Introduction
Traditional medicine is defined as ‘the sum total of the knowledge, skill, and practices based on the theories, beliefs, and experiences indigenous to different cultures, whether explicable or not, used in the maintenance of health as well as in the prevention, diagnosis, improvement or treatment of physical and mental illness’ (WHO, 2023). Various systems of traditional medicine being used around the world include acupuncture, herbal medicines, traditional European medicine, traditional Chinese medicine, traditional Korean medicine, traditional African medicine, Ayurveda, Siddha medicine, Unani, naturopathy, homeopathy, chiropractic, osteopathy, medieval Islamic medicine (Che et al., Reference Che, George, Ijinu, Pushpangadan and Andrae-Marobela2017; Park et al., Reference Park, Lee, Shin, Liu, Shang, Yamashita and Lim2012; WHO, Reference Health Organization2019; Yuan et al., Reference Yuan, Ma, Ye and Piao2016). In India, it is not just a type of medical treatment but also a way of life deeply rooted in their civilisations. It traces back to the ancient texts of Ayurveda, which means ‘knowledge of life’, emphasising a balance between mind, body and spirit (Mukherjee et al., Reference Mukherjee, Harwansh, Bahadur, Banerjee, Kar, Chanda, Biswas, Ahmmed and Katiyar2017; Pandey et al., Reference Pandey, Rastogi and Rawat2013; Subhose et al., Reference Subhose, Srinivas and Narayana2005). This method is built on in-depth knowledge of regional plants, minerals, herbs, roots, and other natural resources passed down through the years, fostering the collective wisdom of tribe healers and shamans (Parasuraman et al., Reference Parasuraman, Thing and Dhanaraj2014; Patwardhan et al., Reference Patwardhan, Vaidya and Chorghade2004).
The utilisation of traditional and complementary medicine (TCM) has been noted in several studies. In a 32-country study, the prevalence of TCM use in the past year was 26.4%, while in another nine high-income countries study, it was found to be 21.1% (Harris et al., Reference Harris, Cooper, Relton and Thomas2012; Peltzer & Pengpid, Reference Peltzer and Pengpid2018). Additionally, a previous study reported that 6.5% of middle-aged and older adults had utilised AYUSH (Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy) practitioners in the past year, and 7.0% had consulted traditional healers in India (Pengpid & Peltzer, Reference Pengpid and Peltzer2021). Interestingly, utilisation was observed to be particularly high in certain geographic areas, such as states, and among specific groups, including tribal and minor religious communities (Samal & Dehury, Reference Samal and Dehury2019). A few prior studies stated that despite the accessibility of modern healthcare facilities, many people still place their trust in the traditional therapies provided by their local healer, who lacks any formal training that has stood the test of time (Boro & Saikia, Reference Boro and Saikia2020; Reddy et al., Reference Reddy, Subedi and Guite2023; Sundararajan et al., Reference Sundararajan, Kalkonde, Gokhale, Greenough and Bang2013).
This alternative medicine system is observed to be prevalent among the Scheduled Tribe population in India. According to the Imperial Gazetteer of India, ‘A Tribe is a collection of families bearing a common name, speaking a common dialect, occupying or professing to occupy a common territory and is not usually endogamous though originally it might have been so’. According to Article 366(25) of the Constitution of India, Scheduled Tribes are ‘tribal communities or parts of tribal communities that are declared as such by the President of India through a public notification’. They are identified based on indications of primitive traits, distinctive culture, geographical isolation, shyness of contact with the larger community, and overall backwardness. The purpose of defining them as ‘Scheduled’ is to provide social justice and integrate them into mainstream society. The Scheduled tribe of India constitute 8.6 percent of the country’s total population and are located in the farthest reaches of remote India, tucked away between thick woods, mountains, and green landscapes (Census, 2011; Xaxa, Reference Xaxa1999). They have found solace in their unique cultural identities and age-old traditions and relied on their traditional healing system, which is closely connected to their way of life, philosophy, and spirituality for a variety of physical and spiritual ailments (Bhasin, Reference Bhasin2002; Shankar et al., Reference Shankar, Lavekar, Deb and Sharma2012). For example, the Santhals in the eastern states have developed an Ayurvedic-like treatment based on ‘Panchamohobhuta’, while the Bhils in Western India and Gonds of central India practice animistic spiritual rituals (Karua, Reference Karua2015; Sahay, Reference Sahay2022; Shukla & Chakravarty, Reference Shukla and Chakravarty2010). Additionally, the Nagas and Mishings in the northeast have developed intricate herbal medicine systems (Semy & Kuotsu, Reference Semy and Kuotsu2023; Shankar et al., Reference Shankar, Lavekar, Deb and Sharma2012).
In northeast India, the Scheduled tribe comprises 27.3 percent of this region’s population. This region has remained isolated from the rest of the country because of its location and terrain, making it challenging to access healthcare facilities, leading to a heightened risk of preventable illnesses and complications. In this region, Meghalaya is a diverse and distinct state in political, social, and cultural spheres, making it socio-culturally different from the rest of India. In Meghalaya, the Scheduled Tribe population accounts for 86.5 percent of the state’s residents (Census, 2011). Several prior studies have reported a high reliance on traditional medicine from tribal healers in this state (Albert et al., Reference Albert, Porter and Green2019; Chandra, Reference Chandra2023; Langshiang et al., Reference Langshiang, Debnath, Bhattacharjee, Paul and Debnath2020).
However, with the implementation of the National Rural Health Mission (NRHM) in 2007, AYUSH was integrated into the mainstream healthcare system, allowing individuals to choose treatments such as Homoeopathy, Ayurveda, Yoga, and Naturopathy. Over time, AYUSH has grown and is currently available in all eleven districts of Meghalaya. The outpatient department (OPD) providing AYUSH treatments has been established in district hospitals, community health centres, primary health centres, and dispensaries. One earlier study revealed that the use of tribal medicine in rural households across Meghalaya was 79.1%, but the majority had not heard of the AYUSH system and had little local acceptance (Albert et al., Reference Albert, Nongrum, Webb, Porter and Kharkongor2015; Albert & Porter, Reference Albert and Porter2015).
Previous research has explored the health-seeking behaviour of tribal populations, which is influenced by their socioeconomic condition, adverse location and poor communication. Existing literature often focuses on broader aspects of traditional medicine in India or the Northeast region without delving deeply into the nuanced practices and cultural significance unique to the Garo community. There is a scarcity of studies that investigate the reasons behind the popularity of traditional healing practices among tribal communities despite the availability of modern healthcare services and several government initiatives in Meghalaya. With this background, this study has at first identified the healthcare-seeking behaviour quantitatively and qualitatively investigated the indigenous medical knowledge of Garo women and their health concerns and addressed the gap by examining why traditional medicine from traditional healers is preferred over modern healthcare in Meghalaya and why tribal communities do not utilise government health facilities.
Conceptual framework
There are several theoretical models of health-seeking behaviour. The social-ecological model (SEM) offers a comprehensive approach for understanding and addressing the various levels of influence on health behaviours and outcomes (Figure 1). It encompasses an individual’s perceptions, cultural beliefs, and knowledge and provides a multidimensional perspective that goes beyond individual choices to include interpersonal relationships, community norms, organisational factors, and broader societal dynamics (McLeroy et al., Reference McLeroy, Bibeau, Steckler and Glanz1988; Rimer & Glanz, Reference Rimer and Glanz2005). Approaches focusing solely on individual-level factors may overlook the systemic influences shaping health-seeking behaviour, and SEM offers a more comprehensive understanding of these factors (Lounsbury & Mitchell, Reference Lounsbury and Mitchell2009).
Figure 1. Socio-Ecological Model for Identifying the Factor Influencing Health-Seeking Behaviour.
A few earlier studies have shown that local cultural, social, and environmental factors likely play a significant role in shaping the health of Indigenous people (Deb Roy et al., Reference Deb Roy, Das and Mondal2023; Redvers et al., Reference Redvers, Aubrey, Celidwen and Hill2023). This study uses this framework to understand how various factors impact health-seeking behaviours, from personal beliefs to community resources and societal norms.
Data and methods
Study setting and study participants
The research was carried out in May 2023 in the East Garo Hill district, which is situated 244 kilometres away from Shillong, the capital of Meghalaya. This particular district was selected intentionally due to the significant presence of the Garo tribe. The Garo people make up approximately one-third of Meghalaya’s population and live in the Garo hills. They are listed as ‘Scheduled Tribe’ as per the constitution of India. They belong to the Tibeto-Burmese ethnic group, and their traditional animist religion is called ‘Songsarek’. However, at the present time, most of them converted to Christianity. Our study included participants from the Garo community who only practice Christianity. Their language is called ‘Achikku’.
Study design
The study adopted a three-stage sampling design to choose respondents. In the first stage, two blocks, Rongjeng and Songsek, were randomly selected from the five blocks of the aforementioned district. Secondly, eight villages (4 each from each block) were randomly selected after listing all villages. The district’s hospital (Willimnagar Civil Hospital) is located at a distance of at least 25 to 70 kilometres from the villages. Primary health centres (PHC), sub-centres, or community health centres (CHC) are accessible within a range of 2 to 15 kilometres. Thirdly, 96 (12 from each village) women aged 15–49 were randomly selected for interview.
The following formula was used to calculate the sample size for this study; this method is widely used in cross-sectional studies to estimate the prevalence of an unknown parameter (Cochran, Reference Cochran1977).
$$sample\;size\;\left( n \right) = {\rm{ }}\frac{{{Z^2}\;p\left( {1 - p} \right)}}{{{d^2}}}$$
where
$n$
is the sample size,
$Z$
is the statistic corresponding to the confidence level,
$p$
is the expected prevalence, and
$d$
is the margin of error. In this study, with a 95% confidence level (Z ≈ 1.96), the p is considered 0.5 (for maximum variability, as there is no previous study on this for this particular community in this study area), and a margin of error
$d$
= 0.1 (10%), the sample size calculation would be 96. This sample size can be justified based on a combination of statistical calculations, practical constraints (available resources such as time, cost, and manpower), and objectives of the study.
In this explanatory study, the first author first collected the quantitative data, and after a preliminary analysis of quantitative information, the qualitative data were gathered.
Data collection methods
Quantitative data collection: Quantitative data (N = 96) were collected through an interview schedule to understand the health-seeking behaviour of Garo tribal women. At first, the women were asked, ‘Have you fallen sick in the past six months? If yes, have you sought treatment at a healthcare facility?’ After that, they were asked, ‘What type of treatment it was?’ Apart from that, the background characteristics of respondents, such as age, educational qualification, household wealthFootnote 1 , occupation, relationship with household head, and distance to the nearest health centre were collected.
Qualitative data collection: After the quantitative data collection, qualitative data were collected through 12 in-depth interviews (IDIs) conducted with Garo women aged 15–49. The sample size was decided based on sample sizes for saturation in qualitative research for homogenous study populations (Boddy, Reference Boddy2016; Hennink & Kaiser, Reference Hennink and Kaiser2022). To minimise potential personal bias, semi-structured interview guides were developed and used. Participants were asked about their illnesses, different dimensions of traditional medicines, reasons for dependency on traditional medicines, and quality of care in the government health centres.
Data analysis
Descriptive statistics were used for the preliminary quantitative analysis. Thematic analysis was used for qualitative analysis. The typed transcripts were reviewed for accuracy, completion, and familiarisation and were read by authors. A word cloud was created from the in-depth interviews to identify the illness faced by Garo women. It is a popular way to visualise qualitative data composed of text where the size of a word represents its frequency (DePaolo & Wilkinson, Reference DePaolo and Wilkinson2014; Heimerl et al., Reference Heimerl, Lohmann, Lange and Ertl2014). Atlas Ti was used to analyse the qualitative data. The qualitative survey and analysis have been conducted using the guideline of consolidated criteria for reporting qualitative studies (COREQ) (Appendix A1) (Tong et al., 2007).
Results
Characteristics of the study participants
Table 1 presents the characteristics of Garo women interviewed in the study to explore health-seeking behaviour through the interview schedule. The data indicate that of the total women, 7.3% were under 20, 37.5% were between 21–30, 35.4% were between 31–40, and 19.8% were over 40 years old. Regarding education, 41.7% of the women either lacked formal educational qualifications or had only primary education, while 45.8% had attained secondary education. Regarding occupation, the majority of women (39.6%) were cultivators, 22.9% were housewives, and 15.6% were shopkeepers. Furthermore, 60.4% of women were heads of their households, with the remainder being daughters of the household head. Concerning access to healthcare facilities, 25.0% of women had a public health centre within 5 km of their household, 50.0% had one within 5–10 km, and 25.0% had to travel more than 10 km to reach a public health centre.
Table 1. Socio-Economic and Demographic Profile of Garo Women Respondents in the Quantitative Survey, East Garo Hill District, Meghalaya (Primary Field Survey During May 2023)
The socio-demographic profile of Garo women who participated in qualitative in-depth interviews is displayed in Table 2.
Table 2. The Socio-Demographic Profile of Garo Women Who Participated in Qualitative In-Depth Interviews (Qualitative Field Survey Conducted in May 2023)
Healthcare-seeking behaviour of Garo Tribal women
Table 3 displays the healthcare-seeking behaviour of Garo women. In this study, among the 96 interviewed women, 86 women stated that they had fallen sick in the last six months. Among the 86 women, the data (N = 86) indicate that a majority of women, almost 84%, seek treatment from Ojha for achik medicine, while only 6% opt for modern health facilities. An additional 10% of women do not visit any healthcare providers and instead rely on traditional herbal home remedies for their treatment. It is worth noting that there appears to be no discernible pattern in utilising modern healthcare services based on age, education, or household wealth. Traditional health remedies, including achik medicine and herbal home remedies, are prevalent among women from all educational and economic backgrounds. Furthermore, it is noteworthy that 86.4% of women prefer achik medicine from Ojha, while only 4.6% opt for modern public health facilities, despite a health centre being located within 5 km of their village. Moreover, 81.6% of women prefer achik medicine when it is 5–10 km away from their village, and 85.0% when it is more than 10 km away.
Table 3. Healthcare-Seeking Behaviour for Women for their Health Issues, East Garo Hill District, Meghalaya (Primary Quantitative Field Survey During May 2023)
Health issues faced by Garo women----Findings from in-depth interview
One of the major health issues that young women have been struggling with is a menstrual disorder. As per their report, they experience bleeding for more than two weeks, which is known as menorrhagia. During this time, they feel incredibly weak and fatigued. If they don’t seek any treatment, it can even last up to a month, which is quite distressing. Another one is amenorrhoea. Some women don’t get their menstrual bleeding for 3 or 4 months. As per their experience, these conditions can have adverse effects, particularly on pregnancy.
‘I am grappling with a menstrual disorder known as amenorrhea, wherein I have not menstruated for the past two months’. -------(26 years old Garo women)
Additionally, many women experience post-delivery weakness, known as ‘bolsuda’, which can further complicate their health. Apart from that, women also suffer from white discharge.
‘Currently, I am suffering from ‘bolsuda’. Bolsuda is a weakness that is felt after child delivery. Two months ago, I delivered a baby boy’. -------(27 years old Garo women)
Apart from those reproductive health issues, another major health issue mentioned by Garo women is fever with a severe headache.
‘I often face this severe headache. Yes, it can be quite debilitating. Sometimes, it can even drive someone to the point of madness’. -------(33 years old Garo women)
Women are also suffering from respiratory diseases as they use uncleaned fuel. Unclean fuels are polluting fuels used for cooking, such as kerosene, coal, wood, charcoal, straw, shrubs, grass, agricultural crops, and animal dung. Although the government has implemented Ujjwala Yojana, women can’t afford the cylinders. As a result, they use readily available wood as cooking fuel.
‘Actually, madam, I cook food for my family using firewood in the kitchen. The smoke makes the air inside bad and can cause health issues like breathing problems’. -------(26 years old Garo women)
‘Ma’am, I got the LPG gas cylinder under the Ujjwala Yojana, but only the first one was free. After that, we have to pay for the cylinders, and it’s really hard for my family to afford it. The cost is too much for us, so I use wood for cooking because it’s easier to get and doesn’t cost money like the gas does’. -------(48 years old Garo women)
This study has found that jaundice and gastrointestinal problems are also prevalent for Garo women. This is mainly due to the use of unimproved sources of drinking water. Other major health issues mentioned by Garo women are anaemia, arthritis, fracture, hypertension, jaundice, low blood pressure, and typhoid.
‘Yes, another health issue I often deal with is gastrointestinal problems. It can be caused by contaminated water or improper food handling. During the monsoon season, it is more challenging to maintain proper hygiene’. -------(43 years old Garo women)
‘Actually, ma’am, Jal Jeevan’s mission has not started in this village yet. It has been implemented in our neighbouring villages. So, we depend either on wells or spring water as a source of drinking water’. -------(25 years old Garo women)
Garo women also mentioned some minor health issues such as cold, cough, diarrhoea, dysentery, fever, body pain, and indigestion.
‘I often suffer from fever, cold and cough. Actually, this cold and humid weather of Garo hills is quite harsh on our immune systems’. -------(33 years old Garo women)
Figure 2 presents the word cloud of different health issues faced by Garo women.
Figure 2. Word Cloud of Different Types of Health Issues Faced by Garo Women Participants, East Garo Hill District, Meghalaya (Primary Qualitative Field Survey During May 2023).
Description of Achik medicine: The most prevailing Garo traditional medicine system
Garo traditional medicine, known as ‘achik medicine’, is deeply ingrained in their society. The Garos prefer to call themselves Achik, which means ‘hill man’. Traditional medicine in the Garo Hills involves the use of various plants for medicinal purposes. They have traditional healers called ‘ojhas’ who possess extensive knowledge about local herbs and medicines. Leaves are most commonly used in the treatment. They also use fruits, bark, roots, root barks, stems, seeds and flowers. These ojhas are crucial in providing them with remedies and guidance when they seek assistance.
‘I visit Ojha for treatment for any illness. He provides me achik medicine prepared through local herbs and plants, which is very useful for me’. -------(22 years old Garo women)
The most used achik medicine is ‘poron.’ Garo women use it when they have severe headaches. It is a combination of medicinal herbs provided by the ojha. They prepare a band of clean and fine cotton cloth and apply the poron mixture onto it, which is then tied around the forehead to alleviate the symptoms. In case of fracture, they use ‘jak rik chu’ medicine or ‘anchimrang’ medicine. In case of swelling, they use ‘rajamuri’. They use those medicines over the affected body parts. For stomach aches, ojha provides them with ‘sam sko’ for consumption. To stop the bleeding from cutting hands and legs, ojha provides them with an achik medicine called ‘meghalaya budu’.
This study also found that each household has some medicinal plants, and all Garo tribes have a vast knowledge of the plant’s medicinal use, which they use as a first resort.
‘Indeed, every household has some medicinal plants, each possessing a diverse array of therapeutic properties. In my household also, we have some medicinal plants. I also use some home remedies. Notably, virtually every plant has some form of medicinal use within our traditional knowledge’. -------(38 years old Garo women)
From the Garo women, we have noted some medicinal use of herbal plants for some particular diseases (Table 4).
Table 4. Indigenous Traditional Knowledge of Medicinal Plants of Garo Women Participants, East Garo Hill District, Meghalaya (In-Depth Interviews from Primary Field Survey During May 2023)
Reasons for using achik medicine
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More effective than modern medicines
The reliance on traditional medicine for Garo women in Meghalaya is predominant, as they find successful healing outcomes through these age-old practices. They feel positive results and complete healing through their traditional achik medicine.
‘I feel complete relief and comfort after seeking Achik medicine’. ---------(26 years old Garo women).
With the help of traditional medicine, women have witnessed successful recoveries from various ailments. It has proven to be more effective than any modern medical treatment.
‘When I take achik medicine for my menorrhoea, my bleeding stops within a day. However, if I were to seek modern medicine, it would take up to a week to achieve similar results. So, based on my experiences, I find traditional medicine to be a better choice’. --------(42 years old Garo women).
This study also found that participants visit modern healthcare only for serious health conditions, such as accidents and typhoid.
‘In case of typhoid, I visited the nearest CHC. Otherwise, I use our traditional medicine’. -------(35 years old Garo women)
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An integral part of Garo culture and identity
Traditional medicine is tied to the history, traditions, and beliefs, making it an integral part of the identity of the Garo women. It is more than just a remedy; it reflects their connection to nature, ancestors, and community. It instils trust and reliance on their traditional healing methods, which have stood the test of time and continue to be the primary choice for everyone to ensure their good health.
‘Our traditional medicine, known as ‘achik medicine,’ is deeply ingrained in our society. Our village’s wealthy and educated individuals also rely on achik medicine’. -------(29 years old Garo women)
Despite the availability of modern healthcare, traditional healing practices persist among the Garo women, as they have a strong cultural and historical connection with these practices. By using traditional medicine, these women also want to preserve their ancient knowledge of medicinal plants and their healing properties.
‘Our ancestors have been using these remedies for generations, and they have been passed down as a valuable part of our heritage’. -------(35 years old Garo women)
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Preference for natural herbal remedies
Traditional medicine relies on sustainable practices, such as harvesting herbs and plants from the local ecosystem, which aligns with the Garo women’s values of living in harmony with nature. Many believe that traditional medicines have fewer side effects compared to modern pharmaceuticals, contributing to their preference for natural remedies.
‘In truth, this traditional medicine is meticulously crafted from a rich array of medicinal plants, rendering it highly potent and effective’. --------(35 years old Garo women).
It is important to note that these women do not trust spiritual practices.
‘No, as a Christian, I don’t believe in spiritual practices. Spiritual practices are more prevalent in the Sonsarek religion. In our village, there are very few Sonsarek people left, as most have converted to Christianity. In the past, there used to be a person called ‘kamal’ who practised spirituality using some evil powers for healing purposes’. --------(25 years old Garo women).
-
• Efficiency of Ojhas
The healers, known as ‘ojha,’ have generations of wisdom and experience using herbal remedies. Their practices involve using local herbs, shrubs, and medicinal plants for various health-related applications. They know about local flora and their healing properties to treat various ailments. Their practices have stood the test of time. This history builds trust within the community.
‘Our traditional healers, ‘ojhas’ possess extensive knowledge and expertise about local herbs and medicines, inherited through generations. They utilize more than 50 medicinal plants for various treatments’. ---------(27 years old Garo women).
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• Availability and accessibility of traditional healers
Garo women often have limited access to modern medical facilities and pharmaceuticals due to their remote locations. Traditional medicine, based on locally available plants, is usually more accessible. Moreover, Ojhas are readily available and accessible to them.
‘In this village, there are 4 Ojhas. I can approach them at any time. Whereas, in this village, there is no health centre. The nearest health centre is almost 6 km distance from our village. In every village, there are 3 to 5 Ojhas’. --------(45 years old Garo women).
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• Affordability
One of the key advantages of Achik medicine is its cost-effectiveness. The ingredients used in traditional remedies are often sourced locally and are readily available, making them more affordable than modern medications and treatments.
‘When it comes to the cost of traditional healers, there is no fixed amount. It is up to us to decide how much we will pay them’. --------(42 years old Garo women).
While money may not be a significant issue for the Garo tribal people, if a person is sick and their medical treatment is costly, the female head of the household arranges a ‘mahare meeting’ to raise funds. This involves all family members and distant relatives who come together to decide on the treatment and contribute some money, sometimes even selling domestic animals or land to raise funds.
‘It’s a collective effort to ensure that no one is deprived of medical care due to financial constraints. Mahare meeting is compulsory’. ---------(22 years old Garo women).
Reasons for limited use of modern Health care system
-
• Poor quality of service in government health centre
The quality of care in government health facilities is very poor in this tribal region. There is a scarcity of doctors and medicines. Doctors are not available for round the clock.
‘In our village, there is a health subcentre. I can easily reach there. But doctors are not there all the time. Medicines are not properly available. For this reason, I go to Ojha for my treatment. I can approach him any time’. --------(25 years old Garo women).
Even in Community Health Centre (CHC), there is no infrastructure for surgery and medical equipment. For specialised treatment, they are referred to the civil hospital. Moreover, doctors and medicines are not available.
‘Not all necessary medicines are available in CHC. We often have to purchase them from a pharmacy’.---------(22 years old Garo women).
In addition, individuals are typically directed to the civil hospital due to the absence of proper infrastructure.
‘Most of the time, we are referred to Willamnagar Civic Hospital’ --------(33 years old Garo women).
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• Remote location
The distance to the modern healthcare facility is a problem. Moreover, there is no public transport. Arrangement of private care is very costly to them.
‘Sonshak PHC is 15 km away from our village. This long distance makes it challenging to reach medical help quickly, especially in emergencies or critical health situations’. --------(45 years old Garo women)
‘PHC is very near to my house. But most of the time, it refers to Willamnagar Civic Hospital, which is almost 70 km from my village. For this, booking a private car is necessary, which is very costly’. --------(38 years old women).
However, this study has identified that ASHA has a significant role in assisting pregnant women for institutional delivery and child immunisation.
‘Home deliveries were common in the past, but now it has been almost institutionalized. ASHA takes the responsibility of taking pregnant women to CHC for delivery. She told about the potential risks associated with childbirth at home and the benefits of institutional delivery’. -------(27 years old Garo women)
‘Actually, madam, Ojha provides the medicines. He is not involved in child delivery’. -------(25 years old Garo women)
Discussion
This study explored the health issues, health-seeking behaviour and the factors that influence the health-seeking behaviour of Garo tribal women. It found that Garo women always prefer traditional medicines prepared by local herbs from their traditional healers (Ojhas) for their health issues. Moreover, all Garo women have some knowledge of medicinal plants. Factors contributing to the high dependency on traditional medicine are the perceived effectiveness of traditional remedies, cultural identity, preference for natural remedies, the expertise of traditional healers, affordability, availability and accessibility of Ojha, and the limitations of modern healthcare facilities in remote regions.
This study has identified that one of the major health issues suffered by Garo women is menstrual disorders. A few earlier studies conducted in east India, while identifying the problem related to menstruation, also found that tribal adolescent girls suffer from menorrhoea (Das & Gautam, Reference Das and Gautam2022; Dey & Mahapatra, Reference Dey and Mahapatra2020). Moreover, women suffer from prolonged weakness after delivery. It may be that the matrilineal tribal women are engaged in both household and productive work, and during and after pregnancy, they don’t get proper rest. Our study also finds that women suffer from respiratory infections due to uncleaned cooking fuel. Studies found that exposure to particulate matter (PM) pollution increases the risk of acute respiratory infections (ARI), oxidative stress, and inflammation in the respiratory tract, damaging epithelial cells and impairing pathogen clearance (Adhikary et al., Reference Adhikary, Mal and Saikia2024; Noor et al., Reference Noor, Aftab, Aslam and Imanpour2023). This study also found that colds, coughs, and fevers are very common for Garo women. Meghalaya, including Garo Hills, experiences relatively cooler temperatures, especially during winter. The region also has a high humidity that can weaken the immune system, making individuals more susceptible to colds, coughs, fever, and respiratory infections, especially during the monsoon season. High humidity can create favourable conditions for the growth of viruses and bacteria (Qiu et al., Reference Qiu, Zhou, Chang, Liang, Zhang, Lin, Qing, Zhou and Luo2022).
While exploring health-seeking behaviours, this study found that the Garo tribal people of Meghalaya heavily rely on herbal Achik medicine from traditional healers and show a minimal preference for modern healthcare systems, regardless of socioeconomic background or the availability of modern medicine. Herbal practice still plays a significant role in managing and curing various health problems, particularly in the remote and rural areas of tribal India (Laldingliani et al., Reference Laldingliani, Thangjam, Zomuanawma, Bawitlung, Pal and Kumar2022; Malik et al., Reference Malik, Bhat, Ballabha, Bussmann and Bhatt2015; Reddy et al., Reference Reddy, Guite and Subedi2023). The qualitative aspect of the study identified intrapersonal factors, such as the perception of health and illness, faith, trust and belief in traditional achik medicine, individual knowledge of medicinal plant and effectiveness of achik medicine, which contribute to pulling tribal women towards local traditional medicine. Additionally, the study found that demographic and socioeconomic status, such as age, education, wealth, and occupation, do not influence the health-seeking behaviour of Garo women. At the interpersonal level, family, peers, gender roles, households with medicinal plants, and most importantly, knowledge and expertise of local traditional healers (Ojhas) influence the health-seeking behaviour of Garo tribal women. Furthermore, community-related factors, including culture, traditions, and the accessibility of traditional healers, also exert a significant impact on healthcare-seeking behaviours. Dependency on traditional medicine from traditional healers is often determined by their faith, traditions, practices handed down from generation to generation and cost-effectiveness (Cáceres et al., Reference Cáceres, Ramesh, Newmai, Kikon and Deckert2023; Kala, Reference Kala2005). Women typically rely on modern healthcare for addressing maternal health concerns related to institutional childbirth. The preference for modern health facilities in childbirth highlights an adaptive strategy to mitigate the higher risks associated with childbirth at home. As community health workers, ASHA act as a bridge between the tribal communities and the formal healthcare system. This highlights the achievement of Janani Suraksha Yojana (JSY) at the policy level in promoting institutional delivery. Furthermore, for major accidents and severe health issues, they seek treatment at modern healthcare facilities.
Apart from traditional medicine from traditional healers, our study also found that Garo women hold valuable insights into the uses of plants, their medicinal properties, and sustainable practices. Historically, it was often women who first domesticated plants, initiating the art of agriculture and the science of farming (Sood et al., Reference Sood, Gupta and Jan2015). Indigenous women pass down traditional knowledge to younger generations through oral traditions, ensuring its continuity (Singh et al., Reference Singh, Rallen and Padung2013). Women’s knowledge often stems from their roles in providing household care and tending to family members due to historical gender divisions of space and labour (Voeks, Reference Voeks2007). Within the matrilineal social structure of these communities, where lineage and inheritance are traced through the maternal line, women hold central roles as caregivers, nurturers, and custodians of cultural knowledge (Ellena & Nongkynrih, Reference Ellena and Nongkynrih2017). The most visible advocate of ecofeminism in India, Vandana Shiva, argues that women from low and middle-income countries have both a unique dependence on ‘nature’ and an exceptional knowledge of ‘nature’ (SHIVA, Reference Shiva1992).
This study has identified that the Christian Garo women do not rely on spiritual practices. However, different previous studies have found that many tribal people rely on spiritual practice for healing (Bhasin, Reference Bhasin2002; Ranganathan, Reference Ranganathan2018; Sahay, Reference Sahay2022). This study determined that study participants exclusively utilise traditional medicines made from local herbs. In examining the efficacy of herbal remedies, various scientific investigations have revealed that a number of herbal treatments may be effective and relatively safe (Hasani-Ranjbar et al., Reference Hasani-Ranjbar, Nayebi, Moradi, Mehri, Larijani and Abdollahi2010; Long et al., Reference Long, Soeken and Ernst2001; Tan et al., Reference Tan, Gwee, Tack, Zhang, Li, Chen and Xiao2020). Phytochemistry has identified a wide range of bioactive compounds in medicinal plants, such as anti-inflammatory, antioxidant, antimicrobial, and analgesic properties (Gonfa et al., Reference Gonfa, Tessema, Bachheti, Rai, Tadesse, Nasser Singab, Chaubey and Bachheti2023; Ndezo Bisso et al., Reference Ndezo Bisso, Njikang Epie Nkwelle, Tchuenguem Tchuenteu and Dzoyem2022). An earlier study suggested that the medicinal practices of the indigenous people of India should be termed ‘Ethnobotanical medicine’ as the use of plants in treating diseases (Kala, Reference Kala2005).
Another approach to address the high dependence on traditional medicine is the perceived deficient quality of care in health centres. The scarcity of healthcare professionals and low quality of services/medicines were identified as key factors deterring individuals from seeking healthcare services. A typical response noted was referring the patient to civil hospital, which is far distance. Similar findings were reported in the studies of barriers to utilising modern health systems in central and northeast India (Boro & Saikia, Reference Boro and Saikia2020; Contractor et al., Reference Contractor, Das, Dasgupta and Van Belle2018).
Conclusion and policy recommendation
The health-seeking behaviour of the Garo tribal population of Meghalaya is deeply rooted in their cultural and traditional practices, primarily relying on herbal Achik medicine prepared from local herbs from traditional healers. They do not place faith in spiritual practices for healing. Despite the availability of modern healthcare facilities, there is a marked preference for traditional medicine, influenced by intrapersonal and interpersonal factors, such as trust, cultural beliefs, and the perceived efficacy of traditional treatments. Community-related factors, such as affordability and accessibility to traditional healers, further reinforce this preference. The study also underscores the significant role of Garo women in preserving and transmitting traditional medicinal knowledge. Such a role emphasises the intertwined relationship between gender roles, cultural heritage, and healthcare practices within the community. However, in specific circumstances like maternal health and severe health issues, there is a noted shift towards modern healthcare facilities, influenced by the interventions of community health workers and initiatives like Janani Suraksha Yojana (JSY).
At the policy level, the government should recognise and integrate the role of traditional healers and traditional remedies within the mainstream healthcare system. This includes support for traditional healers by implementing initiatives that facilitate cooperation between tribal traditional healers and contemporary healthcare providers, thereby fostering a more holistic approach to culturally sensitive health and providing access to modern medical facilities. Government health policies should actively promote the use of ethnomedicine, ensuring that tribal people have access to safe and effective traditional treatments alongside modern medical options. In addition, the government should support further research and documentation of traditional therapeutic practices and their effectiveness. By partnering with local academic institutions and research establishments, a scientific foundation can be established for integrating traditional and modern medicine, preserving indigenous knowledge, and encouraging evidence-based practices.
Furthermore, there should be improved access to gynaecological services in rural health centres and ensure that women receive timely and appropriate treatment for menstrual disorders. Policymakers should also promote nutritional programmes addressing anaemia and other deficiencies contributing to menstrual issues. Mobile health clinics and telemedicine services can be introduced to bridge the gap in remote areas, thus alleviating the distance and accessibility challenges experienced by the Garo community. Additionally, there is also a need to improve the public transportation facilities in that remote region.
Acknowledgements
The authors are grateful to the respondents and research participants who cooperated and invested valuable time in this study. They also extend their gratitude to Mr. Bappi Sangma and Mrs. Chingchime for their assistance in conducting the Survey.
Funding statement
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Competing interests
There are no known conflicts of interest/competing interests to declare.
Ethical standard
Ethical approval was granted by the Institutional Ethical Review Board of the International Institute for Population Sciences (IIPS) with order no. IIPS/ACAD/SREC/PM/IO-256/2023 dated 08/03/223. Verbal consent was obtained from the respondents and participants before the interviews.
Appendix
Appendix A1. Consolidated criteria for reporting qualitative studies (COREQ): 32-item checklist
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