Health Seeking Behavior of Marginalized Santhal Population in Jhapa District, Nepal

Introduction: Santhal is one of the ethnic groups, living in Jhapa and Morang districts of Nepal. The proportion of Santhal population compared to the previous census report is continuously declining because of marginalization and migration to India. Methods: This study was carried out qualitative cross-sectional study based on a household survey. The research work was undertaken in two Village Development Committees (VDCs) and two wards from each VDC by using simple random sampling. A total of 382 households were selected as respondents to the study. A Santhal graduate and three more interviewers were trained for data collection. The research was funded by Purbanchal University, Research Division. Approval for data collection was taken from the Research Division of Purbanchal University and permission for data collection was taken from the concerned VDC authority. Results: The study found that 84.8% had a poor level of knowledge of health-seeking behavior, very few that is 1.7 % of respondents visited traditional healers whereas 92.9% of Santhal people had a positive perception of modern medical treatment. The majority of respondents (97.4%) took medicine when they got sick, among them 46.5% got the medicine from a primary health care center. Conclusion: The majority of Santhal people visit healthcare settings when they become ill. Regarding the information on health-seeking behavior about two/third were informed from the senior member of the family. The majority of Santhal people had poor knowledge of health-seeking behavior and the majority had positive health-seeking behavior on modern treatment.


INTRODUCTION
Santhal in Nepal is considered one of the first settlers in the eastern plain area.Now they are concentrated in the Jhapa and Morang districts of Nepal.As per the census data of 2011, the total population of this community was 42,698 (0.19 percent), and was found scattered in almost 30 districts; however, the number is negligible in other districts.Santhal have been considered tribal people living nomadic lifestyles and are found in India, Bangladesh as well in Nepal.In India, they live densely in the Southern part of the country.Traditionally this community relied on hunting and fishing as their livelihood however the modernization of the society and geo-political changes forced them to shift into other occupations mainly working as daily wage laborers in agriculture and other areas. 1 The Santhals believe in folk medicine.They have their traditional healers upon whom they have considerable faith and confidence and they have few common characteristics regarding their perception of health and disease.They believe diseases to the wrath of God, the mischief of evil spirits, and the magic of human beings.Their traditional healer/ priest can appease the deities.Treatment is based upon the removal of causative factors by appeasing god.The Santhal people invariably used to drink country liquor, they believed that it gave them the required energy to work in their fields. 2e Santhal people have been introduced to the modern healthcare system through Primary Health Care, hospitals, etc.In earlier days, Santhal people used to collect medicines from the nearby forests but nowadays it has become difficult to get medicinal plants due to extensive deforestation and a lack of willingness to practice traditional health care systems among the new generation. 3Health Seeking Behavior also includes the perception of the cause of disease.This perception always leads to treatment-seeking behavior among the Santhal people. 4is community falls under a highly marginalized group, some research has already been carried out basically focused on their language, socio-economic and cultural aspects rather than health-seeking behaviour.The quantitative baseline data which was generated in this study, would be very useful for the development agencies and public health administrators.Due to the limitation of time shortage and given the inadequacy of available information on this subject in a country like Nepal, the proposed study is bound to be a large measured descriptive study.

METHODS
A descriptive cross-sectional study design was carried out based on a household survey.The sample size was 382 by using the sample size calculation formula.A simple random sampling technique was used and developed the sample the sampling frame to select the study site where the research work was undertaken in two Village Development Committees (VDC) and two wards from each VDC by using simple random sampling.A Santhal graduate and three more interviewers were trained for data collection.Santhal people above the age of 18 years who were able to respond to the questionnaire were included whereas non-Santhal and physical and mentally ill were excluded.Self-constructed pre-tested tools were used to collect data.A face-to-face interview technique was used.The research was funded by Purbanchal University, Research Division.Approval for data collection was taken from the Research Division of Purbanchal University and permission for data collection was taken from the concerned VDC authority.Informed consent was taken from each respondent.Descriptive statistics was used to identify the health-seeking behavior and data was analyzed by using SPSS 16 version.

RESULT
This study showed that 35.1% of respondents were at age between 20-25 years groups, 29.1% between 26-35, 12.3% between 36-45, and 18.1% between 46-60 whereas 5.5% of respondents >60 years age group with mean age 34.99, Std.Deviation 15.371.Similarly, 53.1% of the respondents were female and 46.9% were male.Regarding religion, 79.1% were Hindu and 20.9% were Christian.Regarding the family type, 55.5% were living in a nuclear family followed by 39.5% living in a joint family, and the rest 5.0% were extended family.Illiterate was higher (61.5%) in Santhal population.Regarding the level of education, 25.9% were primarily educated whereas 2.1% completed higher secondary education.The majority (80.1%) of the respondents were wage laborers whereas very few (0.5%) were fishermen.Near about half (40.6%) of the respondent's family income was below 3000, and 10.5% had above 8000 per month; whereas 8.6% refused to answer.
Among the respondents regarding the information, 65.7% were informed by a senior member of the family whereas very few (2.4%) got information from a newspaper regarding medical treatment.Utilization of health services determines the health status of Santhal people, 34.8% of respondents visited health care center for one year, 89.5% received medicine and health services from a primary healthcare setting, 28.5% told they had to pay for the service utilization, and 19.6% (n=75) replied the service they receive is affordable.The majority of respondents (91.6%) understood the language used by the health care provider, 96.1% said that the health care provider offers them to sit before providing any health care services, and 95.3% were satisfied with the behavior of the health care provider.
Regarding medical treatment 46.5% said due to past experience, 42.5% relieved the problem sooner, 10.0% unavailability of traditional healer whereas very less 1.0% told other causes.The majority (89.1%) visited healthcare settings, 6.8% homeopathic and 1.7 % visited traditional healers.Regarding medicine after illness, 46.5% were from primary health centers, 30.8% from hospitals, and 22.7% from pharmacies.Regarding complications of treatment, 57.5% suffered from headaches, 21.7% faced nausea and vomiting and 9.4% faced itching.
Regarding the level of knowledge on Health Seeking Behavior, 84.8% had poor knowledge, 13.4% had average and 1.8% had high knowledge.Regarding health-seeking behavior, 68.3% had moderate healthseeking behavior whereas 3.1% had good healthseeking behavior.

DISCUSSION
The discussion section of this study aims to contextualize and compare our findings with existing literature on the health-seeking behavior of Santhal people.By evaluating similarities and disparities between our results and those from previous studies, we can gain a deeper understanding of the implications of our findings and contribute valuable insights to the field of health-seeking behavior of different marginalized ethnic groups similar to Santhal people.
The Government of Nepal has enlisted Santhal as indigenous and aboriginal people and Santhals are the old inhabitants and ancient ethnic people of eastern Terai of Nepal.Similarly in this study most of the Santhal people felt good about their traditional practices and rituals of their daily living though they had positive beliefs about the modern medical treatment system.
A study was conducted on the Rajbanshi population which is similar to the Santhal population, the finding of this study showed a drastic difference in that the Santhal people had a positive belief in the modern health care system.This could be due to the mixed community residing in the study area.Whereas the healthseeking behavior of Rajbanshi people.Rajbanshi people were going to take a particular health care service i: e one fourth (82.8%) of despondences which is similar to this recent study on Santhal people The Santhal villages have been introduced to modern healthcare systems through government PHCs hospitals etc.In urban localities, private clinics have also flourished in recent years because Santhal people want to stay among their own ethnic community group.A different study showed that the recent decline of the Santhal people from Nepal to India was because they wanted to stay in their own community.Similarly in this study, almost half of the respondents received medical care when they became ill at was Primary Health Care center.PHC was the suitable place of treatment for Santhal people which is due to their low socio-economic status.
In this study, one-third of the respondents had less than NPR 3000 per month family income.
In this study, the least number of respondents felt under the age of 60 years.The age factor of the respondents was found to have more impact in determining the inclination towards a particular health care system than any other factors.It showed that on average the aged people were more inclined to traditional methods of treatment whereas the young generation was heading towards a modern medicine system.It was also found that irrespective of age and educational level percentage of people having exclusive faith in traditional healthcare practices was in decline.
Most of the Santhal people knew the information regarding availability of the health services by the senior family member.This may be because most of the Santhal family did not have access to TV, Radio, and other means of mass communication.It could be because of their occupational involvement that in this study majority of Santhal people had daily wages based on occupation.They work on the farm and most of the time they spend time with agricultural work.If we go back to the history of their arrival in Nepal, they were brought to Nepal from India for agricultural purposes.

Health Seeking Behavior of Marginalized Santhal Population in Jhapa District, Nepal
Regarding the place from where they take medicine after being sick, almost all of the respondents took medicine when they got sick and half of the respondents got the medicine from the primary health center when they became ill.This may be due to most of the Santhal people having poor socioeconomic status and also majority of Santha people did not face any drug-related reactionary which is directly proportional to the modern health care system.
The majority of Santhal people had a poor level of knowledge on health-seeking behavior whereas above two-thirds had moderate health-seeking behavior.This may be due to Santhal people being illiterate, having less awareness related to health campaign programs in their community, and also due to low socioeconomic condition This very spiritual insecurity plays a vital role in tribal health care services, lack of which leads to failure of the system.It has been revealed from several studies that the Christian Missionaries used religion branded with allopathic medicines as a spiritual shield to propagate Christianity among tribal groups with known success.But it is sad to see that many government policies hardly accept this very component in their health-related aids and campaigns for a better result.A rational synthesis of traditional perception with health-seeking behavior of modern medical treatment would certainly do good in tribal health issues in our country From the above discussion, it is clear that education, migration, and globalization have several direct and indirect impacts on the health status and healthseeking behavior of the Santals people.The spread of education has helped them to adapt to new methods of agriculture and be aware of socio-economic mobilization.Migration to cities and towns, understand the need for education for their children, get exposure to modern health practices.In short, in this study, I have mainly highlighted the Santhal health-seeking behavior.

CONCLUSION
The Santhals believe in folk medicine.They have their traditional healers upon whom they have considerable faith and confidence.The Santhals have few common characteristics regarding their perception of health and disease.This perception always leads to treatment-seeking behaviour among the tribes The majority of Santhal people visited healthcare settings when they became ill.Regarding the level of knowledge on health-seeking behavior, a majority had a poor level of knowledge and moderate health-seeking behavior.Some recommendations for the local government, provincial government, and Federal government to strengthen outreach and communication efforts to increase the accessibility of health seeking behavior of Santhal people on modern treatment addressing socioeconomic and socio-cultural barriers such as poverty, low education levels, and limited access to health services and infrastructure etc.This help to improve the health seeking behavior of marginalized Santhal people in Nepal, leading to better health outcomes and health protection for entire Santhal communities as well as other similar marginalized ethnic communities.