Comparison of Health-care Utilization Pattern and its Correlates among the Tribal and NonTribal Population of Kerala.

BACKGROUND: The isolation from mainstream development activities, together with poverty and inaccessibility to health facilities made the tribal communities specifically vulnerable to various health problems.
OBJECTIVES: This study aimed to compare the utilization of antenatal care, immunization, and supplementary nutrition services by tribal and nontribal mothers and its correlates in the selected districts.
MATERIALS AND METHODS: The study was a comparative cross-sectional study. The study population comprised tribal and nontribal mothers utilizing antenatal care, immunization, and supplementary nutrition services. A multi-stage cluster sampling strategy was employed for the study. The Chi-square test was used to assess the association between antenatal care services utilization, utilization of immunization services, supplementary nutrition services utilization and sociodemographic variables, and other service characteristics.
RESULTS: Effective utilization of antenatal care services was not seen in 5.6% of tribal mothers. The incidence of low-birth weight (≤2500) was significantly more among tribal mothers (31%) when compared to nontribal mothers (15%). The proportion of tribal children receiving complete immunization without delay was 74%, and among nontribal children, it was 78%. Effective immunization coverage was significantly lower among children of tribal mothers with education below high school level. Receipt of take-home ration was reported by nearly 90% of tribal and nontribal mothers. 90% of tribal mothers felt that quality of take-home ration that they received was of good quality.
CONCLUSIONS: The comparison of health-care utilization restricted to the domains of antenatal care, immunization services, and supplementary nutrition suggests that the tribal mothers and children had a relatively comparable utilization pattern in most of the indicators measured. Copyright:

INTRODUCTION

The scheduled tribe population of Kerala is 484,839 persons constituting 1.45% of the total population of the State (3.338 crores).[1] Wayanad (31.24%) has the maximum number of scheduled tribe population followed by Idukki (11.51%), Palakkad (10.10%), and Kasaragod (10.08%).[2] Over the years, displacement and acculturation of the tribal communities have brought about dramatic changes in their lifestyles and value systems. From the historical point of view, the scheduled tribes in Kerala have been subjected to the worst type of exploitation or social exclusion.[345] This exploitation and subduing of the tribes have cut them off from the mainstream of socioeconomic development. Although there have been many policies and programs which tried to address these, scheduled tribes still remain more or less in the same position. It was found that the incidence of deprivation among tribal households in five basic necessities of well-being, inclusive of health care, is 45.14%, which is higher than that of the deprivation index of the state (24.24%).[6] The isolation from mainstream development activities together with poverty and inaccessibility to health facilities made the tribal communities specifically vulnerable to various health problems.

The sociocultural, political, and topographical uniqueness of the tribal groups in Kerala, their needs of health care, attitudes, and health-care-seeking behaviors differ from the nontribal population and thus, challenge the present service-delivery system that has largely been based on the needs and priorities formulated for the nontribal population. Despite the wealth of studies on health and health-care-seeking behavior among the Kerala population, relatively few studies have focused specifically on the tribal groups in the state.

The rationale of the study

This study attempted to bring out the nature of health inequities in terms of service provision and acquisition in antenatal care, immunization, and supplementary nutrition services.

Objectives of the study

To study the antenatal care service utilization by tribal and nontribal mothers who have delivered in the past 1 year in the selected districts

To study the utilization of immunization services by tribal and nontribal children of 1–2 years of age in the selected districts

To study the supplementary nutrition services utilized by tribal and nontribal mothers who have delivered in the past 1 year or with 3–6-year-old children in the selected districts.

MATERIALS AND METHODS

Study design

The study was a comparative cross-sectional study. Quantitative research methods were employed in the study, which involved interviews using a structured questionnaire to tribal and nontribal mothers in the selected districts.

Study setting

The study was carried out in Kerala. Wayanad, Palakkad, Idukki, and Thiruvananthapuram were selected since these districts contained the majority of the tribal population within the state.

Study population

The study population comprised tribal and nontribal residents of the gram panchayaths selected, falling in the following subcategories:

Antenatal Care Services: Mothers of children (Tribal and NonTribal) <1 year in the households falling within 500 m of the selected random geo-locations

Immunization Coverage: Children (Tribal and NonTribal) 1–2 years of age in the households falling within 500 m of the selected random geo-locations

Supplementary Nutrition Services: Mothers with the last child <1 year of age (lactating mothers) or with 3–6-year-old children (Tribal and NonTribal) in the households falling within 500 m of the selected random geo-locations.

The sample size was calculated for each of these objectives and the largest was taken for the study. The sample size calculation was based on a study conducted to assess maternal health-care utilization among tribal (85.7%) and nontribal (100%) population.[7] Considering these two proportions, a 95% confidence interval, 80% power and a design effect 2; the sample size was estimated to be 192 (96 in each arm).

A multi-stage cluster sampling strategy was employed for the study. From each of the selected districts, two Grama Panchayats were randomly chosen from a list of 10 Grama Panchayats having the highest proportion of Tribal population in the district.

Data analysis was performed using the SPSS software version 16. The analysis was compartmentalized into three based on the objectives. The Chi-square test was used to assess the association between antenatal care services utilization, utilization of immunization services, supplementary nutrition services utilization and sociodemographic variables, and other service characteristics. Values of P < 0.05 were considered statistically significant.

RESULTS

Utilization of antenatal services

For assessing the utilization of antenatal service among tribal and nontribal, 109 tribal mothers and 107 nontribal mothers from 5 districts were studied. The proportion of mothers with primary level education was significantly lower among the tribal population when compared to nontribal. [Table 1] The type of houses and use of cooking gas were taken as a proxy indicator for economic status. The usage of cooking gas and possession of concrete/tiled houses was significantly lower among the tribal population. [Table 1].

Table 1

Socioeconomic characteristics of the tribal/nontribal mothers and their family

Characteristics	Category	Tribal, n (%)	Nontribal, n (%)	Significance
Education of mother	Up to primary school education	36 (33.0)	11 (10.3)	0.001
	High school and above	73 (67.0)	96 (89.7)
Type of house	Concrete/tiled roof	79 (72.5)	91 (85)	0.04
	Thatched/sheet roof	30 (27.5)	16 (15)
Use of cooking fuel	LPG gas	27 (24.8)	88 (82.2)	0.001
	Others	82 (75.2)	19 (17.9)
Overcrowding	Present	25 (22.9)	7 (6.5)	0.001
	Absent	84 (77.1)	100 (93.5)
Illiterate member in household	Yes	36 (33.0)	13 (12.1)	0.001
	No	73 (67.0)	94 (87.9)
Elderly in household	Yes	20 (18.3)	24 (22.4)	0.5
	No	89 (81.7)	83 (77.6)

LPG: Liquefied petroleum gas

Among the tribal mother's studied, 41.3% were primigravida and among nontribal 39.3% were primigravida. [Table 2] Around 13% of tribal mothers had a history of abortion and 3% had a history of intrauterine fetal death. [Table 2]. All the tribal mothers in the study sample delivered in a hospital setting. Delivery by cesarean section was conducted among 27% of tribal mothers in comparison to 33% of nontribal mothers. The incidence of low-birthweight (≤2500) was significantly more among tribal mothers (31%) when compared to nontribal mothers (15%) [Table 3]

Table 2

Comparison of antenatal and natal history of tribal and nontribal study participants

Characteristics	Category	Tribal, n (%)	Nontribal, n (%)	Significance
Status of last pregnancy	Primigravida	45 (41.3)	42 (39.3)	0.9
	Multigravida	64 (58.7)	65 (60.7)
Number of pregnancy	Up to three pregnancies	100 (91.7)	104 (97.2)	0.08
	More than three pregnancies	9 (8.3)	3 (2.8)
History of abortion	Yes	14 (12.8)	12 (11.2)	0.7
	No	95 (87.2)	95 (88.8)
History of intrauterine death	Yes	3 (2.8)	0	0.2
	No	106 (97.2)	107 (100)
Type of the last delivery	Normal	80 (73.4)	72 (67.3)	0.3
	LSCS	29 (26.6)	35 (32.7)
Place of delivery	Hospital	109 (100)	106 (99.1)
	Home/during transportation	0	1 (0.9)
Birth weight of the last child	<2500 g	34 (31.2)	16 (15)	0.005
	>2500 g	75 (68.8)	91 (85)
Sex of the last child	Male	65 (59.6)	49 (45.8)	0.04
	Female	44 (40.4)	58 (54.2)

LSCS: Lower segment cesarean section

Table 3

Utilization of antenatal care services

Characteristics	Category	Tribal, n (%)	Nontribal, n (%)	Significance
Services received during antenatal care	Physical examination	103 (94.5)	106 (99.1)	0.119
	Advice on child care	94 (86.2)	101 (94.4)	0.064
	Advice on warning signs during pregnancy	88 (80.7)	97 (90.7)	0.051
Received effective antenatal care services	Received 4 or more ANC visit	102 (94.4)	107 (100)	0.03
	Received <4 ANC visit	6 (5.6)	0 (0)
The proportion of tribal and nontribal mothers visited by JPHN/ASHA during the antenatal period	JPHN	92 (84.4)	91 (85)	0.926
	ASHA	104 (95.4)	102 (95.3)	0.874
Type of facility used	Public health system	91 (83.5)	58 (54.2)	0.001
	Private provider	18 (16.5)	49 (45.8)
The proportion of mother who received JSY/JJR benefits	Janani Suraksha Yojana	49 (45)	30 (28)	0.011
	JJR scheme	47 (43.1)	NA
The proportion of tribal and nontribal mothers visiting subcenters/Anganwadi during the antenatal period	Subcenter	59 (54.15)	68 (63.6)	0.149
	Anganwadi center	94 (86.2)	86 (80.4)	0.239

ANC: Antenatal care check-up, JJR: Janani Janma Raksha, NA: Not available

100% of tribal and nontribal mothers utilized antenatal services. However, effective utilization of antenatal care services (4 or more antenatal visits)[8] was not seen in 5.6% of tribal mothers (P < 0.03). Utilization of ANC services through the public health system was significantly more among tribal mothers (83.5%) when compared to nontribal mothers (54.2%) [Table 3].

Utilization of immunization services

For assessing the utilization of immunization services, 110 tribal mothers and 108 nontribal mothers with children in the age group 12–24 months were studied.

The proportion of partially immunized children (the child had not fully immunized but received only one or two doses of vaccine for his/her age as per UIP schedule) among tribal and nontribal was 3% and 1%, respectively. The proportion of tribal children receiving complete immunization without delay was 74% and among nontribal children, it was 78% [Table 4]

Table 4

Utilization of immunization services

Characteristics	Category	Tribal, n (%)	Nontribal, n (%)	Significance
Vaccination coverage	Completely immunized	107 (97.3)	107 (99.1)	0.6
	Partially immunized	3 (2.7)	1 (0.9)
	Never immunized	0	0
Vaccine	BCG	110 (100)	108 (100)
	OPV (zero dose)	110 (100)	108 (100)
	Hepatitis B (zero dose)	95 (86.4)	94 (87)
	Penatavalent1 OPV 1	110 (100)	108 (100)
	Penatavalent2 OPV 2	110 (100)	108 (100)
	Penatavalent3 OPV 3	110 (100)	108 (100)
	Measles	107 (97.3)	107 (99.1)

BCG: Bacille calmette guerin (against Tuberculosis), OPV: Oral polio vaccine

For pentavalent vaccine doses, the main reason for the delay reported by the mother was fever or illness at the time of due date. For measles vaccines, the main reason for the delay was the lack of awareness about the vaccine date. Immunization coverage was not found to be significantly related to the gender of the child, type of tribal settlement, and education of the mother [Table 4]

The effective immunization coverage (complete immunization without delay) was lower in the native tribal settlement in comparison to resettled colonies. Effective immunization coverage is also significantly lower among children of tribal mothers with education below high school level (60.6%) [Table 4].

Utilization of supplementary nutrition

For assessing the utilization of supplementary nutrition through Anganwadi, 110 tribal and 113 nontribal mothers with the last child <1 year of age or with 3–6-year-old children were interviewed.

Nearly 90% of tribal mothers utilized supplementary nutrition service through Anganwadi during pregnancy period. While among nontribal mothers the utilization was 80%

Receipt of take-home ration was reported by nearly 90% of tribal and nontribal mothers. Iron and folic acid (IFA) tablet consumption were reported by 97% of tribal and nontribal mothers. Difficulty in reaching Anganwadi was the main reason for nonutilization of supplementary nutrition

Nearly 90% of trial mothers reported that the Anganwadi staffs come to enquire when they are not attending Anganwadi for availing services. Ninety-five percent of tribal mothers' reports that the growth chart of their child is maintained in Anganwadi. About 90% of tribal and nontribal mothers reported that they were notified about the conduct of health education classes in Anganwadi

IFA tablet consumption was lower in Idukki district (87.5%) when compared to others (P = −0.01). About 90% of tribal mothers felt that quality of take-home ration that they received was of good quality. On the basis of the gender of the child, utilization of Anganwadi services during the postpregnancy period did not differ among tribal mothers.

DISCUSSION

The gap between receipt of effective ANC in tribal and nontribal was statistically significant. The coverage of schemes such as JSY and JJR was low among tribal. The coverage of these schemes was <50% when it should have been 100%. Majority of the potential beneficiaries was unaware of the scheme. This reveals the apathy of the health system in the identification and informing the beneficiaries. The study identified that tribal mothers with lower education status and primigravida were less likely to receive the benefits. The coverage of BCG and 3 doses of pentavalent vaccine was 100% among tribal children studied. The complete vaccination coverage was 97% in tribal and nearly 100% in nontribal children. This coverage was higher than the state figures as per NFHS-4 survey which showed coverage of 82%. The national-level statistics for complete immunization coverage among tribal was 31% in 2006. When delay in immunization beyond scheduled date was considered, around 70% of tribal and nontribal children had complete immunization without delay. Delay was seen in receiving pentavalent 3rd dose and measles. The lack of awareness was reported as the main reason for the delay. Around 5% of tribal mothers were not informed about due immunization. The delay was seen more among tribal mother with lower education. This shows the need for strengthening the informing system for vaccination date by the health worker, particularly for mothers with low educational status. Despite high coverage of supplementary nutrition and IFA supplementation, the low-birth weight incidence is very high among the tribal population.[910] Thus, service utilization is not translating to good pregnancy outcome. One possible explanation is that the baseline malnutrition (anemia and undernutrition) is not accounted for during service provision.

CONCLUSIONS

The comparison of health-care utilization restricted to the domains of antenatal care, immunization services, and supplementary nutrition suggests that the tribal mothers and children had a comparable utilization pattern in most of the indicators measured. However, there were gaps in some of the indicators between the general population and the tribal population suggesting tribal deprivation. It is to be noted that a more or less comparable utilization of services does not necessarily imply an equitable distribution of the same.

Financial support and sponsorship

The study was funded by International Development Research Centre and was facilitated through the project titled “Closing the Gap: Health equity research initiative in India”.

Conflicts of interest

There are no conflicts of interest.