Challenges of tuberculosis (TB) among tribals in India. Dr. Beena E. Thomas Social Scientist Social & Behavioural Research

Transcription

1 Challenges of tuberculosis (TB) among tribals in India Dr. Beena E. Thomas Social Scientist Social & Behavioural Research 11 th April 2016

2 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 %20a%20glance.pdf

3 TB Prevalence among Tribal Wide variation in TB prevalence ( per population with a pooled estimate of 703 per 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)

4 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)

5 RNTCP Tribal Action Plan (TAP) 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 Source: Tribal Action Plan 2005

6 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

7 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

8 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

9 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

10 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 (MP) Regional Medical Research Centre, (ICMR), Chandrasekharpur, Nandankanan Road, Bhubaneswar Regional Medical Research Centre (ICMR), Post Bag No: 13, Port Blair Andaman and Nicobar Islands Pondicherry Institute of Medical Sciences, (A Unit of Madras Medical Mission) Kalathumettupathai, Village No:20, Kalapet, Puducherry Rajendra Institute of Medical Sciences (RIMS), Department of PSM, RIMS, Bariatu, Ranchi , Jharkhand Madhya Pradesh and Chhattisgarh Odisha Andaman and Nicobar group of Islands Pondicherry and Tamilnadu Jharkhand Madhya Pradesh-16 Chhattisgarh-06 Odisha-06 Andaman-03 Maharashtra-08 Jharkhand-09

11 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

12 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

13 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

14 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

15 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

16 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

17 Difficult terrain

18 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

19 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

20 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

21 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

22 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

23 Progress thus far (Quantitative findings) Data available for 11 villages till date Total no. of households in all these areas 3747 households individuals No. of chest symptomatic identified 537 No. of sputum positive (TB) 58

24 Progress thus far Study area Total no. of No. of No. of Total No. of Villages individuals Symptomatics positive culture covered positive Andaman (1.72) 0 0 Chhattisgarh (5.2) 13(7.2) 0 Jharkhand ( 4.6) 0 0 Madhya Pradesh (6.9) 38(15) 14 Maharashtra (1.5) 1(4.2) 0 Odisha (2.7) 6(26.1) 0

25 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

26 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

27 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

28 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

29 Holistic Multi-sectoral approach We need to work towards TB elimination and develop model districts where possible such as in the Car Nicobar Islands

30 We need to wash away the scourge of TB

31 Thank You