Indigenous Health: Access to healthcare among children In tribal dominated villages of Simdega, Jharkhand With reference to Acute Respiratory infections Dr. Supriya Bonnie Minz Dissertation submitted in partial fulfillment for the award of Masters of Public Health Degree Year 2008 Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthpuram, Kerala October, 2008 ACKNOWLEDGEMENTS First of all I would like to thank my father Lieutenant Colonel (Dr) C B Minz who opened my eyes to the fate of the Tribes of Jharkhand. This inspired me to select such a topic. Sadly he passed away just before the data collection got under way. I extend my sincere gratitude to my guide Dr. Biju Soman, Associate Professor, AMCHSS, SCTIMST for his guidance at every step since I started working on this dissertation. I thank Professor K. R. Thankappan, Professor Raman Kutty, Dr. Sundari Ravindran, faculty at AMCHSS, for their valuable suggestions and inputs. I’d like to thank all the people from the Government of Jharkhand, including my husband Dr Rajeev Arun Ekka, IAS who extended support in various ways to put this work together. I would also like to thank the field investigators who assisted me in data collection to the best of their ability against the odds of difficult terrain and weather. Lastly, I extend my thanks to all the participants of this research for their cooperation CERTIFICATE Certified that the dissertation titled, “Indigenous Health: Access to healthcare among children in tribal dominated villages of Simdega district, Jharkhand with reference to acute respiratory infection” is a bonafide record of original research work undertaken by Dr. Supriya Bonnie Minz, in partial fulfillment of the requirement for the award of the Master of Public Health degree under my guidance and supervision. Guide Dr. Biju Soman Assistant Professor Achutha Menon Centre for Health Science Studies (AMCHSS), Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST), Thiruvananthpuam DECLARATION I hereby certify that the work, embodied in this dissertation titled, “Indigenous Health: Access to healthcare among children in tribal dominated villages of Simdega district, Jharkhand with reference to acute respiratory infections” is the result of original research and has not been submitted for any degree in any other university or institution. Thiruvananthpuram October, 2008 Supriya Bonnie Minz CONTENTS: Page no. 1. Introduction 1 2. Background 3 3. Rationale 8 4. Review of Literature 9 5. Objectives 14 6. Variables 14 6.1 Outcome Variable 6.2 Predictor Variables 7. Methodology 19 7.1. Study design 7.2. Study Setting 7.3. Sample frame 7.4. Study Population 7.5. Case Definition 7.6. Inclusion and exclusion criteria 7.7. Sampling procedure 7.8. Sample size estimation 7.9. Study tools 7.10. Ethical consideration 7.11. Data collection 7.12. Data analysis 8. Results 26 9. Limitations 44 10. Discussion 45 11. Conclusion 48 12. Recommendations 50 13. References 51 14. Appendix 1. Appendix-1 2. Appendix-2 3. Appendix-3 4. Appendix-4 5. Appendix-5 ABSTRACT: Background: Indigenous people have worse health outcomes yet there is limited data on their health status or healthcare access from developing countries. Acute respiratory infections are among the leading cause of preventable deaths among under five children. Objective: This study was to describe the healthcare access, identify barriers to access, and estimate the prevalence and pattern of acute respiratory infections in children less than five years of age. Methodology: Using a multistage random sampling 1028 children 0-60 months were selected from 19 out of 117 villages that had 90-100% tribal population. Information on demographics, severity of ARI and access to health care was collected from mothers, village heads and health providers using a pre-tested structured interview schedule. Results: The study reveals that about 20 percent of these children belong to families that have ever visited the primary health center or a private clinic, while less than 50 percent have ever visited even a health sub center. ARI was reported by 318 (30.9%) percent of which 89.6% belonged to cough and cold category, 6.6% to pneumonia, 2.8% to very severe pneumonia, and 0.9% to very severe disease . Access to healthcare was found to be significantly associated with distance to sub center< five km (OR 4, p<.001), availability of various resources at sub center (OR 2-8, p<.005), public transport to health facility (OR 5.6, p<.001), and mother’s perception of various aspects of the nearest Health sub center as favorable (OR 4-10, p<.001), mother’s perception of illness as serious (OR 3.4, p<.001), presence/regular visits of community level health workers (OR 3-5, p<.001), and IEC activity in village within six months (OR 3.2, p<.001). Conclusion: In our study prevalence of ARI was high and the major barriers to access were – poor connectivity, ill equipped health facilities, low awareness of healthcare availability, low motivation among community level health workers, and distance to health facility. Efforts to bridge these gaps could improve healthcare access in indigenous populations. CHAPTER 1 1. INTRODUCTION 2. BACKGROUND 3. RATIONALE 4. REVIEW OF LITERATURE 1. INTRODUCTION: The World Health Organization fact Sheet on The Health of Indigenous Peoples states that the estimated 370 million indigenous peoples living in more than 70 countries worldwide, continue to be among the world’s most marginalized population groups and that there health status varies significantly from that of non-indigenous population groups in countries all over the world. They differ in levels, patterns, and trends of health. The gap in life expectancy between indigenous and non-indigenous populations has been found to vary between 4-21 years in Australia, New-Zealand, Canada, and the United States and in Australia, the gap in median age at death seems to have widened. Rates of avoidable deaths among indigenous people tend to be much higher than for non- indigenous people and can be reduced substantially by improving quality and access of preventive, diagnostic and therapeutic services to these people.1 Lack of existing evidence about the state and determinants of indigenous health and their access to health services and education have been important themes picked up at discussions relating to these people (International symposium on Social Determinants of Indigenous Health Adelaide, 29-30 April 2007 & United Nations Permanent Forum on Indigenous Issues, Fourth Session). Access to appropriate health and other infrastructure or services are necessary to ensure equity in their health outcomes and there is an urgent need for more information on indigenous health 2 and there is an ‘overwhelming need for action on indigenous peoples health’. 3 India with 84.3 million people classified under scheduled tribes and its state Jharkhand with such people constituting 26.5 percent of its total population 4 deserves attention in this regard. Child health disparities between indigenous and non-indigenous groups are evident in India as per NFHS 2 and 3 reports. Acute respiratory infections are a leading cause of morbidity and mortality in children less than five years of age. Despite the increasing availability and the use of antibiotics for the treatment of acute respiratory infections (ARI), global mortality from ARI, mainly due to pneumonia remains high since many children developing countries do not have access to appropriate healthcare. 2. BACKGROUND Indigenous people make up about 6% of the world’s population in about 5000 separate groupings of languages and culture.5 and they differ in levels, patterns, and trends of health. An official definition of “indigenous” has not been adopted by the UN system but a modern and inclusive understanding of indigenous has been developed and includes peoples who: - Identify themselves and are recognized and accepted by their community as indigenous. - Demonstrate historical continuity with pre-colonial and/or pre-settler societies. - Have strong link to territories and surrounding natural resources. - Maintain distinct social, economic or political systems. - Form non-dominant groups of society. And resolve to maintain and reproduce their ancestral environment and systems as distinctive peoples and communities. Situation in India: There are 461 ethnic groups are officially recognized as the ‘Scheduled Tribes’ in the Constitution of India fulfill these criteria and can be considered as India’s Indigenous population. They are often referred to as ‘Adivasis’, meaning the original inhabitants and make up 8.4% of India’s total population which translates to 84.3 million people 4. Therefore it can be said that India houses the largest number of Indigenous people. According to the International Institute of population sciences report-2000, the child health indicators in India are the worst among the scheduled tribes when compared with any other group. Table 1: Indicators of child health in different groups in India Outcome Scheduled Scheduled Other Rest of Caste Tribes disadvantaged population classes Infant mortality(per 1000 live 83.0 84.2 76.0 61.8 births) Under-five mortality(per 1000 119.3 126.6 103.1 82.6 births) Children under 3 years 53.8 55.9 47.3 41.1 underweight (percent) Children under 3 years with 78.3 79.8 72.2 72.7 anemia (percent) Children under 3 years with ARI 19.6 22.4 19.1 18.7 (percent) Children under 3 years with 19.8 21.1 18.3 19.1 Diarrhea (percent) Source: National Family Health Survey Summary, India 1998-99. Jharkhand is a small state in eastern India and is among its newest, having being carved out of the state of Bihar in 2000 after a long struggle for statehood. It forms a part of the central tribal belt of India and 26.3 percent 4 of its population belong to the scheduled tribes.