Vijaya Hegde : Implications of Tobacco Use by a Tribal Community
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- Vijaya Hegde : Implications of Tobacco Use by a Tribal Community
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2022-23
n
Community Health Learning Programme
Mr. S J Chander(Mentor)
Dr. Vijaya Hegde
A Report on the Community Health Learning Experience
1
ACKNOWLEDGEMENT
This humble piece of work is a sincere token of gratitude to all those
who have been the reason for its conception as well as its successful
completion.
My sincere thanks to my mentor S.J Chander for his guidance,
positive encouragement and quest for perfection.
I also thank Mr KartiK, Ms Uma, Janelle for their moderation of the
programme and support. it is to them that I owe my deepest gratitude.
I express my gratitude to my batch mates for their valuable insights
during the online sessions.
I also like to express my gratitude to all my study participants for
their timely help for which I am forever grateful.
1
PART A:
Why did I join the fellowship?
Community Health Learning Program (CHLP) training trains in many of the areas
that has not been covered during my post-graduation. This fellowship allowed me to
get direct field experience of my choice, and this will go a long way to help me to
come into contact with some of the most common issues faced by the communities .
I also got an opportunity to make an impact on the community that I chose to work
with for my filed work.
What were my learning objectives and were they met?
1) To acquire knowledge on program planning and evaluation.
2) To develop advocacy and policy development skills.
3) To identify a problem in a community and evolve possible solutions in
collaboration with the community
4) To develop responsive community leadership.
In my view most of them were met. It gave me opportunities to get involved in new
issues like Trans-Gender Care, Rural People, Women and Health which otherwise
would have remained untouched area by me.
Learning from modules and how I applied the learning in my work.
My Reflections:
The Orientation was very helpful and made me feel at ease and also created a feeling
of belonging. The program convenors seemed to be approachable and most important
was that there was no teacher student environment.
Understanding community Health:
Community should be a vital part of any program, and we need to increase
community capacity by increasing health knowledge. In the end of the program the
community should feel that their program was a success. Discussions on various
organisations gave us an insight into the application of various axioms of community
health. Improving community health is a huge undertaking that involves cooperation
between public health workers, local government, volunteers and average citizens
alike.
The discussion on Community health approach versus Public Health Approach was
very insightful. But I find the two terms synonymous in many ways since they are
both concerned with improving overall health care amongst groups of people. Public
2
health can be placed on a larger scale since some issues are more global, while other
issues are more community-based and on a smaller scale.
However, SEPCE helps in evaluation, and is based on the needs of the community.
Understanding the perceptions of the community towards health equity and equality
will help us in framing health care initiatives. As per my knowledge health
inequlaities may be due to lack of awareness, social stigma and discrimination
especially in rural areas.
The greatest burden of oral diseases is on disadvantaged and socially marginalized
populations. Rural communities often lack adequate oral healthcare which may be
due to lack of awareness, difficulty in accessibility as well as affordability. Oral health
is also an neglected entity especially among the rural mass .The socioeconomic
status, gender, literacy are also the contributing factors to avail oral health care
among the rural mass. There is a need to know the felt needs of the rural
communities and also inculcate a positive attitude towards oral health care.Hence it
is imperative to to tackle issues and challenges to achieve health equity.
The right to health module emphasised that public health is not a technical activity
but is to be seen as a way of asserting the value of human life.WHO creates a legal
obligation on states to ensure access, makes it affordable and acceptable. It is also
the state's responsibility to allocate the maximum available resources so that there
is greater equity and also one should ensure that there is meaningful participation
from all stakeholders.
the obligations of the state towards healthcare is that it needs to be:
Accessible
Affordable
Available
no discrimination
informative
Acceptable
Quality of services needs to be good.
Social Determinants of health:
3
Social determinants of health are the conditions in the environments where people
are born, live, work , play , worship and age that affect a wide range of health ,
functioning and quality of life outcomes and risks
The class on social determinants of health gave us insight on the concept of “Health
for all”. The social determinants of health (SDH) are the non-medical factors that
influence health outcomes. The circumstances in which people are born, live, grow
up, work and age and the systems put in place to deal with illness are called social
determinants.
The Commission on Social Determinants of Health was set up by the World Health
Organisation. It shows how social, economic and political mechanisms give rise to a
set of socioeconomic positions, whereby populations are stratified according to
income, education, occupation, gender, race and other factors. The socioeconomic
positions in turn shape specific determinants of health status (intermediary
determinants) reflective of people’s place within social hierarchies based on their
respective social status.
4
To construct a CSDH framework we need to first know the community, we need to
gather adequate evidence, perform SEPCE analysis, know the barriers, categorise the
various factors under the CSDH framework and later know the mechanisms and the
various interventions we need to perform. mainly we need to focus on the social
determinants to health.
The module 6 on cultural determinants of health helped me to know that culture is
a way of life, which includes values, beliefs, arts, science and modes of perception.it
gave me an insight of the difference between cultural awareness, cultural sensitivity
and cultural competency.
As a researcher we need to address the cultural issues like:
We need to listen, understand and respect the cultural practices, share and be a part
of the community, we need to discuss the results of the study and also make them
part of the writing process.
Overall the videos by Sunil George was very informative and interesting.
The session on 19th of June on issues related to LGBTQ community was a ice
breaker. Though I have been working for transgender population sine the past six
years, I was not aware of the gender identification. I also got to know that we are not
supposed to discuss of their past unless and until we have obtained permission from
them. With my work experience with this minority population, is that they give least
importance to health care , unless and until it is their felt need. I worked in silos for
them but since the past few months i have collaborated with Yenepoya university,
5
where we tried to provide them alternate employment training.However according to
me , I feel they exploited and ill treated. However this session gave me more insight
in to different sex identities, which in fact was new to me.
*Gender Identity: Gender identity is how you, in your head, think about
yourself. It’s the chemistry that composes you (e.g., hormonal levels) and how
you interpret what that means.
Gender Expression: Gender expression is how you demonstrate your gender
(based on social constructs within the culture) through the ways you act, dress,
behave, and interact.
Biological Sex: Biological sex refers to the objectively measurable chromosomes,
hormones, and organs (secondary sexual characteristics).
Sexual Orientation:This is to whom we are attracted to based our sex.
*(https://www.geneseo.edu/lgbtq/gender-identity)
6
Module 7: Comprehensive primary health care:
Primary health care is defined as an essential healthcare which is made
universally accessible to individuals and families through their full participation
and at a cost that the community and country can afford to maintain at every
stage of their development in the spirit of self reliance and self determination.
The principles of primary health care are as follows:
Equitable distribution, community participation, intersectoral coordination,
appropriate technology and focus on prevention.
My reflections are that, PHC approach has been challenging in a country like
India because of the increased prevalence of non communicable disease, lack of
education, poverty, and non availability of resources as and when needed .
Majority of the population live in urban slums resulting in poor sanitation and
compromised health, the major reason being rapid urbanisation. The people are
also not satisfied with the treatment provided in the primary health care , not
only because of the poor infrastructure but also the staff who are rude and abrupt
, and also show discrimination towards vulnerable population. There also has
been a shortage in manpower which also may be one of the reasons for their
attitude.the current primary health care has been very rigid which does not
respond to the needs of the population.
Qualitative research into this area could yield lessons for the delivery of future
services. Research into factors influencing service utilization could lead us to
developing a public health marketing strategy for care access. A conjoint effort
by the state and the institutes can thus be used to reinvent primary healthcare
and bring it to the forefront. Qualitative research, to know the factors for
inadequate utilisation can be used to reinvent primary health care and bring it
to forefront. India's progress towards sustainable development goals.by
strengthening the primary health system in india.
Module 8: Equity in Health:
7
Rights of persons with disability by Dr Anup Antony several aspects of
Community based Rehabilitation.
What is CBR?
It
enhances
the
lives
of
the
people
with
disability
within
their
communities.Community-based rehabilitation (CBR) was initiated by WHO
following the Declaration of Alma-Ata in 1978 in an effort to enhance the quality
of life for people with disabilities and their families.
It was also shocking to know that in india there are 2.68 crores of individuals
who are disabled.
Essential components of CBR?
1. ·
It should cover everyone
2. ·
Should be a part of inclusive environment.
3. ·
Should look for all round development
4. ·
Should have a balance on service delivery
5. ·
It should strengthen their groups.
Key activities of CBR:
1. ·
Capacity Building
2. ·
Quality Education
3. ·
Rehabilitation
4. ·
Livelihood Opportunities
5. ·
Social Inclusion
Merits of CBR:
1. ·
Improvement in knowledge
2. ·
Cost effective
8
3. ·
Comprehensive and holistic development
4. ·
Early identification, intervention and follow up
5. ·
Community involvement
6. ·
Equip’s PWD’s with confidence and teaches them to move forward.
Demerits of CBR:
1. ·
Government does not replicate
2. ·
Limited training
3. ·
Little funding
4. ·
No referral services.
Challenges of CBR:
1. ·
Lack of acceptance, understanding
2. ·
Lack of finance
3. ·
Poor management
4. ·
Limited models of good practice
5. ·
Government has other priorities.
Sustaining CBR:
1. Building Capacity
2. Community Ownership
3. Effective Leardership
4. Local resources to be needed
5. Increased Collaboration
6. Political Support
9
Module 9: HEALTH SYSTEMS IN INDIA
Oral health is still neglected not only by the community but also by the health
systems in our country. India is primarily a rural community with 72.2% of its
population living in rural areas.Majority of the population is affected with
periodontal disease, dental caries, malocclusion and Oral Cancer. but these
diseases can be prevented to a large extent.The key barriers to oral health are
affordability,
lack
of
awareness,
accessibility,psychological
barriers.By
integrating oral health in to the health systems, it can be made more accessible
and affordable. This necessitates for a return to primary health care principle of
focus on prevention.
Barriers in integrating oral health in to primary health care:
·
Lack of political leadership, poor understanding of the oral health status
of the population and low prioritisation of oral health on the political agenda as
well the absence of appropriate oral health policies were identified as barriers for
integrated care.
·
Scarcity of various trained human resources such as care coordinators,
public health workforce and allied dentists were important barriers to oral health
integrated care.
·
Absence of healthcare policies.
·
The primary healthcare providers did not attribute value to continuity of
care in the field of oral health because oral health conditions are rarely life
threatening
Module 10: Pluralism in health care:
Lot of research has been conducted on the use of medicinal plants on oral health,
but they are not still integrated with conventional oral health care.herbs that are
commonly used are neem, mango, cashew, eucalyptus, babul and guava leaves.
miswak is a popular chewing stick commonly used among the muslim
community. The chewing sticks not only cleanes the teeth but also believed to
10
have anti oxidant properties. Several trials has been conducted to assess the
effectiveness of herbal medicines as mouthwashes. however they are not available
commercially. In india as a post eating ritual not only people wash their hands
but also rinse their mouth which removes the food debris and plaque.The picture
is entirely different in rural india when compared to urban india.There is a
common belief among the mass that extraction of upper teeth leads to loss of
eyesight and also harms the brain. Use of tobacco, cloves, charcoal is commonly
used for tooth ache. beliefs are normally passed from one generation to the other.
These beliefs are deep seated.Hence i feel there is a need not only to create
awareness but also to respect the autonomy of our Cultural beliefs.This is
dependent on the local eco system resources.
MODULE 15:
Gender Health:
Gender Equity is fairness in the distribution of resources, budgeting,accessibility
and benefits
Gender Equality is absence of discrimination on the basis of persons sex in
accessibility , allocation and distribution.
Gender: Gender refers to socially constructed roles, behaviours, expressions and
identities .
SexIt is differences in sexual attributes.
Gender and Health is an ever present challenge.It is a social construct which
determines our social position, gender differences, leading to biased health
issues,
biased
health
care
facilities
and
thereby
leading
to
gender
inequality.Gender as a stndalone factor does not cause any disease but in
interacts with other factors leading to health issues. Reasons for gender
inequalities may be emphasis on womens child bearing roles, excessive workload
which not only exposes them to health hazards but also make it difficult for them
to take care of their health. In India caste and gender are closely intertwined and
hence women empowerment would be incomplete without consideration of the
role of caste
11
In Indian society primary beneficiaries of inheritance are the sons, and in those
lines they are provided higher place and also more support to them when
compared to the girls. Inequality starts from birth , leading to les importance to
education, getting them married against their wishes , shunned during their
periods, increased frequency of suicides, and also increased maternal death.
Gender based budgeting and restructuring of revenues and expenditure needs
to be made at all levels of health care.
Gender Inequality can be improved based on the following attempts:
Women leaderships,
Creating awareness,
Capacity building, advocacy
funding women's organisations
empowerment.
investing in health care
Mentorship process and reflections:
My mentor Chander SJ is an authority in the field of Tobacco. He is a seasoned
adviser, who supported me right from the time of topic selection. Though
getting mentorship offline would have been an added experience. But at every
phase of my project, I did get his expert guidance and he was there for my
presentations.
Project learning experience:
My project was on implications of tobacco use by a tribal community. My first
and foremost challenge I faced was in building trust with the community.
12
Though I have involved the community members in the planning phase itself,
the community was reluctant to get involved. However, I managed to convince
a few in the beginning. But as I kept visiting their hamlets frequently, I began
to see a change. Majority of them co-operated and agreed to join us for my
second survey.
The second insight I gained was that the community gave priority to general
health when compared to oral health. They were under the impression that
oral health issues will not take away their lives.
They had other day to day problems of concerns such as inadequate water
supply, electricity, land issues. These were more important than those related
to health. Those who went to schools were only a few in numbers.
Take away from CHLP and Looking Ahead -Where do I go from here?
The fellowship empowered me into various other core areas in Public Health.
It also helped me to gain vast knowledge and new insights on the most current
trends and skills in public health and resource persons who have contributed
immensely to the field of Public Health. It may help me for a career transition.
It is also be a valuable element to my Resume, as it will make me stand out.
I intend to inculcate the knowledge gained here in my public health activities.
Impact of Covid-19:
This had affected my day to day life and the major hurdle that I faced was on
taking extensive precautions such as extensive hygiene protocol, social
distancing, wearing masks and so on. The impact of the pandemic on me
can be divided in to various categories:
a) Healthcare:
Got infected with the virus
Family got infected
Challenges in the diagnosis, quarantine and treatment of suspected or
confirmed cases.
High burden on the medical system.
Health care professionals were at risk.
13
Requirement of protection
Disruption of medical supply
b) Economic:
Loss in salary
Poor cash flow
c)Social:
Restricted travel
Interpersonal family relationships issues
Social distancing
Closure of Public Places
Closure of places of entertainment
Postponement of exams.
d) Mental Health:
Undue stress
Depression, Anxiety
Feeling of Uncertainty
Financial pressure
Social Isolation
Loneliness
14
PART-B
Background
“Time and health are two precious assets that we don’t recognize and
appreciate until they have been depleted.” – Denis Waitley
15
Health is a valuable asset not only for an individual but also for the social
system. A nation may progress rapidly when its population is healthy and
leads a productive life. Oral health is considered as an integral part of general
health. Our society is highly stratified by caste and socioeconomic positions.
At the bottom of the hierarchy are the lower castes and the indigenous groups1
.The Koraga tribe is a primitive tribe or to say is one of the oldest tribe of the
region is found mainly parts of Dakshina Kannada and Udupi districts of
Karnataka and Kasaragod district of Kerala, South India. Their existence is
believed to be prior to 6th Century A.D. Though Koragas are tribals, they are
regarded as untouchables and are not allowed inside temples and upper caste
households in the local conservative Hindu society. It is to be noted that
Dakshina Kannada district has, in terms of the Human Development index,
very high literacy and health indicators, matching those of Europe. However,
The Koraga community has received less attention
by the mainstream
communities. . But koragas in Dakshina kannada have resolved to free
themselves of their degrading occupation once and for all. But due to benefit
of welfare programmes their younger generation have acquired education, and
some of their young men have studied up to undergraduate and even postgraduate levels. Some are working as teachers and lecturers2. The population
of the Koraga community is 6,200 persons (1,283 families) in Udupi taluk, 3,154
persons (853 families) in Kundapur taluk, and 1,779 (432 families) persons in
Karkala taluk. The major problems faced by this community are health and
education realed. The life expectancy of Koraga community members is short when
compared to that of other communities3
In spite of some positive changes taking place in the social, economic and
educational spheres of Koragas since the last decade, Oral health is still a
16
neglected issue. This may be due to their ignorance , lack of awareness, lack
of accessibility and affordability to oral health care.
Tobacco and alcohol use has been prevailing in this community for long and
it is a regular practice in their culture. Such habits seems to commence at a
very young age and are imparted from generation to generation. They are also
unaware of the harmful effects of these habits. This not only causes Oro
dental problems but also a precursor for many general health issues.
Tobacco is identified as one of the major risk factor for Non Communicable
Diseases, especially among those from low socioeconomic status. Evidence
shows that the use of smokeless tobacco is high among the koraga community
and health inequalities are rampant. Tobacco use does not only cause oral
health related issues but also affects the general health and the environment.
From the history, we all know, tobacco use and alcohol consumption has been
prevailing in the tribal communities for so long that it is a regular practice in
their culture. Such practices habitually commence at a very young age and
sustained life long, additionally it is
being imparted from generation to
generation. The tribal people being so rooted to their culture are unaware of
the outside world and the harmful effects of these practices. Hence by
engaging the entire community and volunteers alike from sectors other than
health may help to address tobacco control related issues through
intersectoral collaboration and capacity building. This will also reduce the
burden of Oral Diseases to a great extent.
The cultural patterns and life style of the tribes vary a lot and so does their
health seeking behavior. Moreover, the tribal culture is guided by traditionally
laid down customs and each member of the culture is ideally expected to
conform to it. They rely on traditional systems for their oral health care.
Though most of them are agriculturists and are
depending on forests
products for livelihood. , At present they are engaged in many other
occupations too. Most of them are laborers dependent on daily wages.
Due to their ignorance, they do not take much care pertaining to their own
health. They believe that diseases are caused by hostile spirits and ghosts.
They have their own traditional means of diagnosis and cure. Good number
of them fall prey to the diseases such as skin disease, forest fever, T.B, small
17
pox, Oral Health Problems etc. Accessibility to proper health care facilities,
advanced check-ups and treatments are not affordable to majority of them.
The present study will shed light on their oral health and also the implications
of Tobacco use on the oral cavity. Based on this understanding, the study will
enable to plan and develop strategies for the control of tobacco use and also
reduce the oral disease burden which is largely preventable.
18
SWOT analysis of the community:
STRENGTHS:
Unique folk culture.
Illiteracy, Poverty
Traditional medicines
Chronic diseases like TB, Skin
Basket making skills.
Agriculturists
WEAKNESS:
diseases, anemia
Superstitious beliefs
Lack of Accessibility to health
care
Lack
of
any
health
care
initiatives
by
the
local
government officials.
OPPORTUNITIES:
Threats:
Regular Check up’s, Antenatal
Risk of Extinction due to years of
and Post-natal care at PHC’s.
neglect,
Basic facilities like water supply,
exploitation.
electricity and land.
Lack of Community Cohesion
Nutritional
supplements
Substandard Housing
for
Poor Living Conditions
expectant mothers
Community Gathering Spaces
Schools for their children
discrimination
19
and
Rationale
20
Tobacco is one of the major risk factor for Non Communicable Diseases
especially among those from low socioeconomic status. A study conducted by
Dey S.M shows that the use of smokeless tobacco is high among the koraga
community and health inequalities are rampant. Tobacco does not only cause
oral health related issues but also affects the general health and the
environment. From the history, we all know, tobacco use and alcohol
consumption has been prevailing in the tribal communities for so long that it
is a regular practice in their culture. Such practices habitually commence at
a very young age and sustained life long, further
being imparted from
generation to generation. The tribal people being so rooted to their culture are
unaware of the outside world and the harmful effects of these practices. Hence
by engaging, the entire community and volunteers alike from sectors other
than health may help to address tobacco control through intersectoral
collaboration and capacity building. This will also reduce the burden of Oral
Diseases to a major extent.
The purpose of the present study is therefore to assess the implications of
Tobacco use on the oral cavity. Considering the high prevalence of tobacco
use among koraga community, anti-tobacco activities need to scale up for the
community, with more emphasis on behavior change through group or
personal approach.
21
Review of Literature:
22
•
Reichart A et al (1987)4 conducted a study in six major hill tribes of
Northern Thailand. Chewing, smoking and oral mucosal lesions were
recorded. Considerable differences in the chewing and smoking habits among
the various tribes were recorded and some of them were considered tribespecific. Chewing of betel and miang was more prevalent among the older
people, these habits seem to have lost their attraction for the younger people.
Cigarette smoking was more prevalent among the middle aged. Leukoedema
and preleukoplakia was the most common lesion.
Bhasin V (2004)5 conducted a study to assess the oral behavior among
Bhils, a tribal community of Rajasthan. During the course of the study, 200
Bhil community indicated that there are no traditional or advanced methods
of oral hygiene as such for their oral hygiene maintenance. Authors
recommended the development of dental caries and infrastructure to impart
education about oral hygiene and dental care should form part of the health
policy.
Syed Z Q (2011)6 conducted a cross-sectional study to assess the
prevalence and pattern of tobacco use, exposure to tobacco prevention activity
among adolescent from tribal area. Data was collected by interview from 240
adolescent by home visits. Prevalence of tobacco use (all forms), smokeless
tobacco use and smoking in tribal adolescents were 54.45%, 53.41%, and
23.14%, respectively. Prevalence of tobacco use in boys (66.25%; 95%
Confidence Interval (CI) = 60.29-72.21) was more than girls (26%; 95% CI =
25.84–37.57). Prevalence of tobacco use was more in late adolescent period
and earning adolescents. The average age of starting smokeless tobacco use
and smoking was 13.75 years (SD 2.26) and 14.22 years (SD 2.54),
respectively. Boys start smoking relatively earlier than girls (P = 0.04).
23
Narayan D.D (2011)7 conducted a study to know the prevalence and
the pattern of tobacco consumption among 502 adolescents in Five tribal
villages under the Primary Health Centre, Waradh, in the District Yavatmal,
Maharashtra State, The results showed that the overall, prevalence of tobacco
consumption among the adolescents of the tribal areas was 45.42%. 65.31%
male and 26.46% female adolescents were habituated to it. All female, and
majority of the male adolescents predominantly consumed a smokeless form
of tobacco. Most of them (89%) started chewing tobacco/gutkha between 515 years of age. The females had started consuming tobacco at younger ages
than the males. Social customs were the major influencing factor for the
tobacco consumption, followed by peer pressure. The consumption of tobacco
among the family members significantly (p<0.001) increased the tobacco use
among the adolescents. Social customs, peer pressure and the consumption
of tobacco by the family members were the major contributing factors which
emphasized the need of strengthening the information, education and
communication (IEC) activities.
Sushi-Kadanakuppe(2013)8 A study was carried out on 2605 people
belonging to the Iruligas, a native Karnataka tribe, residing in 26 villages of
Ramanagar district in Karnataka to assess their periodontal health status and
oral hygiene practices. The study revealed a relatively low prevalence of
periodontal disease among these people perhaps because of their practice of
using of chew stick which was observed in as many as 80 per cent of the tribal
population.
Deepa KC(2013)9 Total of 523 individuals belonging to the age group
10-80 years were selected randomly from different tribal groups of Wayanad
district of Kerala. Selected individuals were personally interviewed in local
language and subsequently oral examination was carried out to note the
details. Out of 523 participants, 445 (85.1%) were consuming tobacco in one
form or other. 91.3% of tobacco users were males and 79.3% females with
relatively equal distribution among different communities. Different types of
habits observed were chewing, smoking and Snuff of which chewing was
found to be more prevalent (60.1%). Various tobacco related oral mucosal
lesions observed among the study populations were Leukoplakia 93 (17.8%),
24
Oral
submucous
fibrosis
(OSMF)
38
(7.2%),
Oral
squamous
cell
carcinoma(OSCC) 2(0.4%), and Chewers mucosa 61 (11.7%). Prevalence of
tobacco habits and related oral mucosal lesions are high among the tribes of
Wayanad. Their ignorance about the adverse effect of tobacco is highly
alarming and special attention from government and health professionals is
required for improving the health awareness and welfare of this tribal
community.
Dey S.M (2017)10 conducted a study to assess the periodontal health
status among Koraga tribal community residing in Mangalore Taluk. Of the
total population examined, 81% brushed once daily with 34% of the subjects
using tooth paste and brush as oral hygiene aid while, the rest of them used
a combination, with other indigenous methods. Majority of them used tobacco
in the smokeless form (36%). The oral hygiene status was poor in 56% of the
subjects. The present study showed that majority of the Koragas suffered from
various gingival and periodontal diseases as assessed by community
periodontal index. The dental aesthetic index indicated that 37.5 % of study
subjects had very severe malocclusion.
Karuveettil V (2020)11 Conducted a study to assess the prevalence of
tobacco chewing, and related oral mucosal lesions amongst the Paniya tribes
of Wayanad. Fifteen in-depth interviews and two focus group discussions were
conducted among the key informants from within the tribal colonies of
Cheepram and Madikkunnu. This study showed that parental influence and
peer pressure as the key factors for smokeless tobacco initiation amongst the
adolescent. There was a greater predisposition for women to be chewers of
tobacco, particularly after marriage. The key factors influencing initiation of
the habit amongst men include peer pressure and availability of tobacco at
workplace.
The
role
of
contextual
factors
such
as
enculturation,
marginalization and perceived health benefits also play a substantial role in
development of this habit.
25
Ray
S
S(2021)12
A
cross‑sectional
survey
of
256
tribals
of
Chamarajanagar district was conducted. A modified WHO oral health
assessment form 2013 was utilized and examined according to the WHO
methodology 2013. Based on the age-category, majority of them belonged to
the age group of 35-44 years. All the participants belonged to the sub-caste
of Soligas. The total decayed missing filled teeth (DMFT) among the subjects
was 5.5±4.14,114 (44.5%) of them had gingival bleeding, 76 (29.7%) of them
had pockets of 4-5 mm depth, 14 (5.5%) of them had pockets of >6 mm depth,
74 (28.9%) had loss of attachment of 4-5 mm, 16 (6.3%) of them had loss of
attachment of 6-8 mm, 3 (1.2%) had leukoplakia, 1 (0.4%) had lichen planus,
12 (4.7%) had ulceration and 12 (4.7%) had abscess. The study showed that
a majority of tribes used toothbrush and toothpaste to routinely clean their
teeth. High prevalence of dental caries and periodontal diseases was observed
among the participants.
26
Aim: To assess the implications of tobacco habits on the oral health of
people belonging to Koraga Community
Objectives of the community health action
initiative:
1. To identify the reasons for the initiation of tobacco use.
2. To assess the patterns of tobacco habits among the Study participants.
3. To assess the impact of Tobacco use on their Oral Health.
27
Community context:
The Koragas are a tribal community found in coastal Karnataka. According to
Mr. Suresh a Koraga Community Leader, the major problem faced by them
are Health related issues and Illiteracy. Life expectancy is short and reduced
fertility rate. Alcoholism and use of tobacco is highly prevalent. Another
grouse is that, the basic necessities of the people are not met like power and
water supply.
The areas in which Koragas live comprise mostly of agricultural land and
forest. They are known for Drum beating and Flute music. They have their
own dialect which is strongly influenced by Tulu, Kannada and Malayalam.
Their main occupation is basket making and few of them work as scavengers
and Labourers. Presently they are Classified as Scheduled Tribes by the
Government of India.
Stakeholders:
Koraga Tribal Community
Interns from our Dental Institute
Indian Cancer Society
Department of Community Medicine
28
Methodology:
29
The present study was conducted to assess the implications of tobacco use on oral
health among the Koraga community.
a) Study setting: The study was conducted at the hamlets belonging to koraga
community close to the research institute.
b) Study design: Mixed method cross-sectional study
c) Study duration: September 2022 to December 2022.
d) Sampling criteria
Participants were included based on Convenience sampling according to the
following inclusion criteria and exclusion
Inclusion criteria
Subjects above the age of 18 years were included.
Subjects who gave informed consent
Exclusion Criteria:
Subjects not belonging to koraga community
Subjects who were not present in their house on the day of visit
Sampling technique
Time bound enumeration (quantitative study).
The data collection period of the study was from September 2022 to December
2022. Respondents for the in-depth interviews and focus group discussion
were selected through convenient sampling technique. A total of 80 subjects
were included for the quantitative survey. 8 in-depth interviews were
conducted amongst those using tobacco
Ethical consideration
30
The study commenced after taking ethical clearance from the Institutional
Ethics Committee, A.J.Institute of Dental Sciences (AJIEC 179/2022). After
explaining to the respondents on the purpose of the study using a participant
information sheet, written informed consent were obtained. Participation was
voluntary.
Study tool
For the quantitative survey a structured, closed-ended, investigator
administered questionnaire was used to understand the prevalence of tobacco
use and its implications on oral health.
In-depth interviews were conducted using an in-depth interview guide. The
close-ended questionnaire was designed to collect detailed information such
as individual’s demographic details, history of tobacco abuse, type of tobacco
use, duration of use and its implication on oral health.
Data collection method:
Quantitative data collection was conducted at their hamlet and in a hall which
was meant for koraga community.
The in-depth interviews were conducted among 10 subjects in their houses in
the evenings after they returned home from their work. Written informed
consent was obtained at the beginning of each interview, and also participant
information sheet was given to each of the respondents before the interview.
Respondents were informed regarding confidentiality of data as per the ethical
guidelines. Duration of each in-depth interview or focus group discussion
varied between 20 to 40 minutes to one hour. Interviews were conducted in a
single session. All in-depth interviews were voice recorded, transcribed and
this data along with the survey data served as the primary data for drawing
inferences and conclusions. All study subjects were anonymized.
Data analysis
The data was entered into excel sheet (Microsoft Office), and SPSS statistical
software package was used. Descriptive analysis was conducted for the
quantitative data. Data analysis of the qualitative interviews included the
following steps: 1. transcribing the interviews 2. reading through the data 3.
coding the data 4. generate codes and categories 5. interpreting the codes.
31
Results:
32
Table 1: Sociodemographic Details
Age
40.75 years
(Mean)
Gender distribution
Frequency (%)
Males
45(56.3%)
Females
35(43.8%)
Education
Frequency (%)
Graduate
14(17.5%)
High school certificate
16(20%)
Illiterate
12(15%)
Intermediate or diploma
12(15%)
Middle school certificate
15(18.8)
Primary school certificate
11(13.8%)
Occupation
Frequency (%)
Clerical
4(5%)
Clerk
1(1.3%)
Elementary occupation
36(45%)
Intermediate or diploma
2(2.5%)
Skilled agriculture and fishery
1(1.3%)
worker
Skilled workers and shop and
8(10%)
market sales worker
Technician and associate
2(2.5%)
professional
Unemployed
26(32.5%)
The above table depicts that out of 80 respondents, the mean age of the respondents
was 40.75±14.16 years. Majority of the respondents were males (56.3%) when
compared to females (43.8%). Among the 80 respondents 14(17.5%) had completed
33
their graduation, 16(20%) had completed their high school and 12( 15%) were
illiterates. Among 80 respondents, 36 (45%) of them were doing elementary
occupation, 26(32.5%) completed their high school and 12(15%) of them were
unemployed.
Table 2a: Utilisation of Dental Care
Utilization of dental care
Frequency (%)
Not used
35(43.8%)
Used
45(56.3%)
The above table depicts that 35(43.8%) of them had not utilized the oral care
and 45(56.3%) had used the dental care.
Table 2b: Reasons for not utilizing dental care:
Reasons for not utilizing dental care
Frequency (%)
Not accessible
44(55%)
I don’t have dental problems
31(38.8%)
Fear of dental procedures
4(5%)
Teeth are not important for me
1(1.3%)
The above table depicts the reasons for not utilizing dental care, among the
various reasons 44(55%) of them responded that oral health care is not
accessible. 38.8% of them felt that they do not have any oral problems and
5% of them had fear of dental treatment.
34
Table 3: Prevalence of Tobacco Use
Smoking
Smokeless
Alcohol
Yes
3(3.8%)
No
77(96.3%)
Yes
18(22.5%)
No
62(77.5%)
Yes
2(2.5%)
No
78(97.5)
The table depicts that 18(22%) of them used smokeless tobacco when
compared to 3(3.8%) of them who used smoked form of tobacco. Surprisingly
only 2(2.5%) of them consumed alcohol.
35
Table 4: Effect of tobacco on caries
Mean
Standard
T
Sig.
1.198
0.235(NS)
-1.955
0.016(S)
deviation
Smoking
Yes
6.67
4.509
No
3.51
4.483
Smokeless Yes
1.83
2.975
No
4.15
4.742
The above table shows the mean distribution of dental caries among the study
population. The results show that the mean caries was more among smokers
than those using smokeless forms of tobacco. However, a significant
difference was seen in dental caries among those consuming smokeless forms
of tobacco.
36
Table 5: Effects of tobacco on Periodontal status
CPI
0
Smoking
Chi
1
2
3
4
x
2(66.7)
0(0)
1(33.3)
0(0)
Yes
0(0)
0(0)
No
7(9.1)
1(1.3) 40(51.9) 14(18.2) 14(18.2) 1(1.3)
Smokeless Yes 3(16.7)
No
4(6.5)
0(0)
8(44.4)
4(22.2)
3(16.7)
0(0)
Sig.
square
value
1.369
0.928(NS)
2.881
0.718(NS)
1(1.6) 34(54.8) 10(16.1) 12(19.4) 1(1.6)
The above table shows that the prevalence of calculus was more among those
who are smokers when compared to those using smokeless forms of tobacco.
However, the prevalence of shallow pockets and deep pockets was more
among smokeless tobacco users. But the results did not show any statistical
significant difference(p<0.05)
37
Table 6: Effect of tobacco on oro mucosal lesion
Lesions
Chi square
absent
OSMF
Yes
3(100)
0(0)
No
75(97.4)
2(2.6)
Smokeless Yes
16(88.9)
2(11.1)
No
62(100)
0(0)
Smoking
Sig.
value
0.080
0.926(NS)
7.066
0.048(S)
The most common lesion seen among those using smokeless forms of Tobacco
was OSMF (Oral Sub Mucous Fibrosis)
38
Qualitative Analysis:
Reasons for starting the use of Tobacco:
Most of them started smoking after the age of 18 years. The main reason to
start tobacco use was due to the stress and to keep them alert. The reason
was found similar among the female subjects also.
One of them who performs Buta Kola a highly stylized ritual dance usually
performed by the Tulu speaking population for the worship of local deities of
Tulunadu, had a large lesion at the base of the tongue. When questioned
about the habit, he said “I use tobacco, it keeps me awake and makes me
salivate more, so that I can deliver my Nudi very efficiently”.
His wife works in a factory close to her house, said that “I started the habit
as everyone in my house used to chew tobacco, and now, if I do not
consume, I will not be able to do my work at my workplace, I lose
interest in everything”.
Another respondent said “We all start at an early age, everyone eats, no
one in the family objects”
Reasons to continue smoking
All the participants considered smoking as a stress buster and they could
divert their mind from what was troubling them.
A young adult said “Whenever I have tension I want to smoke and relax.
It gives relaxation and I would forget all the tension in association with
drinking”
39
A housemaker said “It's a good pass time when I am alone at home, and
I don’t see the need to stop chewing also”.
A Buta Kola performer said “Though I have a lesion, I don’t want to waste
time in getting it treated, I have lots of work to do, and I will come to
your hospital during rainy season as there is no work then, Anyways I
have got to die”
Knowledge regarding health effects
When asked about the harmful effects of tobacco on health, all them said they
are aware of the ill effects of tobacco which they got to know from mobile
phones.
The Person who had the lesion at the base of the tongue said that “I know
that it is because of my chewing habit, I can put my finger into the
lesion, but I do quit for few days and start it again”. They were not aware
of the COTPA act and its regulations, however watched anti-tobacco
advertisements and heard from people that smoking in public is prohibited.
Quitting Tobacco:
Only a few have attempted to quit but were unsuccessful, but they do not
want their children to start the habit. An old lady said “the habit will go
only when she dies”.
Another lady said that “I am ready to stop having food, but without
chewing I cannot survive”. The men said that “tobacco is a major stress
buster, and everyone in the family use tobacco. So many people chew
tobacco, nothing happens, so why to worry, anyways we have to die”
The main leader responded when asked about their habit is that “We are a
community who worship nature like the trees, stones, water. What can be more
powerful than this nature, which is giving us our daily bread. We do not go to
any temple; we worship those trees which discharges a milky sap. We get a
stone from the River, place it under the tree and start worshipping that stone.
We mainly eat Chicken and on the date of marriage, we are supposed to show
40
a live chicken and a Coconut to the Groom and the Bride, just to ensure that,
we do not cook any other meat other than chicken. We have been condemned
by the society, and till last year (April 2021) our health services are borne by
the ITDP department, but now we have to pay from our pocket. Even in
government hospitals some of the medicines and treatments are not free”.
Barriers to cessation: Dependency to tobacco was the main barrier among
the respondents and inability to manage stress.
“I get severe headache, and loose interest in day to day activities” was
told by a respondent.
Regulations Related to Tobacco:
The respondents were not aware of any regulations related to tobacco. An
adolescent who works in a shop said that “laws come and go, it is our wish,
but I will not encourage others, but at the same time they start the
habit, I will not stop them”
41
Discussion:
42
The quantitative data shows that quite a few of them did not utilize oral care
as majority of them felt that oral health care was not accessible, and they do
not have any dental problems. This is similar to a study done on pregnant
tribal women where the most reported barrier included the lack of awareness
and knowledge of the availability of the dental services13.
The surprising part of the results is that majority of them did not use any
form of tobacco, this may be an information bias and they did not want to
share information, thinking it may scare them. A study done by Aluckal said
that the prevalence of tobacco use was more among the males when compared
to females in koraga community14. In the present study, stress and family
culture was the main reason the participants started tobacco use. A study
by Chellapa L R A et al. in 2021, found that main reason to start smoking was
due to the influence of peer groups and friends, and also inquisitiveness15.The
reason to continue smoking and relapse in quit attempts in the present study
was stress which was similar to statement in the previous studies16.Medical
problems caused by smoking are very well known, major of them being lung
cancer and cardiovascular disorders. Oral health is also negatively affected.
Oral problems include staining of teeth and dental restorations, reduction of
ability to smell and taste, development of diseases such as smoker's palate
and melanosis, coated tongue, precancerous lesions and cancer, oral
candidiasis, periodontitis, implant failure, and dental caries17. However, the
present study releveled that those consuming smokeless forms of tobacco had
less dental caries when compared to those who used smoked form of tobacco,
this may be because the pits and fissures of the teeth get smoothened due to
constant salivation, increase in salivation as a result the teeth are selfcleansed. Evidence shows that smoking actually helps to reduce dental caries.
43
The reason might be smoking increases the thiocyanate level in saliva.
Thiocyanate is a normal constituent of saliva that inhibits the possible caries
effect18. On the other hand, the decreased buffering effect and possible lower
pH of smoker's saliva and the higher number of Lactobacilli and Streptococcus
mutans may indicate an increased susceptibility to caries. People consume
tobacco
without
realizing
its
hazards,
and
the
main reason for the addiction is due to nicotine, which is the main chemical
content present in tobacco19. The periodontal health was poor among those
among smokeless tobacco users. This may be because of constant chewing
the oral hygiene is not maintained well, resulting in accumulation of debris
around the teeth leading to poor oral health. The result was contradictory to
a study carried out by Sushi-Kadanakuppe on 2605 people belonging to the
Iruligas, a native Karnataka tribe, residing at 26 villages of Ramanagar district
in Karnataka to assess their periodontal health status and oral hygiene
practices. The study revealed a relatively low prevalence of periodontal disease
among these people perhaps because of their practice of using of chew stick
which was observed in as many as 80 per cent of the tribal population 8. A
study done by Dey S M said that Majority of them used tobacco in the
smokeless form (36%) resulting in poor oral hygiene status which was found
in 56% of the subjects10. The present study showed that majority of the
Koragas suffered from various gingival and periodontal diseases as assessed
by community periodontal index
However, the qualitative data helps us to understand their beliefs,
experiences, behavior and attitudes. This study was devised to explore the
perceptions of tobacco initiation in the tribal population. The study confirms
that koragas start chewing tobacco as early as 14 years of age, which
emphasizes the adolescent onset of tobacco initiation. This is in line with
various studies conducted on both smokeless and smoking tobacco
initiation11.This information gives voice to the participants permitting them to
share their experiences of effects of tobacco . this is an eye opener not only to
their culture but also help us to modify our strategy in tobacco control
methods. Present study revealed that tribes were aware of the harmful effects
44
of chewing, but did not want to quit the habit. The reason stated being they
have not seen any examples with such severe outcomes and even if they do,
they do not link this to tobacco chewing.
Tobacco chewing is strongly rooted in the culture of Koraga tribes. It is a part
of their customs and festivals and has been practiced across generations.
Most of the tribes testified that they have grown up seeing their elders chewing
tobacco and how normal this habit is perceived in the community. As culture
leads to behaviour this factor forms an integral role in habit initiation.
45
Learning
and Reflection
46
Learning and Reflection
Built rapport with the community
Understood the felt needs of the community
Understood their attitude and awareness towards their oral health
Reflections:
APPLICATION OF PRINCIPLES RELATED TO COMMUNITY HEALTH:
1) Autonomy over Oral Health: Made Oral Health Accessible and
Affordable.
2) Integration of other health services: Other medical departments were
also involved, to be a part of the programme.
SEPCE ANALYSIS: (In the next page)
47
SEPCE ANALYSIS:
Social:
Economic:
Political:
Cultural:
Ecological:
Low
Socioeconomic
status
Discrimination
No Tribal
Health Care
Spiritual
Beliefs
Dominating Men in
the family – social
No access
to food.
Socioeconomic
Status – is it
good or
bad,poor or
beter
No support to the
females
Illiteracy
Poor
neighbourhood
Poor housing
Unemployment
Addiction
Poor social
support
Income –
Because of
illiteracy
Wealth
Education –
No
administrat
ive support
Increased
Infant
mortality Ratealso more a
social
Education
Lack of Awareness
-social
Poor Living
Condition
Behavior
Norms
Childhood
Illness
SOCIOECONO
MIC
Social
Hierarchy
Material
Circumstances:
POLITICAL
Discriminatio
n
Poor Living
Condition
Social Det
CONTEXT:
No
aa
administrative
support
Power
Low SES
Poor
Neighbourhood
Lack of access
to healthcare
Dominating
Men
Traditional
Practices
No Tribal
Health care
Women do
not have voice
No awareness
No Income
Differences in
exposure and
Vulnerability
to health
compromising
conditions.
Social Determinants of Health
Inequities
Traditional
Beliefs
Psychosocial
Factors
Differences in
exposures and
vulnerability to
health
compromising
conditions
Impact on
Equity in
Health
care
Differences in
health care
Psychological
factors
Interventions addressing the health
,like better accessibility, making it
affordable,
creating awareness on
Intermediary determinants
of
health related issues,
health
demonstration
48
Conclusion:
49
Targeted strategies for effective tobacco control can be developed through an
understanding of the socio-cultural factors leading to initiation of smokeless
tobacco use among disadvantaged communities. Interventions are suggested
which can be applied to similar populations for preventing tobacco initiation
based on our findings is given below:
1. Parental awareness on how they influence their children to initiate
chewing.
2. Community awareness about the laws of selling tobacco products to
minors, sale of tobacco near schools,prohibition of smoking in public
places and sale of single stick.
3. Dispelling the myth of tobacco chewing relieving tooth ache by
dentists.
4. Educating koraga groups to break the habit together.
5. Assisting the youth in tobacco cessation
50
Recommendations:
51
Awareness programmes on tobacco can be incorporated into health
education programmes already being conducted by the dental institutes
in collaboration with the district tobacco control cell in all the schools
close to their hamlets. Constant exposure to messages related to health
effects of smoking and drug addiction via awareness campaigns can deter
many young people from taking up this habit.
Tobacco cessation programme can be incorporated in primary health
centres.
Awareness needs to be created regarding the National Quitline which is
very effective and practical, it is an online service.
The quit line number is mentioned on all tobacco products, so people are
required to be motivated to quit.
52
Limitations:
A significant number of potential respondents declined to participate in
the study due to their personal reasons and refused to give written
informed consent. The findings from this study cannot be generalized due
to limited sample size. Lack of Time was also a contributing factor for
small sample size.
Lack of Previous studies in the area of interest, due to which the
discussion was compromised.
Inferential statistical analysis could not be done as the participation from
the female subjects was less when compared to males.
53
Summary:
The koragas are most backward among the tribes of Karnataka state. Their
health status is badly affected by their lifestyles, living conditions, illiteracy,
income and employment. Their main health related issues are tuberculosis
and skin disorders. They do not give much importance to oral health and is
often neglected. But there are limited information on their oral health status
and also on oral health related habits like tobacco. So a mixed method study
was planned to explore the implications of tobacco use on Oral health.
The subjects were recruited for the study after conducting a meeting with
their leaders, so that access to their community is made easier. After several
visits, they were approached at their hamlets close to our institute. Many were
reluctant to cooperate. Later a total of 80 subjects were recruited for the
54
quantitative data collection. In-depth interview was conducted only with 10
subjects who had the habit of using tobacco, due to lack of time.
On observation it was found that the dental caries was more prevalent among
smokers when compared to those using smokeless forms of tobacco.
Periodontal status was poor among those using smokeless forms of tobacco.
This may be due to poor maintenance of oral hygiene. The qualitative data
shows that they do not intend to quit tobacco and feel that it is part of their
culture and they are all nature lovers.
Acknowledgements: We appreciate the Community for their time and valuable
thoughts and also arrangements made by the leaders for the clinical
examinations.I also wish to
Pease include all those who have supported you in your study.
55
Annexures
56
Annexure 1: PATIENT INFORMATION SHEET
TITLE OF RESEARCH:
A study to assess the implications of tobacco habits on the oral health of
people belonging to Koraga Community
INVESTIGATOR:
Dr Vijaya Hegde
Professor and Head of the Department
Department of Public Health Dentistry
A.J Institute of Dental Sciences, Mangalore
Email id : drvijayahegde15@gmail.com
Contact number - 9880004859
INTRODUCTION:
I am Dr. Vijaya Hegde from the Department of Public Health Dentistry, A.J.
Institute of Dental Sciences, Mangalore. I will be doing a study to assess the
implications of tobacco habits on the oral health of people belonging to Koraga
Community. I am going to give you information and invite you to be part of
this research. You do not have to decide today itself whether or not you will
participate in the research. Before you decide, you can talk to anyone you feel
comfortable with about the research.
There may be some words that you do not understand. Please ask me to stop
as we go through this information sheet and I will take time to explain. If you
have questions later, you can ask me.
VOLUNTARY PARTICIPATION
Your participation in this research is entirely voluntary. It is your choice
whether to participate or not. Whether you choose to participate or not, it will
not affect your treatment in any way
57
EXPLANATION OF THE PROCEDURE:
Koraga community residing close to the research centre will be considered as
study subjects.. Details regarding the socio demographic factors , tobacco use
and their effect on oral health will be assessed using a proforma. Details
regarding the starting of the habit, frequency, duration, reasons for quitting,
relectance to quit will be taken by conducting an interview.
POSSIBLE BENEFITS
There may not be any benefit for you at this stage of the research, but your
participation is likely to help us find the answer to the research question.
There may not be any benefit to the society but future generations are likely
to benefit.
POSSIBLE RISKS: By participating in this research your will not be at risk.
CONFIDENTIALITY:The information that we collect from this research
project will be kept confidential. Information about the patient that will be
collected during the research will be put away and no one but the researchers
will be able to see it. Any information about the patient will have a number
code and the name and identity of the patient will be kept confidential.
WITHDRAWAL:You are entitled to withdraw from the study at any point of
time.
SIGNIFICANT NEW FINDINGS:New findings, as and when made, regarding
your condition, during the duration of the study, would be informed to you.
COST INCURRED BY YOU FOR PARTICIPATION:The procedure will be free
of cost.
PAYMENT IN CASE OF UNTOWARD INCIDENTS DURING THE STUDY:No
monetary compensation would be given in case of untoward incidents.
CONTACT:If you have any questions you may ask me now or later, even after
the study has started. If you wish to ask questions later, you may contact us
as follows:
58
Dr Vijaya Hegde,Professor and Head of the Department,Department of Public
Health Dentistry,A.J Institute of Dental Sciences, Mangalore
Email id : drvijayahegde15@gmail.com,Contact number - 9880004859
LEGAL RIGHTS:By signing on the consent form you will be waiving off all
legal liabilities against the institution and staffs
CERTIFICATE OF CONSENT
I have read the foregoing information, or it has been read to me. I have had
the opportunity to ask questions about it and any questions that I have asked
have been answered to my satisfaction.I consent voluntarily to participate as
a participant in this research.
Name of Participants’ parent/ guardian:
Signature of Participants’ parent/ guardian:
Date
If illiterate
I have witnessed the accurate reading of the consent form to the potential
participant, and the individual has had the opportunity to ask questions. I
confirm that the individual has given consent freely.
Name of witness
participant
Thumb print of
Signature of witness
Date
Statement by the researcher/person taking consent
59
I have accurately read out the information sheet to the potential participant,
and to the best of my ability made sure that the participant understands that
the following will be done.
1.
Examination of the mouth will be done
I confirm that the participant was given an opportunity to ask questions about
the study, and all questions asked by the participant have been answered
correctly and to the best of my ability.
I confirm that the individual has not been forced into giving consent, and the
consent has been given freely and voluntarily.
A copy of informed consent form has been provided to the participant.
Name of Researcher/person taking consent:
Signature of Researcher/person taking consent:
Date
60
Photos
61
62
63
64
65
Annexure 3: DATA COLLECTION SHEET
66
67
References:
68
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