Basic Necessities and Health Indicators of Tribal Population of India: A Secondary Analysis from National Family Health Survey-IV

INTRODUCTION

There are 104 million indigenous people in India (8.6% of total population) which makes India the second largest in terms of the absolute concentration of indigenous peoples. Majority of the Scheduled tribe population live in rural areas in forest and hilly geographical areas. They are usually hunter-gatherers, shifting cultivators, pastoralists, and artisans.

Ministry of Tribal Affairs, Government of India (GOI) in their report on tribes mention that only 10.7% of tribal population have access to tap water and around 75% defecate in open. Only 51% are literate, although this has increased in a decade. The tribal community lags behind the national average on several health indicators, with women and children being the most vulnerable.^(1,2) The concept that health depends broadly on two sets of factors- genetic and environmental factors needs a modification. In developing countries like India, where traditional life style still persists, risks of illness and health are connected with behavioural and socio-cultural practices also. This interplay between genetic, environment and behaviour practices need can be indirectly studied through the health indicators and outcomes.

The tribal people have almost same health problems, similar health needs as general population and hence the uniform national pattern of rural healthcare would be applicable to them as well, albeit with some alteration in population. The accessibility to health care among tribal population is also one of the factors affecting their health. It is a general notion that most tribal people live in remote rural settlements in hilly, forest or desert areas where illiteracy, unfavorable physical environments, malnutrition, inadequate access to safe water, and lack of personal hygiene and sanitation make them more vulnerable to disease.⁽³⁾ If a population's basic necessity is not accessible or available health becomes their second priority.

A number of studies in different countries have studied the interplay of different determinants of health but very few studies have tried to explore the effect of accessibility to basic services on the nutritional and core health indicators of tribal population. Using the National Family Health survey 2015-16 (NFHS-4)⁽⁴⁾ district reports of various districts where tribal population reside the correlation between various health and accessibility indicators have been studied.

OBJECTIVES

To determine the correlation between accessibility of services and health indicators among tribal population of India using the indicators from National Family Health Survey report 2015-16.

MATERIAL & METHODS

The ecological correlation was conducted as a secondary analysis using reports of National Health and Family Survey-IV (2015-16) between January and June 2020. The district wise NFHS reports are available on public domain.⁽⁴⁾ The list of tribal districts across the country was sought from the annual report of Ministry of Tribal Affairs.⁽²⁾ A total of 95 districts were included in analysis. Further the altitude of every tribal district was noted as available from the websites of district administration of each district. The variables selected from NFHS report were grouped as follows:

RESULTS

Overall better literacy (both female (r:0.12, p:0.26) and male (r:0.23, p:0.03)) is positively correlated with proportion of fully immunized 12-23 months children. Increasing literacy rate is correlated with decrease in the prevalence of stunting, wasting, underweight and diarrhea among children. Electricity in households showed a significant moderate to strong negative correlation with prevalence of wasting, stunting and underweight among children (r: - 0.54, -0.39, -0.56, p<0.001 respectively).

Improved drinking water and sanitation facilities are correlated with decrease in prevalence of diarrhea (r:-0.18, p: 0.80) and symptoms of ARI (r:0.30, p:0.003). A significant decrease in prevalence of poor nutritional status of children under five-year age was observed with improved sanitation facilities among households. The increase in altitude was correlated with increasing immunization, decrease in prevalence of stunting, wasting, underweight and diarrhea among children.(Table 1)

Increase in altitude is positively correlated with higher BMI of adults (males; r:0.20, p:0.05; females: r: 0.19, p: 0.07) but negatively correlated with prevalence of males and females with blood sugar level> 140 mg/dl (males; r:0.14, p:0.18; females: r: 0.13, p: 0.21). There was a weak positive correlation of altitude and prevalence of high blood pressure among adults (males; r:0.03, p:0.79; females: r: 0.17, p: 0.10). Higher literacy (both males and females) had significant strong negative correlation with prevalence of underweight and significant positive correlation with prevalence of overweight and obesity among adults (both males and females).(Table 2)

DISCUSSION

The current analysis tried to establish an ecological correlation between the accessibility indicators and health indicators obtained from NFHS-4 reports. The core health indicators of tribal districts like adult underweight and anemia prevalence showed negative relation with better accessibility to electricity, water and sanitation. Accessibility to water and sanitation were correlated with decreased prevalence of diarrhea and acute respiratory symptoms among children. However, the lifestyle diseases and their risk factor prevalence were increasing with accessibility to basic necessities.

The lack of development in socio cultural tribes have been opined as probable causes of decreased wellbeing of the Indigenous tribes.⁽⁵⁾ Indigenous communities can gain better access to services such as education, healthcare etc., by adopting the ideas and values of the dominant culture. Current analysis tried to establish correlation between basic services accessibility and health indicators. Literacy is positively correlated with proportion of fully immunized 12-23 months children. Increasing literacy rate is negatively correlated with prevalence of stunting, wasting, underweight and diarrhea among children. However, the literacy in further subgroups of gender and altitude was much higher as compared to national data of tribes given by government reports.⁽¹⁾ The probable reason is inclusion of districts’ report in our analysis which include a sampled population based on methodology of NFHS-4. Hence these are indirect indicators. Economic survey 2020-21 constructed a Bare Necessities Index (BNI) at the rural, urban and all India level from two National sample survey rounds viz., 69th and 76th on Drinking Water, Sanitation, Hygiene and Housing Condition in India. Survey pointed to a positive correlation between access to bare necessities and better health and education outcome. It also observed improvement in child survival, decline in still births, malnutrition, and infant mortality with improved access to sanitation and clean drinking water.⁽⁶⁾

According to the NFHS-4 data, 94.7 per cent of children below five years of age and 83.2 per cent of women between the age of 15 and 49 in tribal district of Lahaul and Spiti in Himachal Pradesh were suffering from anemia.⁽⁷⁾ The overall prevalence of malnutrition and anemia was higher as compared to general population, however those with access to electricity, drinking water and sanitation fared better. As the proportion of households with electricity increased a significant moderate to strong negative correlation was observed with nutritional indicators of children and adults. Improved drinking water and sanitation facilities are correlated with decrease in prevalence of diarrhea, symptoms of ARI and poor nutritional status of children under five-year age. Drinking water, sanitation, sewage disposal, electricity, rural roads, and urban transport influence human development outcomes. These basic services are provider dependent and governed by policy makers. However, health impact of a household's sanitation practices is affected not only by the household's behavior but also by the practices of the community.⁽⁸⁾ For centuries the tribal population have suffered from neglect from policy point of view. Even today, areas where tribal live, the health services remain grossly underdeveloped and population access to good quality health services is at best terrible.⁽⁹⁾

Overweight and obesity among adults were positively correlated with increasing altitude. High blood sugar was negatively correlated with altitude however; high blood pressure was positively correlated with high altitude among tribals. This was in contrast to the notion that due to increased physical activity in high altitude ranges result in low obesity among these tribes. It is important to understand the multifactorial causation of these non-communicable diseases like socio economic status and urbanization.⁽¹⁰⁾ The findings were concurrent with the meta-analysis findings by Rizwan et al. The pooled prevalence reported by two meta-analysis on tribals of India and on high lander tribals were comparable to those reported in current analysis.^(11,12) The high altitude climate has a potential of modifying morbidity and mortality of those who are permanently residing at elevations above 1500 meters.⁽¹³⁾ Low barometric pressure and related low partial pressure of oxygen (hypoxia) and increased ultra violet radiation are components of the high altitude climate which are probably interacting in a complex way with genes and other environmental factors.^(14,15) Upadhyay et al., in their systematic review on prevalence of diabetes among tribal population of India reported a range of prevalence from 0.7% to 10.1%.⁽¹⁶⁾ The tribal populations are still at lower risk for having hypertension and diabetes as compared to general population. The increasing trend in low land tribal populations probably provides proof to the belief that even tribal populations are not immune to the health effects of modern lifestyles. It is need of hour to plan our interventions in prevention of non-communicable diseases in tribal population tailored to their existing lifestyle and customs.

STRENGTH AND LIMITATIONS

The accessibility as a factor has been discussed and followed in country for decades. However, the tribal population has lagged behind due to the inequalities prevailing. The strength of the analysis lies in the availability and usage of the national survey figures. However, the measures of exposure (accessibility and basic necessity indicators) are only a proxy based on the average in the population. The ecological fallacy can only be corrected by individual data from stratified population based on performance of tribal districts.

CONCLUSION

The core health and nutritional indicators in terms of immunization, prevalence of childhood diseases, anemia, and non-communicable diseases were better among those with access to basic necessity. Health infrastructure and services are not the only factors determining status of health. The socio behavioral determinants of tribal health play a key role in their health status. Ensuring the basic needs of a tribal population may be a step in improving their health.

AUTHORS CONTRIBUTION

All authors contributed equally in conducting the study and preparing the manuscript.