FORMAL AND INFORMAL ARTEFACTS WITH RESPECT TO NON-

COMMUNICABLE DISEASES AMONG TRIBES OF ATTAPADI IN

PALAKKAD DISTRICT

A research proposal for the thesis of the

Master of Public Health (MPH) program (2021- 23),

to be submitted to Kerala University of Health Sciences, Thrissur.

DIVYA SURESH

ID. NO. 213140002

Under the Guidance of

Prof. Dr. K. Rajasekharan Nayar

GLOBAL INSTITUTE OF PUBLIC HEALTH

ANANTHAPURI HOSPITALS AND RESEARCH INSTITUTE

THIRUVANANTHAPURAM- 695024

KERALA
FORMAL AND INFORMAL ARTEFACTS WITH RESPECT TO NON-
COMMUNICABLE DISEASES AMONG TRIBES OF ATTAPADI IN
PALAKKAD DISTRICT

INTRODUCTION

Non-communicable diseases are medical conditions or diseases that are not caused by an infectious
agent. These are chronic diseases of long duration, generally slow progression, and are the result of
a combination of genetic, physiological, environmental, and behavioral factors. (1) NCDs are one
of the major challenges of public health in the 21st century, not only in terms of human suffering
but also in terms of the harm they inflict on the country's socioeconomic development. NCDs kill
approximately 41 million people (71% of global death) worldwide each year including 14 million
people who die too young between the age of 30 and 70(2). According to the WHO projections, the
total annual number of deaths from NCDs will increase to 55 million by 2030 if timely
interventions are not done to prevent and control them. In India, nearly 5.8 million people (WHO
report, 2015) die from NCDs (heart and lung disease, stroke, cancer, and diabetes) every year. One
in four Indians has a risk of dying from NCD before they reach the age of 70. In short, they are the
leading cause of death and disability through their effects on the societal, economic, and
environmental domains that affect negatively the sustainability of human development.

There could be a lack of awareness and health promotion activities, given the developing burden of
NCD in rural and tribal areas. The tribal population primarily inhabits remote areas and is among
the most vulnerable and marginalized sections of society. Moreover, they lag behind all other social
groups in various social, health, and developmental indicators (3). A systematic review of
hypertension among the tribal population in India revealed an increasing prevalence of
hypertension across decades (4). The National Nutritional Monitoring Bureau had done a multi-
state survey among the tribal population a decade ago which showed that the prevalence of
hypertension varied from 8% in Gujarat to 51% in Orissa. One out of every four tribal adults
suffers from hypertension in Kerala. The major modifiable NCD risk factor was found to be among
the people of the Kani tribe compared to the general population in Kerala. (5)

The population of Scheduled Tribes in Kerala is 4,84,839 which is 1.45% of the total population of
Kerala. 36 tribal communities are listed as Scheduled Tribes in the 14 districts of Kerala. (6) The
tribal population in Kerala is concentrated mainly in Wayanad, Kannur, Palakkad,

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Thiruvananthapuram, Kasaragod, and Idukki districts. Attapadi of Palakkad district is one of the
main tribal settlements in Kerala. Attapadi is the valley below Nilgiris hills, part of the western
ghats. (6)

Culture is essentially a building block for constructing a personal understanding of health and
illness. Providing access to culturally sensitive, high-quality health care is extremely important to
enhance the health and well-being of such marginalized sections. it is very important to understand
history, culture, and heritage. Culture is defined as the people9s way of life, including symbols,
language, beliefs, values, and artefacts that are part of society. The artefacts are the material
culture, including all the society9s physical structures which are created by humans, and
understanding such a dimension is relevant in health services, an institutional mechanism evolved
to improve the health of the people. (7)

REVIEW OF LITERATURE

TRIBES

The Adivasi or scheduled tribes are known as the nation9s indigenous population and they remain
the most marginalized and vulnerable group in the country. According to the census 2011, 104
million tribals are in India which accounts for 8.6% of the total population. They remain
socioeconomically, politically, and geographically marginalized despite their large number. The
tribal population in the country mainly reside in the hilly areas and mainly they are collectors of
forest procedure, hunter-gathers, shifting cultivators, pastoralists and nomadic herders, and artisans
and are heavily dependent on agriculture (3).

According to the 2011 census, the total tribal population of Kerala was 426,208 constituting 12.7%
of the total population. The tribal population comprise 43 different communities. Most of them are
marginalized, and economically and socially vulnerable. They are facing land alienation,
displacement from traditional avenues, ill health, erosion of traditional knowledge and culture, lack
of educational opportunity, poverty, gender inequity, alcoholism, and economic and social
powerlessness. Wynand district stands first with 35.94 per cent of the scheduled tribe population of
the state followed by Idukki (12.42 per cent) (6)

TRIBAL HEALTH

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The United Nations Declaration on the Right of Indigenous people (tribal population) refers
specifically to their right to health (articles 23,24 and 29) with particular attention to the need of
indigenous elders, women, youth, children and persons with disabilities. According to National
Family Health Survey 5 (2019-21), the infant mortality rate (IMR) among the tribal population was
41.6 per 1000 live birth and the under-five mortality rate was 50.3 per 1000 live birth (8). A very
low data set is available for the health condition and disease profile of tribal groups (9). The tribal
population suffers a triple burden of disease, communicable, non-communicable, and mental health
and addictions. Available evidence indicates that vector-borne diseases are common among such
population groups. 30 per cent or more tribal population comprising only 3 per cent of the total
population contributed to 14 per cent of malaria (10),703 per 100000 population is suffering from
tuberculosis (11), 42% of the children is underweight and about 77% under-five children are
anaemic (12). There is an increasing prevalence of chronic diseases such as diabetes, hypertension
and cancer throughout India, associated with the use of tobacco, lack of physical activity and
consumption of unhealthy diet, and such diseases are also experienced by the tribal population in
India. (9)

The health-seeking behaviour of each community is depended on their culture, traditions etc. and
factors like socioeconomic, demographic and political factors. The tribal population groups have
low literacy levels and face isolation from mainstream society, extreme poverty, backwardness etc.
Therefore, the health and health care of the tribal population need special focus for achieving
Universal Health Care. The provision of culturally appropriate and accessible health care is
important as most tribals use both modern and traditional medicines depending on their availability
and accessibility. (13)

NON-COMMUNICABLE DISEASE

Global scenario

According to the world health organization, non-communicable diseases are conditions not mainly
caused by acute infections, resulting in long-term health consequences and creating a need for long-
term treatment and care which include cancers, cardiovascular diseases, diabetes and chronic lung
illnesses (1). It accounts for 71% of all death globally and kills 41 million people each year world
(1). Modifiable behaviors like tobacco use, physical inactivity, unhealthy diet, and the harmful use
of alcohol are increasing the risk of NCDs. In 2012, the UN conference on sustainable development
4
referred to the non-communicable disease as one of the major challenges to sustainable
development in the 21st century (14).

According to the study by Dyah Purnamasari, the mortality rate in Indonesia is dominated by non-
communicable diseases (NCD). The factors like Alterations in environment, technology and
lifestyle influenced the pattern of disease. So that diseases such as diabetic Mellitus, heart disease,
dyslipidemia, obesity, kidney disease, lung disease and malignancy dominated in Indonesia. (15). A
study done to assess the prevalence and determinants of non-communicable disease risk factors
among the older adult population in Kathmandu, Nepal using the WHO STEP-wise approach
highlighted the high prevalence of behavioral and metabolic risk factors (16).

Tobacco accounts for over 8 million deaths every year (including from exposure to second-hand
smoke). world health organization estimated that the major risk factor that contributed to NCD is

raised blood pressure, overweight or obesity, and hyperglycemia.

Poverty is closely linked with NCDs. Vulnerable and socially disadvantaged people get sicker and
die sooner than people with higher social positions because they have been exposed to harmful
products such as tobacco, and unhealthy dietary practices and they have limited access to health
care services (2).

INDIAN SCENARIO

Non-communicable diseases (NCD) contribute to around 5.87 million (60%) of all deaths in India.
A case-control study reported that hypertension is the most important risk factor for CVD in India
and the study estimated that hypertension led to 1.6 million deaths and 33.9 million DALYs due to
it in 2015 and is the most important cause of disease burden in India (4). Cardiovascular disease has
emerged as the leading cause of death in India, including in rural areas. This could be due to
various socioeconomic factors, tobacco use and changing food styles (17).

Concerning Diabetes, rapid socioeconomic development and demographic changes along with
increased susceptibility for Indian individuals have led to an increase in the prevalence of diabetes
mellitus in India over the past four decades (18).

KERALA SCENARIO

Epidemiological and demographic transitions in Kerala are more advanced than elsewhere in the
country. It was also found that one in five of the population is diabetic and one in three is
hypertensive (19) (20) (21). And the lifestyle changes in Kerala are the major cause of the high
5
NCD prevalence in Kerala (22). A community-based cross-sectional survey conducted in Kerala
revealed that there were no differences in urban-rural differences in terms of raised blood pressure
or raised fasting blood glucose prevalence in Kerala. (23)

NON-COMMUNICABLE DISEASES AMONG TRIBALS

Non-communicable diseases pose a significant burden on global health with increasing prevalence
in rural and tribal communities. Several studies show adverse outcomes in the Indian tribes
concerning NCDs but there have been only a few studies which assess the perceptions and cultural
factors.

Based on a hospital-based cross-sectional descriptive study conducted in Gudalur Adivasi hospital,

Nilgiris district, Tamil Nadu, 78% of tribals were aware of the presence of NCDs in their
community. Seventy-two per cent and 25% of tribals reported the association between an unhealthy
diet and family history (24). A cross-sectional study conducted in Kinnaur tribal district found that
hypertension was prevalent in 19.7% and diabetes in 6.9% of the population, and the consumption
of tobacco and alcohol was reported as 22.6% and 24.9% of the population. The association
between demographic and behavioural risk factors concerning hypertension and diabetes mellitus is
important and it increases with age, sedentary lifestyle, and harmful conception of alcohol (25).

A study conducted among Kani tribes shows that Abdominal obesity (22.1%) is found to be higher
among Kani tribes compared to other tribal groups in India. The modifiable NCD risk factors were
found to be higher among the Kani tribe than the general population in Kerala (5). There were no
rural-urban differences in terms of raised blood pressure or raised fasting blood glucose in Kerala
(23).

CULTURE AND HEALTH

The sociocultural system influences diseases and illness, and health promotion and preventive
activities are shaped by the system. Culture is the way of life and it includes shared values,
attitudes, beliefs, behavior etc. The perception of health or illness can be understood by cultural
patterns. According to a study conducted in the rural and remote settings of Australia Australia, the

6
differences in culture will affect the health outcome and that difference might affect the
effectiveness of health interventions and health care (7).

According to Cynthia A Cadoret, the health professional should become culturally and
linguistically proficient while caring for patients for the elimination of health disparities (26).

CULTURAL DIMENSIONS OF NON-COMMUNICABLE DISEASES

There is only limited literature related to the cultural aspect of non-communicable diseases among
tribals.

According to one study, the belief in magic and spirit plays a role in tribal health and their health-
seeking behaviour. The concepts of Health, disease, treatment and death of tribal are very much
different from the general population. According to them, the sun, rain, wind and other elements are
in harmony with nature. The components like value systems, cultural traditions, and social
economic and political organizations have a deep influence on health and are related to their health
culture. (27)

A study from West Java, Indonesia concludes that the components like the involvement of social
institutions in health activities, knowledge and practice of medicine covered in the local knowledge
system, involvement of social actors like traditional healers and local health communication are
important and they have been considered while designing an NCD prevention strategy. (28)

A study conducted to find out the reason behind alcoholism among tribals showed that cultural
factors, pressure, and emotional problems due to low self-esteem are behind the high prevalence of
substance abuse among tribals. (29)

The study conducted among Kani tribes, Thiruvananthapuram, found that the formal transfer of
traditional knowledge of medicinal herbs to the next generation is very less due to social and
cultural changes. (30) The negative or positive implications of such changes need to be ascertained.

ATTAPADI

Attapadi is a tribal area bounded on the north by Nilgiri and on the south by Mannarkkad taluk in
Palakkad district which consists of Sholapur, Pudur and Agali Panchayath, and is one of the
prominent forest regions. The major tribes includes Irula(84%), Mudguards(10%) and
Kurumbas(06%).(31) As per the census 2011, the population in Attapdi is 64318, out of this,
7
32035 are females and 32283 are males. Litracy rate in Attapadi block is 66%. Of the total of 187
hamlets, 144 are Irula hamlets, 24 are Muduga hamlets and the rest 19, are Kurumba hamlets.

The chief of each Adivasi community is known as 8Mopan9, and the 8Kurutala9 is taking care of the
relationship between Oorus. The person who is taking responsibility for ensuring food security is
known as 8Bhandari9 and they ensure that no one in the hamlet goes hungry. 8Mannukaran9 is the
agriculture leader and they are responsible for conducting an agricultural operation on time and
maintaining the distribution of agricultural land. (32)

The health system in Attapadi is provided mainly by the government which includes 28 subcenters,
three primary health centres, one community health centre, four Homeo colleges and one Ayurveda
dispensary. In addition to the service provided in the PHC and CHC, each of them has two mobile
units (MMUs) which consist of a doctor and a nurse and they visit every village. The accredited
social health activist and junior public health nurses have a responsibility to join the MMU during
the visits. There are two private hospitals and a few private clinics which provide healthcare. (33).
Due to cultural and socio-economic reasons, healthcare accessibility is very poor in the area.
Advanced checkups and treatment facilities are not affordable to the majority of the tribal people.
(32)

A survey conducted by Thampu, a non-governmental organization found that there are 200
malunited children from 300 tribals. According to a study conducted in Attapadi, ages back, they
cultivated 69 different Navadanyas, 60 types of leafy vegetables, honey etc. and they concluded
that because of that they never faced any infant death or disease (32).

The tribals in Attapadi have a very rich culture and tradition as their own and health is rooted in
their culture. They believe that the environment, their food and their connection with their ancestors
are essential for good health (33). The study conducted in Attapadi states that the acculturation and
the lifestyle changes including the social and cultural patterns are because of the technological
evolution, state-sponsored interventions, migration etc. and the poor health outcomes are due to the
loss of traditional shifting cultivation such as ragi, Chama, veraku, thina, thuvara, honey, roots,
medicinal vegetables and neglection of tribal people, failure of the public distribution system,
failure of the public programmers and project that meant for the Attapadi tribal community. the
communities9 age-old traditions and social customs are destroyed because of external interference.

Several government programs are implemented in the tribal areas but the procedure is very slow
and ineffective in most of the areas. (34) The centralization of healthcare delivery acts as a barrier

8
to the community because of the hierarchical setup of the hospital and it increased the social
distance between the community and the health system. (33) The govt of Kerala implemented
several programs for improving the health and livelihood of the Attapadi community members
including the financial package to incentivize hospital-based antenatal care and delivery even
though they are facing poor health outcomes. Despite these development programmes the formal
health care system failed to provide culturally respectful care, discrimination at the health centres,
centralization of services and lack of power etc. (33)

The rationale for the study

Due to the epidemiological transition, NCD is on the rise in Kerala. There are very few studies
concerning NCDs among the tribal people of Kerala especially focusing on both internally
generated and externally driven cultural strategies and possible divides between the two. Culture,
traditions, values and beliefs are very important in maintaining health and illnesses. The literature
review shows that the studies related to non-communicable diseases and culture among tribals are
nominal. There are no studies which document the formal and informal artefacts among the tribal
communities. There is a need to understand the differences in the system9s formal function, which
include the programs and approaches undertaken by the health service system and informal human
understanding and strategies related to NCD among the tribal community. This understanding
might help in designing culturally sensitive programs or projects on non-communicable diseases
and it may help in suggesting suitable policies in this regard.

Research question

 What are the formal and informal artefacts concerning NCDs among the tribal population of
Attapadi in Palakkad District?
 Are the approaches and programs undertaken by the health system acceptable to the
community?
 What are the challenges faced by the community while dealing with the NCDS and are there
any strategies evolved by the community themselves in dealing with the emerging disease
scenario?

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Research Objectives

 To document the cultural factors including beliefs and practices about NCDs among the
tribal population.
 To study the acceptability of the tribal community to the formal health approaches and
programs and the extent of any conflicts between internally evolved strategies and the
formal health care programs.
 To identify the challenges faced by the community as well as the formal health system in
dealing with the NCDs.

PROPOSED METHODOLOGY

Study population
The universe of the present study is the tribal population in Attapadi, Palakkadu district, Kerala

Study design

Given the focus of the study, a qualitative study design is found appropriate for the study.

Sample selection procedure

The participants will be assigned through the purposive sampling method. Information from the
PHC will be used for the selection of the sample and the help of ward members/tribal
representatives will be sought to identify the individual who has NCD.
Apart from the sample, individual stakeholders and key informants from the community will also
be interviewed. They include Panchayath Members, primary health care workers including ASHA
workers, local political/tribal leaders, teachers etc. The sample size will be finalized on the basis of
data saturation, but we expect to cover 35 members of the group.

Criteria (Inclusion & Exclusion)

Inclusion criteria: inhabitants of Attapadi aged above 45 who have any of the following non-
communicable diseases

1. Cardiovascular diseases
2. Cancer

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 3. Diabetic Mellitus
4. Hypertension
5. Stroke

• Exclusion criteria: bedridden patients who are unable to face the in-depth interviews will be
excluded from the study.

Study variables (with operational definition)

Artefacts with respect to the present study are the factors, facilities or institutions which help
sustenance of life in general and health in particular, including all the society9s physical structures
and facilities.

The formal artefacts express the functionality of the system and in the case of the present study,
these involve the approaches and programs undertaken by the health service system. It is important
to understand the acceptability including problems concerning acceptability as this may help any
further refinement of the programs.

The informal artefacts are those factors which need in-depth exploration and include many
dimensions of handling non-communicable diseases by the tribal community. This will also form
the major investigative dimension of the present research

Data collection methods and tool

A qualitative method will be used in collecting data. The format includes conducting an in-depth
interview of the respondent using an interview guide, focused group discussion and a checklist.
The interview guide, information sheet, and consent form were developed in English and then
translated into Malayalam. Informed consent will be obtained before the interview schedule.

Data collection procedure

the data will be collected in two phases. During the first phase, an exploratory study will be
conducted among five participants to understand the context and in the second phase, the final data
collection will be completed.

11
The data collected from all the respondents will be undertaken by the principal researcher. The data
will be recorded using a voice recorder only after getting consent.

Validation/standardization of tool
The content validity of the in-depth interview will be done by two independent schoolers from the
field of public health. The in-depth interview guide will be prepared in English and will be
translated into Malayalam. After content validity, an in-depth interview guide will be improved if
required. To identify any problems such as communication, level of understanding etc. The
interview guide will also be administered to two participants. Based on this, suitable modifications
if any are required will be made.

Data storage and data cleaning

The interviews will be transcribed and analysed using qualitative techniques. The hard copies of the
interview guide will be stored in a locked chamber under my supervision. Also, the privacy and
confidentiality of respondents will be strictly maintained by analysing the data and reporting the
results without the identifiers of the respondents.

Data analysis and statistical methods

Thematic analysis will be applied to analyze the data. In-depth individual voice-recorded,
interviews will be collected and transcribed verbatim. The transcribed data will be coded and
grouped into themes, subthemes and categories. The final theme, sub-theme, and categories will be
further analyzed for achieving research objectives.

Quality assurance

Data will be collected by the principal researcher using a pre-tested questionnaire and focus group
discussion. Data will be analyzed manually.

Protection of human subjects

Ethical consideration risk: The risk to the respondent in the study will be minimal. No compulsion
will be there for the respondent to participate in the study.

12
Confidentiality: The privacy and confidentiality of the information given to the researcher will be
upheld during the study and even in the future. Written informed consent will be taken from all the
participants and details about the researcher will be given to each respondent to facilitate
clarification of any doubts regarding the study that arise among participants.

Ethical community clearance

The protocol will be submitted to the ethical committee of the Ananthapuri Hospital and Research
Institute for approval and ethical clearance obtained from the IEC.
Informed consent

Budget: self-funded

REFERENCE

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24. Dsouza. Perception of noncommunicable diseases among the tribals of the Gudalur Valley,
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Appendices

Appendix 1: IN-DEPTH INTERVIEW GUIDE FOR RESPONDENT.

Appendix 2: INFORMED CONSENT FORM (ENGLISH AND LOCAL LANGUAGE) FOR

RESPONDENTS.

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 Appendix 1:

IN-DEPTH INTERVIEW GUIDE FOR RESPONDENTS

RESPONDENT ID NO:
AGE:
DATE:
GENDER:

FORMAL AND INFORMAL ARTEFACTS WITH RESPECT TO NON-

COMMUNICABLE DISEASES AMONG TRIBES OF ATTAPADI IN PALAKKAD
DISTRICT

Time: 45 TO 60 minutes Introduction: [3-5] minutes

Dear Respondent, I am Divya Suresh, a Master of public health (MPH) scholar at the Global
Institute of Public Health, Anantapuri Hospital and research institution, Thiruvananthapuram under
Kerala university of health sciences. I request you participate in the interview, done for my research
project as a part of my curriculum. For my study, I have planned to conduct an interview using face
to face interview method. The interview will include questions regarding formal and informal
artefacts in tribes of Attapadi with respect to non-communicable diseases. the interview may last
for 45 to 60 minutes. I will be audio recording the above-mentioned interview process with your
consent. The study findings might not be of direct benefit to you but the information provided could
be used for academic research, planning programmes and policies. I assure you that the information
revealed here will remain confidential with the research team and will be destroyed as soon as they
are transcribed. You may refuse to answer any questions or withdraw from the study at any time.
You may ask questions to clarify your doubts in between the interview also.

1. Where do you live? whom do you live with?

2. Please describe your experience living here
3. Do you feel any changes in the general health of you and your family members in recent
times? If yes, please describe.

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4. Do you have any of the following diseases (cardiac problems, cancers, diabetic Mellitus,
hypertension, COPD, stroke)
5. How do you diagnose the diseases?
6. Are you under medication or any other treatment modalities?
7. Do you have any barriers to taking medication or any other treatment?
8. Did anyone else from your family have the same disease or the following diseases (cardiac
problems, cancers, diabetic Mellitus, hypertension, COPD, stroke)?
9. Does this disease cause problems for you?
10. Which treatment do you use when you get sick?
11. If you get sick, do you treat it at home?
12. Do you think it is good to treat at home?
13. What is the health facility accessible to you?
14. Are those settings adequate to meet your health needs of you?
15. How is the behaviour of health care providers?
16. Do you have any hesitation to deal with formal healthcare workers?
17. What do you think about the main cause of these diseases?
18. What do you know about non-communicable diseases?
19. According to you why do people develop NCDs?
20. Do you know why NCDs are increasing in your area?
21. Are there any beliefs about NCD in your community?
22. According to you whether NCDs can be treated or not? Please describe.
23. How do you manage diabetes Mellitus or hypertension according to your culture?
24. do you change your dietary pattern when you are diagnosed with diabetes mellitus or
hypertension?
25. Do you have any experience from your community or culture in managing NCDs?
26. Do you think there is a cultural problem in taking normal treatment?
27. Did you take any kind of ethnic medicine?
28. What is your perception of the role of community members in reducing NCDs instead of the
member from outside the community who is trained?
29. Do you believe/trust the formal health system?
30. Do you discuss such ailments in the community?
31. Do you accept any treatment or prevention activities which are not allowed in your cultural
activities?

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32. What is your suggestion to make culturally safe health care for the tribal community?

This concludes the interview. Thank you for your time and participation.

Divya suresh

MPH Scholar

Global Institute of Public Health

Ananthapuri Research Institute.

Contact number: 7994260637

Email: divyasuresh7dev@gmail.com

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 Appendix 2:

INFORMED CONSENT FORM (ENGLISH) FOR RESPONDENTS.

INFORMATION SHEET

FORMAL AND INFORMAL ARTEFACTS WITH RESPECT TO NON-

COMMUNICABLE DISEASES AMONG TRIBES OF ATTAPADI IN PALAKKAD
DISTRICT

I am Divya Suresh, Master of Public Health (MPH) scholar at the Global Institute of public
health (GIPH), Ananthapuri Hospital and Research Institute (AHRI), Chakka,
Thiruvananthapuram. As a part of my course curriculum, I am doing a study on formal and
informal artefacts among tribes of Attapadi with respect to non-communicable diseases. For my
study, I have planned to conduct an in-depth Interview using Face to Face interview method.
The interview will include questions regarding cultural factors associated with NCD,
management and treatment modalities of NCD etc. The interview may last for 60 to 90 minutes.
I will be audio recording the above-mentioned interview process with your consent. The study
findings might not be of direct benefit to you but the information provided could be used for
academic research, planning programmes and policies. I assure you that the information
revealed here will remain confidential with the research team and will be destroyed as soon as
they are transcribed in to verbatim. So I would like to humbly request you to voluntarily
participate in my study after understanding clearly the below-given consent form. If you have
any questions about this study, you may ask me now or you may contact me through the
following details. For additional queries, you may contact the Member Secretary, Institutional
Ethics Committee (IEC) of AHRI.

Researcher,

Divya suresh Member secretary

MPH Scholar Dr. A. Gopal

Global Institute of Public Health institutional ethics committee,

GIPH

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Ananthapuri Research Institute. AHRI, Chakka,
Thiruvananthapuram

Contact number: 7994260637 Contact number: 0471-2577990

Email: divyasuresh7dev@gmail.com Email: iecahri@gmail.com

CONSENT FORM FOR RESPONDENTS

 I understand that even if I agree to participate now, I can withdraw at any time or refuse to
answer any question without any consequences of any kind.

 I understand that I can withdraw permission to use data from my interview within two weeks
after the interview, in which situation the material will be deleted.

 I have had the purpose and nature of the study explained in the Information Sheet that was
provided to me and I have had the opportunity to ask questions about the study.

 I understand that participation involves a detailed audio recording of the in-depth personal
interview (Face to Face).

 I agree to my interview being audio-recorded.

 I understand that all information I provide for this study will be treated confidentially.

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  I understand that in any report on the results of this research, my identity will remain
anonymous.

 This will be done by changing my name and disguising any details of my interview which
may reveal my identity or the identity of people I speak about.

 I understand that disguised extracts from my interview may be quoted in dissertations,

conference presentations, published papers, journals etc.

 I understand that if I inform the researcher that I or someone else is at risk of harm they may
have to report this to the relevant authorities - they will discuss this with me first but may be
required to report with or without my permission.

 I understand that the signed consent forms, original audio recordings and the transcript of the
interview will be stored in a locked chamber, under Researcher9s strict supervision.

 I understand that under freedom of information legalization, I am entitled to access the

information I have provided at any time while it is in storage as specified above

.  I understand that I am free to contact any of the people involved in the research to seek
further clarification and information. I………………………………………aged………………
voluntarily agree to participate in this research study.

Signature of participant ……………….

Date:

I believe the participant is giving informed consent to participate in this study.

Signature of researcher …………..

Date:

* INFORMATION SHEET, INTERVIEW GUIDE, AND CONSENT FORM were translated into
MALAYALAM. But due to the larger file size were not able to upload the same.

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