Empowering Healthcare Access: Ethnographic Insights into Sustainable Solutions for a Particularly Vulnerable Tribal Group (PVTG) in South India- a Qualitative Research

Purpose of the study

After conducting a sufficient review of the literature and preliminary studies with the selected PVTG, we aimed to explore their health-seeking behavior and identify prevailing barriers and facilitating factors that contribute to the utilization of health care services. The qualitative research tradition adopted in this study is Ethnography.¹³

Research framework ( Figure 1)

Figure 1. Health Belief Model (HBM) in the context of a PVTG in Udupi district.

The HBM recommends enhancing communication, motivation, and engagement to promote a more positive health paradigm.

The framework adopted for this study was the (HBM).¹⁴ We gathered information on health beliefs, practices, and factors influencing healthcare to generate scientific evidence for our research question, focusing on the key factors influencing the health-seeking behavior of this tribal population, including their sociocultural beliefs, accessibility to healthcare facilities, and indigenous healthcare practices.¹⁵ The majority of this tribal community often adheres to traditional and home remedies, and the prevailing cultural beliefs and social barriers further impede their health-seeking behavior.

Research design

This ethnographic research was conducted within a PVTG community located across multiple settlements in the Udupi district, alongside the stakeholders engaged in delivering services to this population. Ethnographic methods are particularly effective for understanding interactive dynamics, as they provide both insider (emic) and outsider (etic) viewpoints, enabling objective and thorough analysis and interpretation. Furthermore, ethnography is an important tool for exploring health beliefs and experiences with a specific focus on issues or situations that emerge within cultural or subcultural frameworks.

Study setting and sampling

This study was conducted using various taluks in the catchment area. The study population consisted of adult individuals from the selected PVTG, Administrative Medical Officers (AMO), healthcare workers, officials from Non-Governmental Organizations (NGO), and the Integrated Tribal Development Project (ITDP), Udupi district. The participants were chosen through a combination of mixed purposeful sampling to facilitate triangulation and flexibility in meeting the needs of multiple stakeholders. This included snowball sampling, homogenous sampling, opportunistic sampling, and intensity sampling,¹⁶ in which information-rich participants were identified through a sample frame of key respondents from each category in the inclusion criteria of Focus Group Discussions (FGD) and In-Depth Interviews (IDI). The tribal population who showed resistance to utilization of current health services and those who had experience of health care seeking or followed traditional healing practices were included in the study.¹⁷

Role of the research team

The research team comprised experts in community medicine (RSS; UB; SDM; AK), who are MD in Community Medicine and are teaching faculty in medical colleges, and (HK) a public health expert and scientist, who were the key people in the methodological approach and design of the study. Further, the research team had a male research scholar (BS) and a male research assistant, both of whom had over ten years of experience in designing and conducting qualitative studies on field activities and data collection processes. RSS is the Principal Investigator (PI) of this project and has authored papers using qualitative research methodologies. BS performed the IDIs and FGDs and the research assistant took part in ice breaking of the sessions, transcription, and translation of the data.

Ethical considerations

Permission was obtained from the State Health and Family Welfare Department, Bengaluru, Karnataka, and the ITDP, Udupi, to conduct the study among the selected PVTG. Approval was sanctioned by the Kasturba Medical College and Kasturba Hospital Institutional Ethics Committee (KMC-KH IEC), Manipal Academy of Higher Education, Manipal, Karnataka (IEC No: 778/2019 Approved on 19 November 2019). The participants were explained about purpose of the study by using a Participant Information Sheet (PIS), and Informed Consent (IC) was obtained from each participant before enrolling into the research. The research was conducted as per the Declaration of Helsinki.¹⁸ This study was registered on 16 December 2019, under Clinical Trials Registry- India (CTRI/2019/12/022385).

Data Collection

Ethnographic fieldwork was conducted from April 2022 to March 2023 in the Udupi district of southern Karnataka, India, which included FGDs and IDIs¹¹ among the target groups.

During FGDs and IDIs, the research assistant facilitated the sessions by taking field notes, recording conversations, and capturing non-verbal cues through field notes.¹⁹ All sessions were conducted using the FGD schedule and IDI guide, which were prepared, validated, and pilot tested by the research team. Only the consenting respondents were present at the venue, and no other individuals attended the sessions. After consenting, none of the participants refused or dropped out during the sessions. The study was conducted among different groups of respondents in each FGDs and IDIs until data saturation was reached. There were no repeated sessions in the study with the same group or individual respondents. The data and participant identities were treated with complete confidentiality, and the recordings and transcripts were stored securely.

Reflexivity and rigor

To establish a connection with the interviewees and key stakeholders, the research team attended various meetings conducted periodically at the NGO office and district administrative office, along with leaders of the selected PVTG community, to ensure that bias and assumptions were eliminated in the study process. In situations where the research team faced difficulty in accessing the tribal hamlets and establishing rapport due to language and distance barriers, assistance was sought from the hamlet chief to ensure a smooth communication process.^20–22 We ensured the trustworthiness of the information provided by the participants by adopting multiple data collection methods from stakeholders and beneficiaries of the healthcare services. Thorough feedback from the participants after the collection of data was made by the research team to adhere to the confirmability and credibility of the research process.

Validity and reliability

To ensure that the captured data contained the lived reality of the tribal community in accessing healthcare services, rigorous and multiple strategies were adopted, such as various forms of member checking, triangulation, dependability, peer debriefing, and confirmability²³ ( Table 1).

Data analysis

All audio recordings were transcribed and translated verbatim into Kannada (native language of Karnataka State, India). To ensure accuracy, the transcriptions were translated into English and cross-checked with the original audio recordings by a language expert who was part of the research team and cross-verified by the principal investigator.

The data analysis process began with each member of the research team individually and repeatedly reading through the transcripts, confirming that the data were rich and sufficient for analysis. The translated scripts were manually coded by two independent reviewers adopting reflective and inductive approaches, and various themes were derived from the coding process, which were then reported and discussed with selected respondents to ensure consistency of the data.²⁴ In cases where there were discrepancies in coding, the team resolved them through negotiated consensus and discussion.²⁵ An unconstrained coding matrix was established, and sub-categories were created under generic categories.²⁶ Transcript coding was performed manually, and the data were organized using an Excel worksheet.

A. Barriers to healthcare utilization

Traditional practices and culture

The public health system has evolved through various stages and phases, mainly based on the principles and systems of healing practices that exist in many parts of the world. Modern medicine is based on various models.²⁷ However, the selected PVTG communities still preserve and follow traditional healing practices, especially among the elderly and those living away from mainstream society. Although healthcare services and systems try to percolate into their community, the beliefs and traditional practices of the people are very strong. Some stakeholders have highlighted these points.

Lack of awareness and non-participation

Many participants mentioned that the tribal community members do not possess knowledge of schemes and other healthcare facilities offered by the government. Although several coordinated activities are initiated by district administration and NGO, their participation in such programs is suboptimal. ASHAs, ITDP officers, and NGO members had to frequently visit the community at certain intervals to motivate them to feel the need for empowerment. The following discussion of the respondents highlighted the necessity of improving their utilization of healthcare services.

Mental health and substance abuse

Mental health issues, as well as alcoholic malnutrition, were also commonly identified. The majority of these patients experience weight loss and anemia. The overall health and nutritional status of mothers and children is unsatisfactory. Poor eating patterns, lack of awareness about methods of cooking, and consumption of nutritious diets further worsen their nutritional status.

Attitude of healthcare workers

A positive attitude of healthcare providers towards the tribal community can bring about desired changes among them. Tribal community members often report that the attitude of healthcare providers does not always motivate them to approach and accept the services offered by healthcare facilities. The tribal participants emphasized that staff from healthcare facilities, especially those from the upper cast, always demonstrate an unwelcoming attitude and a kind of distancing behavior.

The tribal community felt that healthcare personnel and the systems were not considerate towards them; on the contrary, the healthcare personnel expressed disapproval of the tribal group when services were offered to them.

Non-acceptance of services by the PVTG

Despite several government schemes being provided to them, many at times they do not accept them due to a lack of awareness, which further hinders their progress. While discussing the attitude of this tribal community towards the utilization of healthcare services, the respondents highlighted that they still have culturally based practices that make them reluctant to accept services provided by the government.

B. Facilitators for utilization of healthcare services

Implementation and sustenance of community-based programs in tribal regions

There are a lot of programs initiated by the government and NGO, and various social welfare agencies for this tribe. However, the sustainability of the programs depends on funding, manpower, availability of other resources and infrastructure, and the successful implementation of the programs. Hence, a strong policy-based plan that focuses on the improvement of tribal groups must be established to attain long-term goals.

Although many programs have been initiated for this PVTG by various agencies and NGOs in the past years, the objectives and outcomes of the programs, especially among vulnerable populations, are successful only if such programs are sustainable. Respondents reiterated this point, as mentioned below.

Inter-sectoral cooperation in community enhancement

Inter-sectoral cooperation is a key element in the success of community-based programs, especially healthcare services. Improvement of the PVTG, especially in health-related matters, is achievable through a collaborative approach from the government, private sectors, and NGO. Some participants shared their experiences and views on the successful operation of the intersectoral collaborative approach in their upliftment.

The major barriers to the utilization of healthcare services identified from the qualitative analysis were traditional practices and culture, lack of awareness and initiation, alcoholism and malnutrition, unfavorable attitude of healthcare providers, and non-acceptance of services by this PVTG community, which has been depicted in the fish-bone diagram as a cause–effect relationship ( Figure 2).

Figure 2. Fishbone diagram representing the cause effect phenomena in the poor utilization of healthcare services by the selected PVTG in Udupi district.

The fishbone diagram depicts the causes of poor healthcare utilization among the tribe based on the HBM framework used in this study. This diagram highlights minor themes that contribute to barriers that lead to inadequacy in the utilization of healthcare services by the tribal group under the study. Overcoming these barriers would enable the implementation of facilitating factors more successfully and sustainably to enhance the health status of the tribal community.

Inductive approach to suggest improvement of health status of tribal population

After the analysis of the qualitative descriptions of the research participants, we used the themes to incorporate an inductive approach in our qualitative inquiry. We identified five core areas that act as key components that surround the outcome of the tribal population’s health status. The inductive approach in this study enabled us to formulate a theory that explains the lacunae in the health status of the tribal population in the study area. We have adapted the interpretive inductionist approach, as this method enhances the balance between deductive and inductive approaches in qualitative studies.²⁸ The inductive theory in our research explains “The outcome of health status of tribal population can be enhanced through a multidimensional approach” which has been depicted through the ‘Star Model of Health Status Improvement to promote health status of the tribal population.’ ( Figure 3).

Figure 3. “Star model of health status improvement” to promote health status of tribal population.

The “STAR Model of Health Status Improvement” for the tribal group is a conceptual framework, developed by the authors which focuses on, a comprehensive and multi-domain cooperative approach to enhance overall health status of the tribal community in Udupi district.

Various healthcare policies have made remarkable contributions to the modification of the existing healthcare practices and healthcare system approach towards tribal health.²⁹ Amendment of policies and the addition of new policies based on the requirements for tribal societal needs could certainly make a positive change towards a healthy lifestyle of them.³⁰ Knowledge of the tribal population hovers traditional healing and magical remediation. Ignorance and lack of awareness restrict them from using the available healthcare services and other schemes for them. On the other hand, the non-favouring attitude of the tribal population globally, which is supported by evidence, literally brings them back from the scientific and modern approach to treating illness and focusing on reducing maternal and child mortality rates.³¹ Effective educational intervention programs by various agencies can change the attitude and knowledge of the tribal population towards a positive paradigm. However, the programs should be sustainable, and funding for such programs should be examined. Another crucial component in the “Star Model of Health Status Improvement” is the availability of healthcare facilities in the tribal areas. As the majority of the tribal population dwells in the forest and hilly areas, it is difficult for the healthcare facilities to operate in those regions; hence, there are many hurdles to overcome to operate the facility in a smooth way.³² Conversely, efficient planning and operational success with the supply of money, materials, and manpower by the government can meet this challenge. Another arm of the model points to the motivation of the tribal people. Even if the four elements mentioned above are adequate to meet the healthcare needs of tribal people, their motivation is most important to change their attitude and perception towards a healthy lifestyle by utilizing the facilities in the fullest way.³³ Awareness programs based on information education and communication (IEC) must help improve the health status of the tribal population.³⁴

Despite the existence of all these elements, the dotted lines represent the significance of the interrelation between these elements and their collaborative activities to help beneficiaries in the most effective way.³⁵ Any lack of communication or misrepresentation of information might lead to a deficiency in the effectiveness of healthcare-related programs; thus, it would weaken the other five elements, eventually reducing the motivation of tribal people and weakening their attitudes and practices. The central aspect of the model pertains to the health outcomes of the tribal population, which are significantly influenced by several essential factors represented by the five points of a star. Any modification to the current state of these critical components will undoubtedly affect the health status of tribal communities. Despite efforts made by governmental and private healthcare entities, certain community-based obstacles that diminish the efficacy of interventions aimed at these populations persist. Enhanced and purpose-driven programs that prioritize increasing awareness and fostering positive attitudes towards health improvement are likely to yield more effective results.³⁶

Limitation and contribution to future research

We conducted research in a PVTG in India, which has a declining population and many barriers in their access to healthcare services and schemes. As our study was conducted on a limited number of people, the generalizability of the studies has narrowed down. Although the other 74 PVTG in India face similar barriers and atrocities, each tribal group has its own culture and traditions, which should be considered in their particular context of social systems. This research is first of its kind among a PVTG in South India, and the findings of the study and the ‘Star Model of Health Status Improvement for tribal population’ which we have developed would indeed be an eye opener and helpful for further research among other tribal population in India or elsewhere globally.