Health-Seeking Behaviours of Indigenous Peoples in Bangladesh: A Narrative Review of Cultural Practices, Structural Barriers, and Pathways to Equity

Over 50 different ethnic groups make up Bangladesh’s Indigenous population, which suffers from severe health disparities stemming from social exclusion and historical marginalization. Designing successful and equitable health treatments requires an understanding of the intricate interactions between institutional barriers and cultural traditions, which are reflected in their health-seeking behaviors. This narrative review synthesizes two decades of evidence to map these behaviors and identify the trajectories for achieving health equity for these communities.We undertook a structured narrative review of the literature produced between the years 2000 and 2024. Databases such as PubMed, Google Scholar, and BanglaJOL were searched using the appropriate terms. The inclusion criteria included peer-reviewed publications and grey publications addressing the health practices of Indigenous people living in Bangladesh. The sources amounted to a total of 65, which were chosen for qualitative synthesis, and the results were structured into key theme-based areas.Our review confirms the reality of health-seeking as involving widespread medical pluralism, such that the traditional healer (e.g., kaviraj, shamans) remains the first line of care. Important access barriers for formal health care are multi-dimensional: (1) structural barriers like geographical isolation and economic barriers; (2) cultural and gender regimes which restrict the autonomy of women and a preference for culturally suitable care; and (3) limited health literacy which operates to restrict the use of preventive services. The factors result in drastic inequalities, particularly in maternal and mental health, which remain seriously undertreated. NGOs provide irreplaceable complementary services, but their advantage lies in decentralizing the benefit. The overriding finding is that even when the facilities operate, a lack of cultural safety and mistrust operate to restrict the use of the facilities.There is no one-size-fits-all approach that can be used to achieve health equity for Bangladesh’s Indigenous peoples. Interventions must be co-designed with communities, incorporating culturally safe methods, hiring health practitioners who speak Indigenous languages, and utilizing traditional healers’ trust. Enabling focused policies and specialized resources requires the legal recognition of Indigenous status. Future studies must broaden their scope beyond the Chittagong Hill Tracts to encompass the varied perspectives of groups residing in the plains.Keywords: Indigenous health, health-seeking behaviour, structural barriers, medical pluralism, Chittagong hill tracts, Bangladesh.1. IntroductionThere are approximately 1.5 to 1.6 million Indigenous people in Bangladesh, which makes up 1-2 percent of the country’s total population. These people primarily reside in the Chittagong Hill Tracts (CHT) and some plains regions (IWGIA, 2024; Rahman & Hasan, 2021). Speaking dozens of languages, they are made up of more than 50 different ethnic groups, including the Chakma, Marma, Garo, and others (IWGIA, 2024). They are permanently marginalized: poverty, food insecurity, land insecurity, and bias are prevalent, and health metrics for hill districts fall short of national averages (IWGIA, 2024; Rashid, 2015).Bangladesh has made remarkable strides in health (such as lowering maternal and child mortality), but indigenous people are still isolated and have not seen similar advancements (Rashid, 2015). Known as ”tribal” or ”pahari” (hill) populations, they are not granted any special legal status and frequently face service gaps, cultural insensitivity, and language barriers when seeking care (Rashid, 2015; Rahman & Hasan, 2021).Health-seeking behaviour – the process by which individuals seek out cures for noticed symptoms – is shaped by cultural beliefs, gender standards, socioeconomic level, and system of health factors. For the Indigenous people of Bangladesh, this means medical pluralism (combining traditional and modern treatment) and special barriers for formal facilities. Early ethnography reports a pattern of tribal families putting off or skipping biomedical treatment for older or spirit-based issues (Rahman et al., 2012; Haque et al., 2018). Furthermore, gender roles tend to restrict women’s freedom (men or elders must permit a clinic visit) and determine whether a woman patient can be treated by a male provider (Rahman et al., 2012; Nawaz & Bushra, 2023). Poor health literacy – limited self-knowledge of the cause of diseases and formal treatment – and limited formal education boost adherence to well-known folk treatment (Hossen et al., 2023; Rahman & Hasan, 2021). Geography also casts a long shadow: the CHT and other tribal communities are located well away, in mountainous country with sparse roads, so the time spent getting there and the lack of transport make visits to facilities costly or unaffordable (Hossen et al., 2023; Akter et al., 2019). This narrative review synthesizes the evidence (2000–2024) for health-seeking among indigenous Bangladeshis. We focus on traditional healing, maternal/reproductive care, mental health, nutrition, gender/cultural barriers, health literacy, NGO/community roles, and access to public health systems. We compiled peer-reviewed sources (2000–2024) and credible reports (government/NGO) (≥40 sources), organizing findings into IMRAD format.This analysis highlights one of the main shortcomings of the current research, which is its heavy emphasis on Indigenous groups in the Chittagong Hill Tracts (CHT). The results may therefore not be as generalizable to plains-dwelling people (e.g., Garo, Santal) and are more reflective of hill tribes like as the Chakma and Marma.2. MethodsWe performed a structured literature search of PubMed, Google Scholar, Google, and BanglaJOL for terms like “indigenous health”, “tribal Bangladesh”, “health-seeking behavior”, “health literacy”, “Chittagong Hill Tracts”, and the thematic terms above. In order to get the most recent evidence, the search was carried out in May 2025. Titles and abstracts were used to determine the relevance of the original pool of entries. After that, the complete texts of the remaining sources were evaluated in light of the inclusion requirements. The ultimate selection of 65 sources for thorough analysis and synthesis was the result of this approach.Inclusion criteria were studies or reports (2000–2024) focusing on health practices of Bangladesh’s Indigenous peoples (tribal, Adivasi) or disaggregating data by ethnicity. We prioritized peer-reviewed articles with DOIs, supplemented by government/NGO reports. In total, 65 relevant sources were identified, of which ~30 were primary empirical studies and others were reviews or background sources. Content was extracted on thematic areas and synthesized into a journal-style narrative.3. Results3.1. Traditional and Spiritual Healing PracticesMedical pluralism is widespread. Several studies report that traditional healers (kaviraj, faith healers, shamans) remain primary health-care providers in tribal villages (Rahman et al., 2012; Haque et al., 2018). A qualitative study of rural Bangladesh found “traditional healing was widely practiced as the means of primary healthcare” (especially among poorer households) (Haque et al., 2018). In tribal communities, herbalists and spiritual healers are “still very popular” (Rahman et al., 2012), and entire families often consult a folkloric healer (kabiraji or bhandari ) before or instead of a clinic. Folk practices include herbal remedies, amulets, religious rituals (Kalami, Bhandai), and tribal herbal medicine (Haque et al., 2018). For example, an UNESCO review notes “the majority of the rural and ethnic communities of Bangladesh still rely on the kavirajes for their primary health care”. (UNESCO, 2009)Importantly, many Indigenous patients will use both systems sequentially: they may first try a kabiraji, and if symptoms persist, later visit a doctor. According to studies, even in cases where biomedical care is free, patients may choose to spend more on a healer if they feel heard: perceived ”quality” of treatment (respectful care) can occasionally surpass cost (Rahman et al., 2012). Choice of healer is also influenced by gender roles: women may seek the services of a female spiritual healer for stigmatized conditions (such as gynecological problems or gender-based violence).3.2. Maternal and Reproductive HealthIndigenous women experience notably poor maternal and reproductive outcomes. Bangladesh has seen dramatic MMR declines nationally, but the CHT has “the worst health record in the country” for mothers (Akter et al., 2019). Low-birth-weight (LBW) infants, a major risk factor associated with maternal neglect, are most common in the CHT in Bangladesh, according to UNICEF data (Akter et al., 2019). Tribal women utilize prenatal and skilled delivery services at significantly lower rates than other groups, which reflects deeper care gaps.For example, one CHT survey found only 14% of pregnant tribal women had ≥4 prenatal visits, while 70% had no antenatal care at all (Karim & Kamal, 2020). Only 46% of tribal deliveries were attended by a skilled birth attendant (SBA), compared to ~52% nationally (Karim & Kamal, 2020).Barriers are cultural and structural. Many women expressed a preference for home-based, culturally relevant care (e.g., birthing at home with an older female relative) (Akter et al., 2020). Formal facilities are often seen as for emergencies only. Key obstacles include a lack of awareness about the importance of MHC, costs (even “free” services incur transport and opportunity costs), and language/communication issues with Bengali-speaking staff (Akter et al., 2019). For instance, Akter et al. report that women wanted “culturally relevant, respectful, home-based and affordable care,” and that many perceived clinics as only for complications(Akter et al., 2020). In addition, surveys note that distance to facilities (hilly terrain, poor roads) and service costs (informal fees) deter even motivated women(Akter et al., 2019; Hossen et al., 2023). Some indigenous women fear mistreatment: demands for unofficial payments and reports of abuse by staff were also documented(Akter et al., 2019).Notably, targeted interventions have shown promise. Evaluations of the UNDP-led CHT Development Facility reported increased maternal care usage in intervention areas (Akter et al., 2019). For example, Akter et al. report that more tribal women than before sought prenatal, skilled delivery, and postnatal care in project locations (Akter et al., 2019). This implies that when outreach initiatives and female community health professionals appropriately address cultural demands, uptake can be improved.3.3. Mental HealthMental health care is deeply underserved. Indigenous communities report high stigma: one study found that traditional beliefs still dominate, with many attributing mental illness to evil spirits rather than medical causes (Faruk & Hasan, 2022). In Bangladesh, mental disorders carry heavy stigma, and avoidance is common. For example, Faruk et al. note that “mental illnesses in Bangladesh are generally seen as a consequence of possession of evil spirits” and that stigma leads to low help-seeking.In remote hill areas, professional services are extremely scarce: one country profile notes, “few seek attention from professional services…because in these remote areas few resources are available” (Faruk & Hasan, 2022). In practice, this means few psychiatrists or psychologists serve Indigenous districts. Faruk et al. (2023) highlight that almost no mental health professionals come from Indigenous backgrounds, so even available services often feel alien. Concretely, one analysis attributes poor access partly to“insufficient number of healthcare professionals representing Indigenous communities” .Gender also affects mental health: according to a stigma study conducted among CHT tribes, women reported overall lower awareness of treatment choices and higher levels of stigma than men (Faruk et al., 2023). Prayer and the use of traditional healers for ”possession” are common community coping mechanisms. Finally, limited awareness of mental illness and a lack of culturally competent counseling continue to be major obstacles.3.4. Nutrition and MalnutritionIn both mainstream and Indigenous populations, chronic malnutrition is prevalent. Undernutrition and rising overweight are two burdens highlighted by recent studies. Similar levels of malnutrition were seen in tribal and non-tribal populations in a 2024 survey of schoolchildren, with approximately 15–18% of both groups experiencing stunting or wasting (Karim, 2024). In other words, tribal children’s nutritional status is no better than that of Bengalis. A similar trend can be seen in adult data: according to a PLOS study conducted in northwest Bangladesh, tribal adults showed much lower rates of obesity than non-tribals but comparable rates of undernutrition (Karim et al., 2023). For example, among men, ~9% of tribal men were underweight (vs ~12% of tribal women) with far fewer tribal adults overweight (≈11% vs ≈27–29% in non-tribals) (Karim et al., 2023).However, pockets of severe malnutrition exist: media and NGO reports on tea estate communities (often Garo and Santal) describe “hunger and hardship”, with under-5 stunting rates exceeding 30%. One recent global pediatrics study in a Garo region found 27.98% stunting among under-5s (with ~7.7% also overweight) (Hasan et al., 2025), indicating a coexistence of under- and over-nutrition. Environmental factors contribute: poor sanitation is a key determinant of tribal child growth. A Bangladesh study showed that high rates of open defecation in tribal villages were strongly linked to worse height-for-age scores (Sinharoy et al., 2019).Poor nutrition reflects multiple drivers: food insecurity, poverty, and limited education on diets. Indigenous diets, often based on plantation labor wages or upland farming, can lack diversity. Health services rarely include nutrition counseling. Though beyond the scope of “seeking care,” poor nutrition increases illness risk and thus amplifies health-care needs.3.5. Gender and Cultural BarriersPatriarchy and cultural norms heavily mediate care-seeking. In Indigenous families, men and elders typically control health decisions. Rahman et al. found that “gender and age play a role in making [health] decisions” in tribal households (Rahman et al., 2012). For example, a young tribal woman may require her husband’s or father’s permission to visit a clinic. Female patients also often prefer female providers due to modesty – a huge issue when rural clinics seldom have female doctors. Language is another cultural barrier: many hill tribes do not speak Bengali, and interpreters are rarely available (Akter et al., 2019).An analysis of ethnic women living in rural areas highlights the interplay between gender, and socioeconomic In rural ethnic and status to health-seeking according to Nawaz & care is frequently by social norms (e.g., women stigma associated with addressing reproductive Some people are also from clinics by cultural such as the that spiritual or these cultural that even when services women may are female community health Health awareness of and modern health care to be note poor health literacy among Indigenous Rahman et al. describe tribal elders as health literacy and health-seeking factors include low formal education literacy among tribes is well the national and lack of health A qualitative study in the CHT of about healthcare as a (Hossen et al., 2023). Many not or as to for example, people may not to or severe to high Language barriers and a lack of formal education the of public health which are frequently in of prenatal care, and mental health health literacy is often outreach and in of NGOs and play a but In many tribal areas, NGOs and public services. For example, and NGOs have community health and that health and One the CHT Development which was by the focused on maternal health by clinics and delivery The usage of maternal health services in indigenous according to of this (Akter et al., 2019). NGOs occasionally (e.g., an for isolated and have health education and literacy in indigenous the has not by any one The majority of are or and they frequently when According to some tribal a thorough understanding of the such as women’s that have on The use of traditional healers as health of has also in other is not well in Bangladesh, like a in of the that healers the NGO but for health tribal are seen as to services to these to to mainstream public health facilities remains In remote hill areas, primary health clinics are sparse and often where clinics their services address community (Rashid, 2015). For instance, a study notes that outreach in CHT often do not the most remote and when they they are to tribal (Rashid, barriers are distance and transport the A qualitative study of tribal people found that – on or – are a key Health may be even transport or can be of pregnant women that cost costs like of and lack of health or social safety deter care (Akter et al., 2019; Hossen et al., and issues Many tribal patients that they are to with healthcare professionals in Bengali, which results in or that they are to (such as the Cultural is a some patients from ethnic that or According to one the clinic staff as are in country” from qualitative services like more For instance, a study in found among tribal vs in non-tribals et al., 2018). This that when Bangladesh’s on remote areas, Indigenous are not other public health areas (e.g., chronic care) have tribal these access problems that Indigenous people often only use formal care when illnesses and primary care remain that health system must be culturally Akter et al. that indigenous maternal health in the CHT will require “culturally appropriate education and service delivery reviews legal recognition of indigenous status so that health can tribal (Rashid, the is focused on the of communities the Chittagong Hill Tracts this study the health-seeking behaviors for Indigenous peoples in Bangladesh. This review Bangladesh’s indigenous with a healthcare deeply beliefs and traditional healers and continue to play a there are other at play Geography and are socioeconomic is the primary cause of the low health literacy and poor nutrition that is a major factor in health and health-seeking according to global health and education are not obstacles will continue to and gender both play a According to women’s lack of and or getting medical attention (Rahman et al., 2012; Nawaz & Bushra, 2023). and focused outreach (such as women’s health groups in may be to address the norms be by health literacy culturally relevant indigenous on the can be by incorporating traditional with formal such as some first or maternal care. 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