Association Rai Rajiv, Nath Vijendra. ”Use of (ed. by B. Chaudhuri. Inter-India of Anthropological Sciences, Medicinal Plants by Traditional Publications). Pune, India. Herbal Healers in Central India”. Paper submitted to the XII World Singh, Bhupinder (1994). “Factors Registrar General of India (RGI): Forestry Congress, 2003, Quebec Influencing Health of Tribal (2005-06): Sample Registration City, Canada. Available from: http:// Population Groups”, (pp.40-56) in System Report (SRS): www.fao.org/DOCREP/ARTICLE/ S. Basu (ed.), Tribal Health in India. New Delhi: Government of India. WFC/XII/0185-A3.HTM Delhi: Manak Publications Pvt. Ltd. RGI, SRS

References 39 LIST OF ACRONYMS

AIDS Acquired Immuno Deficiency Syndrome ANC Antenatal Care ANM Auxiliary Nurse Midwife AWC Anganwadi Centre AWW Anganwadi Worker BCG Bacillus Calmette-Guérin CHC Community Health Centre CINI Child In Need Institute DPT Diphtheria, Poliomyelitis and Tetanus FGD Focus Group Discussion FP Family Planning ICDS Integrated Child Development Services IDI In-Depth Interview IFA Iron and Folic Acid IUCD Intrauterine Contraceptive Device IUD Intrauterine Device IMNCI Integrated Management of Neonatal and Childhood Illnesses IMR Infant Mortality Rate JSY Janani Suraksha Yojna KII Key Informant Interview MCH Maternal and Child Health MMJSSA Mukhyamantri Janani Shishu Swasthya Aiyan MMR Maternal Mortality Ratio NGO Non-Governmental Organisation PHC Primary Health Centre PNC Postnatal Care PRA Participatory Rural Appraisal PTG Primitive Tribal Group RCH Reproductive Child Health RMP Registered Medical Practitioner RTI Reproductive Tract Infection SC Sub Centre ST Scheduled Tribe STI Sexually Transmitted Infection TBA Traditional Birth Attendant TT Tetanus Toxoid VHC Village Health Committee WHO World Health Organization

40 Health Issues and Health Seeking Behaviour of Tribal Population in Jharkhand List of Acronyms Annexures

INSTRUMENT 1A

PRA – SOCIAL MAP last three years) – Use centres/FP depots – Use Manpower : Facilitator – 1 blue marker green marker and write down Assistants – 3 ii. Houses with maternal Time Expected : 2 hours deaths/near deaths/severe NOTE maternal illness (last three  This exercise will take at least one STEPS years) – Use red marker hour. 1. The local NGO facilitator gathers iii. Houses with under 5  Facilitate the villagers to do it the people together. deaths/near deaths/severe themselves (the adolescent and 2. The facilitator explains the reason childhood illness (last one youth are usually the first to come for the exercise. year) – Use yellow marker forward). 3. The group then prepares a social iv. Houses of traditional  Take a photograph of the social map1 which lists the following: healer/TBA – Use green map and leave it behind. Data is a. All households marker and write down collated in the format. b. Houses who have had: v. Drinking water/sanitation/ i. Recent child birth (in the nutrition (ICDS)/Health

Fill the following Format No: 1 Child Birth in the last three years Name Mother’s Date of Sex Place of Birth Attended By Present Status – Head of Name Birth (M or F) Birth (Home, (Relative2, TBA, (Well, Sick or Household (at least Institution – Nurse, RMP, Doctor) Dead) month) mention name)

Maternal Morbidity/Mortality in the last three years Name – Head of Mother’s Name Date of Illness or Death Present Status Household (at least month) (Well, Sick or Dead)

Child Morbidity/Mortality in the last one year Name – Head of Mother’s Name Child’s Name Sex Date of Illness/Death Present Status Household (at least month) (Well, Sick or Dead)

1 To draw a Social Map, you will need chart papers and markers. A map of the roads/paths of the village are drawn along with major land marks. Each house is denoted with a square and the name of the head of the household is written next to it. If there are a lot of households, then divide the area and make more than one map. 2 Mention relationship like husband/mother-in-law/neighbour

Annexures 41 INSTRUMENT 1B

PRA – TIME ANALYSIS does the exercise in three  Health – Modern drugs, Manpower : Facilitator – 1 stages. injections, first modern medicine Assistants – 3 practitioner etc Time Expected : 2 hours Group One – Pregnancy, Child Material : Chart paper, Care and Family Planning The assistant takes down markers  Draw a line across the chart notes on when, how and who paper and mark the following introduced modern technology Three groups will be doing this points: and the perceived benefits of the simultaneously. Facilitators will  Detection of pregnancy introduction of technology. divide themselves and assist the  Pregnancy groups.  Delivery Group Three – Annual Timeline  Breastfeeding  Mark the annual festivals out on 1. Activities done during  Weaning a straight line pregnancy, child birth to child  List traditional practices/rituals  Mark the agricultural practices rearing until age 5. taking place in each period – Free and mark points on another line 2. Timeline of major village listing and later, pile sorting. relative to the annual festivals events in the past, followed  Discuss practices and rituals for  Mark food availability on the by introduction of various birth spacing and family planning. next line technology including electricity,  Mark illness that occur modern water delivery Group Two – Introduction to episodically, like malaria, mechanisms (hand pump), Technology diarrhoea, measles, respiratory roads, transport, modern drugs, tract infection (cold, cough, injections, first modern medicine Timeline of major village events in pneumonia), white discharge practitioner, school, etc. the past, followed by introduction of (reproductive tract infection) 3. Seasons mapping for work in technologies in the following fields: village, agricultural practices,  Farming NOTE food availability and childhood  Crafts (if applicable)  Take photographs of the chart illnesses.  Amenities – Includes electricity, modern water delivery papers and leave them behind.  Assistants must maintain notes STEPS mechanisms (hand pump), roads, of discussion. Final notes are 1. The local NGO facilitator transport etc to be prepared on the first day gathers the people together.  Education – First school, first itself and shared with the group. 2. The facilitator explains the student, first high school pass reason for the exercise and out, first graduate etc

42 Health Issues and Health Seeking Behaviour of Tribal Population in Jharkhand INSTRUMENT 1C

PRA – HEALTH study and get their consent. it that is expected? (List RESOURCE LISTING Mention that the exercise will various first choices of the Manpower : Facilitator – 1 take a little more than an hour. group, even if only one Assistants – 3 3. List the common and serious person prefers it.) Time Expected : 2 hours illnesses that occur in the village. e. Second opinion – When Material : Chart paper, Probe mostly for illnesses that is second opinion sought? markers affect children and women. Who is the second choice? Note: To be done on the second or 4. Choose two minor and one or Why? What is expected? third day. two major illness and for each f. Traditional medicine over illness, probe the following: modern medicine – When Objective: Listing health resources a. How do they recognise the do they prefer either? Why? in the village and beyond, as well as illness? List service providers and symptoms that treatment is sought b. Home remedies suggested rank them by popularity and for and ranking of service providers. or tried out? perceived understanding c. At what stage of illness of competence. (This has STEPS would they decide to see a to be done in detail. Spend 1. Get a group of eligible couples health provider? equal time on this – probe and traditional leaders together. d. First choice of health for reasons for preference, 2. Explain the objective of the provider. Why? What is availability and practice).

Annexures 43 INSTRUMENT 2A

FGD – ELIGIBLE conversation with the interviewees  Do couples know the COUPLES as possible and to probe issues that common family planning Manpower : Facilitator – 1 the interviewees bring up (even if methods? Reporter – 2 that issue is not listed below). The  What methods are Observer – 1 interviewer needs to use his/her commonly used by the Time Expected : 2 hours skills to draw out the interviewee couples and the reasons Material : Probe and to decide on the spot what for using them? Probe for Questionnaire, areas of conversation might be spacing, limiting and for consent form, relevant and when to divert the delaying first pregnancy. writing pad, topic. The entire purpose of the  Where do couples go for FP pens, recorder, focus group discussion will be lost if or contraception? camera, chart the guidelines are used like a survey  What are the traditional paper, markers question–answer session. contraception/family planning methods known INTRODUCTION The interview should also be and used by the couples? Introduce yourself and the documented verbatim with full Probe for the spacing, accompanying note takers and details. limiting and for delaying first explain the purpose of your visit. pregnancy. You may mention the name of the Section A: Marriage  Effectiveness of traditional facilitating NGO and CINI. Mention  Start with type of marriage vs. modern methods of that the government would like  Age at marriage appropriate contraception. to prepare a plan for tribal health for boys and girls in their  Is there an unmet need and their inputs could be used to community as well as actual which hasn’t come in the prepare the same. practice findings related to the use  Involvement of probable groom of contraception among the CONSENT and bride for decision regarding couples in the community? Take consent after reading out the marriage and choice of partner  Who generally decides on form.  Belief and customs related to when and which method to marriage use? Issues to be covered  What is the desired number The issues listed below should Section B: Family planning of children among most not be treated as questions to be 1. List the common family planning couples? asked one after the other. They methods known to the people in  Where do couples go for FP do not have to be covered in any the area: or contraception? particular order. They are to be  What does the community  Is there any source of used only as guidelines. The key is feel is an ideal family size? information regarding the FP to carry on as much of a natural Probe gender preference. methods among the couples: Individual or organisation?

44 Health Issues and Health Seeking Behaviour of Tribal Population in Jharkhand Section C: Maternal and child  What is the general practice:  What do most of the people do health related to menstruation: Say when a child gets ill? (Discuss Start the discussion with rituals, when a girl starts her first home remedies) beliefs and practices during period (MC), what’s her  Where do they usually take pregnancy. Ask specifically by mother’s role, how do women them and why? trimester, accompanied by the keep themselves clean during  Are people in this community following information on health those days, and what do the satisfied with the kind of seeking behaviour. (This will facilitate women use (napkin, cloths etc.) services provided at this place? a frank and well placed discussion  Do they clean their genitals  How much money do parents/ among the group members with very during bath and after going to others spend during such little probe and direct involvement of the toilet? Should be worded instances? the Moderator) thus: Now let us discuss about how people usually clean Immunisation List the services that are available in themselves during bath as well Probe questions on practices and the area: as when they go for toilet, and belief on child immunisation  List the MCH services that are before going to sleep?  Do people know about available in the area.  Who initiates the sexual activity immunisation?  Ask them about the utilisation among couples? Do couples  Is it really needed? pattern of those services that usually plan it?  Where do people take their are available.  Do you think couples usually child for immunisation?  Are they satisfied with the kind clean their genitals before and  What, if they can not reach the of services they get? after intercourse? immunisation centre?  Who influences their decisions  Have they ever seen/  Does anybody come to about when to seek care, where experienced any itching, ulcer, their village to administer to seek care or what practices pain and discharge in their immunisation? to follow? genitals or heard about this from  Where do they get information  What traditional practices do their people? about the Immunisation they follow in the pre delivery  What do women/men generally day? How is the message period? do when they see/experience communicated in the village  What traditional practices such symptoms? regarding immunisation? do they follow at the time of  Do they seek any medical help  Do people know which delivery? (traditional or modern)? If yes, vaccine protects the child  What traditional practices do where? from which disease? Who they follow during new born  Do they seek treatment along usually has this knowledge in care? with their sexual partner? (Ask: your community?  What practices do they follow if Who do you think should  How do parents/others track any kind of complications arise initiate treatment? Do any of which vaccine is to be given next during and after pregnancy? you know a woman/man who and when?  The interviewer should be took treatment for a problem  Do parents with small children open to the responses about such as ………. have cards? traditional practices as well  Does any one of you know as modern practices, i.e. from Section E: Child Care any incident or have a negative the sub-centre or public health Health seeking behaviour on child experience of immunisation of system. care children in your community? (What happens after BCG and Section D: RTI/STI List the various steps that they take DPT? Like fever, scar, which To assess information on their in case of health related problems in deter them from going for hygiene and sexual health practices children: immunisation/full immunisation)

Annexures 45 Section F: Health Providers  Who else in the village mothers  Did they seek care, if so what  Do you know about Sahiyya? and young couples? (Probe type of care and where did they (If yes/no, what about the about different Women’s seek care? other members of the Group etc.)  How much money did they community?) spend, did they have to spend  Does she visit you and your Section G: Mortality/morbidity extra money? other community members? Recall deaths/near deaths that have  Were they happy with the kind  What do they feel about the occurred in the village or nearby of care they received? attitude/behaviour of the village in the last three years (both ANM? (She is friendly, not maternal and child). (Plan for in- Thank the participants and invite friendly, does counselling depth interview later, but get basic them to ask you questions. Attempt before and after immunisation) details.) to answer their questions to the  If friendly/not friendly, do you  Describe the experience best of your knowledge. If you are think she behaves in a similar  How did he/she recognise the not sure, say that you will get back way with everyone? problem? to them through the facilitating NGO with the correct response.

46 Health Issues and Health Seeking Behaviour of Tribal Population in Jharkhand INSTRUMENT 2B

IDI – CARETAKER3 OF (even if that issue is not listed below). g. Was money a constraint? SEVERELY ILL CHILD The interviewer needs to use his/her h. Were they happy with the Manpower : Facilitator – 1 skills to draw out the interviewee and kind of care they received? Reporter – 1 to decide on the spot what areas of Time Expected : 2 hours conversation might be relevant and 2. Service providers Material : Probe when to divert the topic. The entire a. If they used traditional or Questionnaire, purpose of the interview will be lost modern medicine, why did consent form, if the guidelines are used like a survey they do so? writing pad, pens, question–answer session. b. Behaviour of the service recorder provider – Rude or The interview should also be pleasant? Probe for INTRODUCTION documented verbatim with full details. their understanding of Introduce yourself and the Government service accompanying note takers and PROBES providers/private providers/ explain the purpose of your visit. 1. Illness traditional providers. You may mention the name of the a. Ask the care taker to c. Were preventive services facilitating NGO and CINI. Mention describe the child’s illness. for children available? Probe that the Government would like Allow them to describe the for immunisation. Were to prepare a plan for tribal health experience. AWW visiting mothers and their inputs could be used to b. How did he/she recognise and sick children during prepare the same. the problem? postnatal periods? c. Was any home remedy used, d. Has she met the ANM and CONSENT if so what, why was it used, does the ANM live nearby? Take consent after reading out the and what was the result? e. Does the AWW or ANM form. d. Did they seek care, if so stock any medicines in the what type of care and where village? Issues to be covered did they seek care? Probe The issues listed below should not be for preference and reasons. 3. Health System treated as questions to be asked one e. If care was delayed, probe a. What are their suggestions after the other. They do not have to for reasons – distance, safety for improving health care be covered in any particular order. (night travel), uncomfortable services in the area? They are to be used only as guidelines. to go for modern medicine The key is to carry on as much of treatment. Thank the person for the interview a natural conversation with the f. How much money did they and answer any questions posed to interviewees as possible and to probe spend and did they have to the best of your ability. issues that the interviewees bring up spend extra money?

3 Could be mother, father or any close relative that was involved with the decisions of care during illness.

Annexures 47 INSTRUMENT 2C

IDI – CARETAKER4 OF listed below). The interviewer needs h. Were they happy with the SEVERELY ILL MOTHER to use his/her skills to draw out the kind of care they received? Manpower : Facilitator – 1 interviewee and to decide on the Reporter – 1 spot what areas of conversation 2. Service providers Time Expected : 2 hours might be relevant and when to a. If they used traditional or Material : Probe divert the topic. The entire purpose modern medicine, why did Questionnaire, of the interview will be lost if the they do so? consent form, guidelines are used like a survey b. Behaviour of the service writing pad, pens, question–answer session. provider – rude or pleasant? recorder Probe for their understanding The interview should also be of government service INTRODUCTION documented verbatim with full details. providers/private providers/ Introduce yourself and the traditional providers. accompanying note takers and PROBES c. Were preventive services explain the purpose of your visit. 1. Illness for mothers available? Probe You may mention the name of the a. Ask the caretaker to for ANC at village level, IFA facilitating NGO and CINI. Mention describe the maternal illness. tablets and TT, AWW visiting that the Government would like Allow them to describe the mothers during postnatal to prepare a plan for tribal health experience. periods. and their inputs could be used to b. How did he/she recognise d. Has she met the ANM, does prepare the same. the problem? the ANM live nearby? c. Was any home remedy used, e. Does the AWW or ANM CONSENT if so what, why was it used, stock any medicines in the Take consent after reading out the and what was the result? village? form. d. Did they seek care, if so what type of care and where 3. Health System Issues to be covered did they seek care? Probe a. What are their suggestions for The issues listed below should not for preference and reasons. improving health care services be treated as questions to be asked e. If care was delayed, probe in the area? one after the other. They do not for reasons – distance, safety b. Was she enrolled in the JSY have to be covered in any particular (night travel), uncomfortable scheme? If yes, describe the order. They are to be used only as to go for modern medicine entitlement received and the guidelines. The key is to carry on as treatment. experience. much of a natural conversation with f. How much money did they the interviewees as possible and to spend and did they have to Thank the person for the interview probe issues that the interviewees spend extra money? and answer any questions posed to bring up (even if that issue is not g. Was money a constraint? the best of your ability.

4 Could be the mother herself, husband, father or any close relative that was involved with the decisions of care during illness.

48 Health Issues and Health Seeking Behaviour of Tribal Population in Jharkhand INSTRUMENT 3

IDI – AWW/ANM/TBA/ one after the other. They do not and children in the area? DOCTOR/TRADITIONAL have to be covered in any particular 4. What are the major morbidities HEALER order. They are to be used only as among children and what Manpower : Facilitator – 1 guidelines. The key is to carry on as treatment do you provide Reporter – 1 much of a natural conversation with for the same? (Please provide Time Expected : 2 hours the interviewees as possible and to information with age band 0-6 Material : Probe probe issues that the interviewees years, 6-10 yrs. and 11-16 yrs.) Questionnaire, bring up (even if that issue is not 5. Where do women go to consent form, listed below). The interviewer needs seek treatment and advice on writing pad, pens, to use his/her skills to draw out the pregnancy related problems? recorder interviewee and to decide on the 6. What are the major problems spot what areas of conversation faced by the community in INTRODUCTION might be relevant and when to seeking treatment for common Introduce yourself and the divert the topic. The entire purpose morbidities? accompanying note takers and of the interview will be lost if the 7. Who assists deliveries mostly explain the purpose of your visit. guidelines are used like a survey and who takes the decisions at You may mention the name of the question–answer session. the place of delivery? facilitating NGO and CINI. Mention 8. What traditional beliefs and that the government would like The interview should also be practices regarding pregnancy to prepare a plan for tribal health documented verbatim with full and lactation are prevalent and their inputs could be used to details. within the community? prepare the same. 9. What are the traditional healing PROBES practices and what is the CONSENT 1. What services are you providing preference for them vis–a–vis Take consent after reading out the form. to pregnant and lactating women? modern medicine? 2. What services are you providing 10. Do tribal couples seek advice on Issues to be covered to children (0–5 years)? family planning and sexual health The issues listed below should not 3. What are the major health from you? If no, where do they be treated as questions to be asked related issues regarding women go for the same?

Annexures 49 INSTRUMENT 4A

KII – SOCIAL ACTIVIST order. They are to be used only as working with the community. guidelines. The key is to carry on as 3. Probe his/her general impression Manpower : Facilitator – 1 much of a natural conversation with of the health status of the Reporter – 1 the interviewees as possible and to people and the health care that Time Expected : 2 hours probe issues that the interviewees they can access. Material : Probe bring up (even if that issue is not 4. What are the most important Questionnaire, listed below). The interviewer needs health issues/illnesses faced by consent form, to use his/her skills to draw out the the people? writing pad, pens, interviewee and to decide on the 5. Where do they seek care and recorder spot what areas of conversation what are the hurdles faced in might be relevant and when to seeking care? INTRODUCTION divert the topic. The entire purpose 6. Are there any examples of the Introduce yourself and the of the interview will be lost if the government, NGO, mission accompanying note takers and guidelines are used like a survey addressing access to health care? explain the purpose of your visit. question–answer session. 7. What are the effective You may mention the name of the traditional medicines and facilitating NGO and CINI. Mention The interview should also be treatments that according to that the government would like documented verbatim with full him/her are being offered in to prepare a plan for tribal health details. the locality as per the tribal and their inputs could be used to customs? Describe in detail. prepare the same. PROBES 8. Are there any ecological 1. Ask the activist about the factors that affect the health of CONSENT number of years s/he has these tribes? Probe – Forests Take consent after reading out the been working with the tribal (malaria), mines, drought, roads form. community and in which field? etc. Allow the person to describe 9. What are his/her suggestions to Issues to be covered his/her experience. address the above issues? The issues listed below should not 2. Is the person from the same 10. Note his/her suggestions for be treated as questions to be asked tribal community or from improving tribal health in the one after the other. They do not another community? Mention region, especially within the have to be covered in any particular the community and reason for cultural specifications.

50 Health Issues and Health Seeking Behaviour of Tribal Population in Jharkhand INSTRUMENT 4B

KII – HERBAL MEDICINE guidelines. The key is to carry on as 3. Probe his/her general impression SPECIALIST much of a natural conversation with of the health status of the Manpower : Facilitator – 1 the interviewees as possible and to people and the health care that Reporter – 1 probe issues that the interviewees they can access. Time Expected : 2 hours bring up (even if that issue is not 4. What are the most important Material : Probe listed below). The interviewer health issues/illnesses faced by Questionnaire, needs to use his/her skills to the people? consent form, draw out the interviewee and to 5. Where do they seek care and writing pad, pens, decide on the spot what areas of what are the hurdles faced in recorder conversation might be relevant seeking care? and when to divert the topic. The 6. What are the effective INTRODUCTION entire purpose of the interview traditional medicines and Introduce yourself and the will be lost if the guidelines are treatments that according to accompanying note takers and used like a survey question–answer him/her are being offered in explain the purpose of your visit. session. the locality as per the tribal You may mention the name of the customs? Describe in detail. facilitating NGO and CINI. Mention The interview should also be 7. Has s/he systematically that the government would like documented verbatim with full documented herbal remedies? to prepare a plan for tribal health details. If yes, is a copy of the same and their inputs could be used to available? Has anybody else prepare the same. PROBES documented these? 1. Ask him/her about the number 8. Does s/he charge for any CONSENT of years s/he has been working treatment provided? If yes, get Take consent after reading out the with herbs? How did she get the rate. form. interested in the study of these 9. Are tribals still comfortable herbs? Allow the person to with using herbal remedies or Issues to be covered describe his/her experience. are they showing a disinterest The issues listed below should not 2. Is the person from the same in it? be treated as questions to be asked tribal community or from 10. What are his/her suggestions to one after the other. They do not another community? Mention address the above issues? have to be covered in any particular the community and reason for order. They are to be used only as working with community now.

Annexures 51 List of Team Leaders and Investigators Tribe Santhal Ho Munda Oraon Pahariya District Dumka Chaibasa Khunti Gumla Sahebganj Facilitator Rajendra Pranav Abhijit Harishanker Parker Team Members Sunita, Parvej Pankaj, Pallavi Sanchita Rani Bachman, Celin Horo, Joshi, Tanvir Mukhopadhyay, Sarita Parvej, Anuj, Rakhi, Monika, Saket, Sunita Jaybanti, Shikhar

52 Health Issues and Health Seeking Behaviour of Tribal Population in Jharkhand

Health Issues and Health Seeking Behaviour of Tribal Population Jharkhand

January 2009