Perception of health and health seeking behaviors

among the Tribal people

Perception and concept of health by the Tribal population

Most of the tribal population in general live in remote areas in relative isolation, in natural surroundings, maintaining a socio-cultural distance from others have their own concept of health.

TRADITIONAL MEDICINE:

The term traditional medicine (indigenous medicine) describes medical knowledge systems, which were developed over centuries in societies across the world, much before the era of modern medicine. The genre includes herbal, Ayurvedic and Unani medicine, acupuncture, spinal manipulation, siddha medicine, traditional Chinese medicine, south African Muti, Yoruba Ifa, as well as other medical knowledge and practices all over the globe.

The WHO Defines traditional medicine as the health practices, approaches, knowledge and beliefs incorporating plant, animal and mineral based medicines, spiritual therapies, manual techniques and exercises,applied singularly or in combination to treat, diagnose and prevent illnesses or maintain well-being.

Concept of health

• WHO:"a state of complete physical, mental and social well-being and not merely the absence of disease and infirmity" (WHO, 1971).

The perception about health, disease and health seeking behaviors are not the same across culture. Human culture as a part of their cognitive development have complex ideas regarding causes of sickness and ways of cures. This is the base of empirical medical systems that provide means for prevention and cure.

In the context of India, the traditional health care system is in contrast to the official health care system based on modern science and technology separating it from broader social and cultural concerns and influences. Several studies have proved that traditional societies do not get the most needed psychological security in modern medical system as it ignores the cultural components of disease and treatment prevailing in a given society.

l Tribal world of belief and practices have been constructed and surrounded by their parochial perception and action of natural and supernatural entity. They find themselves closely knot with the web of these entities in every sphere of life.

l The studies on medical systems worldwide have revealed that they are based primarily on two principles:

l First, the belief about the nature of health, the cause of illness, and the remedies, various curing techniques used by doctors, &

The second, the ways employed by the society to deal with sickness andmaintenance of health.

The perception of health and healthseeking behaviors among the tribal people the world over is thus intertwinedwith factors such as their traditional beliefs,practices, nature of interaction with physical environment and changing social,cultural and economic domain

• The study of regional variations in human health, the effect of environment on health and the holistic causes of disease goes by many names, medical geography, physical anthropology, medical sociology, , epidemiology and medical anthropology.

• India alone provides unbounded range for the practice of medical geography. Medical anthropology, on the other hand, is the study of ethnomedicine, explanation of illness and disease, from both an emic and etic point of view.

l The traditional healers act as the medium between man and nature the supernatural entity and provide spiritual security to the tribal people.

l It has been argued that lack of emotional content and spiritual security in modern health care system causes the failure of its utilization.

l It has been observed that among the tribal people the universal index of a threat to health is expressed through withdrawal from normal day to day work. Mahapatra (1994), therefore, sees health among tribal groups as a functional and not clinical concept.

Thus the diseases caused to tribals in their faith are the supernatural agencies broadly coming under four types of super-natural powers: 1.Protective spirits who always protect them.2.Benevolent spirits who are worshipped at the community and familial level regularly, otherwise they may bring diseases or death.

3.Malevolent spirits-the evil spirits who control smallpox, fever, abortion, etc. &

4.Ancestral spirits, the spirits of their ancestors that always protect them.

John Bryant (1900) sees the involvementof the individual and the local communityin primary health care not as a social nicety, rather as a medical necessity. It has been revealed that the diverse and deep-rootedsocial and cultural phenomenon of a society play important and many a time decisive role in deciding acceptance or non-acceptance of particular health care option.

• Bhasin's (2004) study among the Ladakhis shows a blend of health care involvement, she finds that in case of serious illness people tend to attend modern health care facilities. Nevertheles, people invariably believe in spirit and other supernatural beings as causes of disease and priority of treatment inclined mostly towards traditional healers.

Guite and Acharya (2006) the health care system among the tribal people mostly depends on its availability and accessibility. The tribal groups following traditional religion use traditional medicines putting religious or supernatural value on it, the converted Christian tribes use the same medicine excluding its religious tune. Thus the educated tribals do attend PHCs but without ignoring the importance of traditional healing practices.

Pramukh and Palkumar's (2006) study shows that the tribal groups namely, the Savaras, Bogatha, Konda dora, Valmiki, Koya, Kond Reddi etc. believe in the power of prayers and rituals that enables them to act as medicines to heal their diseases. They attribute diseases to certain deviant acts of self and others towards elders, nature, and divine rules, thus, their first priority is to get spiritual cure in a traditional way.

• The Santhals: The third largest tribal community of India after the gonds and the Bhills with a population over 4.26 million living in the states of Bihar, West Bengal, Orissa, and Tripura. They have clan and family deities or spirits called 'bonga'. The dead ancestors are also considered to belong to the realm of Bongas.

• They believe in folk medicine. They have their traditional healers upon whom they have considerable faith and confidence.

They attribute a lot of diseases to the wrath of god, mischief of evil spirits and magic of human being. Treatment is based upon the removal of causative factors by appeasing God, controlling evil spirits through counter magic, use of sorcery along with herbal treatment. Thus religious practices of the Santhals are closely related to their health care system. • Apart from a host of spirits, the pantheon consists of the following deities or Bongas, namely:

• Sing Bonga: the sun god, the supreme deity, worshipped after harvesting and before sowing seeds.

• Marang Buru: The mountain god is a community as well as a family deity and a guardian God.

• Jahera Bonga: The widely celebrated goddess for protection from diseases, she is village deity ( grama devi) and while displeased can punish with diseases.

• Gossain era: the associate of Jahera bonga.• Moeiko and Turuiko: the deity of fire and are placed in Jahera, a place of worship in forest outside village

• Majhi haram and Majhi burhi are protective deities that stop bongas and spirits from doing harm to their people.

• Besides these deities listed above they have their family deities like "ora Bongas" and the "Abge Bonga". There are 178 different bongas, which the santhals propitiate by magic

Health problems faced by people

Fever (Bukhar), Malaria & Poisoning (JAHAR, VISH): caused by snake bite, sting of Scorpio and various other worms the faith healer is the immediate relief and trouble shooter as effective treatment for all the illness. Cough and cold: The common treatment for such problems comprises of taking honey, crushed tulsi leaves (sacred basil) and tea with black pepper and consuming or chewing of Adrak with salt etc.

DENTAL PROBLEMS:• The dental problems identified comprises of tooth ache caused by (keera) and swelling etc. People do not attach much importance to dental problems. they apply ice, rub tobacco (tambacco) to the aching parts, they also apply cloves (long) or clove oil (long ka tel) for curing dental problems. Thus it is very rare that people go the hospital dental treatment.

• Jaundice (peelia), The sufferer is administered sugarcane cane juice and avoid going to hospital for receiving modern medicines.

• The faith- are especially called in for removing the ill effects of 'evil eye' (nazer), spells of black magic (tona), etc

Diarrhoea (dast) is most common amidst young children under 5 years of age. Local treatment comprises of giving some water with lemon (nimbu paani) and salt , milk with sugar (doodh), some people visit PHC & receive ORS (Oral Dehydration solution). • ACUTE RESPIRATORY INFECTION ( ARI) ( SAANS CHALNA):

Acute Respiratory Infection (Pneumonia) is the second most common problem among the children. The domestic treatment included giving nutmeg ( jaiphal), clove (long) and saffron (kesar) at the first stage. In some areas the application of a hot iron rod by faith healers do prevail.

ANTE-NATAL CARE:• The problems faced by pregnant women during their term includes indigestion, vomiting, edema (haath pag sooje), general weakness (kamjori) and body ache (haath pag toote). some home remedial measures applied include giving " burnt and ground corn cobs" to those suffering from vomiting. Generally, It is accepted as a normal process of pregnancy.

• If the problems still persists, the help of a doctor would be sought, depending upon the economic status of the family.

NATAL AND POST-NATAL PROBLEMS:• The problems during childbirth identified are: excessive bleeding (gano khoon chale) and weakness following the delivery (kamjori), the home remedies include giving a solution of unrefined sugar in water ( gurh ka paani), solution of the gum of certain trees such a Babul (acacia Nilotica) ( gond ka pani), and turmeric powder in milk (haldi ka doodh).

Infertility, prolapse ( Bacchedaani Kamjor) excessive bleeding during menstruation ( menorrhagia), irregular menstruation, convulsions ( akrana) and miscarriages are the other problems faced by the women.

Treatment for such problems are confined to the local herbalists or other unqualified practitioners.

• ANTE-NATAL CARE AND CHILDBIRTH:• it has been found that pregnancy among women does not associate with reduction of workload at home as well as outside. Visit to PHC for regular health check-up is a rare event unless any complications arise.

• The IFAs supplied by the attending health workers are many a time not used at all as they feel that they are protected from all odds by tying a sacred thread provided by the Bhogot/traditional healers. Particular metallic wear, hooks, chilies and lemons etc are used to deter evil spirits from the pregnant women.

Breastfeeding practices:• Earlier, the community did not provide colostrum to the newborn, and fed it goat's milk instead for reason being that the first milk is harmful to the child. Today, people have become more aware and realize the importance of the colostrums as it helps build the baby's immunity.

• Breastfeeding starts on the first day soon after birth, but exclusive breastfeeding is still an issue, since most mothers continue to give their infants honey and sugar between feeds.

ABORTION AND HEALTH SEEKING BEHAVIOUR:• There are traditional medicines for abortion. If a woman wants to get an abortion, a jadi-booti (local herbs) is kept in her birth canal for two to three days, which damages the embryo. This method can be use for a woman who is up to three months pregnant.

• Termination of pregnancy is not resorted to avoid unwanted children in the marital alliance. but, it is resorted to in cases of pre-marital pregnancies and pregnancies resulting from extra-marital relationships. With a view to keep the pregnancies a top secret, the seek the help of local herbalist.

Treatment includes, administering of some root portion of a plant locally known as Gainski, followed by a liquid blend of jaggery (gurh) and black pepper. As a last attempt they add some country liquor to the mixture, that induces sever bleeding and abortion in most cases.

• RAGINI KULKARNI AND SANJAY CHAUHAN• In India, an ignored aspect of maternal morbidity is chronic obstetric morbidity. Information on community level chronic obstetric morbidities such as vesico-vaginal fistula/ recto-vaginal fistula, uterine/vaginal prolapse, chronic pelvic inflammatory disease and secondary infertility is sparse.

• The major causes of these morbidities in India are early age at marriage, early age first pregnancy along with frequent childbearing, poverty, illiteracy, deliveries conducted by untrained personnel, prolonged/difficult labor and lack of access to emergency obstetric services.

• Sexual behaviour and hygiene during menstruation:

• Most of the women use homemade sanitary napkins made from old clothes, as they cannot afford to buy.

• Awareness and practice of family planning methods:

• Related to seeking treatment for gynecological problems such as vaginal discharge and menstrual problems, they do not prefer accessing any clinic due to privacy reasons.

• In some cases of tribal communities for a problem of vaginal discharge, they take homemade alcohol as medicine, get treatment by "rubbing the abdomen till dirty blood drained & for itching in genital region, brick powder and soap are applied.

• Heath issues and thealth seeking behaviour of tribal population in Jharkhand. (Madhumita das, nikhil kumar, shivani kapoor, suranjeen prasad.)

• The study conducted among 5 major tribes in Jharkhand: Munda, Oraon, Ho and Pahariya. It is 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.

• Home remedies for morbidities: traditional healers and home remedies for treatment of morbidities during pregnancies. as:

• A mix of salukittha, otechama, tejpal, hessa, bokla (local herbs), jojo jam (seed of imli) and sugar, thrice a day, for white discharge

• Family planning decision-making: The sterilization is attributed to deterioration of physical strength and reduced life span through remains one of the most preferred methods of FPMs.

• Use of pills and condoms as birth spacing methods prevail mostly amidst educated persons.

• People are aware of the FP and mostly acquire from the fail healers.

• The other method is rigorous massage of the abdomen of women to prevent conception.

• Copper-T, are rarely used as they do not feel confident of using it.

Identification of pregnancy:The tribals identify pregnancy with the bulging of abdomen of the pregnant woman. They are also aware of other symptoms like cessation of the menstrual cycle, loss of appetite, vomiting, tiredness and weakness.

• Decision-making on ANC: it lies either with the husband or the in-laws (usually, the mother -in-law), and the expectant woman doesn't have much say in it. usually the AWW provides information and services to pregnant women, including checkups and distributes iron and folic acid (IFA) tablets.

• Traditional rituals during pregnancy, delivery and postpartum period: pregnant women are not allowed to attend any funeral ceremony, owing to the belief that it may affect the baby adversely in Munda tribe. they also sacrifice a hen to protect the pregnant woman and child form the evil eye (buri nazar) only a few cases of institutional delivery opted by the people.

TBA's key role is to assist the pregnant woman during delivery and to cut the cord with a new blade and one rupee coin, using it for severing the cord. • the newborn is usually given a bath with warm water and turmeric immediately after birth. An old cotton cloth is used to wipe the baby after birth. The TBS massages the lactating mother and the baby till the cord turns dry. six days after the birth, a function called Chhattiyari is celebrated, during which the TBA receives grain, money, cloth and rice bear (local liquor) for her services to the mother and the child.

l Adanjho disease after the birth. The symptom of this disease is that baby's leg gets entangled/crossed with each other. No allopathic medicine and treatments available for it but can be treated only by traditional faith healer who usually prepares liquid ointment of herbs for massaging for the legs of the baby suffering from.

STDs: The people do not really bother for the treatment of STDs as regarded it to be their fate (kismat). some cannot afford due to lack of money.

GENERAL PERCEPTION ABOUT CHILD HEALTH AMIDST TRIBAL POPULATION:• Children are the gift of God, and God has written their fate which is unchangeable.

• The children have enough time left to come to eat and enjoy good things including food etc. rather, it is the older people who should enjoy with good food.

• Children should grow-up with the nature- in mud and dust, in sun and rain etc, so that they develop the power to resist all odds to come in life.

Children would grow up with their own destiny and enjoy the life already set byThe Divine who created them. Thus parents and no other can alter it. therefore, one should not think much about their future.

All seedlings may not grow into a food crop. Many of them may die in due course. Likewise not all children would survive with good health

Reasons for utilizing the services of health healer/herbalists

• The effectiveness of the treatment of the faith healers.

• Easy to access,Cheaper bound by the custom,

• Have good behaviour, understanding, sympathetic,

• The traditional healer have supernatural power.

• Their believe is that, their traditional healers/priest can appease the deities, their ancestors, who have direct bearing on their health and well being.

• it is also believed that, the traditional healer can control the evil spirits".

• lack of health facilities in remote rural areas.

• Discriminatory behavior by health care providers. there is deep-rooted cultural chasms between tribal groups and the largely non-tribal health care providers , resulting in insensitive, dismissive and discriminatory behavior on the part of health care personnel

l Dirty beds and linen, and generally unhygienic conditions at the PHC and CHCs. In this context they go even to state that these government hospitals, due to their poor hygiene, are not the centers for effecting cure but for spreading diseases.

l Financial constraints.

Role of faith healer

Challenges faced by the faith healers during the present era:• Earlier the forests were the chief sources of herbal medicines but now it has dried up due to extensive deforestation and depletion of herbal medicines.

• Lack of willingness to practice traditional health care system among the new generation, in due course of time traditional healers are also losing their power, because of the lack of practice and willingness.

• The traditional health practice is in decline due to the inclination of the new younger generation towards modern medicine. They are shifting from traditional medicine system to modern medicine system.

• Need to be sensitive:• If the traditional healers' techniques and knowledge is studied, documented and disseminated amongst them for a more systematic, cohesive and uniform approach, these service providers can prove valuable to the government and the doctors in providing first aid and primary health care to the tribal groups.

• The government needs to promote scientific verification and documentation of traditional medicine, so as to help legitimize and thus, standardize this health care genre.

• Unfortunately, the government seems unwilling and unable to integrate with the traditional healing systems.

Need to be sensitive• Thus, to understand the health seeking behaviour of tribal people, it is important to identify the processes by which they recognizes sickness and the ways to counteract it. To understand the concept of health and the health behaviours of the tribals, various means and ways are advocated. Choudhury (1994) and Lewis (1958) believes that the study of tribal health should be with reference to their distinctive notions regarding different aspects of diseases, health, food, human anatomy and faiths and the process of interaction with modern world.

Thus , a study regarding nature and extent of acceptance of modern health care facilities among the tribal group is very essential, so that a holistic approach covering the social and cultural environment of the people can be forwarded towards policy planning.