An ethnographic approach to understand cultural perspectives of tribes on branding practice for sick children in Odisha, India

Branding is a traditional indigenous healing practice1. In ancient times, the Portuguese king marked enslaved people with a hot iron to symbolize their ownership2,3. In ancient India, people used thermal cautery and branding therapy. Traditional healers used it to treat joints, spine and nerve disorders, jaundice, abdominal pain, breathing difficulty and paralysis4-6. The providers commonly applied hot-metal-rod, heated nails, wires, incense sticks and hot bangles on the face, forehead, abdomen and chest wall7-10. Such dangerous practices are more prevalent in rural India, especially among indigenous communities and at times cause significant morbidity and delay in receiving appropriate medical care for children8-10.

In India, tribal communities account for 8.6 per cent of the total population11. The under-five mortality rate among tribal people has been recorded at 57.2 per 1000 live births, compared to 38.5 among others, and the infant mortality rate was 44.4 per 1000 live births, compared to 32.1 among others in India12,13. Previous research found that a child born into a scheduled tribes (ST) family in India has 19 per cent higher risk of dying during the neonatal period and six times higher risk of dying during the post-neonatal period when compared to children from other social classes14.

The State of Odisha has 22.8 per cent ST population, with 62 major tribes and 13 particularly vulnerable tribal groups15. Many tribal communities have faith in their indigenous health-care system14,16. Traditional beliefs and practices regarding child and neonatal healthcare exist among the tribal communities in Odisha16. The cultural beliefs can often lead people to seek potentially harmful practices such as branding. However, there is a gap in people’s perceptions, attitudes and beliefs about branding practice. Therefore, we documented the cultural motivation, ability and opportunity for branding practice among women having children under five, traditional healers and community health workers (CHWs) in a tribal district of Odisha, India.

Material & Methods

Study design: An ethnographic approach was followed; qualitative data collection methods such as observation, in-depth interviews (IDIs) and focus group discussions (FGDs) were deployed. The study was approved by the Institutional Ethics Committee of the Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India, and written informed consent was obtained from all the participants. Throughout the study, confidentiality and privacy was maintained.

Study setting and participants: This study was carried out in the district of Nabarangpur, Odisha. The district consists of ten blocks, seven community health centres and 289 subcentres with a population of 1.2 million, with STs comprising 55.8 per cent of them; Bhottada, Paroja, Kadha, Saora, Gond, Kandha, Gauda and Omanatya being the major tribes. The district is designated as a high-focus district for intensive maternal and child health programme interventions due to its low health indicators16-18. Purposively two blocks i.e. Dabugaon and Jharigaon, were selected for the study; Dabugaon having 59.86 per cent (n=40496) , whereas Jharigaon with 62.38 per cent (n=93605) ST population, respectively. Their primary sources of income included farming, forestry and animal husbandry. The present study mainly included Bhottada, Paroja and Kandha tribes.

Local newspapers usually cover the branding practices. However, there is non-availability of scientific data and information, and the local health system has not recorded any data because it is frequently regarded as a locally sensitive subject. The mother and traditional healers often conceal the facts for fear of legal action by the local administration, making participant recruitment difficult. The first author of this article is from one of the study blocks and has been involved with the community for a long time, which facilitated the participants’ recruitment process.

Participants in this study included women with under-five children who had prior experience with branding, CHWs working in the healthcare system and providing health services at the community level, liaisoning between community members and the health system and traditional healers who were providers of branding. With the support of local volunteers and healthcare professionals, women and CHWs were recruited. A snowball sampling approach was used to include traditional healers as the topic was sensitive.

Data collection, management and analysis: The first phase involved passive observation of branding practices in the community during three months visit to the study settings by the first authors. This aided in identifying cases and traditional providers and establishing rapport with them to conduct formal discussions. In the second phase, ten IDIs were carried out among women having under-five children, eight IDIs among traditional healers and six FGDs among CHWs. Fifteen women who had children under five year of age and used branding therapy for their children were approached; five of them refused to participate. Similarly, 16 traditional healers were identified and contacted who were providers of branding therapy; half of them declined to participate; they feared local administrators because they were sceptical about their own healing methods.

The IDI and FGD guides (open-ended questions with probes) were designed to collect information on the current procedure, consequences and health system readiness to prevent these beliefs and behaviours. The IDIs were conducted until saturation points were attained. The first author performed all the interviews in local language from May 2019 to January 2020.

The IDIs and FGDs were digitally recorded, transcribed and translated into English. Each IDI and FGD lasted for 25 to 40 min. A thematic framework analysis was adopted using Motivation-Opportunity-Ability-Behaviour Model19. After the initial coding, the text was coded using MAXQDA Analytics Pro 2020 (VERBI GmbH Berlin). The digitally recorded versions and the transcripts were cross-checked. Two authors cross-checked the coding, themes and descriptions. The Consolidated Criteria for Reporting Qualitative Research guideline was used to report the study20.

Results

Results are described under the following themes; (1) branding practice for sick children, (2) motivational factors influencing branding practices, (3) ability to recognize the consequences of branding practices, and (4) opportunity – health system action on branding practices. The conceptual framework for branding practices for sick children using the Motivation-Opportunity-Ability-Behaviour Model is presented in Figure.

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Figure

The conceptual framework for branding practices for sick children using Motivation-Opportunity-Ability-Behaviour Model.

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Theme 1: Branding practice for sick children: Local tribal communities referred to branding as ‘dhasaeba’, ‘chapba’, ‘lachba’ or ‘chenka’. In the case of ‘Anasi’ illness, the healers must first soak the broken black bangle in ‘Mahua’ oil and heat it on fire before applying it to the child’s black vein. According to them, the term ‘Anasi’ refers to black veins found on newborns’ bodies immediately after birth or after breastfeeding, which causes stomach to swell and children’s inability to digest milk.

‘Alachi’ refers to minor infection/wounds with pus spread over children’s scarp. Some healers used wet cotton to cover the body before applying a T-shaped hot-iron rod to the black vein. In the case of ‘Alachi’, the healers placed hot raw turmeric on the wound. Some healers contended that in the case of abdominal pain, they first move the flow of the pain to the middle part of the abdomen using massage therapy, then cover the belly with wet cotton and apply hot fox bone. In case of paralysis, the healer used a hot iron rod on the leg and head. They even used a hot black angle and deer’s bone on the child’s tongue.

Theme 2: Motivational factors influencing branding practices: Traditional beliefs and social norms were identified as the causative factors underlying the practice of branding. Practitioners had strong beliefs about the usefulness of branding in cases of ‘Anasi’, ‘Alachi’ and paralysis. They used branding by recalling God and their forefathers. According to the healers, the iron rod that falls during thunderstorms is suitable for branding.

‘During a thunderstorm, I saw an iron rod falling from the sky. I am fortunate to have that iron rod, which was priceless’.

(Traditional healer)

They believed branding as a preventative measure; many parents claimed branding would protect their children from various diseases. Woman and other family members carried uncooked rice, coconut and an incense stick to the healer for God’s worship; the healer then began to pray and decided whether the child would undergo branding treatment or be referred to the hospital.

‘If my child died while seeking branding therapy, I would never blame the healers; it was God’s wish’.

(Women having under-five children)

Inability of modern medicine doctors to guarantee the cure: Traditional healers emphasized that while modern medicine sometimes could fail, they succeeded with branding. Furthermore, they claimed that a doctor could not guarantee a mother that her baby would be completely cured. The tribal women believed that doctors frequently failed to treat ‘Anasi’ and ‘Alachi’ and instead of arguing to outlaw branding, they mentioned that it might be permitted in their community.

Success of branding cited by traditional healers: Traditional healers frequently demonstrated that branding therapy was suitable for children suffering from stomach pain; they classified it into three types: upper, lower and one side of the abdomen. For upper abdominal pain, branding was considered to be more effective. The healers in the community were confident about branding practices.

‘Since my treatment cures children and no one has died due to it, people are not opposed to me. In our culture, my treatment is well-known’.

(Traditional healer)

Social norm: According to the CHWs, tribal mothers preferred consulting traditional healers for illnesses of the children. Their families and community would frequently force them to seek treatment from local healers.

‘They have strong faith in traditional healers. It is normal for black veins to occur after birth, but, in our culture, people have the misconception that if black veins appear on an infant’s body, the infant is suffering from ‘Anasi’ and is provided branding’.

(CHW)

According to the traditional healers, their ancestors had practised branding in the community, and they learnt it from them; the practice running in the family. They continued it, and, their children would do so afterwards Saturday, Tuesday, Sunday and Monday mornings reportedly were the timings for branding. They stated that ‘Lord Shani’ and ‘Indrani Maa’ would be honoured on Saturday, Tuesday and Sunday, respectively, and ‘Lord Shiva’ will be pleased on Monday. Some CHWs said that traditional healers and community members believed that branding applied on the day of lunar phase of the new moon, children would be free from diseases. On that day, the traditional healers would touch all children lightly with hot iron rod.

Theme 3: Ability to recognize the consequences of branding practices: Almost all the women faced negative consequences. A mother stated that her daughter was only 21 days old when she underwent branding therapy with a black bangle. Following that, the child’s belly swelled and she began to cry uncontrollably. The mother then went to the nearest hospital, where the doctor reprimanded her and referred her to a paediatric specialist. The doctor prescribed medication and recommended hospitalization; however, due to a lack of family consent, she refused to admit her daughter to the hospital.

A mother revealed that the provider treated her son’s abscess under the jaw with a hot iron rod. However, the spot swelled after branding therapy, and the infection worsened. The CHWs urged her to seek hospitalization, but she refused because she believed she would not be able to afford the medical costs and would not receive support from her family. After two years, she went to the government hospital, and the doctor referred him to a tertiary care hospital. Her son recovered after surgery, for which she paid ₹ 10,000 (US$121) in a private hospital. Another female participant reported that branding therapy did not help her daughter who was paralyzed to heal. She then visited several hospitals, but due to financial crisis, could not bear the treatment-cost and was depressed. Her daughter recovered from paralysis after being treated with herbal medicine by another local healer.

CHW- participants accepted branding therapy as part of their culture. They also subjected their children to branding therapy but became aware of incorrect beliefs surrounding such therapy after contacting the health department.

Theme 4: Opportunity – health system action on branding practices: According to CHWs, the most pressing problem in their society was shortage of qualified doctors and acceptance of modern healthcare. One mother explained that her child died because she refused to listen to CHWs and was forced to undergo branding therapy by her family. She later realized that seeking care from the hospital could have been the right choice. CHWs perceived themselves as part of the same tribal communities and previously preferred branding treatment. Following their entry in the modern health-care system, they become inclined to modern care, and also started realising the ill effects of branding. As a result improving community literacy, changing people’s attitudes towards healthcare and integrating community members with modern care became their focus.

During the home visit and routine immunization programme, the CHWs informed community members about the adverse effects of branding practices. Every year, the Child Development Project Officer educates all traditional healers on the risks of branding practices and encourages them to refrain from performing such procedures.

‘We are not currently choosing brand treatment for our children….. because our Asha Didi advised us [against it]…., we always choose a public hospital for treatment’.

(Mother)

Since many tribal cultures heavily emphasize conventional healthcare, tribal women often disregard CHWs’ messages and recommendations. According to the CHWs, the district administration conducted periodic awareness campaign through folk plays to improve community literacy and integrate them into modern health care. Simultaneously, during the monthly distribution of old-age pensions, they warned all block offices in the district about the adverse effects of branding through songs.

‘We educate them about the risks of branding and encourage them to seek medical help; we also advise them to call us immediately if their children become ill’.

(CHW)

‘We fear police can arrest us for such practices. This is our traditional custom; our forefathers had practiced it’.

(Traditional healer)

Discussion

The current study seeked to triangulate the perspectives of multiple stakeholders on branding practices. The key drivers of branding therapy are influence of traditional cultural beliefs on child healthcare decisions and health-seeking behaviour. The primary determinants of branding practice in the tribal communities were poor health literacy, proximity to conventional care and strong motivation from family and friends. Alongside, the local public health system, through health compaign influences health-seeking behaviour of indigenous people. Opportunities in the health system such as availability and quality of health services, also encourage them to seek healthcare through public health infrastructure. In this context, effective and routine health communications improve their ability to make better healthcare decisions and motivate them to choose modern healthcare.

Our study investigated how several factors contributed to branding practices in the Nabarangpur district. It was, at times, challenging to comprehend the conversation as historically there had been limited interactions between the study community and researchers which was one of the key constraints. The leading newspapers served as sole discussion platform for ongoing branding practices in the district. According to the National Family Health Survey (NFHS)-4 (2015-16), the female literacy rate in the community was 41.8 per cent, with only 10 per cent of women having ten or more years of education. About 40 per cent of women aged 20 to 24 married before the age of 18. The rate of institutional births was 64.3 per cent. 71.5 per cent of children aged 12 to 23 months were fully vaccinated (BCG, measles and three doses of polio and DPT)21. The government also devised a plan as part of the child and mother health strategy; in the form of translation of all health messages (IEC: information, education and communication) into the Desia and Saura languages. However, qualitative interviews with mothers during the present investigation revealed, that they preferred traditional healers for branding because they believed that doctors would not be able to treat their conditions, indicating a lack of trust in doctors and health systems. The health services’ efforts to address the dangers related to branding practices are limited to IEC.

According to cultural norms, communities initially visit traditional healers and then incorporate branding practices. Conventionally, traditional branding occurs when black veins are found on newborns’ bodies, stomachs swell (abdominal distension) with or without pain, and occurrence of infected wounds. In this context, incorporating information about the dangers of branding therapy into school health education programmes, may offer help to end this long-standing practice. Community literacy on branding is also critical to prevent such practices and involvement of community-based organisations such as women’s self-help groups would be crucial in this regard. Noticeably in 2016, the local government launched a programme called ‘Jyoti’ to educate healers about the dangers of branding. While this is an intervention in the right direction, ensuring sustainability and scalability of such a programme is critical.

Branding is an ancient healing technique that involves inflicting ‘therapeutic’ burns on the skin with hot iron rods or metallic objects to treat various health conditions without scientific evidence10. Despite widespread health awareness around it, our findings indicate that certain tribal populations are still compelled to undergo branding as a form of treatment due to cultural beliefs. In tribal villages in Madhya Pradesh, India, previous studies identified that hot iron branding were being used to treat certain illnesses such as ascites, headache, pneumonia, the common cold and hernia1,22. Conventionally, impoverished tribal women seek branding therapy for their children because it is convenient and inexpensive8,23,24. Due to their execution in non-sterile environments, most traditional branding methods invite numerous complications25-27 such as breach of skin and infection26,28. Managing such patients can be difficult as they have lower resistance to infection, and, as with any third-degree burn, parenteral antibiotics cannot penetrate the dead tissue due to lack of blood supply4,29,30. Other clinical complications following branding are also on record1,22,26.

Traditional healers in their communities are strong proponents of branding practices. However, some mothers knew that branding therapy was unsafe for their children but yielded to peer pressure. Community members accept this healing approach as this treatment is a part of their culture and several members in the community – parents, in-laws and husbands – compelled women to engage in branding practices1-4. Often, traditional beliefs resulted in practices that strengthened mothers’ belief systems26,28.

India has made significant strides regarding access to and improvement in quality of healthcare services in the last decade. However, it is challenging to ensure equity across its diverse geographies, community groups31 and social welfare systems32. Inadequate health facilities, such as workforce shortages, inaccessibility, poor health-seeking behaviour and cultural differences with healthcare providers, most notably language barriers in indigenous communities, act as significant barriers to equitable services6,10. The Ministry of Tribal Affairs, Government of India has already been collaborating with local governments, civil society organizations and other stakeholders to address health challenges pertaining to tribal population. Anamaya, a multi-stakeholder initiative launched recently (April 2021), will also bring together the efforts of numerous public and private partnerships to improve the health and nutrition status of India’s tribal communities33.

In conclusion, the present study showed that culture significantly impacts social interactions and the concept of illness and healthcare. Tribal people strongly bond with nature, contributing to their belief in traditional healing including harmful practices such as branding. They are used to consult local traditional healers for minor or major health issues. Although the government has made efforts to increase tribal community health literacy through various platforms engaging multiple stakeholders, the availability of modern care and health promotion interventions at doorstep are still critical to mainstream tribal health needs. A community-based, operationally feasible and culturally acceptable intervention will play significant role in increasing the knowledge and volunteer support against branding practices.