Dr. Beena E. Thomas

Social Scientist

Social & Behavioural Research

11th April 2016

Challenges of tuberculosis (TB) among tribals in India

Background – Tribal in India

• Tribal population constitutes 8.6% of the nation’s

total population (Census 2011)

– 11.3% of the total rural population in India

– 2.8% of the total urban population

• Information among this group is limited

particularly on their health status, health seeking

behavior, socio-cultural characteristics

• Limited information on TB situation among

the Tribal population.

Source: Tribal profile at a glance 2013 http://www.indiaenvironmentportal.org.in/files/file/tribal%20profiles%20at%20a%20glance.pdf

TB Prevalence among Tribal

• Wide variation in TB prevalence (133 – 3259 per 100 000

population with a pooled estimate of 703 per 100 000 which is

higher than that estimated for India (256 per 1 lakh)) (Beena

Thomas et.al., IJMR 2015; V.G.Rao et.al., 2015)

• MDR-TB is comparable with the non-tribal population (2.2% of

new cases and 8.2% among the previously treated case) (J.Bhat

et.al., IJMR 2015)

• TB studies among tribals are mainly on prevalence. Very few

studies on other aspects (V.G. Rao et.al., IJT – In press)

Prevalence of chest symptomatics

• General population – 3 to 5 %

• Adult OPD attendance – 3 to 5 %

• Among the tribal population

– Madhya Pradesh – 7.9% (2009)

– Car Nicobar – 9% (2004)

– Saharia tribe – 11.4% (2010)

TAP emphasizes on…

(a) Strengthening early reporting,

(b) Enhancing treatment outcomes, and

(c) Closer supervision of tribal areas

Action Plan proposed

Improve service coverage and provide quality RNTCP services

Improve accessibility and utilization of the services

Promote community participation and inter-sectoral coordination

RNTCP Tribal Action Plan (TAP)

Source: Tribal Action Plan 2005

RNTCP performance in tribal areas in India

• Poor performance in terms of case detection rate (CDR) in

tribal districts compared to other districts in India

• Among tribal districts

– 53 % in 2010, 45% in 2011 and 56% in 2012 had CDR of

new smear positive <70%

– 26% of tribal dominated districts had CDR of <51% in 2012

• More than 50% of tribal districts were not able to achieve

<85% of cure rate

Source: Muniyandi M et.al., IJMR 2015; Published as a news in ‘The Pioneer’ on June 2015

An ICMR Task Force study has been initiated to

Estimate the burden of TB among the tribal

population and develop an innovative health

system model to strengthen TB control

Objectives

Primary

• Estimate the prevalence of TB amongst tribal groups (TGs)

• To find out the health seeking behavior patterns of chest symptomatics

• Develop a tribal health system model with feasible interventions

Secondary

• Identify socio-cultural determinants as risk factors for TB

• To understand the knowledge, attitude and perceptions on TB among

tribal

• To review the functioning of RNTCP in DMCs, TUs and DTC in these tribal

areas

Methodology

Sequential phases which included…

• Situational analysis

– Social mapping, health facilities available, distances between health

facilities, staff structure of the facilities and profile of the tribal

population

• Qualitative assessment – to find out the gaps and barriers identified

among tribals

– FGDs and interviews with key informants

• Quantitative assessment (Multistage cluster sampling)

– General information-census of households

– Identify the chest symptomatics

– No. of TB patients

The study has been initiated in 6 states in India…

Name of the Institutes Proposed area for study States & No. of Clusters or Villages

Regional Medical Research Centre for Tribals(ICMR), Nagpur Road, Jabalpur – 482003 (MP)

Madhya Pradeshand Chhattisgarh

Madhya Pradesh-16Chhattisgarh-06

Regional Medical Research Centre, (ICMR),Chandrasekharpur, Nandankanan Road,Bhubaneswar – 751023

Odisha Odisha-06

Regional Medical Research Centre (ICMR), Post BagNo: 13, Port Blair 744 101. Andaman and NicobarIslands

Andaman and Nicobar group ofIslands

Andaman-03

Pondicherry Institute of Medical Sciences, (A Unitof Madras Medical Mission) Kalathumettupathai,Village No:20, Kalapet, Puducherry – 605014

Pondicherry and Tamilnadu Maharashtra-08

Rajendra Institute of Medical Sciences (RIMS),Department of PSM, RIMS, Bariatu, Ranchi –834009, Jharkhand

Jharkhand Jharkhand-09

Interim findings – Geographical area covered

• 40 villages in the 6 states have been covered thus far for the

The situational analysis

Social mapping

Qualitative data to assess the gaps and barriers

STATE_NAME SNO Village Name

ANDAMAN 1 Arong

2 Sawai

3 Harmender

CHHATTISGARH 4 Ratenga

5 Kargi Khu

6 Jenjra

7 Singhor

8 Baghmalla

JHARKHAND 9 Kolgi

10 Rampur/ Jura

11 Kundibart

12 Kuri /Hebrom

13 Sagipi

14 Murakanji

15 Tegra

16 Bundu

17 Ghutbahar

STATE_NAME SNO Village Name

MADHYA PRADESH 18 Chhulha

19 Mondra

20 Khuddurpa

21 Salaiya K

22 Sarmesar

23 Padaliya

24 Sarjpura

25 Kichkhidi

26 Urdani

STATE_NAME SNO Village Name

MAHARASHTRA 27 Ghoti

28 Chandsury

29 Pankheda

30 Sitarampu

31 Roshamal

32 Ekadare

33 Hanumantp

34 Kharpadi

ODISHA 35 Maghamara

36 Jantaribo

37 Penagaber

38 Bhadua

39 Gandirabe

40 Kasiabeda

The tribes in these areas

• Madhya Pradesh – Kol, Gond, Korku, Rathya, Bhumiya, Bhil, Sahariya, Baiga, Bhilal, Gwali

• Jharkhand – Oran, Lohra, Mahli, Chik Baraek, Santhal, Malpahadiya, Munda, Ho, Yadav-MOM-Tribal, Lohar-MOM-Tribal, Sourya Pahariya, Bhumij

• Maharashtra – Hindu-Mahadev, koli, Pawara, Bhil, Kokani, Mavachi, Bhil, Patil (OBC), Padavai, Hindu-Varli, Hindu-Kokna, Hindu-Koli, Hindu-Kokand

• Chhattisgarh – Muriya, Bhatara, Kunwar, Bhaina, Urao, Dhanwar, Sornta, Gond, Kawar, Binjwar, Biyar, Lohar, Khariwar, Mavar, Sanwar

• Odhisa – Juang, Munda, Kondha(Koi), Majhi, Dehuri, Kolha, Bhumija, Santal, Bhuyan

• Andaman & Nicobar – Nicobari

Realities: Challenges among tribals

• Difficult terrain, geographical location (forest, hilly regions)

– Inaccessibility to healthcare facilities

– Long distances between villages

– Very poor road condition and lack of transportation

Difficult terrain

Challenges – Social determinants

• Housing – poor ventilation

• Overcrowding

• Alcohol use (country liquor), tobacco (Gutka),

Smoking

• Indoor air pollution; cooking inside

• Living with cattle in the same house

• Poor education facilities &

reach of welfare services

Challenges – Social determinants

• PDS supply erratic and delayed

• Poor nourishment among children

• No toilet facilities (open defecation)

• No electricity, poor water sources

• Gender discrimination

• Insufficient community involvement

Challenges – Health seeking behavior

• Delays in seeking care

• Low awareness on TB

• Misconceptions on TB

• Dependent on ‘Quack doctors’

• Traditional healing practices (Faith healers)

and cultural beliefs

Challenges – Health system barriers

• Lack of awareness on healthcare facilities / RNTCP

• Sub-centres closed / variations in timings

• Location of sub-centre (schools) – high chances of

transmission

• Long distance covered to reach DMC in collecting

sputum

• High cases of water borne disease & malaria

reported (Odhisa & Maharashtra)

• Lack of staffs or non-availability of doctors

– Pharmacist dispenses medical advice and Rx

– Exploitation by ‘Quack doctors’

Challenges – Health system related

• Poor attitude of staff

• Poor facilities for MDR-TB patients

• Over dependent on ASHAs

• Difficulties faced by ASHA workers, ANM (poor incentives for ASHA),

poor commitment due to lack of monetary rewards

• Lack of healthcare facilities

– Sputum collection

– Difficulties in Rx initiation

• Delays in informing investigation results

• Improper health facilities for technicians

• Inadequate contact screening and chemoprophylaxis

Progress thus far (Quantitative findings)

• Data available for 11 villages till date

• Total no. of households in all these areas

– 3747 households

– 11446 individuals

• No. of chest symptomatic identified – 537

• No. of sputum positive (TB) – 58

Progress thus far

Study area Total no. of

Villages

covered

No. of

individuals

No. of

Symptomatics

Total

positive

No. of

culture

positive

Andaman 1 1048 18 (1.72) 0 0

Chhattisgarh 2 3459 179 (5.2) 13(7.2) 0

Jharkhand 1 852 39( 4.6) 0 0

Madhya

Pradesh4 3676 254 (6.9) 38(15) 14

Maharashtra 2 1566 24 (1.5) 1(4.2) 0

Odisha 1 845 23 (2.7) 6(26.1) 0

The way forward – Possible solutions

• Interventions

» Strengthen access to RNTCP services in the tribal

population for early diagnosis and Rx)

» Active case finding( equipped mobile vans ,door to

door surveys )

» Ensure Patient-centered approach

• Better ward facilities for MDR patients

• Sensitization and training of HCPs

• Ensuring staff in all facilities

Possible solutions

• Ensure contact screening and prophylaxis

• Ensure that incentives reach the ASHA workers

• Explore possible DOTS providers, Family DOTS

• Improve awareness on TB and RNTCP services through community

based activities

» Community engagement – involvement of VHSC, traditional

healers, Panchayati Raj members, Anganwadi workers, ASHA &

ANM, outreach workers, community leaders, tribal youth,

educated members, women, teachers and school students

» Use of fairs, sports for TB sensitization

Possible solutions

• Community based Monitoring and evaluation ( community advisory

boards with representation from the tribal population)

• Provide evidence through Operational and Implementation research

• Sustained collaboration and dissemination of realities with

government and non government institutions at local and national

level for action and translation to policy

Holistic Multi-sectoral approach

• Encourage kitchen garden for better nutrition

• Better ventilated houses

• Nutritional support for children and pregnant

women

• Better sanitation and electricity

• Networking with research institutions, NGOs,

Government for translation

to program and policy

Holistic Multi-sectoral approach

• We need to work towards TB elimination and develop model districts where possible such as in the Car Nicobar Islands

“We need to wash away the scourge of TB…”

Thank You