Factors Associated with Alcohol Misuse among Indigenous Tribal Men in Wayanad: A Qualitative Study.

BACKGROUND: Disproportionate level of alcohol misuse is reported among indigenous people all over the world. A few available studies from India also support higher alcohol misuse among tribal men, but the reason for it is largely unexplored. Thus, we explored the factors associated with alcohol misuse among indigenous tribal men in Wayanad, Kerala.
METHODS: Using a qualitative phenomenological method and purposive sampling techniques, we recruited seven tribal men with a history of alcohol misuse and 28 tribal promoters from the identified tribal colonies in Wayanad, Kerala, India. Data collection was done with a combination of focus group discussions and in-depth interviews. Thematic analysis was applied to the data for identifying core themes.
RESULTS: We identified the important trajectories of alcohol consumption among tribal men. They initiated alcohol misuse at a younger age due to parental influence, home environment, and peer pressure. Alcohol misuse associated with their traditional rituals and practices, exploitation of landlords, occupational factors, and saving habits. It caused a substantial burden to their spouses and children.
CONCLUSION: Alcohol consumption often initiated in their young age was associated with socio-cultural rituals, practices, and exploitation. Copyright:

A disproportionate level of alcohol misuse has been reported among indigenous people all over the world,[123] and the burden of disease associated with alcohol misuse is almost double among them.[4] In India, indigenous people are known as scheduled tribes (STs), or Adivasis, and live as a group with distinctive social, cultural, historical, and geographical circumstances. Evidence from India also supports a high prevalence of alcohol consumption and smoking among indigenous tribes,[56] which is associated with a wide range of health and social problems, including violence, family breakdown, child neglect, loss of income, diverting income away from family needs, high morbidity, and early mortality.[4] The data derived from National Family Health Survey suggests alcohol use among 26% of the indigenous population, while the rate was just 9% among the non-indigenous population.[5] Higher substance abuse[6] and worse health status[7] among this group is inherently related with their socio-economic marginalization[58] and historical oppression.[9]

Wayanad is a home for one-third of the total tribes in Kerala. The Paniya, Kurichiya, Kuruma/Mullu Kuruma/Uraali Kuruma, Kattunaikan, and Adiya are the predominant tribal groups in Wayanad.[10] The tribes are backward in education, health, and living standard as compared to the general population.[11] Our experience and engagement in Tribal Mental Health Program in the district reflect high substance misuse among the tribes, especially alcohol and betel quid use. Evidently, indigenous ethnicity is the strongest predictor of higher alcohol misuse,[5] and the tribes have a different socio-cultural reason for substance misuse.[12] Nevertheless, the socio-cultural factors associated with such practices among tribes are less studied in India, with a few exceptions.[9121314] Even these available studies were either with tribes of Tamil Nadu,[14] quantitative in nature,[12] qualitative study of limited scope with pregnant tribal women[13] or only with Paniya tribes.[9] Thus we explore the factors associated with alcohol misuse among the indigenous tribal men in Wayanad.

METHODS

The study was conducted as part of a Tribal Mental Health Project, supported by the Department of Social Justice, Govt. of Kerala and District Legal Service Authority, Wayanad. The study is part of a larger project that got approval from the Institute's Ethics Committee. Informed consent was obtained from each study participant prior to their participation.

We used a qualitative phenomenological approach to explore alcohol misuse among the tribal men. The aim of the phenomenological approach was to deal with experiences and meanings and to capture as closely as possible how the phenomenon is experienced within the context in which the experience takes place.[1516] The qualitative method was chosen as it best suits to capture the experience and voice of a marginalized group.[16]

Setting

The study was conducted in Wayanad District, located in the north-east of Kerala state. It has a population of 8,16,558. Scheduled tribes account for more than 18.5% of the total population of the district, while the state average of tribes is a meagre 1.5%. Among the scheduled tribe population of 4,84,839 in the state, 1,51,443 are from Wayanad.[10] Wayanad District consists of four community development (CD) blocks, namely Mananthavady, Kalpetta, Sulthan Bathery, and Panamaram, and has 25 Grama Panchayaths in total. The tribe population is spread across all the panchayats, although some Panchayaths like Thirunelly and Noolppuzha have a high concentration of the tribes. The low literacy of the tribes contributes to Wayanad district having relatively lower literacy rates than other districts of Kerala.

Population and sampling

The study population consisted with persons from Paniya, Kuruma, Adiya, Kurichyas, and Kattunaikan tribal groups. The Paniya is the dominant tribal group in Wayanad, and they are less educated and most marginalized. The majority of them are casual agricultural labourers.[17] Kurichiyas are one of the most developed tribes; Most of them possess some land, and they do agriculture for livelihood. The Kurumas are another dominant tribe in Wayanad, and most of them earn a livelihood through agriculture and cattle rearing. Some of them are working in government sector also. Kattunaikan is a primitive tribal group. They are experts in collecting honey and wax and prefer to live in the forest. The Adiya group was bonded labourers of landlords, and the majority of them are now agricultural workers.

Using purposive sampling technique, we selected seven tribal men with alcohol misuse and 28 tribal promoters for the study. The tribal men with alcohol misuse were identified from four tribal colonies in Mananthvady (Begur Paniya colony and Iruvaki Adiya colony) Panamaram (Marakkadavu colony) and Bathery (Ponkuzhi Kattunaikan Colony) CD blocks. The samples were selected from different colonies to have a representation of various tribal subgroups. The selected tribal men were adult who had used alcohol at least once in the past 30 days. The colonies selected for the study were very close to the Kerala-Karnataka border, and these places are known to have high substance misuse.

The potential tribal promoters were selected from the Tribal Extension Offices of Kappiset, Bathery, and Mananthavady. They were available in these places to attend their weekly review meetings. The tribal promoters are members of the tribal community who are appointed to function as facilitators in tribal areas for channelizing and extending the benefits of tribal development schemes to the STs. They also make a link between the ST beneficiaries and the local bodies. All the promoters who were available consented to participate in the study.

Data collection

The data collection for this study was done through a combination of in-depth interviews and focus group discussions (FGD). The in-depth interviews were conducted with seven tribal men who had used at least once in the past 30 days, while the FGDs were with the tribal promoters.

The in-depth interviews were conducted by psychiatric social workers with experience in tribal mental health (first and second authors). The participants were interviewed in their homes at the identified tribal colonies. The in-depth interviews lasted 1-1.5 hours and were audiotaped. Observations and field notes were also used to record the interviews. Data saturation in qualitative research generally occurs between six and twelve interviews.[18] Thus we aimed at seven in-depth interviews in addition to the FGDs.

We conducted three FGDs with tribal promoters, and 28 promoters participated. The FGDs were also facilitated by the psychiatric social workers in tribal mental health and assisted by one Master of Social Work student (third author) and one MPhil trainee (fourth author). All FGDs were audio-recorded and lasted around two hours. We used a brief socio-demographic data sheet and an unstructured interview guide to facilitate in-depth interviews and FGDs. Separate interview guides were used for the in-depth interviews and FGDs. Probes were used when necessary. They were prepared based on a review of literature, discussion with experts in tribal projects, and also reflected our own experience in tribal mental health. The in-depth interview and FGD guides are provided as online only supplementary files.

Qualitative data analysis

The audio-taped in-depth interviews and FGDs were combined for an inductive thematic analysis.[19] Such combined approach would increase data richness and rigor in qualitative studies.[20] First, the researcher performed verbatim transcription. In this process, the audiotaped in-depth interviews and FGDs were converted into text, and the message was captured exactly the way it had been delivered. Second, the converted verbatim transcription and field notes were translated into English. The researcher systematically read the translated text several times to get familiarized with the data and to understand the in-depth meaning. Third, lists of codes were developed based on the reading of the data, and these codes were allocated to data through coding procedures, which helped to categorize and stratify the data in a logical way. Inferences and written comments were also made on the themes. The first author performed the thematic analysis, which was revised and fine-tuned with the suggestion of the remaining authors.

RESULTS

Table 1 shows that the majority of the tribal promoters in FGDs were female (82.1%), married (85.7%) and educated up to high school (50%) and belonged to Kuruma/Uraali tribe. Their average age (SD) was 35.21 (6.17) years. The tribal promoters received INR 9,625 as monthly salary, and they had been working as a promoter for the past 3.26 (3.26) years. Table 2 shows the socio-demographic details of the tribal men who participated in in-depth interviews.

Table 1

Socio-demographic details of the tribal promoters in FGDs

Variables	Frequency (%)
Mean INR 9625 (same salary to all)
Gender
Male	05 (17.9)
Female	23 (82.1)
Marital status
Married	24 (85.7)
Unmarried	01 (3.6)
Divorced/widowed	03 (107)
Education
High school	14 (50)
Higher secondary	10 (35.7)
Under graduation or above	04 (14.3)
Tribe name
Kuruma/Urali Kuruma	10 (35.7)
Paniya	05 (17.9)
Adiya	06 (21.4)
Kurichiya	05 (17.9)
Kattunaikan	02 (7.1)
Age
Monthly salary	35.21 (6.17)
No. of years working as promoter	3.26 (3.14)

FGD - Focus group discussion

Table 2

Demographic and substance use details of the tribal men who participated in the in-depth interviews (n=7)

Respondents	1	2	3	4	5	6	7
Tribe name	Kuruma	Adiya	Adiya	Kattunaikan	Paniya	Paniya	Adiya
Age	28	57	38	35	27	40	40
Education	Higher secondary	Illiterate	Lower primary	Illiterate	Upper primary	Illiterate	Illiterate
Marital status	Unmarried	Married	Married	Married	Married	Married	Unmarried
Are you currently working	Yes	No	Yes	Yes	Yes	Yes	Yes
Nature of work (if applicable)	Office work	-	Daily wage	Petty shop	Daily wage	Collect medicinal plants from the forest	Daily wage
Frequency of alcohol use in the past 12 months	1-4 days a week	1-3 days a month	1-4 days a week	1-3 days a month	5-7 days a week	1-4 days a week	1-3 days a month
Age at time of first alcohol use	23		15	20	18	30	14
Any previous treatment for alcohol use	No	No	No	No	Yes, relapsed after six months	No	No
Do you smoke tobacco	Yes	No	Yes	Yes	Yes	No	No
Frequency of smoking	5-6 per day	-	20 per day	5-6 per day	4-5 a day	-	-
Age at first smoking	20	-	15	22	9	-	-
Use of betel quid	Yes	No	Yes	Yes	Yes	Yes	No
Cannabis use	No	No	4-5 times a month	No	No	No	No
Money spent on substances (INR)	1000	300	1500	750	6000	3600	500

Qualitative results

The trajectory of alcohol misuse

Tribes are exposed to alcohol at a very young age through various routes. First, the parents provide alcohol (smaller quantity) to their children during most of the festivals and special days. Eventually, they start liking it, and when they grow, they perceive that using alcohol is not a problem.

A Paniya tribal promoter said:

“Many of our people drink alcohol regularly. They may even give it to their children on special occasions. Now this practice is being reduced, but is still prevalent in some families”

Secondly, children get exposed to alcohol when parents drink at home. There is also a practice of 'family drink' where parents drink alcohol with their children.

By recollecting childhood experience, an Adiya tribe said:

“Sometimes my parents give me alcohol when they drink…. When they don't give, I used to steal…”

Thirdly, small children often make friends with elder children or adults who are already using alcohol. This friendship also influenced the initiation of alcohol consumption.

Finally, tribal children earn money as they work at a younger age. The early financial autonomy also contributes to their alcohol misuse behaviour.

A Kuruma tribal promoter said:

“Many of our children don't go to school… They go and collect areca-nut or Amla fruit from the forest… They earn enough money to buy the substances”

Surprisingly, some parents served alcohol to their children with the expectation that in return, the children will bring alcohol for them when they are old.

Alcohol use as a ritual and custom

Alcohol use was widely accepted in the tribal community, and it was part of their culture. Alcohol consumption was related not only to the celebration of festivals such as Onam (a popular festival in Kerala) and Christmas but also to many important life events.

A Paniya tribal promoter said:

“From birth to death, we celebrate all the special days with alcohol. You know, our funeral is celebrated with alcohol. We need to serve alcohol to the persons preparing the grave and those attending the funeral. If we don't serve it, it would be hard to get persons for such work”

There was also an event called “Pela chadangu,” related to the funeral function in which a religious leader/priest visits the deceased person's home and graveyard to offer prayers and pujas for a peaceful rest of the soul. Alcohol is used at these events. Alcohol is an indispensable part of the tribal culture on many other important occasions too. For example, the meetings of prospective bride/groom and the fixation of marriage are also associated with alcohol misuse.

A Kuruma tribal promoter said: “We serve alcohol during the meeting of the prospective bride/groom. If the served alcohol is consumed, it indicates the willingness of the family for the alliance, and vice versa”

Furthermore, the parents of the prospective groom and bride are expected to offer alcohol for the neighbors and elders in the colony if a marriage is being fixed or confirmed.

Exploitation by landlords

For many years, the landlords (agricultural landowners) used to offer alcohol to the tribal men for the work. Eventually, the tribal men expected it from the workplace, and they were unwilling or demotivated to work if alcohol is not being served. As serving alcohol at the workplace was a tradition, some landlords who do not offer alcohol had difficulties in getting good workers. It was also a general belief in the community that tribal men work harder if they are intoxicated. Thus, the landlords served an increased quantity of alcohol to the tribal men before they work. The tribal men themselves felt that alcohol would keep them energetic during the work hours.

A Kattunaikan tribe said:

“I like to drink (alcohol) before work. It makes me energetic, and I don't feel the harshness of work if I am drunk”

In some instances, the landlords did not pay money or paid less for the tribal men as they deduct alcohol expenses from the wage. The tribal men agreed to such deals, as they wanted money, to a large extent, only for buying alcohol. A few of them used to spend balance wages too on alcoholic beverages. The exploitation by landlords was also observed in the form of differential treatment at the workplace for the tribal men and non-tribal men.

A tribal promoter said:

“They (landlords) ask our people to work hard and more time in the land. They (tribal men) are less paid for the work. Nontribal men are paid higher than the tribes”

Occupational factors

Unemployment or seasonal employment was frequent among the tribal population. They are at high risk for alcohol consumption at the workplace due to the policies of the landlords; Ironically, being unemployed also contributed to alcohol misuse. The tribal houses are very close to each other as they live in a colony and the young men who do not have regular work gather and plan for a drink. Such peer group meetings, usually occurring in non-working days, contributed to alcohol misuse.

A tribal man said

“We get only three- or four-days' work in a month. The rest of the time, we are simply sitting idle at home. So we (peers) plan for a drink from the morning. There is no other enjoyment for us here.”

The employment and unemployment status reflected variably on alcohol misuse. For example, first, being unemployed and having less option to spend time productively contributed to alcohol misuse among the youngsters. Second, for many tribal men, the predominantly motivation for working was the fact that they can get alcohol from the landlord or buy it with their wages. Finally, many elder tribal men remained abstinent or consumed less simply because they do not have any job and consequently, no money to buy alcohol.

A 57-year-old Adiya man said:

“I want to drink, but I don't have any money. My children earn money. Hence, they drink. Sometimes they offer me a drink.”

Attitude towards savings

Most of the tribal men spend their entire income on alcohol. They do not save anything in cash/bank account or other assets and spend their wages on the same day itself. Since raw food (rice) is available free of cost for them from the government, they spend their earnings predominantly on alcohol and betel quid.

A Kuruama tribal promoter said:

” Many tribal men opened a bank account for Mahatma Gandhi National Rural Employment Guarantee Act (MGNREGA) wages…. But there are no savings in the account, and they withdraw the entire amount when they go to town”

(MGNREGA is a government program that provides at least 100 days of guaranteed wage employment, in a financial year, to every rural household whose adult members volunteer to do unskilled manual work.)

Surprisingly, most of the in-depth interview participants shared that they used to take food only once a day, despite it (rice) being available free of cost. This could be a result of prolonged substance misuse and dependence. The need for regular food intake was not perceived as very important.

The tribal men go for work at far-away places, and they come to their home only once or twice a month. They bring enough liquor when they come home, and they won't go for work until the stock is finished. Alcohol consumption often was contingent upon their earnings.

The burden on spouses and children

As male members spend almost all their wages on alcohol, the financial needs of the family are often met by the women of the household. Such situations demand tribal women to go for work to run the family, and this additional role, along with the existing housewife role, contributes to a high level of burden on them.

A female tribal promoter said:

“We both work, but my husband does not give any money for the family. His wages are not even sufficient for his drinking, and at times he would ask money from me for the drink. I don't drink alcohol, and I use only betel leaf”

The parents are unable to perform parental duties if they have had 'drinks' in the previous night, which resulted in the children being left uncared and unprotected. Children often missed school.

A tribal promoter said:

“Many parents drink heavily. Hence, they wake up late in the morning. They don't go for work and also won't send their children to school”

DISCUSSION

The study revealed increased and hazardous alcohol consumption among tribal men, which is intertwined with their traditional rituals, historical exploitation, and socio-cultural backwardness. A previous quantitative survey on substance abuse among adult tribal men had reported a prevalence rate of 67%, which included a 49% rate for alcohol abuse.[21] Among tribal men alcohol consumption was often initiated at a young age through parental and peer routes and sustained by many socio-occupational and cultural factors which further cause a burden on the family. Severe alcohol misuse prevailed in the tribal community at Wayanad irrespective of their tribal sect, although the prevalence among some of the most socio-economically backward groups like Paniya and Kattu Paniya was relatively on the higher side. Socio-economic marginalization is a major reason for higher substance abuse among tribal men in India.[22]

We agree with the observation of previous researchers that culture shapes alcohol abuse.[23] The tribal men perceived alcohol use as a part of their culture, with high community acceptance,[13] although there were growing dissatisfaction and concern about it among the educated young tribes, especially the ones like the tribal promoters. However, the promoters themselves felt helpless and frustrated about this situation and anticipated no change in the near future. The substance abuse among their children was not even perceived as a major problem by the parents or the community people, maybe because of a lack of education and awareness. Similar to our findings, a previous study among the Paniya tribe had reported the employer's exploitation by providing alcohol as an incentive to attract tribal men to job.[9] In some cases, young Adivasis consumed alcohol first time from the workplace. This practice is not only a factor in initiating or maintaining alcohol consumption among tribal men, but also repeats the historical patterns of enslavement and exploitation.

Alcoholic beverages were easily accessible to our sample. One reason for this finding could be that we recruited people who lived close to the Kerala-Karnataka border. Although no illicit alcohol production was reported in the localities, Indian-made Foreign Liquor was available in the black market in the area, targeting the tribal youth. Many tribal youths from the study area availed alcohol from the Karnataka state by crossing the border through a river. Others availed it from the outlets of Kerala State Beverages Corporation, from the employer/landlords, or as a few did, from the local toddy shops. A study from Andhra Pradesh had found that tribes predominantly use locally prepared handmade liquor which is easily available,[22] while we found more use of Indian-made Foreign Liquor. The increased number of Kerala Beverages Corporation outlets in recent years could be a reason for this finding.

Our study also revealed many consequences, including the huge amount of money spent on alcohol, the burden on spouse and children, and less food intake as a result of increased alcohol consumption. Devastating consequences of alcohol abuse such as high mortality and morbidity, suicide,[4] family discord, and domestic violence[24] has been reported in studies with the indigenous populations.

The present study is one of the few which attempted to explore the socio-cultural factors influencing alcohol misuse among indigenous tribal men in India. The findings of the study have significance for initiating specialized de-addiction services, policies, and programs for the tribal men in Wayanad. The limitation of the study is that although we explored the real-life experience of alcohol misuse through in-depth interviews, the participants of FGDs were the tribal promoters who are not necessarily in alcohol misuse. Although they were rich sources of information on alcohol abuse of the tribal men, most of them lacked real-life experience of being in the phenomenon of alcohol misuse.

CONCLUSION

Parental factors, home environment, peer factors and early financial autonomy contributed to the initiation of alcohol use at a young age. The alcohol misuse among tribal men was linked with their tradition and culture, exploitation by landlords, occupational factors, and saving habits, which in turn resulted in a substantial burden on the spouses and children.

Financial support and sponsorship

The study was conducted as part of Tribal Mental Health Project funded by Social justice Department, Govt. of Kerala, India.

Conflicts of interest

There are no conflicts of interest.