Step 1: Interview guide development.

A semi-structured interview guide was developed through a literature search and discussions with experts from both academic and healthcare fields. It included questions regarding health, nutrition, eating patterns, lifestyle practices, cultural practices, awareness of malnutrition, diet management, and government programmes and policies along with basic demographic details. Examples of questions included: “What does good health mean to you?”, “Describe the strategies or meal plans that you follow to make sure children receive a variety of nutrients?” and “How do you handle challenges related to picky eating or dietary preferences with your child?” Additionally, open-ended questions were added to the interview guide to collect the detailed perceptions of the participants.

Step 2: Interview guide validation.

The guide was validated using the interview protocol refinement method [22], which involved four phases:

1. Confirming the alignment of interview questions and the research questions: Interview and research questions were mapped into a matrix across domains such as background, health, nutrition, lifestyle, hygiene, culture and awareness.
2. Building an inquiry-based conversation: This was achieved by including introductory, transition, key and closing questions.
3. Collecting feedback on the interview guide: Six faculty members from Departments of Nursing, Community Medicine, Pharmacy Practice and Public Health reviewed the guide. Their feedback was incorporated and the guide was translated into Tulu and Kannada. The translated version was reviewed by a bilingual expert for accuracy and cultural relevance
4. Piloting the interview guide: The interview guide was piloted among ten participants to assess clarity and ease of understanding. Minor wording changes were made after piloting to improve the clarity; however, no substantial modifications were required.

The complete English version of the semi-structured interview guide used in this study is provided as S2 File.

Step 3: Data collection.

Data collection was guided by key principles of ethnographic research, including prolonged engagement, rapport building, participant observation and attention to cultural context. The lead researcher, a PhD student fluent in Tulu and Kannada, spent extended periods in the study settings to facilitate trust, familiarity, open communication with participants. Fieldwork for this qualitative phase lasted for an average of five months (October 2023- March 2024), during which the researcher engaged closely with the mothers to develop trust and gain a deeper understanding of their social and cultural aspects. This prolonged immersion involved both formal interviews and informal interactions, allowing the researcher to observe daily lifestyle practices, build meaningful relationships and be actively involved in local settings. These efforts ensured that the data collected reflected social meanings and everyday practices within the participant’s natural cultural environment. The process was conducted under the guidance of the fourth author, a professor and an experienced qualitative researcher, who provided mentorship to ensure cultural sensitivity and methodological rigor.

Data collection took place across ten Koraga settlements, purposively selected to capture geographical diversity, socio-cultural variation and differing access to health and welfare services. In each settlement, 1–3 mothers of children aged 5–10 years were interviewed through in-depth, semi-structured, face-to-face interviews conducted in person by the lead researcher in the privacy of their homes. Each interview lasted approximately 40–45 minutes. Interviews continued until data saturation was reached by the 18th interview, as no new insights emerged. To confirm that all key perspectives had been captured, two additional interviews were conducted, resulting in a total of 20 interviews. Field notes were taken, and interviews were audio-recorded with informed consent. The pilot interviews were not included in the final analysis.

Data confidentiality was strictly maintained. All recordings and notes were anonymized and stored securely in a password-protected file on an encrypted device. In line with Institutional Ethics Committee guidelines, data were retained for three years before being securely destroyed.

1. Theme 1: Evolving perception of health and wellbeing.

1.1Subtheme 1: Improved access and health status

Mothers generally perceived that the health status of their community had improved compared to the past. They attributed this change to reduced health challenges and the regular visits of ASHA workers, who provided support and linked them to healthcare services. In the past, they recalled facing frequent illness episodes and minimal contact with health workers, which often resulted in worsening conditions before care was sought. Limited awareness about preventive practices was also identified as a challenge. While many difficulties were recalled from earlier times, they emphasized that the situation had improved considerably. One mother shared,

“Now it is fine, there is no difficulty in health like before. Now, the healthcare centre gets to know about it, it is good for people who have BP and sugar. They come to the house, because of which it is better now.” [KTP₁₉36F]

1.2 Subtheme 2: Holistic wellbeing practices

Mothers described health as a state of balance that included cleanliness, nutritious food, adequate sleep and physical activity. They emphasized the need to protect children from infections by being cautious when they were unwell, and by maintaining hygienic practices. Eating food that “cool the body”, drinking water regularly, and avoiding oily foods were highlighted as preventive measures. Yoga, meditation, and daily exercise were also viewed as important for maintaining both physical and mental well-being. One mother explained:

“We should eat vegetables, fish and meat. Then, we should walk. We must have our food on time. Sleep. We should sleep well and drink plenty of water at regular intervals. That’s all.” [KTP₁₁31F]

Another added, “We should eat good food. It is good if we exercise and meditate. We should not eat oily food.” [KTP₁₃42F]

1.3 Subtheme 3: Societal influence on health beliefs

Mothers perceived that their health beliefs were shaped by a combination of intergenerational teachings, traditional wisdom, and advice from health professionals. Cleanliness and household health practices were learned from parents and grandparents, while nurses, doctors and community meetings reinforced these practices and encouraged healthier behaviours. As one mother explained:

“Nurses come home, and doctors too visit us. We observe, and they too tell us.” [KTP₁₃42F]

2. Theme 2: Nutrition beliefs and practices.

2.1Subtheme 1: Safe and balanced diet

Mothers emphasized that food should be consumed in moderation to maintain balance in the body. Excessive spicy or oily foods were thought to generate “heat”, leading to discomfort and illness. Proper cleaning and safe storage of food were seen as essential to prevent stomach problems. They identified a variety of foods as beneficial for children’s health, including green gram, eggs, milk, bananas, chicken and fish, with eggs and milk often highlighted as important for strength and growth. Traditional staples such as ganji (rice porridge) and chilli tamarind paste also remained part of their regular diets.

At the same time, mothers expressed concerns about foods considered harmful, particularly oily foods, potatoes and sweets, which they associated with gastric discomfort, tooth decay, and worm infestations.

One mother explained, “Green gram, eggs and all we should give. Milk should be given to children after they finish their meal and before they sleep. They eat bananas also. That’s also good for health know. Then, non-vegeterian food items like chicken and fish we should give.” [KTP₁ 42F]

Another added, “Leafy vegetables, then food that cools our body, tender coconut, grapes. If we give all these it is good for their health.” [KTP₁₀38F]

2.2 Subtheme 2: Cultural food traditions

Mothers expressed the importance of including traditional dishes in their diet, considering them both nutritious and culturally significant. They described preparing foods such as ‘gatti’ (steamed rice dumplings with grated coconut and jaggery filling, wrapped in banana or turmeric leaves), ‘pathrode’ (steamed roll made with rice, spices, coconut and locally available colocasia leaves), and ‘dosa’ (fermented rice and black gram pancakes), often enriched with colocasia or moringa leaves. Dishes like ‘pundi’ (rice dumplings with coconut and jaggery) and ‘idli’, (steamed cakes prepared from fermented batter of rice and black gram) were also prepared for children. As one mother mentioned,

“We make ‘gatti’ using different leaves like banana leaves and turmeric leaves. Then, we prepare ‘pathrode’, ‘dosa’ made up of ‘kesu’ and drumstick leaves and give it to our children; that’s also good.” [KTP₁42F]

2.3 Subtheme 3: Feeding strategies for children

Mothers frequently expressed concerns that their children appeared weak, tired easily or preferred unhealthy foods such as sweets, oily snacks and street food. One mother shared:

“He is little weak. He doesn’t eat properly. Only if we scold him, he eats. He has his food. But he eats more sweets, oily food and street food.” [KTP₁₁31F]

To address these challenges, mothers adopted creative strategies to encourage healthier eating. They blended often disliked but nutritious vegetables into juices with milk, offered alternatives like omelettes instead of boiled eggs, and tried to provide foods that were more acceptable to children. These adaptations were seen as practical ways to improve children’s nutrition while respecting their preferences.

2.4 Subtheme 4: Government nutrition support

Mothers recognized the role of government programs in improving their family’s diet. They highlighted the role of ITDP, which provided monthly rations such as pulses, jaggery, eggs, oil and ghee. These supplements were seen as particularly beneficial for children’s nutrition and overall household food security.

As one mother explained, “We get food, you know-jaggery, and all. For our Koraga community we get monthly nutritious food from -ITDP-. In that, we get chickpeas, toor dal, jaggery, eggs and ghee.” [KTP₁₄42F]

3. Theme 3: Hygiene and health promotion.

3.1 Subtheme 1: Government schemes and role of education

Mothers described being informed about government programs that support maternal and child health, particularly the ‘Thayi Card’, which provides nutritional and health benefits during pregnancy and early childhood. Awareness of these schemes was often facilitated by ASHA workers, nurses, and community members, who visited households to share information and encourage participation. These interactions were seen as an important source of guidance about available services.

At the same time, mothers highlighted the role of education in shaping health practices. Lessons in schools about cleanliness and personal hygiene, were viewed as important for preventing infections. They also noted that, children were regularly given deworming tablets at school, which increased parental awareness of worm-related health issues. This awareness helped families recognize symptoms such as stomach pain or vomiting and seek timely care when needed. One mother explained, “[birds chirping] Thayi card. It has been very useful for us. We have been following that.” [KTP₁₃42F]

Another added, “Yes, education is important. It is very important. If stomach worm increases, children’s stomach starts to pain, they will vomit. All this we understand and get them medicines.” [KTP₁₀38F]

3.2 Subtheme 2: Household and environmental hygiene

Mothers stressed the importance of keeping both the home and surroundings clean to prevent illness. They associated stagnant water with the breeding grounds of mosquitoes and the spread of infections. They also emphasised on regular cleaning of kitchens, bathrooms and toilets. Everyday practices such as washing vegetables, changing clothes, trimming nails, and maintaining pet hygiene were described as part of protecting children’s health. Personal routines like brushing teeth, bathing and frequent handwashing were widely encouraged. One mother shared,

“For dust, it is good to clean. We should not allow dirty water to stay for long time; otherwise, mosquitoes will increase, and they will bite us and cause problems for our health. So, I fear that. If we keep clean, then flies will not come” [KTP₁₀38F]

3.3 Subtheme 3: Preventive health check-ups

Mothers recognized the value of regular health camps and check-ups, describing them as useful for early detection of illnesses such as diabetes, hypertension and anaemia. They reported undergoing blood tests, sputum tests, along with checks for blood pressure, sugar levels, and weight, and were willing to participate whenever such services were available. One mother explained,

“We are going for health checkups. We go once a month to ‘Belapu’ village government hospital. When camps are arranged, we go there and get our BP and other health checkups done.” [KTP₁₀38F]

3.4 Subtheme 4: Child hygiene and deworming

Mothers reported that their children generally followed good hygiene practices at home, including brushing twice daily, trimming nails, washing hands with soap, and wearing footwear outdoors. They stressed that maintaining these habits was essential for protecting children’s health. Additionally, deworming was also considered important, with mothers noting that neglecting it could lead to children becoming thin, developing stomach worms, and suffering from stomach pain, vomiting and fever. One mother explained,

“After getting up in the morning, she brushes her teeth, washes her face and hands, and then has her tea. In the afternoon she washes her hands and has her lunch. At night she baths, washes her hand and has her food. She also trims her nails.” [KTP₁₀38F]

4. Theme 4: Traditional healing with modern care.

4.1 Subtheme 1: Intergenerational knowledge and remedies

Mothers described traditional healing practices as a valuable legacy passed down through generations, particularly from grandmothers. This cultural knowledge, shared orally, has been preserved and actively practiced within households. They reported using a variety of plants for common ailments, such as ‘sambarballi’ leaves (Coleus amboinicus) for headaches, ‘tumbe’ leaves (Leucas aspera) mixed with onion juice to treat colds, and ‘sogase’ leaves (Adhatoda zeylanica) for breathlessness. Brahmi (Bacopa monnieri) was also believed to enhance memory. As one mother explained,

“From generations, our grandmothers were following all these, and they have taught us the same. We continue to follow them. [bangles clinging]” [KTP₁₀38F]

Another mother detailed her household practice, “We use ‘tumbe’ leaves. We add onions to the leaves, grind them, and extract the juice. Once a month, we give this to children. Then there’s ‘sambarballi,’ which we use for headaches. We heat the leaves in the fireplace and place them on our forehead, like this [showing with action]. This reduces our headaches. We also apply the extract on the centre of our head, which helps relieve colds.” [KTP₁₄42F]

4.2 Subtheme 2: Integration of traditional and modern healthcare practices

Mothers described a pragmatic approach to managing illnesses, beginning with home remedies for common ailments and turning to doctors if these were ineffective. This reflected a balanced use of traditional wisdom alongside modern medicine in everyday healthcare. As one mother explained,

“First, we prepare medicines at home. Home remedies. Then, if it doesn’t work, we go to the hospital.” [KTP₁₂34F]

5. Theme 5: Barriers and community solutions.

5.1 Subtheme 1: Geographic and logistics barrier

Mothers identified remoteness and lack of transport as major obstacles to accessing healthcare and education. Families living in forested or hilly areas reported difficulties reaching schools and hospitals because vehicles such as autos were unavailable. One mother shared,

“Aa... [pause] Means how to say, for some people, hospitals are not nearby. Some people’s houses are in remote areas, in forests and on mountains. There they do not get any vehicles like autos to travel. To travel to hospitals also is a problem. If those facilities are given, then it is good.” [KTP₅28F]

5.2 Subtheme 2: Behavioural challenges

Mothers identified lifestyle factors such as alcohol use, tobacco chewing, poor sleep, and frequent consumption of oily foods as key barriers to good health in their community. These behaviours were seen as harmful habits that risk their well-being. One mother explained,

“The major challenges are drinking alcohol, chewing gutka and eating oily food.” [KTP₁₃42F]

5.3 Subtheme 3: Socioeconomic, educational and nutritional barriers

Some mothers perceived that a lack of education and financial hardship were significant challenges in their community. Schooling opportunities were seen as uneven, with some children able to attend while others dropped out, and many families were unable to afford private schools. Poverty further restricted access to both education and healthcare. Mothers noted that they often lacked the resources to follow doctor’s advice or purchase adequate food. In addition, caste-based discrimination was perceived as an added obstacle that compounded their difficulties. One mother shared,

“There might be other problems, but we may not know about other people. Education is less. Problems related to education are more. Some people may face these issues, but I don’t know. Some may have less education; education related problem might be there.” [KTP₁₂34F]

Another noted, “To get proper education, there is poverty, and then there is caste-based discrimination also. These create barriers to education. Then, there is a money problem also.” [KTP₁₈28F]

5.4 Subtheme 4: Suggested solutions

Mothers proposed several strategies to overcome barriers to health and education. They emphasized the role of teachers in encouraging families to send children to school. Structural support, such as bus services through ITDP, was seen as essential for improving school access. Mothers also stressed the importance of family and community involvement, noting that stronger guidance could help overcome bad habits such as chewing gutka, using tobacco, and drinking alcohol. One mother stated,

“The government should do something, so that children don’t drink alcohol and arrange for some rehabilitation centres. At home, elders should not influence their children to drink alcohol. Instead, they should encourage their children to go to school.” [KTP₁₆38F]