ISSN- 0301-1216
Indian J. Prev. Soc. Med. Vol. 54, No.1, 2023
Community voices in attaining health and wellness: Narratives from Assam Kastaurika Saikia,
1Sonali Randhawa,
2Anusha Purushotham,
3Ramnath Ballala
4ABSTRACT
Background: A healthy community is often seen to be the outcome of an effective and accessible health service delivery model, but factors like informed community, equal and adequate access to services as well as social and economic context, significantly contribute to this goal. An explorative research study is conducted across 15 locations in Assam, to capture the need-based narratives of the communities on the subject of health and wellness. Objective: The objective of the study is to understand community experiences and expectations within the context of the social determinants of health. Methodology: The study is qualitative in nature and uses Focused Group Discussions and Key Informant Interviews on a sample size of 294 respondents. The holistic viewing of health and wellness, encompassing social, cultural, economic, and environmental factors through active community engagement, not only helps to contextualize the issues of health as faced by the communities but also to bridge the gap of access and outreach, thereby fostering health equity. Discussion:
Issues stemming from gender, livelihood, and economic disparity largely shape the health-seeking behaviours of individuals and can drive or constrict them from attaining desired levels of well-being. Conclusion: With the idea of universal health coverage as promoted by Govt. of India’s Ayushman Bharat Initiative; an opportunity thus opens up to incorporate these voices from the ground in developing targeted policy interventions.
Key Words: Community Health, Community participation, Health, Wellness,Social determinants of health.
Introduction
The terms - ‘health’ and ‘wellness’, espouse meanings deeper than being free from illness. Health and wellness are multidimensional and interconnected - if a component of either is affected, individuals get affected. With the inception of Health and Wellness Centres (HW&Cs), the term ‘wellness’ appears for the first time, in the public health discourses of India. Modern concepts recognize health as more than the absence of disease and talk about the social determinants of health – societal factors such as education, housing, and income which influence the health of the population 1. The social determinants of health locate communities at the forefront in attaining health and well-being, linking them to positive gains in social capital, social cohesion, and achieving robust health outcomes2.
____________________________
1. Kastaurika Saikia, Senior Manager, Piramal Swasthya, Mobile: 7837875046; Email: kastaurika.saikia@gmail.com 2. Dr. Sonali Randhawa, Research Associate, Health Systems Transformation Platform, Mobile- 8968160392;
Email: sonali.randhawa@hstp.org.in
3. Anusha Purushotham, Senior Consultant, Public Health, Sattva Consulting, Mobile- 97403968721;
Email: anusha.purushotham@sattva.co.in
4. Dr. Ramnath Ballala, Director, Health Systems, BVT Manipal, Mobile- 6302403614, Email: ramnathballala@gmail.com
Corresponding Author: Kastaurika Saikia, Senior Manager, Piramal Swasthya, Mobile: 7837875046;
Email: kastaurika.saikia@gmail.com
Submission 16.01.2023 Revision 28.01.2023 Accepted 05.02.2023 Printing 30.03.2023
The influence of stakeholder perspectives and their effective participation in public health responses are crucial for the success of health programs such as maternal and child health, communicable disease, etc.3,4 However, the literature highlights that there is a limited understanding of the community’s perspective and needs, especially from the under-represented groups such as ethnic minorities, and those from socio-economically disadvantaged backgrounds5. Although the importance of the community’s perspective and participation in health systems is widely recognized, there are limited examples where the communities are given such opportunities 6.
The Government of India’s Ayushman Bharat (AB) Initiative of 2018 introduces the Comprehensive Primary Health Care (CPHC) model of health service delivery through Health and Wellness Centres (HW&Cs) marking a remarkable shift toward achieving universal health coverage, one that has been rallied for by the public health academia and practitioners for a long time now.
An explorative research study conducted across Assam captures the need-based narratives of the communities on the subject of health and wellness. The objective of the study is to understand community experiences and expectations around the subject of health and explore avenues of value alignment with the existing primary health programs.
Materials & Methods
Assam is one of the poor-performing states in the country concerning its conventional health indicators and is categorized to have a low epidemiological transition level 7. The state has a very diverse and unique setting, both in terms of geography and culture; and is broadly divided into five administrative divisions with a population of roughly 30 million people (Male 51 percent, Female 49 percent), with 86.0% of them living in rural areas 8.
The study is of qualitative nature and is conducted in the catchment of 15 operational HW&Cs (out of the 964 health facilities that were listed as HW&Cs as of August 2019 as per govt. accounts) across 10 districts of the state, selected through purposive sampling. The overall study duration is nine months from August 2019 to May 2020 while data collection is carried out from August 2019 to December 2019, before the COVID-19 crisis unfolded. The HW&Cs are selected based on the type of geography (plains, hill areas, char/riverine or tea garden), type of population (ethnicity, religion, cultural beliefs and practices, livelihoods), and location (urban or rural) [Table 1]. A total number of 34 Focus Group Discussions (FGD) are conducted with the study respondents [Table 2] and 30 Key informant interviews (KII) are conducted with community leaders and community health workers, viz. Accredited Social Health Activists (ASHAs) of the respective villages and the HW&Cs.
Table- 1: Type of population covered under the 15 study locations distributed across 10 districts of the state
Population Type Rural Tribal Majuli
(Mishing)
Karbi Anglong (Karbi)
Kohrajhar (Bodo)
Baksa (Bodo)
Tea Tribe Community
Dibrugarh (Upper Assam)
Cachar (Barak Valley)
Char/Riverine Populationa
Majuli (Tribal) Darrang (Minorityb)
Nagaon (Minority
& Non-minority) Dhubri (Minority)
The data is collected by experienced field researchers from the Maternal and Child Health Cell, registered under Assam Medical College, Dibrugarh. Discussions and interviews are audio-recorded and transcribed. The qualitative research software, ATLAS.TI is used for coding the English transcripts that are translated from Assamese/Bengali/Hindi and subjected to thematic analysis.
Ethical approval for the study is attained from the Institutional Ethics Committee of Piramal Swasthya Management and Research Institute (IEC Study Ref No: PSMRI/2019/02) on September 7th, 2019.
Table- 2: Study sample of Focus Group Discussions and Key Informant Interviews Focused Group Discussions (FGDs)
Adult Group
Female Adult Group Male
Adolescent
Group Elderly Group
Total Participants
20-29 yrs 20-59 yrs 10-19 yrs 60+ yrs
No. of
Locations 15 15 2 2
264 No. of
Participants
111 121 16
(F-6, M-10)
16 (F-6,M-10)
Avg. Age 37.52 yrs 37.05 yrs 13.37 yrs 64.5 yrs
Caste/
Ethnicity
General
category 32.4% ST/SC category
39.67% All minority population
F- Tea tribe community M- Mishing tribal
community rEconomic
status
BPL card
holder 73.87% BPL card holder
74.38% All BPL All BPL card holders Education
levels
10th pass 51.0% Illiterate 7.4% All enrolled in schools
All illiterate
Occupation House- wives
92.7% Small business
28.1%
NA
F- Tea garden workers M- Cultivators Cultivation 27.3%
Language
Bengali 40.54% Bengali/
Assamese 66.9%
All Bengali speakers
F- Bengali
Assamese 35.1% M- Mishing /
Assamese Key Informant Interviews (KIIs)
Community Leaders Community Health
Workers (ASHAs) 30
No. of Locations 15 15
Np. of Participants 15 (F-4, M-11) 15 (F-15, M-0)
Total Study Sample
294 F - 48.3%, M- 51.7%
Results
A myriad of themes has emerged as we discuss with the communities about their perception of the terms – health and wellness, viz.
Characteristics of a healthy body: Respondents deem being healthy to be free from diseases and to possess physical strength. They mention seeking medical counsel from community health workers and visiting local health facilities for maintaining good health. Being able-bodied and capable to carry out day-to-day physical activities is seen by most rural communities, both male and female as signs of good health. Going for daily labour, working in the field/tea garden, and not sitting idle at home are also seen as attributes of good health.
‘To be free from diseases is good health’ (Adult male respondent from an urban community)
‘Our ASHA baidew advises us to have two children to enjoy good health but if there are many children, then the health will automatically suffer’ (Adult female respondent from a rural riverine area)
Means of maintaining a healthy body: A number of factors are listed by the respondents as attributing to the good health of an individual; viz.
Physical exercises: Morning walk being the most frequently mentioned activity across groups - male, female as well as the elderly is followed by physical exercises. Respondents mention sports like cricket, and football (by adult male groups) as well as yoga and meditation as preferred forms of exercise.
Food and Nutrition: Eating a balanced and healthy diet comprising locally available green leafy vegetables, fruits, eggs, fish, and milk is deemed important to maintain a healthy body. A few respondents mention eating appropriate diets for physiological conditions like diabetes or high blood pressure, as per doctors' advice.
‘We grow our own vegetables and do not use any chemicals. Eating them keeps us healthy. (Adult male respondent from a tribal community)
Clean environment: Keeping the areas surrounding their houses and workplace clean and dirt-free is seen to be contributing to the health and wellness of individuals.
‘A clean environment with an adequate supply of safe drinking water will result in healthy communities’. (Community Leader from a hilly tribal area)
Personal hygiene: Respondents also mention how maintaining personal hygiene can go a long way in keeping one away from diseases and infections.
‘We have to wash our hands before meals, trim the nails on the hands and if everyone maintains cleanliness then all will be well’. (Adult female respondent, from a rural riverine area) Community Perception on Wellness: The community’s understanding of health is not limited to only the physical body
as they mention several other defining factors such as mental peace, happiness, and blessings as contributing to wellness or well-being.
‘Wellness is about mental health. Some people worry about how to run their family, and sometimes due to such mental pressure some people become mad’. (Adult female respondent from a rural riverine community) Health-care-seeking behaviour and practices of the community members: Public health services are deemed
indispensable for maintaining good health. Following doctor’s advice and taking medicines are seen as ways to regain health in case of any illness.
‘We usually go to the govt. facility; money is a constraint to go to other bigger facilities. People with bigger issues go to Guwahati to seek treatment. (Adult female respondent, from the tribal community)
Communities living in the tea gardens and Char (riverine) areas mention availing gaolian sikitsa (traditional medicine or treatment) for certain ailments by visiting local priests and quacks.
A range of concerns is raised regarding the availability of services in the nearby health centres, which are largely seen to be hindering the communities from attaining timely care. The concerns raised are mostly about the non-availability of services/service providers and poor infrastructure.
‘They only gave me advice, if the doctor was available then he could have prescribed me medicine.
After visiting this centre, I had to visit a specialist doctor again’ (Adult male respondent from tea-tribe Community).
‘Sub-center is only for pregnant women and vaccination of children. They do not treat other illnesses’.
(Adult female respondent from the tribal community)
The frontline health workers- ASHAs, are focused on their role of keeping the community away from diseases through routine health check-ups and emphasizing on maintenance of a clean environment.
‘For cases of pregnancy, we have to do constant follow-ups. For unhealthy mothers or children, there are more rigorous check-ups and home visits’. (ASHA worker from a tribal community)
‘People in our community cannot benefit from health schemes by Govt. as they are mostly uneducated and unaware’. (Community leader from a rural area)
‘Awareness about prevention of diseases and keeping oneself healthy is very important in society, whether it is basic hygiene to avoid infections or to comply with family planning.’ (ASHA worker from a minority community)
Social issues affecting the well-being of the communities: A robust social milieu among people is seen to usher in healthier communities. Community leaders view the provision of basic amenities to all sections of the community to bring peace and harmony contributing to the wellness of the people. Many consider welfare schemes of the Govt. to be crucial in the social and economic upliftment of the communities especially the poor and the marginalized. A number of examples are discussed on behaviour and attitudes of individuals or groups that affect the well-being of the communities; viz.-
Socio-cultural practices: ‘People in our village take part in Bhowna (traditional community dramas/ acts).
Everyone comes together to enjoy the acts and this fosters community bonding and helps in mental well-being’ (Adult male respondent from a rural community).
‘People here (Majuli- a riverine district inhabited by the Mishing tribe) consume a large amount of apong (locally made rice beer). Alcoholism is not only hazardous to health but also creates social discord’.
(Adult male respondent from a tribal community).
‘There are certain miscreants in the community who wants to create social unrest. Sometimes they are politically motivated’. (Community leader from a minority community).
Religious and Spiritual practices: ‘In the Assamese month of Kati, religious scriptures are recited and community gathering takes place. It brings peace to the people’. (Adult male respondent from a rural area).
Leisure and Recreational practices: ‘We have a waterfall nearby. At times, we go and spend some time near it. It makes your mind feel at rest’. (Adult female respondent from a hilly tribal community).
‘A park, already sanctioned but still not built, is required for children. Children are only watching TV these days, they should play and do physical activity. It is important for their growth and well-being’.
(Community leader from a tea-tribe community).
Concerns are also raised about inadequate amenities and facilities that deprive the community of attaining desired levels of wellness, viz. low educational levels and unemployment of the youth, non-availability of drinking water, poor road connectivity to the villages, and lack of basic amenities and recreational spaces.
Economic and livelihood opportunities as means of attaining well-being:
A steady and regular flow of income is seen to be greatly contributing to the wellness of an individual or a household.
‘We all are daily labourers. What should we do to stay healthy? When we have a fever, we do not stay at home we have to go to our work. We are poor people. When we do not work, we do not get our wage’. (Adult male respondent from a rural area).
‘Most of the people are poor in our community; they don't have any steady income source. We don't have any company or factory here. They have to work somewhere else to earn a living and keep healthy’. (Community leader from an urban area).
Role of gender shaping women’s health-seeking attitude:
Female respondents mention about lack of time to carry out the dedicated physical exercise for maintaining good health as they prioritize care duties in the household. A few also mention the lack of suitable infrastructure for women to practice physical exercises.
‘We do our household work; we do not have time for yoga. We need to look after our children as well’. (Adult female respondent from the tea-tribe community).
The poor infrastructure of the sub-centres makes it difficult for women to avail adequate healthcare services.
‘There is no running water. We have to bring water in a bucket when people are going to the toilet etc. Pregnant ladies find it difficult there’ (Adult female respondent from a tribal community).
Discussions
A range of internal and external factors contribute to maintaining a healthy body; such as food and physical activity, which can be abundant or limited within one’s built environment; or the cleanliness of the surroundings and the
In wellness, the concept of health gets expanded from merely the absence of disease or infirmity and is elevated to the integration of an emotional and spiritual health component11 besides physical, mental, and social well-being 12, 13.
As per NHFS-4, there is a large dependency on the public health system in Assam with 79.3% of the population using its services. Community members frequent public health facilities as they are easily accessible, and the treatment provided is inexpensive. However, the utilization of Sub Centres in the state stands at just 4.8 percent (NHFS-4). Often the low quality of care is cited as the prime reason for low service utilization14, together with inadequate infrastructure, limited availability of drugs and consumables, and poor staff motivation 15.
Frontline health workers especially ASHAs, allocated one per 1000 population act as the bridge between the communities and the service providers. The creation of this new cadre of female community health workers, ASHAs is considered one of the profound steps toward communitisation of health by the National Rural Health Mission (NRHM)16. ASHAs are responsible for basic health care provision17 but the role of these frontline workers has been largely limited to carrying out maternal and child health interventions18 and is not adequately able to tackle other rising health issues such as NCDs 19. This has also led to the misconception that Sub Centres manned by frontline workers (ASHAs and ANMs) only provide care for reproductive health.
Communities with lower levels of education or awareness on the subject of health, tend to avail treatment from traditional healers and quacks who are easier to access, inexpensive, and often provide explanations in ways that are easily understood 20 in contrast to the bio-medical model. These practices are observed in the hard-to-reach geographies in Assam such as the riverine (char) areas and among the tribal and tea-tribe communities. From the standpoint of a pluralistic development model, these indigenous practitioners can become important allies in organizing efforts to improve the health of the community21 if they are included within the fold of formal healthcare systems upon validation of their knowledge, awareness generation, and active supervision.
Consideration of the interplay of social and cultural factors is essential when exploring the perspectives of community members 2 on health outputs; such as attitude and behaviour towards health. The dearth of family planning measures, substance abuse – local liquor and tobacco, consumption of adulterated or unhealthy food, and lack of physical activity; are seen as the root causes preventing an individual from attaining good health. Awareness generation, health promotion, and dispelling misinformation were univocally advocated for by ASHAs, who have the closest understanding of the communities as they share similar values and life experiences as the people they serve22, and are the key influential figures to be leveraged upon to develop more effective interventions to change health behaviours 23.
With the focus now shifting to Comprehensive Public Health Care as laid out in the National Health Policy 2017 and further implemented through the Ayushman Bharat HW&Cs; health promotion and prevention are receiving as much attention, with capacity-building efforts for the primary healthcare team and frontline health workers (FLWs) as a crucial first step24 for propagating primary healthcare as an all-inclusive agenda and creating greater awareness in communities about the services available at HW&Cs. Advocacy around universal access to health information and support 25 can go a long way in strengthening health initiatives and addressing the demand barriers that often hinder communities to benefit from public service systems 26.
Economic stability which includes working conditions, financial security, employment, or livelihood status is one key factor impacting physical and mental health and well-being27. The lack of a steady source of income or employment opportunities can hinder individuals from attaining adequate levels of health and well-being. Poor communities prioritize daily income flow and thereby devote the maximum of their time to income earning and livelihood activities while considering activities around maintaining health like physical exercise etc. only as secondary - deemed as leisure activities and considered affordable to only the young and the rich with time and resources to spare.
Gender and age influence people’s perceptions of health as much as their environmental and background factors28. Social factors, such as exclusion or limited participation in public life 20, affect women’s engagement in carrying out health-building activities. Women remain engaged in household and care duties for most of the day with no time to carry out physical exercise or yoga. Gender shapes health outcomes through the differential exposure to intermediary determinants of health i.e. material, psychosocial or behavioural factors.29 The lack of facilities and amenities for women to carry any physical exercise is a major barrier for them in attaining desired levels of health or wellness.
Conclusion
The concept of health has now expanded, moved beyond the physical body, and is located in the lived experiences of the people. The findings of the study accentuate the contextualization of health and wellness as per local milieu, people’s needs, and expectations30. Community involvement is key in driving healthcare improvement through contextualizing learnings and actions 2 taking into account the culture of communities while developing interventions and seeking to engage communities for change 9 to create a deeper sense of engagement and accountability31. Community participation is thus a fundamental element of an equitable and rights-based approach to health2 and can directly build into the scope of all the newly established Health and Wellness Centres32 to offer comprehensive and people-centric primary care services within the context of social determinants of health.
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Citation: Saikia Kastaurika, R. Sonali, P. Anusha, Ballala R.
Community voices in attaining health and wellness:
Narratives from Assam. J Prev Soc Med, 2022; 54 (1): 05-13.
