Prevention & management of snakebite envenomation: A qualitative study on perspectives & practices in Maharashtra & Odisha

Data collection

Data was collected using focus group discussions (FGDs). The study aimed to explore the understanding and practices of communities affected by snakebites. As such, the flexibility provided by the FGD guide proved vital in knowing similar and contrasting opinions from the respondents. FGDs also allowed for probing and enhancing the discussion for better extraction of information. Literature suggests that, the SBE burden is shaped by complex socio-cultural dynamics^4,7. To get the complete picture of these factors, separate FGDs were conducted for men and women. The Primary Health Centres (PHCs) are typically the first contact point for the community with the public healthcare system for SBE management. The availability and accessibility of the PHCs, hence, influence the health-seeking behaviour of communities. The awareness intervention for this study was also provided through the PHCs. In this regard, conducting at least six FGDs per block was decided, giving equal representation to each PHC area. However, this number was kept flexible for gathering new information until theoretical saturation. Village selection was done randomly. The ASHA disseminated information about the conduct of an FGD in the village, and people were invited to participate. Participation in the FGDs was voluntary, and individuals above 18 yr who were residents of the respective village for more than six months were included.

Focused group discussions

The FGD guide was developed based on previous experience⁷ and a literature review of qualitative studies on SBE burden. It underwent critical review by national SBE experts (Supplementary Figure & Annexure). The revised guide was translated into local languages (Marathi and Oriya) and approved by language experts. Project Technical Officers (PTOs) conducted the FGDs (male PTOs - MG, GB, JPD, female PTO - BM). To ensure quality and uniformity, the PTOs received prior training, and pilot FGDs were conducted. No prior personal relationship existed between the research staff and the study participants. Before each FGD, the PTOs introduced themselves, outlined the purpose and process of the discussion, and obtained written informed consent from willing participants. A moderator facilitated each FGD while an assistant took notes of the discussion. The discussions were audio recorded and conducted at convenient locations, such as community halls and Anganwadi centres (Supplementary Figure).

Data analysis

The constructivist or interpretative worldview of the authors believes that truth is relative and context shapes its interpretation¹⁷. Hence, the data analysis and interpretation were carried out from this standpoint. The audio recordings were transcribed verbatim, anonymized, and translated to English after proofreading by four members (MG, GB, BM, JPD) to ensure accuracy and minimize content loss. A sample of the translations was cross-checked by a senior member (HM) for errors and typographical errors. Notes taken by the assistant were used to supplement the transcripts. Two members (HM, RG) independently carried out open coding of the transcripts line-by-line. All coded transcripts were critically reviewed for consistency and accuracy by senior members (HB, SDM). A grounded theory approach explored the respondents’ beliefs, practices and experiences. This approach was particularly relevant as this topic had not been previously studied in the population group¹⁸. Themes were not defined a priori but were extracted by clustering the codes. Senior members (AM, SP, GS) independently reviewed and refined the list of emerging themes. The interpretations and conclusions were discussed with all authors to ensure the credibility and conformability of the findings.

Knowledge about snake species and their nature of toxicity

It was found that knowledge about different species of snakes varied considerably among the responders. When asked about the identifiable features of the ‘big four’, the response was positive and accurate. Distinctive features attributed were the hood and ‘U’ mark (known as Kathau sign in Oriya) for Indian cobra, coin-shaped markings on the ‘fat’ body of Russell’s viper, stripes for the common krait and thin red body for saw-scaled viper. Respondents belonging to the Madiya community, a Particularly Vulnerable Tribal Group (PVTG) in Aheri, aptly labelled the common krait as Narkakalle, meaning the one who enters the night like a thief (Supplementary Table).

Misconceptions, particularly regarding the venomous nature of the snakes, were reported. A majority of respondents considered the Indian rock python venomous. The misconception notably extended to the vine snake and the Forsten’s cat snake, considered mildly venomous for praying but not for humans. In Kasipur, respondents believed that all snakes, except water snakes, were venomous and hid in trees for camouflage.

Swelling of the bitten area, bleeding, and froth coming out of the mouth were reported as symptoms of venomous snakebite in Maharashtra, while severe head reeling, dizziness and fatigue were reported in Odisha. The same symptoms with a milder intensity were attributed to non-venomous snakebites in both States. The venomous nature was reported to impact the duration of symptoms.

“Symptoms are the same. But swelling and bleeding due to a venomous snake remains for at least 10-12 days. Non-venomous bite, everything goes down immediately” (31 yr male, Shahapur).

In Odisha, all the snake species dwelling near or in water were considered non-venomous, and non-venomous snakes were reported never to bite.

“The non-venomous (snake) will never bite. Only venomous does” (26 yr male, Khordha).

Respondents identified various locations, such as ditches, pits, tree trunks, burrows, ant hills, water bodies, paddy fields, piles of woods, tall grass, forested areas, and residential gardens, as preferred hiding places for snakes. Monsoon (June to September) was reported as the breeding season, leading to increased human-snake interactions.

“Some lay eggs, some give birth. This happens in the monsoons, so their number increases” (28 yr male, Shahapur).

Respondents from both States preferred to kill the biting snake. This was preceded by a notion that the dead snake must be presented at a healthcare facility.

“Without seeing the snake, the doctor cannot start the medication” (38 yr female, Aheri).

Non-scientific first aid techniques

Tying a tourniquet above the bite site was the preferred first aid to mitigate venom spread. In Maharashtra, a cloth or ribbon was commonly used, whereas in Odisha, a wheat or rice stem was preferred. Incising the bitten area with a blade or knife was reported to facilitate venom expulsion along with the blood.

In Kasipur, a first aid method involved repeated pouring of cold water over the victim’s head on the premises of a Naag Mandir (snake temple). This practice was mandatory before seeking any traditional treatment. Apart from a tourniquet, respondents provided first aid by calming the victim down and forcing the victim to lay in bed in a straight (supine) position. In Shahapur, especially after a night bite and if it was impossible to reach a healthcare facility, the village elders kept the victim awake.

“Calm the person down; keep talking and don’t let him/her sleep. If he/she is frightened, the venom will spread faster” (40 yr female, Shahapur; 42 yr male, Shahapur).

Factors influencing Health Seeking Behaviour

Most respondents in both States expressed their belief in the health system for snakebite management while also maintaining faith in traditional healers. In Maharashtra, prior positive treatment experiences, at-home services, and cost-free treatment influenced victims to seek traditional management. In Odisha, respondents shared instances where healers would refer the victims to the health system when their ability to manage the situation reached its limits.

“We go to the priest first. He tells us if there is a need to go to the hospital; He will tell us what kind of snake has bitten and whether he can or cannot treat” (54 yr male, Khordha).

In Maharashtra, a common practice involved combining modern medical treatment with traditional medicines for better outcomes. Challenges in seeking treatment from healthcare facilities in both States included non-available doctors and health staff, limited bed availability, and time-consuming and expensive commutes. Odisha faced additional issues of recurrent referrals without adequate amenities, even at higher centres. Lack of accountability was a critical factor undermining respondents’ confidence in the health system. Multiple high-risk consents were reportedly taken before initiating treatment at all study sites.

“They take our signature first and then give saline. They do not tell what is written” (48 yr male, Shahapur). “The doctor only says that this is a critical case and needs referral; victims die on the route to the hospital” (45 yr female, Khordha).

Respondents believed taking victims directly to higher centres was the right approach, as Primary Health Centres (PHCs) often referred them without providing treatment. However, utilization of health facilities was limited due to high treatment costs. Accessibility and availability of ambulances for transferring critical patients also impacted the uptake of healthcare services. Respondents highlighted the challenges of accessing medical care at night and the lack of mobile connectivity to call an ambulance.

“Snakebite occurs at night. We do not have any vehicles to go to the hospital. There is no mobile connectivity in the village to call an ambulance. So, we take gavthi upchar (traditional medicine) and take the victim to the hospital in the morning. The doctors shout about why we did not bring the victim earlier. How should we bring?” (50 yr male, Shahapur).

Differences of opinions among respondents regarding the most effective mode of snakebite treatment are depicted in Figure 2.

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Fig. 2.

Different perspectives regarding effective method for the management of snakebites among male and female respondents in selected FGDs in the study blocks. Note: Cheramuli, a medicinal plant; Usuna, a local rice breed; Gunia, Pujari, Kalasi, Gauda, & Mantrik are different names of traditional healers using non-herbal ways for managing snakebite victims. HF, health facility; TH, traditional healer.

Export to PPT

Non-utilization of prevention methods

Respondents in both States demonstrated awareness of standard preventive measures, such as wearing gum boots in paddy fields, using a torch at night, and carrying a wooden stick while walking through tall grass. However, these methods were severely limited due to financial constraints and difficulties while working.

“We know people who were bitten on the legs while working. We know long boots should be used. But where do we get the money for them? Four of our family members work together in our field. We cannot buy four pairs. If we buy the cheap ones, they get soggy and heavy, and then we cannot work. So, what should we do?” (32 yr male, Kasipur; 36 yr male Aheri)

Moderator, “What about using a torch at night?”

“Few have it, maximum don’t. Now, some use mobile torches. But we don’t have electricity to charge our mobile regularly (laughs).” (29 yr male, Shahapur)

None of the respondents were aware of using mosquito nets against nighttime snakebites. In Maharashtra, respondents reported using Thimet powder (an insecticide containing Phorate as the active ingredient) as a snake repellent. In Odisha, black phenyl (a common disinfectant) was mentioned to have a similar effect.

In Maharashtra, snakebites during open defecation were not uncommon, especially among women who practiced open defecation in fields and forests between 4 AM and 6 AM, making them vulnerable to snake encounters. Participants in Odisha preferred going out for open defecation despite having toilets in their homes.

“Government people came and constructed the toilet in our homes. We did not ask for it. We prefer the open spaces” (43 yr male, Kasipur).

Traditional beliefs and practices

Snakes have been revered in the Indian population for centuries. This has given rise to many beliefs, myths, and misunderstandings regarding snakes, snakebites, first aid, management, and prevention. Our findings reveal that such myths heavily influenced people’s perspectives and practices.

Red chilli powder or spices were used to assess the victim’s taste sensation to distinguish venomous and non-venomous snakebites.

“Feed chilli to the victim. If the taste is gone, then it is venomous, and if the chilli is red hot, then non-venomous” (30 yr male, Aheri; 39 yr female, Shahapur; 47 yr male, Khordha; 43 yr female, Kasipur).

In Odisha, a procedure called Bhanguni requires the victim to ingest the roots and leaves of a plant. Recurrent vomiting after ingestion indicated a nasty bite. It was believed that the venom came out with the vomit, prompting repeated ingestions. However, the healers never disclosed specific details of the plant. An herbal plant, Cheramuli, was frequently used in Odisha to reduce venom effects. No herbal plant use was reported from Maharashtra.

Participants in Aheri and Kasipur described a process where the snake is wounded for the purpose of taking it to a priest. After administering the traditional medicine, it is killed. Table II depicts people’s shared beliefs and practices in the study area.

Implications of this study

The National Action Plan for Prevention and Control of Snakebite Envenoming (NAPSE) in India will be implemented across all high-burden regions. The findings of the present study, though contextual, provide crucial regional inputs from Maharashtra and Odisha not only for the national programme but also for future research (Box). In light of the emerging evidence from this and similar studies across diverse populations in India, national implementation strategies for the control of SBE could be revised for better acceptability and effectiveness.