Faith or Rationality – what dominates the health scenario? – Reflections from a non-governmental organization based health center in a tribal area of rural Maharashtra
Department of Community Medicine, Seth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India
|Date of Submission||30-Oct-2018|
|Date of Acceptance||15-Mar-2018|
|Date of Web Publication||14-May-2019|
Dr. Anuradha Mohapatra
Department of Community Medicine, Seth G S Medical College and KEM Hospital, Parel, Mumbai - 400 012, Maharashtra
Source of Support: None, Conflict of Interest: None
BACKGROUND: The tribals are considered as an underprivileged community who are dissociated from the health-care system. They are known to adhere to old, ancient methods of managing illness. This study was undertaken to understand the issues and challenges in the tribal areas in seeking healthcare.
MATERIALS AND METHODS: Cross-sectional study was conducted during the year 2017 in a nongovernmental organization-based health center located in a tribal area of rural Maharashtra, India. A total of 383 participants were interviewed using a semi-structured questionnaire about the health-seeking behavior and utilization of health services in the study center as well as nearby government facilities. Strengths, weaknesses, opportunities, and threats of the management of diseases at the study center were also identified.
RESULTS: In the event of an acute illness, 40% preferred government hospital, 40% private, 16% of study center, and 4% sought treatment from traditional healers. On comparison with nearby government facilities, the study center was located far away, travel time and fare to reach was more and was preferred by all over government facilities. The difference in user perspective about both facilities was statistically significant (P < 0.00001). All of them trusted the staff and the services provided at the study center completely. Around 97% thought the services were made according to their convenience. About 59% spent on drugs and logistics after visiting the nearest government facility, whereas only 10.8% admitted to having spent on drugs and logistics after visiting the study center.
CONCLUSIONS: Faith-oriented health-care seeking behavior seems to dominate the health scenario. It is influenced by realistic factors such as accessibility, affordability, and acceptability.
Keywords: Health-seeking behavior, opportunities and threats analysis, strengths, tribal population, utilization of health services, weaknesses
|How to cite this article:|
Mohapatra A. Faith or Rationality – what dominates the health scenario? – Reflections from a non-governmental organization based health center in a tribal area of rural Maharashtra. J Edu Health Promot 2019;8:100
|How to cite this URL:|
Mohapatra A. Faith or Rationality – what dominates the health scenario? – Reflections from a non-governmental organization based health center in a tribal area of rural Maharashtra. J Edu Health Promot [serial online] 2019 [cited 2019 Sep 21];8:100. Available from: http://www.jehp.net/text.asp?2019/8/1/100/258140
| Introduction|| |
Tribal communities in India contribute to 8.6% of the total population, and most of them live in forested areas. The tribals are considered as an underprivileged community in the country who are dissociated from the health-care system. They suffer from extreme deprivation and economic underdevelopment. There is little and scattered information on the actual burden and patterns of the illnesses that afflict them. The challenge of inaccessibility to health services and their health-care seeking behavior seem to dominate the discourse in tribal health., Further, tribal cultures are known to adhere to old, ancient methods of managing illness. Thus, scientific knowledge, skills, and treatment modalities are not readily available for tribal patients. As the public sector alone is not able to provide for the health-care services, there has been a phenomenal growth in the nongovernmental organization (NGO) sector in these areas. They are unique as they are private institutions providing public services. The services provided by them to the tribal community is largely unaccounted for. This study was, therefore, undertaken to understand the issues and challenges faced by the people in the tribal areas in seeking health care and their perspectives about the NGO-based and government health-care centers.
| Materials and Methods|| |
This study is a center-based cross-sectional study conducted during the year 2017. The study setting is an NGO-based health center located in a tribal area of a tribal district in rural Maharashtra, India. The area has a total population of 3375 consisting of nearly 600 households. The outpatient service at the study center runs on 2 days-Wednesday and Sunday at 8 a.m. onward. Volunteer doctors (retired/working) come on turn basis to run the outpatient department (OPD). One free meal (Khichdi) is provided to all beneficiaries on the OPD day. The nearby Government health facilities are a primary health unit located at 3 km, two primary health centres (PHC) located at 9.5 and 20 km. Apart from these, a rural hospital is located at 20 km, and the nearest advanced care facility (district hospital) is 50 km away from the study center. All patients above the age of 25 years taking regular treatment at the center for at least 1 year were enrolled in the present study. The number came up to 383 by complete enumeration. All of them consented to participate. The ethical approval was obtained from the Institutional Ethics Committee and permission of the in-charge of the NGO was also sought. A semi-structured, validated questionnaire was used to conduct interviews regarding the sociodemographic profile, health-seeking behavior and beliefs, utilization of health services at the study center and other Government facilities nearby and preventive and curative care received by the participants. The questionnaire was translated into the vernacular language (Marathi) and back translated too. It was pilot tested for consistency. Certain changes were made after the results of the pilot testing. All questions were asked by the investigator. Spot observations regarding health-care delivery and average patient waiting time in the study center were made. The average patient waiting time in the three nearby primary care centers was also observed for a week. Based on the results, strengths, weaknesses, opportunities, and threats (SWOT) of the management of diseases at the study center were also identified. Since this is a center-based study, all the confounding cannot be eliminated. The participants were assured that their responses would not be shared with the health providers and no identifier information like name or house number was asked. They were also assured that this research was being done to improve quality of health services and their responses would not affect their course of treatment at the health center. Data entry was done in Microsoft Excel 2016 and analyzed using SPSS version 21.0 (IBM).
| Results|| |
This center-based cross-sectional study conducted in 383 participants during the year 2017 using a semi-structured questionnaire and spot observations yielded the following results. The sociodemographic profile of the study participants is presented in [Table 1].
Health-care seeking behavior
In the event of an acute illness, first visited health facility in 40% of participants was government hospital, another 40% visited private general practitioners, 16% visited study center, and around 4% sought treatment from traditional healers/quacks. Those who visited private set up spent an average of Rs. 58 INR (Indian Rupee) toward consultation (range Rs. 50–350 INR), whereas, those who visited the study center/government facility spent an average of Rs. 10 INR. Time interval from the onset of symptoms to seeking treatment was immediate in 59% of participants, 1–2 days in 23% of them, and 2–3 days in 10% and >3 days in 8% of the participants.
Utilization of health services
Mean distance of participant's residence to the nearest government health facility was found to be 8.4 km with standard deviation (SD) = 5.3 and that of the study center was 20 km with SD = 13.3. This difference in distance was found to be statistically significant (P = 0.000). Similarly, mean fare to the nearest government health facility was Rs. 16 INR with SD = 8.6 and mean fare to the study center was Rs. 26 INR, SD = 17.0. Even this difference in fare was found to be statistically significant (P = 0.000). The average waiting time to see a doctor was 15 minutes in the nearby PHU, 35 minutes in the nearby PHCs and 2 hours in the study center. All the participants preferred the study center to any nearby government facility. All of them trusted the doctors, pharmacist and the services provided at the study center completely. More than 97% thought that the services were made according to their convenience. About 84.4% of participants thought that all services needed to treat their conditions were available at the study center. Nearly 59% of participants admitted to having spent on drugs and logistics after visiting the nearest government health facility and spent on an average Rs. 75–100 INR, whereas only 10.8% admitted to having spent on drugs and logistics after visiting the study center. As the study center ran on a Sunday, 85.5% of the participants mentioned that they did not have to leave work to visit OPD.
User perspective about the nearest government health facility and study center was determined based on positive/negative response toward factors as depicted in [Figure 1] and [Figure 2]. It was found that the difference in perspective about the study center and the nearest government facility was extremely statistically significant (P < 0.00001) with the study center bearing more positive responses [Table 2].
|Table 2: User perspective about services provided by the study center and nearest government facility|
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About 43% had received no health education session, 39% had received only one session, 17% had received two sessions and 1% had received three or more session. Ninety-one percent thought that they had been explained the importance of medication adherence in detail.
A SWOT analysis of the health-care delivery model at the study center was performed. The findings are given in [Table 3].
|Table 3: Strengths, weaknesses, opportunities, and threats analysis of the health care delivery model at study center|
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| Discussion|| |
This study was conducted to get an insight into the issues and challenges in seeking health care in tribal areas. The setting was an NGO-based health center located in a tribal area of rural Maharashtra, India. The sociodemographic profile showed a large percentage of the study population was illiterate or had only primary education. Majority of them belonged to lower or lower-middle-class socioeconomic status. Farming was the major occupation. These figures are quite representative of the report of high-level committee on socioeconomic, health, and educational status of tribal communities of India.
The tribal areas often said to be dissociated with the health system. There is underutilization of health services by the tribal population.,, In this study, it was found that, in the event of acute illness, nearly half of the participants either visited a government health facility or the study center. Another 40% of them visited private practitioners. Prior research is suggestive of preference of government health facility over private sector, especially for antenatal care and chronic diseases.,,,, There is also enough evidence to show the inclination toward private practitioners for acute/minor illnesses.,,, This may be attributed to the fact that majority of the patients have started seeking immediate treatment on falling ill and these are more accessible.
Travel time, distance, and cost of services are important factors influencing the utilization of health services.,,,, The findings from this study state otherwise. The cost incurred for services in government facility as well as the study center was same, i.e., Rs. 10 INR. However, this was not the case with distance and travel time. Although the study center was located far away from their homes and took way longer for them to consult with the doctor it was still preferred in comparison to the nearest government facilities. Many previously done studies suggested that government health facilities were preferred for various ailments.,, Although the government services were preferred in these studies, the utilization remained low. Various reasons have been cited for this underutilization-unsatisfactory or unacceptable services provided by the hospitals, financial problems, unawareness, unavailability of accompanying person, and unavailability of transport facilities are few of them.,
Other factors which play an important part in determining place of seeking health care are the presence of staff, responsiveness to queries, behavior of the staff,, suitability of time of OPD services,, perceived quality of care,,, and initiation and completion of referral services. In this study, all the participants preferred the study center over any nearby government facility. They trusted the doctors, pharmacist, and the services provided at the study center completely. Most of them thought that the services were made according to their convenience as the center was open on Sundays. Availability of free drugs was an important determinant for seeking health care. Government facilities were preferred for this reason., However, the findings in this study suggested otherwise. More than half of the patients reported having spent money to buy drugs from outside due to non-availability of all medications in the government hospital. The study center overall had a very good brand image. The mobilization of funds by the center was good. The provision of one free meal in every OPD had a good impact on people and added to the brand image and appealed to people's expectations. Regular health promotion activities were also taken up in the study center.
Despite all this, there are some weaknesses/drawbacks of the health-care delivery model of the study center. No clear-cut guidelines of treatment were followed as per Government of India, the referral services were overlooked, all laboratory facilities needed were not available, and there was no provision for screening for complications in case of chronic disease. The doctors and paramedics provided treatment on a voluntary basis. There was no system in place for the verification of their technical credentials.
| Conclusions|| |
With the results of this study, it can be concluded that in tribal areas, “trust” over the health center is an important determinant for deciding place of seeking health care among the tribal population. It is influenced by realistic factors such as accessibility (distance, transport), affordability (fare, Out of Pocket Expenditure), acceptability (behavior, responsiveness, patient friendly attitude). Health-care seeking behavior seems to be influenced by faith. This necessitates effective redressal of the key issues related to compliance with national guidelines, maintenance of disease surveillance records, follow-up of beneficiaries, feasibility of public-private partnership, and availability of advanced diagnostic facilities and treatment of complications in an NGO-based health center.
The authors would like to thank Lt. Dr. Ratnendra Ramesh Shinde, Former Professor and Head, Department of Community Medicine, Seth GS Medical College and KEM Hospital.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Mavalankar D. Doctors for tribal areas: Issues and solutions. Indian J Community Med 2016;41:172-6.
] [Full text]
Balgir RS. Tribal Health Problems, Disease Burden and Ameliorative Challenges in Tribal Communities with Special Emphasis on Tribes of Orissa. Proceeding of National Symposium on Tribal Health. New Delhi; 2006.
Report of the High Level Committee on Socio-Economic, Health and Educational Status of Tribal Communities of India; 2014.
District Level Household and Facility Survey-3 Factsheets India 2007–08; 2008.
Mumbare SS, Rege R. Ante natal care services utilization, delivery practices and factors affecting them in tribal area of North Maharashtra. Indian J Community Med 2011;36:287-90.
] [Full text]
Jose JA, Sarkar S, Kumar SG, Kar SS. Utilization of maternal health-care services by tribal women in Kerala. J Nat Sci Biol Med 2014;5:144-7.
Maske AP, Sawant PA, Joseph S, Mahajan US, Kudale AM. Socio-cultural features and help-seeking preferences for leprosy and turbeculosis: A cultural epidemiological study in a tribal district of Maharashtra, India. Infect Dis Poverty 2015;4:33.
Murthy KS, Chakravarthy BK, Kolli B. A comparative study on maternal care practices in tribal area and urban slums. J Evol Med Dent Sci 2015;4:7477-82.
Varma GR, Kusuma YS, Babu BV. Antenatal care service utilization in tribal and rural areas in a South Indian district: An evaluation through mixed methods approach. J Egypt Public Health Assoc 2011;86:11-5.
Singh A, Kumar A. Factors associated with seeking treatment for postpartum morbidities in rural India. Epidemiol Health 2014;36:e2014026.
Kumar A, Sharma S, Sharma CP, Meghwal SC. A study to assess the level of living and awareness and practices regarding MCH care in a remote tribal village of Udaipur district. Natl J Community Med 2013;4:318-20.
Dongre AR, Deshmukh PR, Garg BS. Childhood morbidity, household practices and health care seeking for sick children in a tribal district of Maharashtra, India. Indian J Med Sci 2010;64:7-16.
] [Full text]
Prasad S. Preference of hospital usage in India. Ann Trop Med Public Health 2013;6:472. [Full text]
Buor D. Analysing the primacy of distance in the utilization of health services in the Ahafo-ano South district, Ghana. Int J Health Plann Manage 2003;18:293-311.
Buor D. Determinants of utilisation of health services by women in rural and urban areas in Ghana. Geo J 2004;61:89-102.
Buor D. Distance as a predominant factor in the utilisation of health services in the Kumasi metropolis, Ghana. GeoJournal 2002;56:145-57.
Abdullah Al-Ghanim S. Factors influencing the utilisation of public and private primary health care services in Riyadh city. JKAU Econ Adm 2004;19:3-27.
Prosser T. Utilization of Health and Medical Services: Factors Influencing Health Care Seeking Behaviour and Unmet Health Needs in Rural Areas of Kenya Recommended Citation. Edith Cowan University; 2007.
Mahapatro M, Kalla AK. Health seeking behaviour in a tribal setting. Health Popul Issues 2000;23:160-9.
Ray SK, Basu SS, Basu AK. An assessment of rural health care delivery system in some areas of West Bengal – An overview. Indian J Public Health 2011;55:70-80.
] [Full text]
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]